**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and facility documentation review, the facility staff failed to ensure food was distributed in a manner to prevent contamination in the main kitchen. The findings included: In the main kitchen, the facility staff failed to ensure that hair restraints were worn by all staff in the food preparation and distribution areas. On 6/10/25 at 12:02 p.m., observations were conducted in the main kitchen of the lunch meal's plating of food and distribution. While the facility's dietary staff were plating food on the serving line, at 12:21 p.m., the facility's maintenance director entered the kitchen and walked over to the serving line without donning a hair net or beard guard. The dietary aide immediately said, Hey, you need a hair net. To which the maintenance director did not respond. The maintenance director went behind the serving line where the cook was plating food, and pulled out a cell phone. The dietary manager then approached the maintenance director and took the cell phone from the maintenance director, who then stepped away from the serving line. The dietary manager took a photo of the labels on the hood system and returned the phone to the maintenance director. The maintenance director then exited the kitchen. On 6/10/25 at 12:30 p.m., an interview was conducted with the dietary manager. The manager was asked if the maintenance director usually enters the kitchen without a hair net and the dietary manager said, Usually the staff stop at the door, I guess he was gung [NAME] on seeing when they [the hood inspectors] come back. The dietary manager confirmed that all persons entering the kitchen are to have hair coverings on. On 6/10/25 at 3:13 p.m., an interview was conducted with the facility's maintenance director. When asked about the purpose of his visit to the kitchen during the lunch meal service, he reported he needed the phone number of who inspects the hood system because the number he had was not correct. When asked if he frequents the kitchen often and if he puts on a hairnet, the maintenance director said, Like yesterday, I ran in there with the plumber to work on the sink. We just run in there and don't wear hairnets. I always just run in and out of there all the time. They always have stuff that needs to be fixed. I wasn't aware I needed a hair net; no one ever told me. I know now but they need to have them for me to get to. The surveyor explained where the hairnets are located, which was just inside the door. The surveyor explained that since he had a beard, he would also need a beard guard, while the surveyor saw dietary staff wearing beard guards and knows they are available, she did not know the location of them, and he would need to inquire about that. The maintenance director thanked the surveyor and said, Now I know, thank you for telling me. Review of the facility policy titled, Prevention of Infection- Dietary Department with a date of 10/1/21 was reviewed. The policy read in part, . 7. Dietary staff will wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food . On 6/10/25, during an end of day meeting, the facility administrator and regional nurse was made aware of the above findings. No additional information was provided.

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to implement their infection prevention and control program by failure to implement precautions to prevent the transmission of diseases and infections in accordance with accepted national standards from the Centers for Disease Control and Prevention (CDC) for one resident (Resident #101-R101) in a survey sample of five residents. The findings included: For R101, who had multiple open wounds, the facility staff failed to implement and adhere to enhanced barrier precautions in accordance with their policy and nationally accepted standards from CDC. On 6/10/25 at 11:33 a.m., during a tour of the facility, two certified nursing assistants were observed to enter R101's room, without donning any PPE (personal protective equipment). Observations noted there was no signage on R101's room door to indicate she was on any type of precautions. On 6/10/25 at approximately 11:45 a.m., the certified nursing assistants exited R101's room, and one pushed the resident in a wheelchair to the dining room, at which time, the surveyor observed R101 had both feet wrapped with cling. On 6/10/25, a clinical record review was conducted of R101's chart. This review revealed that R101 had multiple wounds, which included but were not limited to a stage IV pressure ulcer to the sacrum and three stage III pressure ulcers to the right foot. Review of the physician orders revealed that R101 had orders for Catheter Care: change foley cath as needed for blockage, leaking or malfunctioning. According to the nursing notes, an entry on 6/6/25, noted that R101 had wounds and a foley catheter. There were no physician orders for enhanced barrier precautions. Review of R101's care plan revealed focus areas to include pressure ulcers and skin impairments and the foley catheter. There was no indication that R101 was on enhanced barrier precautions within the care plan. On 6/11/25 at 9:25 a.m., the surveyor noted R101's door closed, there was no signage to indicate the resident was on any precautions or notification to staff that PPE was to be worn during direct care activities. The surveyor knocked on the door and facility staff were providing care. On 6/11/25 at 9:30 a.m., an interview was conducted with a certified nursing assistant (CNA #1). CNA #1 stated that residents on precautions have signs on the door. CNA #1 reported that they currently had no one on precautions in the facility. On 6/11/25 at 9:35 a.m., an interview was conducted with certified nursing assistant #2 (CNA #2). When asked about precautions, CNA #2 explained that if a resident is on precautions or PPE is needed a sign is on their room door and in their care plan, which she stated everyone has access to. When asked about enhanced barrier precautions, CNA #2 explained that it is to protect residents from any possible exposure as well as protect yourself. Right now, the precautions for enhanced barrier precautions are due to tubing, like a foley, nephrology tubes, and such. On 6/11/25 at 9:40 a.m., while the surveyor was in R101's room, licensed practical nurse #1 (LPN #1) entered the room. LPN #1 confirmed she was R101's assigned nurse and said, I just did wound care, and the CNA was helping me with her. When asked if she wore any PPE during that process/wound care, LPN #1 confirmed she had only worn gloves. When asked if PPE has to be worn during care of R101, LPN #1 went on to state, As far as I've been told we use PPE with colostomies, for basic wound care there are no special instructions. When asked about enhanced barrier precautions, LPN #1 said, That is something new to me, her [R101's] wound doesn't have MRSA [Methicillin-resistant Staphylococcus aureus, a type of bacteria], it is just basic wound care so just wear gloves. On 6/11/25 at 9:45 a.m., an interview was conducted with the facility's director of nursing (DON), who is also the facility's designated infection preventionist. The surveyor asked the DON to explain enhanced barrier precautions (EBP), when they are used, the purpose, and so forth. The DON said, EBP is to protect patients with compromising skin issues, medical ports, foleys, etc. We don't want infections to happen. Or people with a history of MDRO's [multi-drug-resistant organisms]. Staff wear a gown and gloves during care, it is a protective process. When the surveyor discussed that R101 had multiple wounds and asked if she should be on EBP, the DON said, Yes, she should be on EBP. When asked if she was aware that R101 is not on EBP, the DON stated she was not aware as she had only started at the facility mid-day on Monday [2 days ago] and explained that she didn't have anyone doing infection control and that was one of the programs/processes she was working on. The DON said, I'm going to do a lot of education, there is a lot of agency staff that don't know. On 6/11/25 at 10 a.m., the facility administrator and regional nurse were made aware of the above findings. According to the Centers for Disease Prevention and Control (CDC), there is a guidance document titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) dated 4/2/24. The document read in part, .Updates as of July 12, 2022. Key Points:1: Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. 2. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. 3. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status Infection or colonization with an MDRO. 4. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care . Accessed online at: https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html The facility administration provided a facility policy titled, Enhanced Barrier Precautions (EBP) Policy dated 3/28/24. According to the policy, which read in part, . 1. Criteria for Implementing EBP: . Residents with wounds and/or indwelling medical devices, irrespective of MDRO infection or colonization status . 4. High-Contact Resident Care Activities Requiring EBP: EBP should be utilized during the following activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, wound care . 6. Duration of EBP Usage: EBP should remain in place for the duration of a resident's say in the facility or until the resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk . No further information was provided prior to the conclusion of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. For R2, the facility staff failed to follow professional standards of nurse practice by failing to administer physician ordered medications within an hour of the scheduled time. On 4/28/25, an interview was conducted with R2. R2 denied any concerns about medications when asked. On 4/28/25, a clinical record review was conducted of R2's chart. According to the medication administration records, R2 had medications scheduled to be administered at 9 a.m., 5 p.m., 7 p.m., and 9 p.m. According to the physician orders, medication administration record and Medication Admin Audit Report, R2 had Valsartan, Hydrochlorothiazide, Quetiapine Fumarate, Pantoprazole Sodium, Clopidogrel Bisulfate, and Metoprolol Succinate ER [Extended release] scheduled to be administered at 9 a.m., and they were not given until 12:43 p.m. On 4/17/25 R2's morning medications scheduled for administration at 9 a.m., were not administered until 11:38 a.m. and on 4/18/25, the medications were not given until 10:41 p.m. On 4/20/25, the scheduled medications for 9 a.m., were not administered until 10:38 a.m. On 4/22/25, R2's morning medications, noted above, were scheduled to be given at 9 a.m., and were not administered until 4:54 p.m. R2 had Mirtazapine and melatonin scheduled to be administered at 7 p.m. and Quetiapine Fumarate and Metoprolol Succinate ER to be given at 9 p.m., On 4/2/25 the 7 p.m., scheduled medications were not administered until 11:45 p.m. and the 9 p.m. medications were given at 10:34 p.m. On 4/3/25, 7 p.m. and 9 p.m. medications were given together at 10:52 p.m. On 4/5/25, the 7 p.m. medications were given at 10:10 p.m. and the 9 p.m. medications were given at 8:35 p.m. On 4/7/25 the 7 p.m. and 9 p.m. medications were given together at 11:35 p.m. On 4/8/25, the melatonin was given with Quetiapine and Metoprolol Succinate ER at 1:31 a.m. on 4/9/25. The Quetiapine Fumarate scheduled for 7 p.m. on 4/8/25 was given on 4/9/25 at 3:28 a.m. On 4/9/25, the 7 p.m. medications were administered at 10:42 p.m. after the 9 p.m. medications were given at 10:12 p.m. From 4/10/25-4/26/25, R2's medications scheduled for 7 p.m., were given outside of the professional standard to give within 1 hour of the scheduled time on 14 occasions. There was no evidence within R2's clinical record to indicate that the ordering provider or attending physician was made aware of the instances that R2's medications were not administered timely. No additional information was provided prior to exit. Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to follow professional standards of nursing practice with regards to the management of an advanced pressure wound for one resident (Resident #4-R4), constituting harm, and the timeliness of medication administration for three residents (Resident #2 -R2, Resident #3-R3, and Resident #4-R4), in a survey sample of six residents. The findings included: 1. For R4, the facility failed to provide appropriate management of an advanced pressure wound per professional standards of care, subsequently resulting in further wound deterioration, which contstituted harm. On 4/29/25 at 10:00 a.m., an interview was conducted with the director of nursing (DON). The DON said, A blank on the MAR means it wasn't given and, on the TAR, means it wasn't done. The DON stated, When the nurse found a new wound, that it was to be reported to me and the unit manager, cleaned with soap and water, nurse practitioner notified, treatment orders obtained until the wound provider evaluated the wound, and the responsible party notified of the findings. The DON stated that weekly skin sweeps were completed by 2 nurses, and that one must be a registered nurse (RN). When questioned about evidence of repositioning, the DON stated that there was no documentation for the repositioning of R4 every two hours and that the nurses talk with the aides to make sure it was done. The DON stated that she checked every morning that xray's and labs were obtained when ordered and results were received in a timely manner. The DON said, I review the wound specialist nurse practioner's documentation. The wound provider recommendations are put in as orders and reviewed by our in-house NP. The NP agrees with the wound providers' recommendations. The DON said, Wound care provider orders and recommendations are put into the system the next business day, within 24 hours. If an order is obtained on the 28th the treatment should begin on the 28th. On 4/29/25 at 10:15 a.m., a review of R4's clinical record was conducted. A progress note written by RN#1 was reviewed. On 3/22/25 RN# found a pressure ulcer on R4's sacral area. RN#1 wrote a progress note that read, Patient brief changed after bm, noted an unstageable pressure ulcer to sacrum/coccyx. Wound bed >70% slough 25% beefy red granulating tissue. Dark red bruising to peri wound. Wound measures 2 cm x 2 cm x 0.2 cm. This RN#1, using aseptic technique cleansed with wound cleanser, patted dry with 4x4, applied Medi honey to wound bed, covered with silver alginate and bordered sacral foam dressing. Patient tolerated well. There were no physician orders for this treatment, nor were any wound care orders obtained to continue this treatment order. On 4/29/25 at 10:30 a.m., a comprehensive review of the TAR was conducted. Following the identification of the sacral/coccyx pressure wound on 3/22/25, there were no treatment orders or evidence that any sacral wound treatment was provided from 3/23/25 through 3/29/25. The first treatment order was written on 3/27/25 but was not implemented until 3/30/25. On 3/27/25, the wound specialist also recommended that R4 be positioned side-lying to offload pressure to the sacral/coccyx wound. On 3/31/25, the wound specialist recommended the use of zinc to the periwound, which was not implemented until 4/27/25. On 4/10/25, the wound specialist recommended an xray, given the documented findings of the wound deterioration with visible bone exposure, but the xray was not obtained until 4/29/25. On 4/10/25, the wound specialist also recommended new treatment with Dakin's solution, which was not started until 4/14/25. On 4/24/25, the wound specialist recommended a change in wound treatment that was not started until 4/27/25. Further review revealed that no treatment was documented on 4/21/25, 4/23/25, 4/25/25, and 4/26/25 to R4's sacral wound, which had been determined to be a Stage 4 - the most severe type. On 4/29/25 at 11:15 a.m., the DON was interviewed about R4's xray not being otained timely. The DON was asked why there were repeated recommendations by the wound specialist on 4/10/25, 4/17/25 and 4/24/25, which was not ordered until 4/25/25, but the xray was not obtained until 4/29/25. The DON said, Our in-house NP did not agree with doing the xray, thought it was too early to obtain an Xray. The DON stated that she texted the in-house nurse practitioner and would find the documentation about the in-house NP not agreeing with the recommendation for R4's xray. When not able to provide any documentation by the in-house NP's not wanting the xray obtained, the DON said, That was a miss on my behalf, usually they [mobile xray] don't take that long to come. They were here over the weekend getting chest x-rays on two residents and we questioned why it was not done. They came and it resulted this morning. On 4/29/25 at 10:40 p.m., a review of the facility document titled, Pressure Injury Prevention and Management, was reviewed and read in part, .develop and maintain systems and processes to ensure that the resident does not develop pressure ulcers/injuries (PU/PIs) unless clinically unavoidable and that the facility provides care and services consistent with professional standards of practice to: promote the prevention of pressure ulcer/injury development; promote the healing of existing pressure ulcers/injuries (including prevention of infection to the extent possible); and prevent development of additional pressure ulcer/injury. 2. For R3, the facility staff failed to follow professional standards of nurse practice to ensure medications were administered within an hour of the scheduled time. On 4/28/25 a clinical record review was conducted. R3's medication administration record (MAR) indicated that medications were ordered to be administered at 7:00 a.m., 9:00 a.m., 7:00 p.m., and 9:00p.m. According to the Medication Admin Audit Report, R3 was scheduled Tums, Thiamine, Divalproex Sodium, Levetiracetam, Vitamin D3, Folic Acid, Multiple Vitamins-Minerals, Aspirin, Fluoxetine, and Gabapentin for 9:00 a.m., but was administered at 11:37 a.m on 4/9/25. R3's Baclofen was scheduled at 7:00 a.m., but was administered at 12:59 p.m. on 4/10/25, administered at 12:21 p.m. on 4/11/25, administered at 9:07 a.m. on 4/12/25, administered at 8:49 a.m. on 4/14/25, and administered at 1:44 p.m. on 4/15/25. Documentation also revealed that R3 was scheduled Thiamine, Divalproex Sodium, Levetiracetam, Vitamin D3, Folic Acid, Multiple Vitamins-Minerals, Aspirin, Fluoxetine, Ciprofloxacin, Lactobacillus and Gabapentin for 9:00 a.m., but was administered on 4/15/25 at 10:22 a.m., on 4/16/25 at 10:32 a.m., on 4/17/25 at 10:40 a.m., and on 4/18/25 at 10:15 a.m. R3's 7:00 a.m. dose of Baclofen, was administered on 4/17/25 at 12:40 p.m., on 4/18/25 at 1:16 p.m., on 4/19/25 at 12:12 p.m., on 4/20/25 at 9:19 a.m., on 4/21/25 at 9:21 a.m., and on 4/22/25 at 11:56 a.m. R3's was scheduled Thiamine, Divalproex Sodium, Levetiracetam, Vitamin D3, Folic Acid, Multiple Vitamins-Minerals, Aspirin, Fluoxetine, Gabapentin and Calcium + Vitamin D3 was administered on 4/22/25 at 11:55 a.m., on 4/23/25 at 10:12 a.m., on 4/24/25 at 10:39 a.m., on 4/26/25 at 1:39 p.m., on 4/27/25 at 11:09 a.m., and on 4/28/25 at 10:45 a.m. R3's was scheduled Baclofen at 7:00 a.m., was administered on 4/23/25 at 10:12 a.m., on 4/24/25 at 11:56 a.m., on 4/25/25 at 9:47 a.m., and on 4/26/25 at 1:39 p.m. R3 was scheduled Atorvastatin and Baclofen at 7:00 p.m. and was administered at 9:24 p.m. on 4/5/25. On 4/6/25 R3 was scheduled Zonisamide, Baclofen, and Atorvastatin at 7:00 p.m., and was administered at 9:11 p.m. On 4/7/25 R3 was scheduled Zonisamide, Baclofen, Ciprofloxacin and Atorvastatin were administered at 9:31 p.m. On 4/8/25 Atorvastatin, Zonisamide, Baclofen and Melatonin were scheduled at 7:00 p.m., and was administered at 8:40 p.m., on 4/9/25 at 8:37 p.m., and on 4/10/25 at 8:36 p.m. On 4/9/25 Divalproex Sodium was scheduled at 5:00 p.m., and was administered at 6:26 p.m. On 4/10/25 R3 had ciprofloxacin scheduled at 7:00 p.m., and was administered at 7:03 p.m. On 4/11/25 R3 had Baclofen, Zonisamide, and Melatonin scheduled at 7:00 p.m., and administered at 10:21 p.m. On 4/11/25 R3 had Atorvastatin scheduled at 7:00 p.m., and was administered at 11:00 p.m., and Levetiracetam was scheduled for 9:00 p.m., and administered at 10:21 p.m. R3 had scheduled Atorvastatin, Zonisamide, Baclofen, and Melatonin at 7:00 p.m., was administered at 9:50 p.m., on 4/13/25, administered at 8:49 p.m., on 4/14/25, administered at 9:17 p.m., on 4/15/25, administered at 9:14 p.m., on 4/16/25, administered at 9:40 p.m., on 4/18/25, administered at 9:58 p.m. on 4/19/25, administered at 9:15 p.m., on 4/20/25, administered at 12:16 a.m., on 4/22/25. R3's Levetiracetam was scheduled for 9:00 p.m., and was administered at 12:16 a.m., on 4/22/25. R3 had scheduled Atorvastatin, Zonisamide, Baclofen, and Melatonin at 7:00 p.m., was administered at 10:17 p.m., on 4/22/25, administered at 11:36 p.m., on 4/23/25, administered at 10:01 p.m., on 4/24/25, administered at 8:59 p.m., on 4/25/25, administered at 10:01 p.m., on 4/26/25, and administered at 11:57 p.m., on 4/27/25.On 4/29/25 at 9:40 a.m., an interview was conducted with LPN. LPN#1 said, A hole in the MAR or TAR means it wasn't done. When a wound is found, we report it to the doctor, complete a change in condition, report to the unit manager and director of nursing, and obtain a treatment order from the doctor. On 4/29/25 at 9:50 a.m., an interview was conducted with LPN#2. LPN#2 said, Holes in the treatment and med record means it was not done. On 4/29/25 at 10:00 a.m., an interview was conducted with the director of nursing (DON). The DON said, A blank on the MAR [medication administration record] means it wasn't given and on the TAR [treatment administration record] means it wasn't done. The DON said, If an order is obtained on the 28th the treatment should begin on the 28th. The DON stated, When the nurse found a new wound that it was to be reported to me and the unit manager, cleaned with soap and water, nurse practitioner notified and obtained treatment until the wound specialist evaluated the wound and the responsible party notified of the findings. On 4/29/25 at 11:30 a.m., an interview was conducted with R3. R3 said, I missed some medications in the beginning of my stay, and I don't refuse any of my medications. 3. For R4, the facility staff repeatedly failed to administer the physician ordered medications within an hour of the scheduled time. On 4/28/25, a clinical record review was conducted. R4's medication administration record indicated that medications were to be administered at 6:00 a.m., 9:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m. According to the Medication Admin Audit Report, R4 was scheduled to receive Baclofen, Senna-S, Eliquis, Theradex M, and Cymbalta at 9:00 a.m., but they was administered at 12:43 p.m. on 4/3/25. R4 was scheduled to receive Oxycodone at 12:00 p.m., but it was administered at 1:42 p.m. on 4/17/25, and at 1:14 p.m. on 4/24/25. R4 was scheduled for Senna-S and Eliquis at 9:00 p.m., but they were administered at 11:46 p.m. on 4/2/25, was administered at 10:28 p.m. on 4/3/25, and was administered at 11:37 p.m. on 4/3/25. R4 was scheduled for Eliquis at 9:00 p.m., which was administered at 1:14 a.m. on 4/8/25. R4 was scheduled for Senna-s at 9:00 p.m. on 4/8/25, but it was administered at 3:28 a.m. on 4/9/25. R4 was scheduled Oxycodone at 12:00 a.m. on 4/9/25, but it was administered at 1:14 a.m. R4 was scheduled Senna-S and Eliquis at 9:00 p.m., and it was administered at 10:12 p.m., on 4/9/25, was administered at 11:03 p.m. on 4/16/25, and at 4:56 a.m. on 4/18/25. R4 was scheduled Oxycodone at 12:00 a.m., but it was administered at 4:56 a.m. on 4/18/25. On 4/28/25 at 1:00 p.m., a tour of the nursing unit on the 400 wing was conducted. R4 was non-verbal and not interviewable. On 4/28/25 at 4:32 p.m., an interview was conducted with a register nurse, RN#2. RN#2 stated that the medications were administered according to the physician orders. RN#2 said, If meds are ordered at 9 in the morning, then you can give one hour before or one hour after schedule time. If a med isn't given timely, then you notify your manager and call the doctor if important like IV's. On 4/28/25 at 4:40 p.m., an interview was conducted with a licensed practical nurse, LPN#1. LPN#1 said, If a med is ordered at 9 a.m., it should be given between 8 and 10. If giving too late, call the doctor to get an order for different time or hold it for the doctor notification. On 4/28/25 at 4:50 a.m., an interview was conducted with the unit manager, LPN#3. LPN#3 said, Meds ordered at 9 a.m. should be given between 8 a.m., and 10 a.m. Notify the doctor if late and a nursing note should have if the doctor was notified. On 4/28/25 at 5:00 p.m., a review of a facility document was conducted. The policy titled, General Guidelines for Medication Administration, read in part, .medications are administered as prescribed in accordance with good nursing principles and practices and only by legally authorized to administer. A facility document titled, Medication Orders, was reviewed and read in part, .the purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. The facility cited [NAME] as the resource used for professional nursing standards. Guidance was given by [NAME], Fundamentals of Nursing, which reads: To prevent medication errors, follow the six rights of medication administration consistently every time you administer medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to these rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation According to [NAME]'s Manual of Nursing Practice, the Eighth Edition, on page 18, the following was noted, Common Legal Claims for Departure from Standards of Care . Failure to administer medications properly and in a timely fashion, or to report and administer omitted doses appropriately . On 4/28/25 at 5:45 p.m., an end of day meeting was conducted with the administrator, the director of nursing and the corporate staff. They were informed of the above concerns. No additional information was provided.

Based on observation, staff interview, and facility documentation review, the facility staff failed to serve meals at a temperature that was palatable to multiple residents eating in their rooms on 4 of 4 wings. The findings included: On 4/28/25, a review of the resident council minutes and grievance logs from June 2024-April 2025 were reviewed and noted that in September 2024, November 2024, and February 2025, concerns were shared about food being cold when served in resident rooms. On 4/28/25, observations were conducted in the kitchen of the evening meal. The meal service began at 4:35 p.m. Residents eating in the dining room were served first and then trays for the residents eating in their rooms were prepared and placed in a transport cart. A test tray was prepared and placed on the cart. It was observed that the facility used insulated plate bottoms and lids but were not using the heated pellets under the plates to hold temperatures. When asked why pellets were not being used, said, They have thick insulated bottoms that hold heat and don't use the pellets. When they run out of the thick insulated bottoms, they will use pellets. Trays were observed being prepared with plates placed in both style bottoms without any heated pellets being used. When asked if the insulated bottoms are heated, the dietary manager said, No. The surveyor explained that she had seen both pellets used at other facilities and the thick insulated bottoms are heated and when the thinner bottom is used there is a metal pellet that goes inside which is heated. The dietary manager confirmed they don't do that. On 4/28/25 at 5:12 p.m., the last tray was placed in the transport cart and the cart exited the kitchen. At 5:14 p.m., the meal trays arrived on the unit. Multiple staff to include managers, began distributing trays to the residents. At 5:24 p.m., the last resident tray was removed from the cart and taken to a resident. On 4/28/25 at 5:24 p.m., as the last resident tray was being served, the dietary manager removed the test tray from the cart, and he obtained the temperature of the foods on the tray. They were as follows: the Swedish meatballs were 123.2 degrees Fahrenheit (F), rice 116 degrees F, green beans 114.6 degrees F, and the fruit dessert was 52.8 degrees F. The surveyor and dietary manager both sampled each of the food items and both agreed that the hot foods were lukewarm and not very appetizing in temperature, but the flavor was acceptable. The dietary manager stated that he likes his food hot and would not be satisfied with the food temperature served. According to the facility policy titled, Food and Nutrition Services, that read in part, . 7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature . On 4/28/25 at 5:45 p.m., during an end of day meeting with the facility administrator, director of nursing and corporate nurse, the above findings were reviewed. On 4/29/25, the corporate nurse notified the survey team that the pellets were being used that day. No additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to complete an accurate minimum data set (MDS) assessment for one of twenty-two residents in the survey sample (Resident #44). The findings include: Resident #44's admission MDS (an assessment tool) dated 1/18/24 inaccurately assessed the resident with having no dental problems, when the resident was edentulous (no natural teeth). Resident #44 (R44) was admitted to the facility with diagnoses that included osteoarthritis, depressive disorder, Parkinson's disease, heart failure and spinal stenosis. The MDS dated [DATE] assessed R44 as cognitively intact. On 2/20/24 at 11:21 a.m., R44 was interviewed about quality of life/care in the facility. R44 stated during this interview that she had pulled all teeth prior to admission to the facility and was waiting to get full dentures. R44 was observed with no natural teeth and stated she was on a soft diet because she was unable to chew some food items because she had no teeth. R44's clinical record documented an admission nursing assessment dated [DATE]. This assessment documented R44 had no natural teeth. The dental section (L0200) of R44's MDS dated [DATE] inaccurately documented the resident with no dental issues. Item B. for indicating no natural teeth or tooth fragment(s) (edentulous) was not checked. On 2/21/24 at 1:08 p.m., the registered nurse MDS coordinator (RN #1) was interviewed about the inaccuracy of R44's MDS dental assessment. RN #1 stated, To my knowledge, the MDS is correct. RN #1 stated she would review R44's dental assessment. On 2/21/24 at 1:55 p.m., RN #1 stated that R44 did not have natural visible teeth. RN #1 stated R44 had ridges on her gums and when she palpated R44's gums she could feel something. When asked about the MDS not indicating the resident was edentulous, RN #1 stated that she felt that edentulous would not be marked because she felt something on the exam. When asked how the assessment would indicate teeth when the resident's teeth had been pulled, RN #1 stated again that R44 had no visible teeth but that she felt something when she palpated the gums. On 2/21/24 at 3:10 p.m., the director of nursing (DON) was interviewed about R44's dental status. The DON stated R44 did not have any teeth as they had been pulled in preparation for dentures. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual on page L-1 documents that the dental section was intended to record any dental problems present in the 7-day look-back period. Edentulous was defined on page L-1 as, Having no natural permanent teeth in the mouth. Complete tooth loss. Coding instructions on page L-2 included, Check L0200B, no natural teeth or tooth fragment(s) (edentulous): if the resident is edentulous/lacks all natural teeth or parts of teeth. (1) This finding was reviewed with the administrator, director of nursing, and nurse consultant during a meeting on 2/21/24 at 4:15 p.m. with no further information provided prior to the end of the survey. (1) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.18.11, Centers for Medicare & Medicaid Services, Revised October 2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility failed to develop a plan of care that addressed Resident #21's (R21's) history of PTSD, the specific trauma that caused the PTSD and triggers that may cause re-traumatization. R21 was admitted with diagnoses that include Alzheimer's disease, cerebral infarction, schizophrenia, dementia, bipolar disorder, post-traumatic stress disorder, anxiety, and major depressive disorder. According to the clinical record, R21 was assessed on 12/30/23 as having moderate cognitive impairment. Review of R21's care plan, initiated 12/14/22 with the most recent revision date of 5/19/23, did not address the diagnosis of post-traumatic stress disorder (PTSD). The care plan revealed that R21 had a behavior problem due to diagnosis of PTSD but did not include the specific cause of the PTSD, what the behaviors were, or what R21's triggers were. On 2/22/24 at 8:31 AM, the social worker, other staff #1 (OS#1), was interviewed regarding cause and triggers of R21's PTSD. OS#1 stated, We never talked about what the triggers were, but smoking schedule changes would make him nervous . if meals were late, we assured him they were coming, he would calm down. If not able to reach his family, he would get upset. On 2/22/24 at 9:37 AM, registered nurse #2 (RN#2), who cared for R21, was interviewed regarding the cause and triggers of R21's PTSD. RN#2 stated that she did not know the specifics of his trauma, but family dynamics played a part. When questioned further, RN#2 stated that R21 was .mostly anxious and one day he thought a family member was a sniper outside his room. On 2/22/24 at 9:46 AM, the minimum data set (MDS) coordinator RN#1 was interviewed regarding R21's care plan for PTSD. RN#1 stated that she was not aware of the specific trauma or triggers for R21's PTSD and then stated, They should be on the care plan. On 2/22/24 at 12:40 PM, a meeting was held with the facility administrator and regional nurse consultants to inform them of the above findings and concerns. No additional information was provided. Based on observation, staff interview, and clinical record review, the facility failed to develop a care plan for three of twenty two residents. 1. Resident #49 (R49) was not care planned for the use of a hoyer lift (hydraulic equipment used to safely transfer residents). 2. R21 had an admitting diagnoses of PTSD (Post Traumatic Stress Disorder) and a care plan had not been developed. 3. R44 did not have a care plan for dental issues. The Findings Include: Diagnoses for R49 included; Acquired absence or right hip joint, osteoporosis, pathological left femur fracture, right knee replacement, and rheumatoid arthritis. The most current MDS (minimum data set - an assessment tool) was a quarterly assessment with an ARD (assessment reference date) of 1/11/24. R49 was assessed with a cognitive score of 9 out of 15, indicating moderately impaired cognition. Section GG Functional Abilities indicated R49 was impaired on all extremities and was totally dependant on staff with sit to stand and chair/bed to chair. On 2/20/24 at 12:17 PM, R49 was observed in a wheelchair with a hoyer lift sling underneath her. When asked about using a hoyer lift, R49 verbalized that staff use a hoyer for transfers from the bed to the chair, but sometimes staff are able to stand R49 up and pivot to the chair or bed. Review of R49 care plan did not indicate the use of a hoyer lift, the size of the sling needed, or the degree of assistance needed. On 2/21/24 at 1:53 PM, certified nursing assistant (CNA#1, assigned to R49) was interviewed. CNA #1 verbalized that R49 is transferred with the use of a hoyer lift and is assisted by 2 staff members when the hoyer lift is used. When asked how do the CNA's know which residents use a hoyer lift, and how many staff are needed for transfers, CNA #1 verbalized that the CNA's get their information from other CNA's or nurses. On 2/21/24 at 2:05 PM, registered nurse (RN #1, MDS coordinator) was interviewed regarding hoyer lift interventions on the care plan. RN #1 reviewed R49's care plan and verbalized having seen hoyer lift interventions being care planned at other facilities, but wasn't sure what the requirement is at this facility as only being employed for 4 weeks. On 2/21/24 at 2:08 PM, the director of nursing (DON) was interviewed. The DON reviewed R49's care plan and verbalized that R49 can assist with transfers at times, but the hoyer lift should be care planned. On 2/21/24 at 4:08 PM the above finding was presented to the DON and administrator. No other information was presented prior to exit conference on 2/22/24. 3. Resident #44 (R44) had no plan of care developed for dental problems related to having no natural teeth or R44's need for dentures. Resident #44 (R44) was admitted to the facility with diagnoses that included osteoarthritis, depressive disorder, Parkinson's disease, heart failure, and spinal stenosis. The minimum data set (MDS - an assessment tool), dated 1/18/24, assessed R44 as being cognitively intact. R44's clinical record documented an admission nursing assessment dated [DATE]. This assessment documented that R44 had no natural teeth and that R44's dentures that did not fit. R44's admission MDS dated [DATE] inaccurately listed the resident as having no dental problems and failed to reflect that the resident was edentulous. On 2/20/24 at 11:21 a.m., R44 was interviewed about quality of life/care in the facility. R44 stated that she had all teeth pulled prior to admission to the facility and was waiting for dentures. R44 demonstrated having no natural teeth and stated she was on a soft diet because she was unable to chew some food items. R44's plan of care (revised 1/31/24) included no problems, goals, and/or interventions regarding the resident's edentulous status or the need for dentures. On 2/21/24 at 1:55 p.m., the registered nurse MDS coordinator (RN #1) responsible for care planning was interviewed about R44's plan of care. RN #1 stated R44 was not assessed with any dental issues, that dental was not triggered on the MDS, and therefore no care plan for dental was developed. On 2/21/24 at 3:10 p.m., the director of nursing (DON) was interviewed about R44's dental status. The DON stated R44 did not have any teeth as they had been pulled in preparation for dentures. This finding was reviewed with the administrator, director of nursing, and nurse consultant during a meeting on 2/21/24 at 4:15 p.m., with no further information provided prior to the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to follow professional standards of nursing practice for one resident (Resident #22- R22) in a survey sample of 22 residents. The findings included: For R22, who refused lab work, the facility staff failed to notify the physician that the order was not able to be carried out. On 2/20/24 and 2/21/24, a clinical record review was conducted of R22's chart. This review revealed that on 1/26/24, the physician entered an order that read, LAB- Valproic Acid [Valproic acid level], CMP [complete metabolic panel], CBC [complete blood count], LFT [liver function tests] on [DATE] and July 26 every night shift every 6 month(s) starting on the 26th for 1 day(s). According to the treatment administration record, R22 refused the lab draw on 1/26/24. There was no documentation within the progress notes, nor elsewhere, that indicated the physician was made aware that the order for labs was unable to be carried out. On 2/21/24, during an end of day meeting, the facility administration was made aware of the above findings. On 2/22/24 at 8 a.m., another review of the progress notes revealed an entry dated 2/21/24 at 5:48 p.m., that read, Resident refused first set of labs. MD [medical doctor] notified. New orders to redraw labs. On 02/22/24 at 10:00 a.m., an interview was conducted with the assistant director of nursing (ADON). The ADON was asked to explain and describe the process when a resident refuses labs. The ADON said, When they refuse, we are supposed to notify the doctor to see if they want to order something else, update chart, and RP's [responsible party's] accordingly .[R22's name redacted] is a little more particular about who does his lab draws, he will allow an in-house nurse. We notified the doctor and got an order to redraw everything this Friday, when the nurse he will allow to draw them is working. When asked if the refusal was documented in the chart, the ADON confirmed that previously it was not. On 2/22/24, mid-morning, the Corporate Director of Clinical Services (CDCS) stated that the facility follows [NAME] and [NAME] Standards for nursing practice. According to [NAME] and [NAME], Fundamentals of Nursing, Eighth Edition, it read in part on page 302, . Common Negligent Acts . Failure to notify the health care provider of problems, failure to follow orders ., failure to follow policies and procedures . A review was conducted of the facility policy titled, Requesting, Refusing and/or Discontinuing Care or Treatment. The policy read in part, . 6. If a resident requests, discontinues or refuses care or treatment, the licensed nurse or appropriate interdisciplinary team member will meet with the resident to: a. determine why the resident is requesting, refusing, or discontinuing care or treatment; b. try to address the resident's concerns and discuss alternative options; and c. discuss the potential outcomes or consequences (positive and negative) of the resident's decision .13. The healthcare practitioner will be notified of refusal of treatment, in a time frame determined by the resident's condition and potential serious consequences of the request . No further information was provided.

2. For Resident #1 (R1), who required staff's assistance with activities of daily living (ADLs), the facility staff failed to provide showers. On 2/21/24, during a group resident council meeting R1 expressed concerns regarding the lack of showers. On 02/21/24 at 03:09 p.m., R1 was interviewed regarding showers. R1 said, showers are overlooked, if you get a shower, you are lucky, they are not every week. Showers are not just a luxury, they are a necessity, they act like it is a burden. R1 went on to say, I use a wash strap and glove, not a washcloth, so they need to wash me early in the morning so the wash strap and glove can be washed and brought back before laundry leaves. On 02/21/24 at 03:23 p.m., an interview was conducted with CNA #4. CNA #4 stated that showers are given twice weekly and are scheduled and on the CNA's assignment sheet. CNA #4 showed the surveyor the assignment sheet, which indicated R1 was scheduled to receive a shower on Wednesday and Saturdays, on the 11 p.m., to 7 a.m., shift. CNA #4 explained that showers are documented in the computer on the ADL (activities of daily living) for each resident to indicate if it was given or if the resident refused. On 02/21/24 at 03:26 p.m., an interview was conducted with other staff #5 (OS#5), who worked in laundry. OS#5 stated that he was aware R1 had a strap and glove that was used in the shower and when it came to laundry, he would wash it and immediately return it to the resident since it could not be put in the dryer. OS#5 said that it is not a problem, but it has only come to laundry for him to wash about 2 times since he has worked there. On 02/21/24 at 03:37 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated, Showers are at least twice a week and they document if they refuse. On 2/21/24, a review of R1's clinical record, to include ADL sheets revealed that from January 1, 2024-February 20, 2024, R1 did not receive a shower on 8 of their scheduled shower days. Review of the nursing notes revealed no documentation with regards to why showers were not given as scheduled. R1 had a quarterly MDS (minimum data set) (an assessment) completed 2/1/24, which indicated R1 had impaired range of motion of her upper and lower extremities on one side. R1 was depedent upon facility staff for assistance with bathing. On 2/21/24, in the afternoon end of day meeting, the facility administrator was made aware of the above findings. On the morning of 2/22/24, the facility administration provided the survey team with forms titled, Skin Care Alert for R1. The administrator stated that those forms were indicative of when R1 received showers. The form had the following directions: Complete this form daily during usual care, bath care and repositioning or per facility policy. Circle the location of any red, open, dry areas and/or other skin concerns on the diagram below. On the Skin Care Alert forms, it was noted that 3 of the forms were completed at 8 p.m., on two occasions and at 10 p.m., on one occasion. R1 was adamant that she is scheduled for showers early in the morning and if they are not offered in the morning she won't take it. On 2/22/24, an interview was conducted with the administrator, and she was asked where on the Skin Care Alert form indicated that R1 had been showered on the days the form was completed. The administrator confirmed that it was not indicated on the form, it was just their protocol that the form is completed when a shower is done. Review of the facility policy titled, Shower/Tub Bath, read in part, The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. General Guidelines: 1. Qualified nursing staff will provide a bed bath to the resident as needed. At a minimum, the resident will be offered at least 2 full baths or showers per week. No further information was provided. Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for two of twenty-two residents in the survey sample (Residents #1 and #3). The findings include: 1. Resident #3 (R3), assessed as needing help with personal hygiene, was observed with long, uneven fingernails. R3 was admitted to the facility with diagnoses that included diabetes, hypertension, chronic pain syndrome, ischemic heart disease, chronic kidney disease, vascular dementia, anemia, and anxiety. The minimum data set (MDS - assessment tool) dated 1/31/24 assessed R3 as cognitively intact and requiring help with self-care. On 2/20/24 at 3:00 p.m., R3 was observed seated in a wheelchair at the doorway of his room. R3 had long fingernails on both hands. The nails extended beyond R3's fingertips, with several nails having uneven/jagged edges. On 2/21/14 at 12:57 p.m., R3 was interviewed about his fingernails. R3 stated that his fingernails were long and needed to be cut. R3 stated, I'd like to have them [fingernails] clipped. On 2/21/14 at 12:58 p.m., certified nurses' aide (CNA #2) caring for R3 was interviewed about the long fingernails. CNA #2 stated she would have to check so see if it was ok to cut R3's nails. When asked if R3 needed help with cutting his fingernails, CNA #3 stated R3 was kind of independent but required assistance with bathing and personal care. On 2/21/24 at 1:01 p.m., the licensed practical nurse (LPN #1) caring for R3 was interviewed. LPN #1 stated that it was ok for the aides to cut R3's fingernails. When questioned further, LPN #1 stated nail care was usually performed as needed during baths and/or showers. LPN #1 stated R3 required assistance with personal care/hygiene. R3's plan of care (revised 2/9/24) documented the resident had ADL self-care deficits due to limited mobility and impaired balance. The plan of care included in interventions to maintain ADLs, .Check nail length and trim and clean on bath day and as necessary . This finding was reviewed with the administrator, director of nursing, and nurse consultant during a meeting on 2/21/24 at 4:15 p.m., with no further information provided prior to the end of the survey.

Based on observation, staff interview, and clinical record review, the facility failed to administer medication according to physician orders for 1 of 22 residents (Resident #27). The findings included: The facility staff failed to follow physician orders during administration of artificial tears for Resident #27 (R27). On 2/20/24 at 3:52 PM, during the task of medication administration, licensed practical nurse #3 (LPN#3) was observed administering one drop of artificial tears to the left eye of R27, with no artificial tears applied to the right eye. Review of R27's clinical record revealed an order (dated 1/29/24) for artificial tears ophthalmic solution, instill 1 drop in both eyes three times a day for eye lubrication, related to acute angle closure glaucoma. On 2/20/24 at 4:52 PM, when questioned about the order for artificial tears for R27, LPN #3 stated that the right eye drop was missed during med administration. On 2/22/24 at 12:40 PM, during the end of day meeting the facility administrator and regional nurse consultants were made aware of the above concern. No additional information was provided.

Based on observation, staff interview, and clinical record review, the facility failed to ensure parameters were put in place for supplemental oxygen for one of 22 residents. An oxygen order for resident #49 (R49) did not have a rate of delivery. The Findings Include: Accorning to the clinical record, diagnoses for R49 included Respiratory failure, asthma, chronic obstructive pulmonary disease, emphysema, and supplemental oxygen dependant. The most current MDS (minimum data set - an assessment tool) was a quarterly assessment with an ARD (assessment reference date) of 1/11/24. R49 was assessed with a cognitive score of 9 indicating moderately cognitively impaired. On 2/20/24 at 12:17 PM, R49 was observed with oxygen via nasal cannula being delivered at 2 liters per minute (LPM). When asked about the oxygen, R49 verbalized using it all the time. Review of R49's physician order for oxygen dated 11/23/23 and revised on 2/5/24 read Oxygen Continuous. There was no information regarding how much and what route to administer the oxygen. On 2/21/24 at 1:25 PM, registered nurse (RN #2 ) was interviewed. RN #2 reviewed R49's oxygen orders and verbalized that there should have been parameters set regarding the delivery of oxygen and would make the physician aware. On 2/21/24 at 4:08 PM, the above finding was presented to the administrator and director of nursing. No other information was presented prior to exit conference on 2/22/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and clinical record review the facility staff failed to identify the specific trauma or triggers regarding post-traumatic stress disorder (PTSD) for 1 of 22 residents in the survey sample (Resident #21). The findings included: The facility staff failed to identify and document the experiences that caused Resident #21 (R21)1 to develop PTSD or preferences to eliminate or mitigate triggers that may cause re-traumatization. Review of the clinical record revealed that R21 was admitted with diagnoses that include PTSD, Alzheimer's disease, schizophrenia, bipolar, anxiety, major depressive disorder and cerebral infarction. It was also documented that R21 was assessed on 12/30/23 as having moderate cognitive impairment. Review of R21's care plan, initiated 12/14/22 with a revision date of 5/19/23, revealed that R21 had a behavior problem due to diagnosis of PTSD but did not include the specific cause of the PTSD, what the behaviors were, or what triggers caused the PTSD. Review of R21's physician progress notes, dated 6/13/23, 7/18/23, 8/29/23 10/10/23 and 1/2/24, documented R21's history of PTSD but did not identify the specific trauma or triggers of the PTSD. Psychiatry notes from 8/23/23, 1/9/24, 1/23/24 and 2/13/24 were reviewed. The initial assessment dated [DATE] documented R21's history of PTSD. There was no documentation of the specific cause or triggers for R21's PTSD found in any of the notes. On 2/22/24 at 8:31 AM, the social worker, other staff #1 (OS#1) was interviewed regarding R21's cause and triggers of PTSD. OS#1 stated, We never talked about what the triggers were, but smoking schedule changes would make him nervous. If meals were late, we assured him they were coming, he would calm down. If not able to reach his family, he would get upset. On 2/22/24 at 9:37 AM, registered nurse #2 (RN#2) who cared for R21 was interviewed regarding the cause and triggers of his PTSD. RN#2 stated that she did not know the specifics of his trauma, but family dynamics played a part. RN#2 stated R21 was mostly anxious. On 2/22/24 at 9:46 AM, the minimum data set (MDS) coordinator RN#1 was interviewed regarding R21's care plan for PTSD. RN#1 stated she was not aware of the specific trauma or triggers for R21's PTSD and stated, they should be on the care plan. On 2/22/24 at 12:40 PM, during the end of day meeting the facility administrator and regional nurse consultants were made aware of the above concerns. No additional information was provided.

Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to provide social services to assist with obtaining glasses for 1 of 22 residents (Resident #32). The findings include: The facility staff failed to assist resident #32 (R32) with obtaining glasses that were prescribed on 12/13/23. Review of the clinical record revealed that R32 had diagnoses that included congestive heart failure, schizophrenia, chronic kidney disease, hypertension, depression and anxiety. It was also documented that R32 was assessed on 12/2/23 as cognitively intact. On 2/20/24 at 3:08 PM, an interview was conducted with R32, during which R32 voiced concerns that she had attended an appointment with an .eye doctor and had not received the glasses yet. Review of R32's clinical record documented an appointment with an optometrist on 12/13/23, in which R32 received a prescription for glasses. On 2/22/24 at 8:31 AM, the social worker, other staff #1 (OS#1) was interviewed regarding glasses for R32. OS#1 stated that R32 has no funds available and that R32 was .supposed to talk to her daughter about paying for the glasses. WHen questioned further, OS#1 stated that she .forgot to follow up. On 2/22/24 at 10:22 AM, the facility administrator and regional nurse consultant (OS#3) were interviewed regarding obtaining glasses for R32. The administrator stated that she did not remember being told about the glasses and stated that .normally the facility would just cover the cost. On 2/22/24 at 12:40 PM, during the end of day meeting the facility administrator and regional nurse consultants were made aware of the above concern. No additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, the facility staff failed to respond to pharmacy recommendations for 1 of 22 residents in the survey sample (Resident #9). The findings included: The facility staff failed to respond to a pharmacist recommendation to attempt a gradual dose reduction of Seroquel for Resident #9 (R9). Acording to the clinical record, R9 had diagnoses that included nontraumatic intracerebral hemorrhage, dementia, major depressive disorder, Alzheimer's disease, and anxiety disorder. The most current minimum data set (MDS - an assessment tool), an annual assessment dated [DATE], assessed R9 with severe cognitive impairment. Review of R9's clinical record documented a physician's order for Seroquel 100 mg tablet, give 1 tablet by mouth at bedtime that started on 11/25/22. Review of R9's psychiatric assessments, dated 9/22/23 and 12/20/23, documented the most recent attempt for a gradual dose reduction for Seroquel was on 8/14/22. On 1/18/24, the consulting pharmacist recommended a gradual dose reduction (GDR) of Seroquel. The pharmacist wrote: This resident has been taking Seroquel 100 mg at bedtime since (11/25/22) without a GDR. Could we attempt a dose reduction at this time to perhaps 75 mg at bedtime to verify this resident is on the lowest possible dose? If not, please indicate response below. No physician response was documented for this recommendation. On 2/22/24 at 11:09 AM, the director of nursing (DON) and the regional nurse consultant, other staff #4 (OS #4), were interviewed regarding R9. The DON stated that the medical doctor had deferred the dose reductions for psychiatric medications to psychiatric services. The DON stated that she .checks the pharmacist recommendation sheets and the psychiatric nurse practitioner documents in her notes if ongoing treatment is needed. Review of the facilities policy for Medication Regimen Review dated 8/2020 stated, The consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly . Recommendations are acted upon and documented by the facility staff and/or the prescriber. On 2/22/23 at 12:40 PM, during the end of the day meeting, the facility administrator and regional nurse consultants were made aware of the above concerns. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, and clinical record review, the facility staff failed to ensure one of 22 residents in the survey sample was free of unnecessary medications (Resident #9). The findings included: The facility staff failed to attempt a gradual dose reduction of Seroquel for Resident #9 (R9). According to the clinical record, R9 had diagnoses that included nontraumatic intracerebral hemorrhage, dementia, major depressive disorder, Alzheimer's disease and anxiety disorder. The most current minimum data set (MDS - an assessment tool), an annual assessment dated [DATE], assessed R9 with severe cognitive impairment. Review of R9's clinical record documented a physician's order for the antipsychotic Seroquel 100 mg tablet, give 1 tablet by mouth at bedtime that started on 11/25/22. Review of R9's psychiatric assessments dated 9/22/23 and 12/20/23 documented the last attempt for a gradual dose reduction for Seroquel was on 8/14/22. Psychiatric notes also documented nursing reports patient can be irritable at times, no aggression .No significant mood changes. Psychiatric documentation did not include any references to a gradual dose reduction (GDR) or that a reduction was contraindicated. On 1/18/24 the consulting pharmacist recommended a GDR of Seroquel. The pharmacist wrote: This resident has been taking Seroquel 100 mg at bedtime since 11/25/22 without a GDR. Could we attempt a dose reduction at this time to perhaps 75 mg at bedtime to verify this resident is on the lowest possible dose? If not, please indicate response below. No provider response was documented for this recommendation. The clinical record documented no attempted dose reduction for R9's Seroquel or clinical justification for not performing or attempting a reduced dose. On 2/22/23 at 11:06 AM, certified nursing assistant #4 (CNA #4), who regularly cared for R9, was interviewed regarding R9's behaviors. CNA #4 stated that R9 was easy going, verbal when he wants to be, pleasant, quiet, friendly and will swat at your hands at times while cleaning him, but after explaining what you are doing, he allows care. R9 was observed laying calmly in bed, but was verbally unresponsive to any questions, merely smiling. On 2/22/24 at 11:09 AM, the director of nursing (DON) and the regional nurse consultant, other staff #4 (OS #4) were interviewed regarding R9. The DON stated that the medical doctor had deferred the dose reductions for psychiatric medications to psychiatric services. The DON also stated that she .checks the pharmacist recommendation sheets and the psychiatric nurse practitioner documents in her notes if ongoing treatment is needed. On 2/22/23 at 12:40 PM, during the end of the day meeting the facility administrator and regional nurse consultants were made aware of the above findings. No further information was provided.

Based observation, facility documentation, and staff interview, the facility failed to accurately label open medication to ensure safe administration and storage. The Findings Include: The facility failed to ensure that a multi-dose vial of medication was labeled with a open date. On 2/21/24 at 11:16 a.m., an observation of the medication storage room was conducted on the nursing unit, in the presence of license practical nurse (LPN1), who provided access. An opened, multidose vial of the influenza vaccine was observed in the refrigerator. No open date was noted on the label. When questioned about this, LPN1 examined the medication, verbalized not seeing an opened date, and removed the medication from the refrigerator. On 2/21/24 at 11:30 a.m., when questioned further, LPN1 stated that an open date should be placed on the vial when medication is opened. A facility policy titled, Medication Storage, read in part, Medications requiring refrigeration must be stored in a refrigerator and medications must be labeled accordingly. On 2/21/24 at 4:05 p.m., the above information was presented to the Director of Nursing, Administrator, and to two Regional Nurse Consultants. No further information was provided prior to exit conference.

Based on staff interview and clinical record review, the facility staff failed to obtain physician ordered laboratory (Lab) services for one of 22 residents (Resident #38 - R38) in the survey sample; a CBC (Complete Blood Count) and A1C (Glycated Hemoglobin Test) were not collected as ordered for R38. The Findings Include: According to the clinical record, diagnoses for R38 included Diabetes, and kidney failure. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 1/19/24. R38 was assessed with a cognitive score of 6 out of 15, indicating moderately impaired cognition. Review of R38's physician order set documented an order, dated 6/24/23, for a CBC and A1C to be collected every three months on March 27th, June 27th, September 27th, and December 27th. Review of lab results did not evidence the lab was collected on December 27th, 2023. Review of R38's treatment administration record (TAR) for December showed a blank box (where a nurse would sign off that the order was completed) for December 27th. On 2/21/24 at 1:17 PM, an interview was conducted with registered nurse (RN #2) to explain the lab documentation. RN#2 reviewed the lab order, then reviewed the TAR, verbalizing that the lab was not signed off on the TAR. RN #2 verbalized being unable to find the results and stated intention to call the Lab. While on the phone, RN#2 stated that the lab verified that there were no results for that date, indicating the labs were not collected. RN #2 got off the telephone and verbalized that the labs were missed. On 2/21/24 at 4:08 PM, the above finding was presented to the administrator and director of nursing (DON). No other information was provided prior to exit conference on 2/22/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, facility staff interviews, and facility documentation review, the facility staff failed to maintain a safe, comfortable, and homelike environment on 1 of 4 nursing units and in the main dining room. The findings included: 1. On the 300 unit of the nursing facility, the facility staff failed to ensure a safe and homelike environment, affecting multiple residents. 1a. For resident #58 (R58), the facility failed to maintain the room furnishings of a bedside table that was in good operating condition, which resulted in an environment that was not homelike. On 2/20/24, in the late morning, it was observed that R58's bedside table was missing 2 of the 3 drawers. R58 was not in the room at the time of this observation. On 2/21/24 at 9:28 AM, R58's bedside table was noted to still have only 1 drawer, the other 2 were missing. When questioned, R58 reported that it had been like that for weeks. On 02/22/24 at 08:53 a.m., an interview was conducted with CNA #5. CNA #5 confirmed the surveyor's observation that R58's bedside table was missing 2 drawers. CNA #5 confirmed that the drawers had been like that for weeks and stated, I think since he was going home, they just decided to not fix it. During the above interview with CNA #5, the CNA confirmed that everyone has access to a system on the computer where they can put in maintenance work orders for items that need repairs. On 02/22/24 at 8:30 a.m., an interview was conducted with the maintenance director (Other Employee #6- OE #6). OE #6 said he was unaware of the cabinet and could immediately replace it with a spare one that he has out back of the facility. 1b. For the bathroom shared between four residents residing in rooms [ROOM NUMBERS], the baseboard left a large, exposed hole in the wall. On 2/20/24, in the late morning, during facility observations, it was noted that the bathroom which was shared among the four residents residing in rooms [ROOM NUMBERS], there was a rather large, exposed hole in the wall behind the toilet. On 2/21/24 at 9:30 a.m., the hole in the bathroom wall was still noted. On 2/22/24 at approximately 8:45 a.m., the shared bathroom between rooms [ROOM NUMBERS], was still noted with no repairs having been made. On 02/22/24 at 08:53 a.m., an interview was conducted with CNA #5. CNA #5 stated that everyone has access to a system on the computer where they can put in maintenance work orders for items that need repairs. On 02/22/24 at 8:30 a.m., an interview was conducted with the maintenance director (Other Employee #6- OE #6). OE #6 was shown the bathroom noted above. OE #6 said no one had made him aware of it. OE #6 said he would be able to make repairs which would require him cutting a piece of sheet rock to repair the hole and then he could re-glue the baseboard. 1c. For the bathroom shared between the four residents residing in rooms [ROOM NUMBERS], there was a dislodged access panel cover, which left a large, exposed hole in the wall, and cold air was coming into the bathroom as a result. On 2/20/24, in the late morning, during facility observations, it was noted that the bathroom which was shared among the four residents residing in rooms [ROOM NUMBERS], there was a rather large, exposed hole in the wall behind the toilet. On 2/21/24 at 9:30 a.m., the access panel in the bathroom wall was still noted to be out of place and unsecured. On 2/22/24 at approximately 8:50 a.m., the bathroom between rooms [ROOM NUMBERS] was still noted to have the access panel out of place. On 02/22/24 at 8:30 a.m., an interview was conducted with the maintenance director (Other Employee #6- OE #6). OE was shown the bathroom and stated he had not been aware of the problem. He made multiple attempts to put the access panel back in place but was not able to make immediate repairs and reported to the surveyor that he would have to come back to it. 2. In the main dining room, the facility staff failed to maintain an environment in good repair and homelike, due to the cove baseboard being damaged and exposing holes in the wall. On 2/20/24 at approximately 12 noon, during observation of the lunch meal, it was noted that on the far back wall of the dining room which adjoined the kitchen, the cove baseboard was damaged and left large, exposed holes in the wall. Throughout the remaining days of survey, 2/21/24 and 2/22/24, the above was noted with no repairs having been made. On 02/22/24 at 8:12 a.m., an interview was conducted with the maintenance director (Other Employee #6- OE #6). OE #6 explained that the facility uses an electronic system for maintenance work orders. Any staff member can access it at any computer in the facility, enter what needs repairs and it will send an alert directly to OE #6's phone. OE #6 was asked about preventive maintenance and facility rounds. OE #6 said, I do an audit once a week. When asked about the wall in the main dining room, the maintenance director said, with that wall, we are in the process of getting a renovation, so I am waiting to see what they are going to do. When asked, how long has the wall been like that? OE #6 said, It is an ongoing issue, the staff push the food carts against the wall, and it causes the damage. The current damage has been like this for multiple weeks and repairs are not being made due to the upcoming renovation of the room. On the morning of 2/22/24, a review was conducted of the current maintenance work orders since January 1, 2024. None of the identified areas noted above were listed in the work order system to notify maintenance of repairs being needed. On 2/22/24 at approximately 9 a.m., the facility administrator was made aware of the above concerns. The administrator confirmed that the facility was going to be undergoing renovations and this would include replacing all the furniture in the resident rooms. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility failed to review and revise the care plan for 2 of 22 residents (Resident #9 and #32) in the survey sample and failed to invite/involve 2 residents (Resident #6 and #25) in their care plan meeting. The findings included: 1. A review of Resident #9 (R9's) care plan dated 9/6/23 revealed that the care plan had not been revised to indicate a code status change from full code to Do Not Resuscitate (DNR). R9 had diagnoses that included nontraumatic intracerebral hemorrhage, dementia, atrial fibrillation, epilepsy, major depressive disorder, Alzheimer's disease and anxiety disorder. The most current minimum data set (MDS) was an annual assessment dated [DATE], which assessed R9 with severe cognitive impairment. Review of R9's clinical record revealed that R9's power of attorney signed a DNR form on 1/7/24 and the physician placed the DNR order on 1/8/24. R9's care plan, which was revised on 9/6/23, documented the resident's resuscitation status as full code and had not been revised with the change to DNR status. On 2/21/24 at 3:17 PM, the MDS coordinator, registered nurse #1 (RN#1) responsible for updating care plans was interviewed regarding R9's code status on the care plan. RN#1 stated that the care plan should have been updated 24-48 hours after the new order was received. RN#1 had no explanation as to why the care plan had not been updated. 2. R32's care plan initiated 8/17/23 had not been revised to indicate that a fluid restriction had been ordered. R32 had diagnoses that included congestive heart failure, chronic kidney disease, hypertension. The most current MDS (minimumdata set - the assessment tool) was a quarterly assessment dated [DATE], which assessed R32 as being cognitively intact. Review of R32's clinical record revealed a physician's order written on 2/5/24 for R32 to be placed on a 1500 ml fluid restriction per day. Review of R32's care plan dated 8/17/23 included no mention of the fluid restriction. Review of R32's medication administration record, treatment administration record, and activity of daily living record showed no documentation of a fluid restriction. On 2/21/24 at 3:17 PM, RN#1 was interviewed regarding updating and revising care plans. RN#1 stated that there were three opportunities to update a care plan: when the new order is written, during the morning meeting, and when the care plan was scheduled to be updated. When questioned about a change in orders, RN#1 stated the care plan should be updated within 24 to 48 hours after the order is received and is mostly based on nursing knowledge. When questioned about R32's fluid restriction, RN#1 agreed that the fluid restriction should have been added to the care plan but offered no explanation as to why it was not. On 2/21/24 at 3:35 PM, licensed practical nurse #2 (LPN#2), who was assigned to work with R32 on 2 /21/24, was interviewed regarding updating care plans. LPN#2 stated that both nurses and the MDS coordinator can update care plans. LPN#2 offered no explanation as to why R32's care plan had not been updated to include the order for the fluid restriction. On 2 22/24 at 8:25 AM, LPN #2 was interviewed regarding the documentation of fluid intake for residents on fluid restrictions. LPN #2 stated, We just give verbal report at each shift change, telling what the intake was for our shift. On 2/22/24 at 9:37 AM, registered nurse #2 (RN #2), who worked on the same unit that R32 resided, was questioned about documentation of fluid intake for residents on fluid restrictions. RN #2 stated that the intake is not documented, but verbal report is given at shift changes. On 2/22/24 at 12:40 PM, during the end of day meeting the facility administrator and regional nurse consultants were made aware of the above concerns. No additional information was provided. 3. For Resident #6 (R6), the facility staff failed to hold quarterly care plan meetings and involve the resident in the development and review of the plan of care. On 02/20/24 at 10:48 a.m., an interview was conducted with R6. During this interview, R6 expressed that he was not aware of care plan meetings and was not invited to attend them. On 2/21/24, a clinical record review was conducted., which revealed no information with regards to care plan meetings being held or R6 being invited to and involved in them. On 02/21/24 at 01:37 p.m., an interview was conducted with Other Employee #1, the Social Worker (SW). The SW stated that the MDS (minimum data set - an assessment tool) nurse, sends out a MDS calendar and SW notifies the resident and family. The SW said, If the resident is their own representative, I let them know, and the ones who have legal guardians, I send a letter or email them. When asked if this information was documented, the SW said, I usually call them. When asked about the timing of the call and if they are notified ahead of time, the SW said, I try my best but sometimes my printer goes down or they don't answer their phone. When asked again, how this information is documented, the SW pulled out a folder that dated back to the summer of 2023, stating, Yes, I try to document it but I am trying to get it put into the computer. Every time I will sit to do it, I get interrupted or now I am doing appointments and just haven't gotten to them. During the above interview, the SW was asked when R6's last care plan meeting was. The SW looked through the file and noted that the last meeting was held on 7/19/23. There was no evidence that R6 was invited to attend or involved in the development of the plan of care. The SW was asked to provide any evidence of when R6 had care plan meetings from January 2023-present. Later on the afternoon of 2/21/24, when asked to explain the purpose of the care plan meeting, the SW said, To talk about their progress, if they have any needs, if there are any concerns, ask about their weight, if they are compliant with dietary and taking their meds, if they still meet criteria for long-term care, find out what they are able to do, talk of discharge or request for discharge, we talk about that as well. When asked why is it important for the resident and/or their representative to be involved, the Social Worker said, for self-care and so they can be patient directed and they can let us know what they want and preferences. On 2/21/24 at 02:02 p.m., an interview was conducted with RN #1, who was the MDS coordinator. When asked about the care plan meetings, RN #1 said, They are held every 90 days based on the date due, typically every 90 days unless there is a significant change. Asked who attends the care plan meetings, RN#1 stated, To my knowledge, therapy, social services, dietary activities and families, the resident and if hospice, a representative from hospice. When asked why is it important for the resident and family to be involved, RN #1 said, I feel it is important because you want the care plan to represent and encourage the resident to have their autonomy and voice is important so they can be reflected. The MDS coordinator stated, I set the schedule and then she [the social worker] sends the invites to everyone. On 2/21/24, during an end of day meeting, the facility Administrator was made aware of the above findings. On the morning of 2/22/24, the SW was again interviewed. The SW provided the surveyor with evidence that R6 had care plan meetings held on 2/21/23, 4/17/23 and 7/19/23. The SW also provided a letter that indicated R6 would have a care plan meeting on 7/19/23. It did not indicate when the resident was given this letter or any specific details at to the time or location of the meeting. There was no evidence that R6 had been invited to the care plan meetings held in February or April. A review of the facility policy titled, Care Planning- Comprehensive Person-Centered was reviewed. The policy read in part, . 6. The resident/resident representative [s] is encouraged to participate in the development of and revisions to the resident's care plan. a. An explanation will be included in the resident's medical record if the participation of the resident/resident representative is determined not practicable for the development of the resident's care plan . 10. Every effort will be made to schedule care plan discussions at the best time of the day for the resident/resident representative . No additional information was provided. 4. For Resident #25 (R25), the facility staff failed to provide quarterly care plan meetings and involve the resident and a representative from nursing in the meetings. On 02/20/24 at 11:37 a.m., R25 stated they were unaware of when care plan meetings were held and were not involved in the development of their plan of care. On 2/21/24, a clinical record review was conducted. This review revealed no information with regards to care plan meetings being held or R25 being invited to and involved in them. On 02/21/24 at 01:37 p.m., an interview was conducted with Other Employee #1, the Social Worker (SW). The SW stated that the MDS (minimum data set - an assessment tool) nurse, sends out a MDS calendar, and then SW notifies the resident and family. The SW said, If the resident is their own representative, I let them know and the ones who have legal guardians I send a letter or email them. When asked if this information is documented, the SW said, I usually call them. When asked about the timing of the call and if they are notified ahead of time, the SW said, I try my best but sometimes my printer goes down or they don't answer their phone. When again asked how this information is documented, the SW pulled out a folder that dated back to the summer of 2023, and stated, Yes, I try to document it but I am trying to get it put into the computer. Every time I will sit to do it, I get interrupted or now I am doing appointments and just haven't gotten to them. The SW was asked to provide information of when R25 had care plan meetings from January 2023-present. During the interview on the afternoon of 2/21/24, the SW was asked to explain the purpose of the care plan meeting. The SW said, To talk about their progress, if they have any needs, if there are any concerns, ask about their weight, if they are complaint with dietary and taking their meds, if they still meet criteria for long-term care, find out what they are able to do, talk of discharge or request for discharge, we talk about that as well. When asked, why is it important for the resident and/or their representative to be involved? The Social Worker said, for self-care and so they can be patient directed and they can let us know what they want and preferences. On 2/21/24 at 02:02 p.m., an interview was conducted with RN #1, who was the MDS coordinator. RN #1 was asked about the care plan meetings. RN #1 said, They are held every 90 days based on the date due, typically every 90 days unless there is a significant change. RN #1 was asked who attends the care plan meetings, and she stated, To my knowledge therapy, social services, dietary activities and families, the resident and if hospice, a representative from hospice. When asked why is it important for the resident and family to be involved, RN #1 said, I feel it is important because you want the care plan to represent and encourage the resident to have their autonomy and voice is important so they can be reflected. The MDS coordinator stated, I set the schedule and then she [the social worker] sends the invites to everyone. On 2/21/24, during an end of day meeting, the facility Administrator was made aware of the above findings. On the morning of 2/22/24, the surveyor was again questioned, met with the SW again. The SW provided the surveyor with evidence that R25 had care plan meetings held on 2/2/23, 7/12/23 and 9/27/23. The SW also provided a letter that indicated R25 was invited to the care plan meetings on 7/12/23 and 9/27/23. However, during the meeting held in July, there were notes that R25 was suspected of having COVID and the meeting needed to be rescheduled. There was no evidence the meeting was rescheduled at a time the Resident could attend. There were notes to indicate the meeting had proceeded to take place without R25. The care plan meeting held 9/27/23, noted that R25 did not attend and there was no one present to represent nursing. There were notes that the meeting was held but needed to be rescheduled. There was no evidence of the meeting being rescheduled. A review of the facility policy titled, Care Planning- Comprehensive Person-Centered was reviewed. The policy read in part, . 6. The resident/resident representative [s] is encouraged to participate in the development of and revisions to the resident's care plan. a. An explanation will be included in the resident's medical record if the participation of the resident/resident representative is determined not practicable for the development of the resident's care plan . 10. Every effort will be made to schedule care plan discussions at the best time of the day for the resident/resident representative . No additional information was provided.

Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain an accurate clinical record for one resident (Resident #25- R25) in a survey sample of 22 residents. The findings included: For R25, the facility staff failed to maintain a complete and accurate clinical record with regards to documentation of when showers were provided. On the afternoon of 02/21/24, during interview with R25's roommate, R25 expressed concerns with not getting showers. On 2/21/24, a review of R25's clinical record was conducted, which included review of ADL (activities of daily living) records. Bathing documentation revealed that R25 had 4 occurrences of showers being provided in January 2024 and 2 showers being provided in the month of February 2024. On 02/21/24 at 03:23 p.m., an interview was conducted with Certified Nursing Assistant #4 (CNA #4), who stated that showers are given twice weekly and are scheduled, which is on the CNA's assignment sheet. CNA #4 showed the surveyor the assignment sheet, which indicated R1 was scheduled to receive a shower on Wednesdays and Saturdays, on the 11 p.m. to 7 a.m. shift. When questioned further, CNA #4 explained that showers are documented in the computer, in the ADL (activities of daily living) section, for each resident, to indicate that the shower was given or if the resident refused. On 02/22/24 at 08:57 a.m., an interview was conducted with CNA #5. CNA #5 reported that showers are given twice weekly in accordance with a shower schedule. On the morning of 2/22/24, the facility administrator was made aware of the above concerns with regards to R25's absent shower documentation. On 2/22/24, the administrator provided the survey team with Skin Care Alert forms for R25. Each of the forms had written across it, Showered, to indicate R25 had received a shower on those dates. The dates were, 1/2/24, 1/9/24, 1/16/24, 1/20/245, 2/6/24, 2/9/24, and 2/13/24. The administrator was asked if this is the facility's protocol for documenting showers and if the provided forms were included in the clinical record. The Corporate Director of Clinical Services (CDCS) agreed that it is the company's protocol that showers be documented on the ADL sheets and the skin care alert forms were not part of the clinical record. During the above interview with the administrator and CDCS, it was discussed that R25's clinical record was incomplete and inaccurate. They both stated they would speak with the director of nursing and follow-up with the surveyor. On 02/22/24 at 11:10 a.m., the Assistant Director of Nursing (ADON) stated the skin care alerts do indicate that they the staff gave R25's showers and it was a documentation issue. Review of the facility policy titled; Shower/Tub Bath was reviewed. The policy read, in part, . Documentation- 1. The date and time the shower/tub bath was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath. 3. All assessment data (e.g., any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath. 4. How the resident tolerated the shower/tub bath. 5. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. 6. The signature and title of the person recording the data . No additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide education and offer the COVID-19 spike vaccine booster for the 2023-2024 season, to 5 of 5 residents (Resident #6, 31, 3, 55, and 14) and 5 of 5 staff (RN #3, CNA #6, Other Employee #1, Other Employee #5, and Other Employee #7) sampled. The findings included: 1. For five residents (R6, R31, R3, R55 and R14), the facility staff failed to provide education and offer the COVID-19 spike vaccine booster for the 2023-2024 season. On 2/20/24 and 2/21/24, clinical record reviews were conducted of R6, R31, R3, R55 and R14's charts. This review revealed no evidence that any of the sampled residents had been offered the COVID-19 spike vaccine. On 02/21/24 at 10:11 a.m., an interview was conducted with the Director of Nursing (DON), who was the facility's Infection Preventionist (IP). During this interview, the DON accessed each of the sampled resident's charts, confirmed their immunization status, and then stated that none of them had been offered the COVID-19 spike vaccine. The review revealed the following: a. R6 had received the COVID primary series and a bivalent booster but had not received the spike vaccine. b. R31 had not received any COVID immunizations. When asked if R31 had been offered any of the COVID vaccines, the DON said, No. c. R3 had received the COVID primary series and bivalent booster. d. R55's records indicated he had not received any immunizations for COVID-19, and again the DON confirmed the facility had not offered any. e. R14 had received the COVID primary series immunization, as well as 2 booster doses, that included the bi-valent. R14 had not been offered or received the spike booster for the 2023-2024 season. During the above interview, the DON said, We can get our covid vaccines through our pharmacy now, I just found this out the other day. We haven't given the current boosters; we were supposed to get a local pharmacy to come but they don't do that. On 02/21/24 at 10:51 a.m., the CDCS (corporate director of clinical services) joined in the interview and stated, I just found out we can get the vaccine so we will start that process. On 2/21/24 at 4:00 p.m., the surveyor spoke with an employee working in the quality assurance department of the contracted pharmacy (Other Employee #9- OE #9), who reported that this has been the contracted pharmacy of this facility since 12/1/22. OE #9 also confirmed that the pharmacy has had available multi-dose vials and single dose vials of the 2023-2024 COVID spike immunization since November 20, 2023, when it was approved. OE #9 went on to say that prior to 11/20/23, it was available under the Emergency Authorization in place, and has always been available for the facility to order. OE #9 also confirmed that the pharmacy had not received any orders from this nursing facility for any of the COVID 2023-2024 spike immunization. Review of the facility policy titled; COVID-19 Vaccination for Residents was conducted. The policy read in part, . 1. Prior to admission, the facility will validate COVID-19 vaccination status. 2. Resident/resident representatives will be educated on: a. risk/benefits of COVID-19 vaccination. b. current CDC guidelines for vaccination of residents for COVID-19 and c. Symptoms, risks and benefits associated with the COVID-19 virus. 3. Residents will be encouraged to accept COVID-19 vaccinations in accordance with CDC guidance. 4. Residents will be screened prior to offering the vaccination for prior immunization, medical precautions, and contraindications as necessary for determining whether they are appropriate candidates for vaccination at any given time. 5. prior to the administration of the COVID-19 vaccine, consent will be obtained . and will be documented in the resident's medical record. 6. If the resident/resident representative declines administration of the COVID-19 vaccine, education will be provided, and declination form will be signed and placed in the resident's medical record . 7. COVID-19 vaccines will be administered according to the CDC, ACIP, FDA, and manufacturer guidelines. 8. Administration of the COVID-19 vaccination will be documented in the resident's medical record . The FDA (Food and Drug Administration) gives information about the 2023-2024 spike vaccine on their website, accessed at:https://www.fda.gov/vaccines-blood-biologics/coronavirus-covid-19-cber-regulated-biologics/novavax-covid-19-vaccine-adjuvanted. The guidance read, On October 3, 2023, the Food and Drug Administration amended the emergency use authorization (EUA) of Novavax COVID-19 Vaccine, Adjuvanted to include the 2023-2024 formula. The Novavax COVID-19 Vaccine, Adjuvanted, a monovalent vaccine, has been updated to include the spike protein from the SARS-CoV-2 Omicron variant lineage XBB.1.5 (2023-2024 formula). The Novavax COVID-19 Vaccine, Adjuvanted (Original monovalent) is no longer authorized for use in the United States. Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) is authorized for use in individuals [AGE] years of age and older as follows: Individuals previously vaccinated with any COVID-19 vaccine: one dose of Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) is administered at least 2 months after receipt of the last previous dose of an original monovalent (Original) or bivalent (Original and Omicron BA.4/BA.5) COVID-19 vaccine. Individuals not previously vaccinated with any COVID-19 vaccine: two doses of Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) are administered three weeks apart . On 2/21/24, during an end of day meeting the facility administration was made aware of the above findings. No additional information was received. 2. For 5 of 5 staff (RN #3, CNA #6, Other Employee #1, Other Employee #5, and Other Employee #7) sampled, the facility staff failed to provide education and information regarding the 2023-2024 COVID spike vaccine. On 2/21/24 at 10:11 a.m., an interview was conducted with the Director of Nursing (DON), who was also the facility's infection preventionist. When asked about COVID vaccines for employees, the DON said, HR [human resources] asks for immunization cards upon hire but it is not a requirement to work with [facility's corporate name redacted]. When asked if they were providing any education to staff regarding the COVID immunizations, the DON said, No. During the above interview, the DON said, We can get our covid vaccines through our pharmacy now, I just found this out the other day. We haven't given the current boosters; we were supposed to get a local pharmacy to come but they don't do that. On 2/21/24 at 2:38 p.m., an interview was conducted with the human resources manager (HRM), Employee #4. The employees selected for review were given to the HR manager and she pulled each employee's file. There was no information with regards to any of them being educated on or given information with regards to the 2023-2024 COVID booster. None of the employees selected had any record of having received the current COVID-booster. The HR manager was asked if the facility gives the employees any information on the COVID vaccine or offers the COVID vaccine. The HR manager said, I thought we moved away from that, so I am not too sure about that. On 2/21/24, in the afternoon, an interview was conducted with Other Employee #1, Other Employee #5, and Other Employee #7. All three stated that they had not received any information or education from the facility with regards to the current COVID booster. On 2/21/24, during an end of day meeting, the facility administration was made aware of the above findings. On 2/22/24, the facility staff provided the survey team with declination forms that Other Employee #5 and RN #3. Across the top of the form it read, 2023_2024 Staff Vaccine Acceptance/Declination Form. The form that RN #3 had signed was dated 10/27/22, which was prior to the 2023-2024 vaccine becoming available. The facility policy titled, Employee Infection and Vaccination Status was reviewed. The policy read in part, . Vaccinations: 1. Employees will be current with mandated vaccinations (i.e., TST, COVID-19) prior to performing direct resident care. 2. Employees will also be offered vaccinations per state or local agency policies/regulations. Employees will be provided with educational materials to make informed decisions for non-mandated vaccinations. If declined, a declination form will be completed and placed in the employee's health record . No additional information was provided.

Based on staff interview and clinical record review, the facility failed to ensure an accurate clinical record for one of 7 residents. Resident #1 (R1) had an inaccurate activities of daily living (ADL) record. The Findings Include: Diagnoses for R1 included; seizure disorder, traumatic brain disorder, dementia, anxiety, and bipolar. The most current MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 11/1/23. R1 was assessed with a score of 10 indicating moderately cognitive impairment. Review of R1's clinical record in regards to a complaint indicated there were no entries made on the ADL record on day shift on 12/25/23 for eating, meal intake, and bowel and bladder elimination. On 12/12/23 at 1:10 PM, CNA #1 was interviewed. CNA #1 verbalized working on 12/25/22 (Christmas day), which was busy because of low staffing, but did remember providing incontinence care to R1 around midmorning. CNA #1 said that while working on the hallway were R1 resides, R1's sister was observed helping to change R1. CNA #1 verbalized the taking over the task of providing R1 care for bladder incontinence and then changing R1's clothes. CNA #1 also verbalized that food trays were passed out by all available staff. CNA #1 verbalized the awareness of being responsible for documenting in the ADL report and that documentation might not have been completed because of being busy throughout the entire day. On 12/12/23 at 3:45 PM, R1 was interviewed and verbalized no concern regarding staff completing incontinence care. R1 stated that she is able to feed herself and didn't have concerns with the facility providing meals. On 12/13/23 at 9:00 AM, the above finding was presented to the director of nursing (DON). The DON reviewed the ADL record, agreed that the record had not been documented on, and verbalized that the record should be completed by the CNA's performing the task. No other information was presented prior to exit conference on 12/13/23.

Based on staff interview and facility document review, the facility failed to provide sufficient nursing staff. Daily staffing logs evidenced low nursing staff during Christmas 2022. The Findings Include: Review of daily working logs (actual hours worked) for nursing staff revealed on 12/25/22 (Christmas day) the working shift from 7:00 AM through 7:00 PM consisted of two nurses and one certified nurses aide (CNA). Review of the scheduled for 12/25/23 indicated there were supposed to be two nurses and three CNA's. The schedule or any other documentation did not evidence what the census was on 12/25/23 in this 60 bed facility. However, documentation did evidence nurse staffing prior to Christmas day and after Christmas day had three nurses and up to 5 CNA's working. On 12/12/23 at 1:10 AM, CNA #1 (identified as the CNA working on Christmas day) was interviewed. CNA #1 verbalized that Christmas was a busy day and between himself, the two nurses, and any other available staff members, residents were being taken care of including meals, incontinence care, and activities of daily living (ADL) needs. When asked about documentation regarding needs being met, such as feeding residents or providing ADL care, CNA #1 verbalized uncertainty as to if documentation had been completed but again verbalized that care was being provided. On 12/12/23 at 2:00 PM, license practical nurse (LPN #1, working on Christmas day) was interviewed. LPN #1 stated that the facility is always staffed with a minimum of 2 nurses and mostly has three but often has 4 CNA's working day shift. LPN #1 stated that because of call outs on Christmas, there were only 2 nurses and one CNA. LPN #1 was asked if there were any concerns of residents not getting needed cared. LPN #1 verbalized that residents were being cared for and it might have taken a little longer to get to everyone in regards to getting them dressed and out of bed, but staff pulled together to get the job done. On 12/13/23 9:00 AM, the director of nursing (DON) was interviewed. The DON verbalized that she or the administrator were not employed at the facility at that time but were somewhat aware of the situation. The DON presented documentation that two nurses and three CNA's were scheduled to work Christmas Day, but that all of the CNA's called out and the facility was able to get CNA #1 to cover the shift. The DON stated that since starting as DON, typically there are 4 to 5 CNA's and three nurses on the day shift and if there is a call out then staff are asked to stay over or split a shift, but if that does not work, then phone calls are placed to find any other staff able to come in. The DON stated that if there are no other staff to come in, then the unit manager, herself (DON), or another manager will cover that shift. The DON agreed that there should have been more staff working that day and verbalized that one CNA and two nurses was not ideal for the workload, but is not common practice for the facility. Grievance logs and resident council minutes along with resident interviews and resident record reviews were reviewed for this time period and did not evidence concerns regarding residents not receiving care. On 12/13/23 at 11:15 AM, the above finding was presented to the administrator, DON, and regional nurse consultant. The administrator agreed staffing had not been ideal and probably was not sufficient for Christmas Day, but felt that it was an isolated case. No other information was presented prior to exit on 12/13/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review and facility document review, the facility staff failed to assess one of eighteen (18) residents for self-adminstration of medications, Resident #31. Resident #31 was observed with an albuterol inhaler at her bedside for self administration as needed. Resident #31 had not been assessed by the interdisciplinary team to ensure safe usage of the inhaler. Findings were: Resident #31 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: Fibromyalgia, depression, respiratory disorder, and chronic ischemic heart disease. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 08/19/2021, assessed Resident #31 as cognitively intact with a summary score of 15. On 10/05/2021 at approximately 8:00 a.m., Resident #31 was observed sitting on her bed. She was wearing oxygen via a nasal cannula at 3 liters per minute. Resident #31 was interviewed about life at the facility and was asked about her oxygen. She stated, I got pneumonia a while back. I didn't wear it before then. Now I get short of breath when I take it off and to walk to the bathroom. My oxygen sats drop .sometimes I wheeze, that's why I have this. Resident #31 held up an albuterol inhaler that was laying on her bed. She stated, The doctor told me to keep it here at my bedside so that's where it is .I use it when I am short of breath or wheezing. Resident #31 was asked how often she used her inhaler. She stated, Whenever I need it .he [her doctor] said I can use it every four hours if I need to. Sometimes it's four hours, sometimes it's longer, sometimes if I'm wheezing I might use it a little before the four hours is up. Resident #31 was asked if she had to get one of the staff to come and help her with the inhaler when she used it or watch her use it. She stated, No, I do it myself, I don't need anybody to help me. She was asked if she had used an inhaler at home or prior to having pneumonia. She stated, No, I never had any problems breathing until then. The clinical record was reviewed at approximately 11:00 a.m. The physician order sheet contained the following order dated 06/09/2021: VENTOLIN [albuterol] HFA DOSE COUNTER 200 INH 90MCG 2 puff inhale orally every 4 hours as needed for Shortness of breath. May keep at bedside per MD. There was no assessment by the interdisciplinary team for safe self administration of the inhaler observed in the clinical record. During an end of the day meeting on 10/05/2021 at approximately 5:30 p.m., with the DON (director of nursing) and the corporate nurse consultant the above information was discussed. The DON was asked what was expected to be in place if a resident was keeping medication at her bedside for self administration. She stated, There should be an assessment, a doctor's order, and it should be on the care plan .it should be in the clinical record. The DON stated she would look to see what she could find. On 10/06/2021 at approximately 9:00 a.m., the DON provided information regarding Resident #31. She stated, She did not have an assessment, we did one this morning. A copy of the facility policy for self administration of medications was requested and received. Per the facility policy, Self-Administration of Medication at Bedside: .Criteria must be met to determine if a resident is both mentally and physically capable of self-administering medication and to keep accurate documentation of these actions Complete Self-administration of Medications Evaluation. The Interdisciplinary Team will review the evaluation and will document .approval granted must be checked yes or no . No further information was received prior to the exit conference on 10/06/2021.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review, the facility staff failed to ensure a safe, operational bed for one of eighteen residents in the survey sample, Resident #11. Resident #11 was in a bed with no functional controls to raise the head, foot or height of the bed. The findings include: Resident #11 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #11 included Alzheimer's, hypertension, dementia with behaviors, protein-calorie malnutrition, history of small intestine infarction, dysphagia and urinary retention. The minimum data set (MDS) dated [DATE] assessed Resident #11 with severely impaired cognitive skills. On 10/5/21 at 11:48 a.m., accompanied by a hospice registered nurse (RN #1), Resident #11 was observed in bed. The head of the bed was raised approximately 30 degrees. RN#1 repositioned the resident for a dressing change and stated the resident's bed did not work. RN #1 stated the bed controls were broken and she was unable to move the resident's bed up/down or raise/lower the head of the bed. RN #1 stated she reported the broken bed to maintenance last Thursday (9/30/21) and the bed had not been fixed. RN #1 stated, They could have called me. We would have gotten a bed. RN #1 stated she was unable to reposition the bed when turning the resident and she was concerned the bed height was not as low as possible. RN #1 stated the resident was a fall risk and had experienced previous falls from the bed. RN #1 demonstrated that the remote did not work. RN #1 stated she was also concerned about the inability to raise the head of the bed for meals and/or resident comfort. On 10/5/21 at 3:40 p.m., the certified nurses' aide (CNA #1) that routinely cared for Resident #11 was interviewed about the bed controls. CNA #1 stated there was a short in the wiring to the bed remote. CNA #1 picked up the remote and there was tape around the wiring near the handset. CNA #1 stated he was aware the bed controls were not working but he did not know how long the bed had been out of service. CNA #1 stated he could move the wiring around and sometimes get the bed to move. On 10/5/21 at 3:43 p.m., the maintenance director (other staff #1) was interviewed about Resident #11's bed. The maintenance director stated the controls on the bed did not work. The maintenance director stated Resident #11's bed was one of several that were donated to the facility and he was unable to get repair parts for the bed or the controls. The maintenance director stated he was told about the broken bed last Friday (10/1/21) and he thought hospice was going to replace the bed. The maintenance director stated he currently had no extra or replacement beds in the facility. Resident #11's plan of care (revised 8/31/21) listed the resident required the extensive assistance of one to two people for bed mobility, transfers and activities of daily living including dressing and incontinence care and was at risk for falls. This finding was reviewed with the director of nursing and regional director of clinical services on 10/5/21 at 5:35 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review and facility document review, the facility staff failed to ensure an injury of unknown origin was reported to the State Survey Agency and adult protective services for 1 of 18 in the survey sample, Resident #48. Resident #48 was found with a medium size gash to the back of his head of unknown origin requiring 5 staples. The findings include: Resident #48 was admitted to the facility on [DATE] with diagnoses that included infarction, hemiplegia and hemiparesis affecting right dominant side, muscle weakness, dementia with behavioral disturbance, hyperlipidemia, anxiety, hypertension, depression, dysphasia and psychosis. The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #48 as severely cognitively impaired for daily decision making with a score of 3 out of 15. Under Section G Functional Status the MDS assessed Resident #48 has requiring limited assistance with one person physical assistance for transfers, ambulation, eating and locomotion; extensive assistance with one person physical assistance for toileting, bed mobility, personal hygiene, and bathing. Under Section J1900. - Falls, the MDS assessed Resident #48 has having one fall with injury since the previous assessment. Resident #48's clinical record was reviewed on 10/05/2021. Observed within the progress notes was the following: 9/25/2021 09:00 Writer was alerted by CNA (certified nursing assistant) that resident had blood on his pillow. Upon assessment a medium size gash was noted to the back of his head. Resident stated I did not fall, the door hit me. [Medical Director] notified and orders were given to send resident to [Hospital] for sutures and evaluation. Resident had no change in LOC (lost of consciousness) . [Ambulance Service] transported resident via stretcher. Facesheet, med orders, bed hold, and care plan all sent with resident. 09/25/2021 19:25 (7:25 p.m.) Resident arrived back to facility around 1530 (3:30 p.m.) via non emergency ambulance on stretcher. He has 5 staples to the laceration on the back of his head. PRN (as needed) Tylenol given due to c/o (complaints of) pain. MD and ADON (assistant director of nursing) aware of his arrival. Staples to be removed in 5 days per MD. resident took evening meds w/o (without) complications. Will continue to monitor. Observed in the clinical record was a Change in Condition (SBAR) form dated 09/25/2021 that documented the same information noted in the 9/25/2021 9:00 a.m. progress note and docmented notification to Resident #48's guardian. On 10/05/2021 at 5:34 p.m. during a meeting with the director of nursing (DON) and corporate consultant the above information was discussed. The DON was asked if the information was reported to the state agency and for the investigation. On 10/06/2021 at 9:36 a.m., the assistant director of nursing (RN #2) was interviewed regarding the incident. RN #2 was asked if there was an initial investigation and if the fall was reported to the state agency. RN #2 stated, no, I had worked a double shift and had just got home when the licensed practical nurse (LPN) called and notified me of the incident. When I returned to work I didn't complete investigation or notify the state agency. I know that's not a valid reason not to complete the investigation. The LPN stated she had notified the MD (medical director) and completed the SBAR (change of condition) form and sent [Resident #48] to the ER (emergency room) per MD orders. RN #2 was asked if it was ever determined how Resident #48 sustained the injury. RN #2 stated, no, [Resident #48] is constantly moving. We have to monitor him because he attempts to walk and/or transfer himself alone and he is a fall risk. During my shift he had a good day and didn't have any falls or any incidents. On 10/06/2021 at 10:25 a.m. the director of nursing (DON) was interviewed regarding the injury sustained by Resident #48. The DON stated, no the incident was not reported to the state agency. I am in the process of reporting it today. The DON was asked why incident was not reported. The DON stated, I apologize I was not here and it got overlooked. As soon as it was brought to my attention I started the process . The DON was asked if she and/or the administrator were notified of the incident. The DON stated no, I was out of work on sick leave due to shoulder surgery and unfortunately the administrator went out on sick leave for COVID. I feel like my staff did what they were supposed to regarding assessing the resident and reporting it the ADON and MD, who gave orders to send the resident to the ER. However, the ADON failed to complete the additional steps to notify the state agency and start and complete the investigation. The DON was asked to provide the facility's abuse policy. A review of the facility policy titled Abuse, Neglect, Exploitation & Misappropriation (Rev. 11/28/2017) documented the following: 7. Reporting/Response - Any employee contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately, but no later than 2 hors after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator and to other officials with the State law. In the absence of the Executive Director, the Director of Nursing is the designated abuse coordinator. Once an allegation of abuse is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations, including notification of Law Enforcement if a reasonable suspicion of crime has occurred. Facility staff should be aware of and comply with their individual requirements and responsibilities for reporting as required by law . Review of Report: Report all results of all investigations to the Executive Director or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken The Abuse Coordinator of The Company will refer any or all incidents and reports of resident abuse to the appropriate state agencies . On 10/05/2021 at 2:50 p.m., the above information was discussed during a meeting with the DON and Corporate consultant. The DON provided copies of the facility reported incident (FRI) dated 10/6/2021 sent to the state agency and the witness statements. No other information was provided to the survey team prior to exit on 10/06/2021 at 5:15 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview the facility staff failed to accurately completed a PASARR (Preadmission screening) for one of eighteen residents in the survey sample, Resident #46. Findings were: Resident #46 was admitted to the facility on [DATE]. His diagnoses included but were not limited to: Schizophrenia, dementia with behavioral disturbance, alcohol abuse, chronic viral hepatitis, and post traumatic stress syndrome. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 09/09/2021. Resident #46 was assessed as cognitively intact with a summary score of 15. Resident #46's clinical record was reviewed on 10/05/2021 at approximately 3:00 p.m. There was no PASARR observed in the clinical record. During an end of the day meeting on 10/05/2021 at approximately 5:30 p.m., with the DON (director of nursing) and the corporate nurse consultant, the above information was discussed. The DON stated that she would locate the PASARR. The copy of a PASARR dated 11/26/2018 was presented on 10/06/2021 at approximately 8:00 a.m. The PASARR did not list any mental disorder diagnoses for Resident #46. Resident #46's medical record documented multiple mental illness diagnoses including but not limited to: Schizophrenia, bipolar disorder, major depressive disorder, and post traumatic stress syndrome. The PASARR was shown to the DON on 10/06/2021 at approximately 9:00 a.m., and she was asked who had completed the document. She observed the signature and stated, I'm not sure who that was. It was pointed out to her that the information on the document was not reflective of the diagnoses listed on Resident #46's clinical record. She stated, I will have to look into that. No further information was received prior to the exit conference on 10/06/2021.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and clincial record review, the facility staff failed to review and revise a comprehensive care plan for 1 of 18 in the survey sample, Resident #48. Resident #48's care plan was not revised for falls, including an injury of unknown origin. The findings include: Resident #48 was admitted to the facility on [DATE] with diagnoses that included infarction, hemiplegia and hemiparesis affecting right dominant side, muscle weakness, dementia with behavioral disturbance, hyperlipidemia, anxiety, hypertension, depression, dysphasia and psychosis. The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #48 as severely cognitively impaired for daily decision making with a score of 3 out of 15. Under Section G Functional Status the MDS assessed Resident #48 has requiring limited assistance with one person physical assistance for transfers, ambulation, eating and locomotion; extensive assistance with one person physical assistance for toileting, bed mobility, personal hygiene, and bathing. Under Section J1900. - Falls, the MDS assessed Resident #48 has having one fall with injury since the previous assessment. Resident #48's clinical record was reviewed on 10/05/2021. Observed within the progress notes was the following: 8/21/2021 18:14 (6:14 p.m.) . Resident s/p (status post) fall day 1 of 3. No pain or distress noted from fall. Resident up in w/c (wheelchair) during shift, at times attempting to walk behind w/c). Resident redirect and assisted back into w/c for safety purposes. No bruising or open areas related to fall noted at this time. 8/23/21 11:25 Fall Meeting Note: Resident observed sitting on the floor by the bedside unable to let staff know what happened due to cognition. Increase in behaviors and unable to be redirected. New intervention Frequent monitoring to ensure safety. MD/RP aware. 8/23/21 12:02 he also had a fall later in afternoon, found on floor up against his drawers. No injuries, no c/o (complaints of) pain, ROM (range of motion) intact. new intervention: Ensure appropriate footwear. MD/RP (responsible party) aware of 2nd fall. 9/13/2021 15:39 (3:39 p.m.) . Resident noted sitting on floor in room. Assisted back into bed. No c/o pain or distress. No skin issues noted. Resident placed on Q (every) 15 min checks, encouraged to use call bell for assistance. Message left for guardian ad litem. MD (medical director) and DON (director of nursing) aware. 9/25/2021 09:00 . Writer was alerted by CNA (certified nursing assistant) that resident had blood on his pillow. Upon assessment a medium size gash was noted to the back of his head. Resident stated I did not fall, the door hit me. [Medical Director] notified and orders were given to send resident to [Hospital] for sutures and evaluation. Resident had no change in LOC (lost of consciousness) . [Ambulance Service] transported resident via stretcher. Facesheet, med orders, bed hold, and care plan all sent with resident. 09/25/2021 19:25 (7:25 p.m.) . Resident arrived back to facility around 1530 (3:30 p.m.) via non emergency ambulance on stretcher. He has 5 staples to the laceration on the back of his head. PRN (as needed) Tylenol given due to c/o pain. MD and ADON (assistant director of nursing) aware of his arrival. Staples to be removed in 5 days per MD. resident took evening meds w/o complications. Will continue to monitor. The clinical record included fall evaluations completed on 8/21/21 and 9/13/2021, both which assessed Resident #48 has a high risk for falls. The 8/21/2021 fall evaluation assessed a score of 65, with interventions of non-skid foot wear and ensuring the call bell was in reach. The 9/13/2021 fall evaluation assessed a score of 80 with an intervention of 15 minute checks. A review of Resident #48's care plans did not include the falls from 08/21/21 and 9/13/21, or the injury of unknown origin on 9/25/21. The care plan did not include the intervention of 15 minute checks. On 10/05/2021 at 5:34 p.m., the above information was discussed during a meeting with the director of nursing (DON) and corporate consultant. The DON was asked who was responsible for updating the care plans. The DON stated the MDS (minimum data set) coordinator nurse was responsible for updating care plans, however she was out sick at this time. The DON was asked how often was Resident #48 monitored. The DON stated, it can vary every 15, every 30 minutes, it just all depends on the particular resident. The DON stated she would review the record and follow-up. On 10/06/2021 at 8:51 a.m., the DON was interviewed regarding the care plans not being updated. The DON stated the MDS coordinator should have updated the care plans. No other information was provided to the survey team prior to exit on 10/06/2021 at 5:15 a.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to perform a pressure ulcer dressing change in a manner to prevent infection for one of eighteen residents in the survey sample, Resident #11. A nurse failed to perform hand hygiene and gloves changes during a dressing change to Resident #11's pressure ulcer. The findings include: Resident #11 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #11 included Alzheimer's, hypertension, dementia with behaviors, protein-calorie malnutrition, history of small intestine infarction, dysphagia and urinary retention. The minimum data set (MDS) dated [DATE] assessed Resident #11 with severely impaired cognitive skills. Resident #11's clinical record documented physician orders dated 9/14/21 with instructions to cleanse the wound, pat dry, apply Santyl ointment and alginate foam dressing daily for treatment of the right gluteal fold pressure ulcer. On 10/5/21 at 11:48 a.m., hospice registered nurse (RN) #1 was observed performing a dressing change to Resident #11's right gluteal fold pressure ulcer. RN #1 entered the room with supplies and without prior hand hygiene, put on clean gloves. RN #1 positioned supplies on the over-bed table, pulled down bed covers and assisted the resident to position on her left side in bed. RN #1 removed the soiled dressing and without removing gloves or performing hand hygiene, proceeded to cleanse the wound with cleanser/gauze. After patting the wound dry with gauze, RN #1 applied Santyl ointment to the wound bed with a cotton-tipped applicator. RN #1 placed the new dressing on the bed, wrote the date and her initials on the dressing and then applied the dressing over the wound. Without removing gloves or performing hand hygiene, RN #1 repositioned the resident in bed and pulled covers over the resident. RN #1 discarded used supplies, removed gloves and then washed her hands prior to exiting the room. On 10/5/21 at 12:00 p.m., RN #1 was asked about glove changes and hand hygiene after removing the soiled dressing. RN #1 stated, We don't do that. On 10/6/21 at 9:03 a.m., the director of nursing (DON) was interviewed about the observed dressing change for Resident #11's pressure ulcer. The DON stated hand hygiene was supposed to be performed prior to any dressing change and glove changes with additional hand hygiene after removing a dirty dressing. The DON stated hand sanitizer was acceptable as long as hands were not visibly dirty. The DON stated the hospice nurses were expected to follow the facility's infection control protocols during dressing changes. The DON stated, They [hospice] should abide by our standards. The facility's policy titled Hand Hygiene (revised 2/5/21) documented, The CDC [Centers for Disease Control and Prevention] defines hand hygiene as cleaning your hands by using either handwashing (washing with soap and water), antiseptic hand wash, or antiseptic hand rubs (i.e., alcohol-based sanitizer including foam or gel) .Purpose: To reduce the spread of germs in the healthcare setting . This policy documented that hand hygiene should be performed, .before initiating a clean procedure .Before and after patient care .After contact with blood, body fluids, or excretions, mucous membranes, non-intact skin, or wound dressings .When hands are moved from a contaminated-body site to a clean body site during patient care .After glove removal . The Lippincott Manual of Nursing Practice 11th edition on page 843 documents concerning infection prevention, Hand hygiene is the single most recommended measure to reduce the risks of transmitting microorganisms .Hand hygiene should be performed between patient contacts; after contact with blood, body fluids, secretions, excretions, and contaminated equipment or articles; before donning and after removing gloves is vital for infection control. It may be necessary to clean hands between tasks on the same patient to prevent cross-contamination of different body sites . (1) This finding was reviewed with the DON and regional director of clinical services on 10/5/21 at 5:35 p.m. (1) [NAME], [NAME] M. Lippincott Manual of Nursing Practice. Philadelphia: Wolters Kluwer Health/[NAME] & [NAME], 2019.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, the facility staff failed follow infection control practices with placement of urinary catheter bag for one of eighteen residents in the survey sample, Resident #11. Resident #11's catheter bag was observed in the floor beside the resident's bed. The findings include: Resident #11 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #11 included Alzheimer's, hypertension, dementia with behaviors, protein-calorie malnutrition, history of small intestine infarction, dysphagia and urinary retention. The minimum data set (MDS) dated [DATE] assessed Resident #11 with severely impaired cognitive skills.On 10/5/21 at 8:50 a.m., Resident #11 was observed in bed. The resident's urinary catheter bag was in the floor beside the bed on the window side of the room. On 10/5/21 at 10:51 a.m., Resident #11's urine collection bag was again observed in the floor beside the bed. On 10/5/21 at 11:48 a.m., accompanied by hospice registered nurse (RN #1), Resident #11's urinary catheter bag was observed clipped to the bottom sheet on the resident's bed. RN #1 was interviewed at this time about the catheter bag previously in the floor. RN #1 stated she found the bag in the floor when she came in to assess the resident. RN #1 stated she did not find a hook or place to hang the bag so she clipped it to the bottom sheet to get it off the floor. On 10/6/21 at 9:08 a.m., the director of nursing (DON) was interviewed about the catheter bag in the floor. The DON stated the urine collection bag was not supposed to be in the floor and was supposed to be in a privacy bag hanging from the bed rail. On 10/6/21 at 9:36 a.m., the licensed practical nurse (LPN #1) routinely caring for Resident #11 was interviewed about the catheter bag. LPN #1 stated the catheter bag was supposed to be hanging from the bed rail and not in the floor. LPN #1 stated she was not aware of an issue with hanging the bag and she had seen the bag hanging from the bed on previous days. The facility's policy titled Catheter Care, Urinary (revised 9/5/17) documented steps for cleansing/care of the catheter tubing that included, .Remove catheter securement device while maintain connection with drainage tube .Wash perineal area .Rinse well and dry .Clean Catheter tubing with soap and water .Rinse well .Reattach catheter securement device .Return equipment to proper place . These findings were reviewed with the DON and regional director of clinical services on 10/6/21 at 2:50 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility documentation review, the facility staff failed to administer the COVID vaccine in a timely manner to one of 18 residents, Resident #27. Resident #27's Responsible Party consented to administration of the COVID vaccine on 06/04/2021, the vaccine was not given until 09/30/2021. Findings were: Resident #27 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: hypertension, paraplegia, mild-protein-calorie malnutrition, adult failure to thrive, gastro-esophageal reflux disease (GERD), depression, and dementia with behavioral disturbance. The most recent minimum data set (MDS) with an ARD (assessment reference date) of 08/09/2021 was an annual assessment. Resident #27 was assessed as has having long and short term memory problems with continuous inattention and behaviors including delusions, rejection of care and behaviors towards others. Resident #27's clinical record was reviewed on 10/06/2021 at approximately 10:30 a.m. Observed in the progress note section was the following entry: 06/04/2021 12:01 [p.m.] Spoke with residents RP [responsible party] .regarding the covid 19 vaccine. Risks and benefits education discussed at this time. Consent received to provide either [NAME] or Moderna vaccine. There was no further documentation in the clinical record regarding administration of the vaccine. The MARS (medication administration records) for June, July, August, September, and October were reviewed. There were no entries regarding the administration of the COVID 19 vaccine. The DON was interviewed at approximately 11:30 a.m. regarding whether or not Resident #27 had received the COVID vaccine per her RP's request. The DON stated that she would check with the ADON (assistant director of nursing) and see what she could find. At 11:55 a.m., an interview was conducted with the DON and the ADON. The ADON stated that the resident had refused the vaccine in June when he attempted to give it to her and again in July. He stated, I actually gave it to her last week. The DON and the ADON were told that there was no documentation in the clinical record on the MAR or in the progress notes that the vaccine had been administered. The ADON stated, I have that in my binder. At approximately 2:45 p.m., the ADON presented a handwritten verbal order from the physician for the COVID 19 vaccine: 9/30/2021 @1920 [7:20 p.m.] Administer 1st dose of Pfizer Covid Vaccine 0.3 ml-IM today Pfizer Lot: (lot number) Exp [expires]: 11/30/2021 RBTO [read back telephone order] (followed by the physician and ADON's name). The order was not signed by the physician nor was the order noted indicating the vaccine had been administered as ordered. The ADON also presented a COVID-19 VACCINE INFORMATION AND CONSENT FORM dated 09/30/2021 and signed by the resident. The Question Have you ever received a dose of COVID -19 vaccine? was marked as No. Underneath that answer the above mentioned vaccine lot number and expiration date were written in. The ADON was asked why the vaccine was not given in June when the RP requested it. He stated, At that time the pharmacy preferred that we have ten vaccines to give before we requested it .the vial is multidose and that kept it from being wasted. He presented a COVID-19 Vaccine Order Form dated 06/23/2021 with Resident # 27's name and nine other names on it. We got the vaccine then, but she refused to take it. He was asked where that was documented. He stated, That wasn't a choice on the form .she refused again in August. He presented a Vaccine Intake Form with Resident #27's name at the top was handwritten Refused 8-11-21. The ADON was asked if there was a consent form that the resident or RP had signed indicating that the vaccine had been refused in August. He stated, We didn't have that choice on the form at the time. The clinical record was again reviewed for evidence that the vaccine had been offered/refused/given. No documentation was observed. The facility policy, COVID-19 Vaccine was obtained and reviewed. Per the facility policy: Documenting COVID -19 Vaccine-Review consent with the staff, resident/resident representative .obtain signature indicating accept of declination .documentation includes, but is not limited to: whether the resident/representative consented or declined vaccine. If consented and administered: Vaccine manufacturers name, dose, location, lot number and expiration date, date of administration, resident monitoring for 72 hours. If declined .reason for declination: Contradiction, refusal, previously obtained outside the center . A meeting was held on 10/06/2021 at 3:10 p.m., with the DON and corporate nurse consultant. The DON was asked about the handwritten order. She stated, That is just the order, it should be noted that it was done and it is not .the order should also be in (name of electronic record), not on paper. She was asked if the electronic system had been down on the day the order was taken. She stated, No, and it should be on the MAR .after the injection we should be monitoring for signs and symptoms of reaction for 3 days, documenting where given the vaccine was given, the type, lot number, expiration date, all of the information. It should also be on the immunization screen in the system. She was told that the Immunization screen still said SARS-COV-2 (COVID-19) (Dose 1) Consent Refused. She stated, That should have been done when it was given .we don't have anything documenting why it wasn't done when requested by the RP or about when it was given. No further information was obtained prior to the exit conference on 10/06/2021.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review and facility document review the facility staff failed to implement their abuse prevention policies regarding promptly reporting an injury of unknown origin to the state agency for 1 for 18 in the survey sample, Resident #48; and failed to follow their pre-employment screening policies for 13 out of 25 employees reviewed. Resident #48 was found with a medium size gash to the back of his head of unknown origin requiring 5 staples. This injury of unknown origin was not reported to the state survey agency or other local agencies as required by the facility's policy for abuse reporting/investigation. The findings include: Resident #48 was admitted to the facility on [DATE] with diagnoses that included infarction, hemiplegia and hemiparesis affecting right dominant side, muscle weakness, dementia with behavioral disturbance, hyperlipidemia, anxiety, hypertension, depression, dysphasia and psychosis. The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #48 as severely cognitively impaired for daily decision making with a score of 3 out of 15. Under Section G Functional Status the MDS assessed Resident #48 as requiring limited assistance with one person physical assistance for transfers, ambulation, eating and locomotion; extensive assistance with one person physical assistance for toileting, bed mobility, personal hygiene, and bathing. Under Section J1900. - Falls, the MDS assessed Resident #48 has having one fall with injury since the previous assessment. Resident #48's clinical record was reviewed on 10/05/2021. Observed within the progress notes was the following: 9/25/2021 09:00 Writer was alerted by CNA (certified nursing assistant) that resident had blood on his pillow. Upon assessment a medium size gash was noted to the back of his head. Resident stated 'I did not fall, the door hit me.' [Medical Director] notified and orders were given to send resident to [Hospital] for sutures and evaluation. Resident had no change in LOC (lost of consciousness) . [Ambulance Service] transported resident via stretcher. Facesheet, med orders, bed hold, and care plan all sent with resident. 09/25/2021 19:25 (7:25 p.m.) Resident arrived back to facility around 1530 (3:30 p.m.) via non emergency ambulance on stretcher. He has 5 staples to the laceration on the back of his head. PRN (as needed) Tylenol given due to c/o pain. MD and ADON (assistant director of nursing) aware of his arrival. Staples to be removed in 5 days per MD. resident took evening meds w/o (without) complications. Will continue to monitor. Observed in the clinical record was a Change in Condition (SBAR) form dated 09/25/2021 that documented the same information noted in the 9/25/2021 9:00 a.m. progress note and docmented notification to Resident #48's guardian. On 10/05/2021 at 5:34 p.m. during a meeting with the director of nursing (DON) and corporate consultant the above information was discussed. The DON was asked if the information was reported to the State Agency and for the investigation. On 10/06/2021 at 9:36 a.m., the assistant director of nursing (RN #2) was interviewed regarding the incident. RN #2 was asked if there was an initial investigation and if the fall was reported to the state agency. RN #2 stated, no, I had worked a double shift and had just got home when the licensed practical nurse (LPN) called and notified me of the incident. When I returned to work I didn't complete investigation or notify the State Agency. I know that's not a valid reason not to complete the investigation. The LPN stated she had notified the MD (medical director) and completed the SBAR (change of condition) form and sent [Resident #48] to the ER (emergency room) per MD orders. RN #2 was asked if it was ever determined how Resident #48 sustained the injury. RN #2 stated, no, [Resident #48] is constantly moving. We have to monitor him because he attempts to walk and/or transfer himself alone and he is a fall risk. During my shift he had a good day and didn't have any falls or any incidents. On 10/06/2021 at 10:25 a.m. the director of nursing (DON) was interviewed regarding the injury sustained by Resident #48. The DON stated, no the incident was not reported to the State Agency. I am in the process of reporting it today. The investigation wasn't completed either. I started that on yesterday and will give you a copy of the witness statements. The DON was asked why incident was not reported and why the investigation was not completed. The DON stated, I apologize I was not here and it got overlooked. As soon as it was brought to my attention I started the process . The DON was asked if she was able to determine what caused the injury of unknown origin. The DON stated, no unfortunately not. [Resident #48] is active and moves around a lot. I can't really say what happened to him. The DON was asked if she and/or the administrator were notified of the incident. The DON stated no, I was out of work on sick leave due to shoulder surgery and unfortunately the administrator went out on sick leave for COVID. I feel like my staff did what they were supposed to regarding assessing the resident and reporting it the ADON and MD, who gave orders to send the resident to the ER. However, the ADON failed to complete the additional steps to notify the state agency and start and complete the investigation. The DON was asked to provide the facility's abuse policy. A review of the facility policy titled Abuse, Neglect, Exploitation & Misappropriation (Rev. 11/28/2017) documented the following: 7. Reporting/Response - Any employee contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately, but no later than 2 hors after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator and to other officials with the State law. In the absence of the Executive Director, the Director of Nursing is the designated abuse coordinator. Once an allegation of abuse is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations, including notification of Law Enforcement if a reasonable suspicion of crime has occurred. Facility staff should be aware of and comply with their individual requirements and responsibilities for reporting as required by law . Review of Report: Report all results of all investigations to the Executive Director or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken The Abuse Coordinator of The Company will refer any or all incidents and reports of resident abuse to the appropriate state agencies . On 10/05/2021 at 2:50 p.m., the above information was discussed during a meeting with the DON and Corporate consultant. The DON provided copies of the facility reported incident (FRI) dated 10/6/2021 sent to the state agency and the witness statements. The LPN and the CNA who provided care for Resident #48 on 09/25/2021 were not available for interview during the survey. No other information was provided to the survey team prior to exit on 10/06/2021 at 5:15 p.m.2. On 10/6/21 at 10:30 a.m., twenty-five employee records were reviewed for compliance with the facility's pre-employment screening protocols. Ten out of the 25 records reviewed were incomplete with missing sworn statements, reference checks and a criminal background check. Three employees worked from five to twenty months in the facility before criminal background checks were obtained. The thirteen employee records with missing pre-employment screening information included the following listed by hire date. 8/14/19 - no sworn statement, no reference checks 9/27/19 - no criminal background check until 6/3/21 4/03/20 - no reference checks 8/31/20 - no criminal background check until 6/2/21 10/1/20 - no criminal background check performed, no reference checks 12/10/20 - no reference checks 12/15/20 - no sworn statement 1/14/21 - no criminal background check until 6/2/21 5/25/21 - no sworn statement, no reference checks 8/31/21 - no reference checks 9/21/21 - no sworn statement 9/28/21 - (two employees) - no reference checks On 10/6/21 at 11:50 a.m., the human resources (HR) coordinator (other staff #6) was interviewed about the missing pre-employment screening information for the identified thirteen employees. The HR coordinator stated she had worked at the facility since April 2021 and had recognized a problem with incomplete pre-employment screening. The HR coordinator stated several of the criminal background checks were late because she had them done when she recognized they were missing. The HR coordinator stated that sometimes there was a delay because staff had not signed permission forms for the background check. The HR coordinator stated she obtained reference checks by telephone for the most recent hires (August 2021, September 2021) but she was unable to find where she documented the calls/references. When asked about the licensed practical nurse hired 10/1/20 that had no criminal background or reference checks, the HR coordinator stated this nurse currently worked prn (as needed). The HR coordinator stated this nurse had not returned the consent for the criminal background check. The HR coordinator stated this employee worked in the facility occasionally since 10/1/20 with the most recent days worked as 9/22/21 and 9/24/21. The facility's abuse prevention policy (N-1265 revised 11/28/17) documented the following concerning employee screening, Persons applying for employment with the center will be screened for a history of abuse, neglect, exploitation of resident property. This includes but not limited to: Employment history .Criminal Background check .Abuse check with appropriate licensing board and registries, prior to hire .Licensure or Registration verification prior to hire .Information from former employers . This finding was reviewed with the director of nursing and regional director of clinical services on 10/6/21 at 2:50 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review and facility document review, the facility staff failed to develop a comprehensive care plan for four of eighteen residents in the survey sample, Resident #31, #38, #46, and #11. Resident #31 was not care planned for self-administration of an albuterol inhaler; Resident #38 was not care planned for smoking; Resident #46 was not care planned for dental issues; and Resident #11 was not care planned with interventions for an existing pressure ulcer. Findings were: 1. Resident #31 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: Fibromyalgia, depression, respiratory disorder, and chronic ischemic heart disease. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 08/19/2021, assessed Resident #31 as cognitively intact with a summary score of 15. On 10/05/2021 at approximately 8:00 a.m., Resident #31 was observed sitting on her bed. She was wearing oxygen via a nasal cannula at 3 liters per minute. Resident #31 was interviewed about life at the facility and was asked about her oxygen. She stated, I got pneumonia a while back. I didn't wear it before then. Now I get short of breath when I take it off and to walk to the bathroom. My oxygen sats drop .sometimes I wheeze, that's why I have this. Resident #31 held up an albuterol inhaler that was laying on her bed. She stated, The doctor told me to keep it here at my bedside so that's where it is .I use it when I am short of breath or wheezing. Resident #31 was asked how often she used her inhaler. She stated, Whenever I need it .he [her doctor] said I can use it every four hours if I need to. Sometimes it's four hours, sometimes it's longer, sometimes if I'm wheezing I might use it a little before the four hours is up. Resident #31 was asked if she had to get one of the staff to come and help her with the inhaler when she used it or watch her use it. She stated, No, I do it myself, I don't need anybody to help me. She was asked if she had used an inhaler at home or prior to having pneumonia. She stated, No, I never had any problems breathing until then. The clinical record was reviewed at approximately 11:00 a.m. Her care plan did not contain any interventions or references to the self-administration of albuterol. During an end of the day meeting on 10/05/2021 at approximately 5:30 p.m., with the DON (director of nursing) and the corporate nurse consultant the above information was discussed. The DON was asked what was expected to be in place if a resident was keeping medication at her bedside for self administration. She stated, There should be an assessment, a doctor's order, and it should be on the care plan .it should be in the clinical record. The DON stated she would look to see what she could find. On 10/06/2021 at approximately 9:00 a.m., the DON provided information regarding Resident #31. She stated, She did not have anything on her care plan regarding self administration of the inhaler. A copy of the facility policy for self administration of medications was requested and received. Per the facility policy, Self-Administration of Medication at Bedside: .Criteria must be met to determine if a resident is both mentally and physically capable of self-administering medication and to keep accurate documentation of these actions Complete the Care Plan for approved self-administered drugs. Self-administration of meds is reviewed by the Care Plan Team with each quarterly review, and when any change in status is noted. No further information was received prior to the exit conference on 10/06/2021. 2. Resident #38 was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included but were not limited to: Diabetes Mellitus, peripheral vascular disease, hypertension, and chronic obstructive pulmonary disease. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 09/02/2021. Resident #38 was assessed as cognitively intact with a summary score of 15. During the entrance conference to the facility on [DATE] at approximately 6:15 p.m., a list of smokers was requested. Resident #38 was on the list. On 10/05/2021, Resident #38 was observed outside during the morning smoke break at approximately 11:15 a.m. smoking a cigarette. Resident #38's clinical record was reviewed at approximately 1:00 p.m. There were no interventions on the care plan regarding smoking. During an end of the day meeting on 10/05/2021 at approximately 5:30 p.m., with the DON (director of nursing) and the corporate nurse consultant the above information was discussed. The DON was asked what was expected to be in place if a resident was a smoker. She stated, There should be an assessment done quarterly, and it should be on the care plan .it should be in the clinical record. The DON stated she would look to see what she could find. A copy of the facility's smoking policy was requested. On 10/06/2021 at approximately 9:00 a.m., the DON stated, He [Resident # 38] did not have a smoking care plan. We did it today. The facility policy regarding smoking was received and contained the following: During designated smoking times staff will be assigned to assist or supervise residents whose care plans indicate assistance or supervision is required while smoking. No further information was obtained prior to the exit conference on 10/06/2021. 3. Resident #46 was admitted to the facility on [DATE]. His diagnoses included but were not limited to: Schizophrenia, dementia with behavioral disturbance, alcohol abuse, chronic viral hepatitis, and post traumatic stress syndrome. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 09/09/2021. Resident #46 was assessed as cognitively intact with a summary score of 15. The clinical record was reviewed on 10/05/2021 at approximately 3:00 p.m. Review of the progress note section contained the following information: 09/27/2021 07:14 [a.m.] Resident c/o [complains of] left lower gum/mouth pain. Resident teeth are decayed. Tylenol 650 mg given for c/o pain. MD notified RP [responsible party] aware. 09/27/2021 07:58 [a.m.] MD called with order for Amoxicillin tid [three times per day] X [times] 7 day[s] and arrange for dental consult. The care plan was reviewed. There were no interventions or problem areas listed for dental care or his tooth infection. At approximately 3:45 p.m., Resident #46 was interviewed. He was asked about his tooth infection. He stated, Yeah, they gave me something for it. It was really hurting. He was asked if he had an appointment to see the dentist. He stated, I'm not sure if I have one yet or not. During an end of the day meeting on 10/05/2021 at approximately 5:30 p.m., with the DON (director of nursing) and the corporate nurse consultant the above information was discussed. The DON was asked if Resident #46's care plan should contain information about his tooth decay and pending appointment. She stated, Yes, it should be on there. I will look for it. On 10/06/2021 at approximately 9:00 a.m., the corporate nurse presented a care plan for dental interventions for Resident #46. She stated, We just created this, he didn't have one. She was asked who was supposed to be doing care plans in the facility. She stated, MDS normally does them but she is out. Nursing does them too .nursing should have care planned his dental problems when he went on the antibiotics. No further information was obtained prior to the exit conference on 10/06/2021.4. Resident #11 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #11 included Alzheimer's, hypertension, dementia with behaviors, protein-calorie malnutrition, history of small intestine infarction, dysphagia and urinary retention. The minimum data set (MDS) dated [DATE] assessed Resident #11 with severely impaired cognitive skills. Resident #11's clinical record documented the resident had ongoing treatment for a pressure ulcer on her right gluteal fold requiring daily dressing changes and wound care. On 10/5/21 at 11:48 a.m., registered nurse (RN) #1 was observed performing a dressing change to Resident #11's gluteal pressure ulcer. The ulcer was irregular shaped and approximately one inch in length and .5 inches wide. The wound depth was superficial and the wound bed was pink/red. Resident #11's plan of care (revised 8/31/21) included no interventions regarding the resident's gluteal pressure ulcer. The care plan listed the resident had a pressure ulcer on the right gluteal fold with goals that included no progression or infection of the wound. The care plan documented no interventions for care or treatment of the wound. On 10/6/21 at 4:45 p.m., the director of nursing (DON) was interviewed about Resident #11's care plan. The DON stated treatments were in place and the resident had an air mattress for prevention of further ulcers. The DON stated the care plan had been started but not completed. This finding was reviewed with the DON and regional director of clinical services on 10/5/21 at 5:35 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and clinical record review, the facility staff failed to ensure care in accordance with the resident's plan of care for 1 of 18 in the survey sample, Resident #27. Resident #27 was not weighed per facility standing orders, and to ensure that she was maintaining weight as directed in her care plan. The findings include: Resident #27 was admitted to the facility on [DATE] with diagnoses that included hypertension, anemia, paraplegia, mild-protein-calorie malnutrition, adult failure to thrive, gastro-esophageal reflux disease (GERD), depression, and dementia with behavioral disturbance. The most recent minimum data set (MDS) dated [DATE] was the annual/comprehensive assessment and assessed Resident #27 has having long and short term memory problems with continuous inattention and behaviors including delusions, rejection of care and behaviors towards others. Resident #27's clinical record was reviewed on 10/05/2021. The weights section of the clinical record documented the last recorded weight as 1/4/2021 129.0 pounds and was entered by the director of nursing (DON). Resident #27's care plan documented, [Resident #27] has nutritional problem or potential nutritional problem r/t (related to) HTN (hypertension), dementia, anemia, history of UTIs (urinary tract infection). Goal: [Resident #27] will maintain adequate nutritional status as evidenced by maintaining weight, no s/sx (signs/symptoms) of malnutrition. (Revision Date: 8/12/2021). Interventions: observe/document report PRN any s/sx of refusing to eat, appears concerned during meals . The care plan documented Resident #27 having behaviors including rejection of care including refusing showers, pocketing medications and spitting them out and yelling and hitting at staff. Neither the care plan nor the clinical record documented Resident #27 refusing to have weights done. On 10/05/2021 at 5:34 p.m. during a meeting with the director of nursing (DON) and corporate consultant the above information was discussed. The DON was asked how often were weights obtained on residents. The DON stated weights were obtained monthly by standing order unless otherwise ordered by the physician more frequently. The DON stated Resident #27 often refused having her weights obtained. The DON was advised there was no refusals documented in the clinical record or on the care plan. The DON stated she would follow-up with additional information. On 10/06/2021 at 8:30 a.m., the DON provided a copy of the Annual Nutritional Evaluation completed on 08/20/2021 by the dietitian. Observed on the evaluation under the weights section was the most recent weight 01/04/2021 129.0 pounds. The evaluation documented the weight history in monthly increments of 1 month, 3 months and 6 months as unknown and documented no weights since 1/4/21 due to resident refusal The DON stated, I checked and you were right there was no documentation on the care plan or clinical record about her refusing weights. Her meal intake documents she has been consistent between 76-100% of each meal. The dietitian and doctor are now aware and we will get an order to d/c (discontinue) the weights due to her refusals. The DON was asked if there was a concern about weight loss. The DON stated, I would think not since her meal intake has been consistent. This should have been done months ago and there should have been some documentation about her refusals. No additional information was provided to the survey team prior to exit on 10/06/2021 at 5:15 p.m.

Based on observation, facility document review and staff interview, the facility staff failed to store food in a sanitary manner in the main kitchen. The findings include: On 10/4/21 at 6:25 p.m., accompanied by the dietary manager (other staff #2) the kitchen and food storage areas were inspected. Stored in the dry storage room were the following: one carton of Thick and Easy dairy beverage - opened and not dated; one 46-ounce carton of nectar thick orange juice - opened and not dated; two 46-ounce cartons of thickened apple juice - opened and not dated. The seals on these beverage were punctured and the product partially used from the cartons. These beverages were not refrigerated but were stored in the dry storage room along with unopened cartons of thickened beverages and juices. The manufacturer's label on each of these cartons stated to Refrigerate after opening. On 10/4/21 at 6:30 p.m., the dietary manager was interviewed about the opened, unrefrigerated dairy/juice beverages. The dietary manager stated the opened beverages should have been dated when opened and stored in the refrigerator. The dietary manager stated he did not know why the opened beverages were returned to the dry storage room. The dietary manager stated, I've got a couple of new people. The Food Storage and Retention Guide (reference FDA Food Code 2013) provided by the dietary manager documented supplements and thickened beverages should be stored per manufacturer's guidelines. This finding was reviewed with the director of nursing and regional director of clinical services on 10/5/21 at 5:35 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, facility document review, staff interview and clinical record review, the facility staff failed to inspect a bed frame and mattress for possible entrapment risks for one of eighteen residents in the survey sample. Resident #11's bed, installed with a specialty air mattress for over 5 months, had not been inspected for entrapment risks. The facility's most recent bed inspections had no documented date of completion and did not include all facility beds in use. The findings include: Resident #11 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #11 included Alzheimer's, hypertension, dementia with behaviors, protein-calorie malnutrition, history of small intestine infarction, dysphagia and urinary retention. The minimum data set (MDS) dated [DATE] assessed Resident #11 with severely impaired cognitive skills. Resident #11's clinical record documented a nursing note dated 4/28/21 stating, Outside vendor arrived at facility at 2130 [9:30 p.m.] to deliver new air mattress. Resident was transferred OOB [out of bed] by staff to wheelchair while new bed was set up .No issues noted with new mattress. On 10/5/21 at 11:48 a.m., Resident #11 was observed in bed with an air mattress in use. On 10/5/21 at 4:37 p.m., the maintenance director (other staff #1) was interviewed about the facility's bed inspection program for entrapment risks. The maintenance director stated he inspected mattresses periodically for cracks and holes and replaced mattress as needed. The maintenance director stated beds were inspected routinely for function, condition and operation and that all beds installed with side rails had inspections for entrapment risks. The inspection for Resident #11's bed with the installed air mattress was requested. On 10/6/21 at 8:23 a.m., the maintenance director stated he checked gaps/measurements for beds/mattresses installed with side rails. The maintenance director stated Resident #11's bed was not a standard bed but was one of several that had been donated to the facility. The maintenance director stated he had no inspections of Resident #11's bed and had not inspected the bed with the specialty air mattress installed for entrapment risks. The maintenance director stated several of the donated beds had been in the facility for months and he did not remember exactly when they were put in use with residents. The maintenance director stated, I haven't gotten to that bed yet. The maintenance director presented a completed bed inspection sheet with measurements for FDA zone 7 (gap between the head and/or footboard and the end of the mattress). The completed form was not dated and listed bed make, model, type, serial number and mattress type. Gap measurements for zone 7 were documented as 2 inches or less. The form did not indicate if the measurements were between the headboard or footboard and the mattress. The list did not include the two beds and/or mattresses in Resident #11's room (Resident #11 and her roommate). The maintenance director presented an inspection list for beds in the facility with side rails dated 2021 that documented measurements for FDA bed zones 1 to 6. There was no safety inspection performed on Resident #11's bed with a standard mattress and there had been no review for entrapment risks since the bed was installed with an air mattress on 4/28/21. There was no formal policy/protocol regarding bed/mattress inspections and documented bed reviews included undated checklists and did not identify and include several donated beds in use or the beds in Resident #11's room. These findings were reviewed with the director of nursing and regional director of clinical services on 10/6/21 at 2:45 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, the facility staff failed to ensure a dignified dining experience during lunch observation for one of 19 residents in the survey, Resident #40. Resident #40, was identified as needing to be fed, was fed by a staff member who stood over the resident while feeding her. Findings include: Resident #40, was admitted to the facility on [DATE]. Diagnoses included malnutrition, Vitamin D Deficiency, falls, dehydration, acute kidney failure, hypernatremia, Alzheimer's Dementia, osteoporosis, septic shock, encephalopathy, and hospice services. The most recent minimum data set (MDS) dated [DATE], was a quarterly assessment and assessed Resident #40 as being severely cognitively impaired with a score of 1 out of 15. The MDS dated [DATE], under Section G (Functional Status), at item G0110 (H), Eating assessed Resident #40 as requiring extensive assistance with one-person physical assistance for eating. A dining observation was conducted in the main dining room during lunch on 03/19/19 at approximately 12:05 p.m. During the meal observation, Resident #40 was observed sitting in a geri-chair seated at a table in the main dining room. The resident's dining tray was brought to her by certified nursing assistant (CNA #1). CNA #1 was observed feeding Resident #40 and remained standing while she fed her the entire meal observation which was approximately 25 minutes. On 3/19/19 at approximately 12:45 p.m., CNA #1 was interviewed regarding Resident #40's need for assistance at meals. CNA #1 stated the resident required feeding assistance at all meals. On 3/19/19, Resident #40's clinical record was reviewed. Resident #40's care plan documented the following: Focus area: [Resident #40], requires extensive to total assistance with ADLs (activities of daily living) at this time due to impaired cognitive status, impaired mobility, impaired range of motion, non-ambulatory .is receiving hospice services. Created on 11/26/2018. Goal: [Resident #40], needs will be met daily through next review. Created on 11/26/18. Target Dated 05/19/19. Interventions: assist with eating at meal time. Created on 11/26/18. These findings were discussed during a meeting on 03/19/19 at 4:30 p.m. with the Administrator, Director of Nursing and Nurse Consultant.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #8 was admitted to the facility on [DATE]. Diagnoses for this resident included, but were not limited to: MS (multiple sclerosis), depression, anxiety, seizure disorder, bipolar disorder, neurogenic bladder, hypothyroidism, and hemiplegia. The most recent MDS (minimum data set) was an annual assessment dated [DATE]. This MDS documented the resident with a cognitive score of 13, indicating the resident was cognitively intact for daily decision making skills. This resident was assessed as requiring extensive assistance for most all ADLs (activities of daily living) with assistance of one staff and required total assistance for transfers and bathing with assistance of two staff. On 03/19/19 at 10:50 AM, Resident #8 was interviewed and stated that she had a complaint. The resident stated that an aide had stated to her hat she was going to punch the resident in the face. The resident stated that she didn't know why the aide said that to her, but stated that maybe it was dominance and stated that the aide has continued working and providing care for her. The resident stated that she doesn't like to have this aide care for her due to what has happened. The resident described the CNA's age, gender and race. The resident stated that she did not know how long the CNA had been at the facility, but stated .probably longer than me. The resident stated that the CNA works with her often. The resident stated that this incident happened about a month ago. The resident stated that this was reported to the administrator and SW (social worker). The resident was asked what the administrator said to her when this was reported. The resident stated that the administrator stated, we can't have that and that was about it. The resident was asked if the administrator asked for specific details. The resident stated that both did talk to her and ask questions, but she didn't know if anything was written down. The resident stated that she could not remember what the SW had said to her about the incidences. The resident again stated that the CNA had been working with her since it was reported. The resident provided a name of the CNA, but stated that she was not exactly sure if that was her name, but stated, It was something like that. On 03/19/19 at 11:00 AM, the administrator was asked for any information regarding any allegations of abuse, complaints and/or concerns regarding this resident. The administrator stated that he was aware of one incident and would present that information. The administrator was asked to check if there were any reports to the SW for any type of abuse or mistreatment for this resident. On 03/19/19 at 12:33 PM, the administrator presented the information (unrelated incident) and stated that he had another documented concern for this resident that was during the fall of 2018. The administrator was asked for that information, in addition to any other allegations, concerns or incidents regarding this resident. On 03/20/19 at 8:45 AM, the administrator presented the concern from the fall 2018. The complaint/grievance report was reviewed and documented this event occurred on 09/17/18. The administrator stated that this was the only other thing the facility had on this resident. The administrator stated that he did not know of or have any information and/or reports from the resident or anyone else that the resident alleged that a CNA had told the resident she was going to punch her in the face. The complaint/grievance documented, .[name of Resident #8] SW (social worker) .verbal .other .reported that she noticed CNA [certified nursing assistant] #2 with her boyfriend and other CNAs in resident room on Saturday 09/08 or Sunday 09/09, reported that she did not remember the day .CNA #3 CNA #2 [documented this statement] .[name of resident] light was on I went to answer her light she asked if I was her CNA I told her no her respond [sic] was then what are you doing here please get my aid [sic] and get out I told her she her she's [illegible word] and walk [sic] out about an hour after I herd [sic] her making a complain [sic] to my mom saying that I took her tray before she start [sic] eating I went in there and I ask her if I took her tray she said yes at lunch time I told her is [sic] supper time now she turn to me and said anyways leave bitch as I was walking out I turn back and ask what she said she said you herd [sic] me bitch leave your a bitch I turn to her and said yes I am and went to [name of nurse] and tod [sic] what happened [signature of CNA #2] On 03/20/19 at 4:44 PM, after review of the above, the administrator and DON were made aware of concerns regarding this incident in a meeting with the survey team. The administrator was asked if he or the DON had read the statement by CNA #2. The administrator and DON stated, No. The statement was read aloud and given to each to read. The administrator was asked who is supposed to look at these to ensure that they are being done correctly, to ensure that the grievance/complaint is accurate and complete. The administrator stated, You can look at me, I'm suppose to read those. The administrator stated that he did not know that was in there or didn't recall reading that initially in September. The administrator was asked what he thought about it. The administrator stated, It isn't good. The administrator was asked, what was the expectation on how staff are to respond to residents who may be upset or having behavior issues. The administrator stated, Not like that, that's unacceptable. The administrator stated that staff are trained on how to respond and interact with residents in different types of situations, but stated that regarding this incident it was not caught in September and there was no education provided for this staff regarding this, primarily because this was not found at the time. On 03/21/19 at 9:45 AM, the SW was interviewed regarding the complaint/grievance process. The SW presented a clinical guideline for complaint/grievance that documented, .The grievance officer/designee shall act on the grievance and begin follow up of the concern or submit it to the appropriate department director for follow up .should be completed within 14 days once the follow up is complete, the results should be forwarded to the executive director for review and filing . The SW stated that he is the one who completed the form and once it is completed it goes to the administrator for review. No further information and/or documentation was presented prior to the exit conference on 03/21/19 to evidence that Resident #8 was treated with dignity regarding the above.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review and facility document review, the facility staff failed to implement written policies and procedures for the prevention of abuse and investigation of abuse allegations, for one of 19 residents in the survey sample, Resident #8. Findings include: Resident #8 was admitted to the faintly on 05/30/17. Diagnoses for this resident included, but were not limited to: MS (multiple sclerosis), depression, anxiety, seizure disorder, bipolar disorder, neurogenic bladder, hypothyroidism, and hemiplegia. The most recent MDS (minimum data set) was an annual assessment dated [DATE]. This MDS documented the resident with a cognitive score of 13, indicating the resident was cognitively intact for daily decision making skills. This resident was assessed as requiring extensive assistance for most all ADLs (activities of daily living) with assistance of one staff and required total assistance for transfers and bathing with assistance of two staff. On 03/19/19 at 10:50 AM, Resident #8 was interviewed and stated that she had two complaints. The resident stated first, that an aide had stated to her that she was going to punch the resident in the face. The resident stated that she didn't know why the aide said that to her, but stated that maybe it was dominance and stated that the aide has continued working and providing care for her. The resident stated that she doesn't like to have this aide care for her due to what has happened in the past. The resident then stated that she was also sexually assaulted by those girls in the shower room, by 5 or 6 girls, including the girl that stated that she was going to punch her in the face. The resident stated that she had reported it to the administrator the following day and the incident happened on the 3-11 shift. The resident could not remember the date, but did state that it was about a month ago. The resident also stated that she also reported it to the SW (social worker). The resident called the administrator and SW by name, but stated that she did not remember the CNA's name (s) that assaulted her, but stated what she thought the name was. The resident again repeated that it was on the 3-11 shift and that she really didn't want to take a shower that day, but ended up going and that is what happened. The resident gave the name again for the CNA that she alleged was going to punch her in the face, which was also was one who was involved in the sexual assault (per the resident). The resident stated that she was not absolutely sure if that was her name, but it was something like that. The resident was asked if she went to the hospital after reporting that she was sexually assaulted, the resident stated, No. The resident was asked if anyone assessed or examined her after this was reported, the resident stated, No. The resident described the CNA by age, gender and race. The resident stated that she did not know how long the CNA has been at the facility, but stated .probably longer than me. The resident stated that the CNA works with her often. The resident stated that this incident happened about a month ago. The resident was asked what the administrator said to her when this was reported. The resident stated that when she reported that the CNA voiced punching her in the face, the administrator stated, we can't have that and that was about it. The resident stated that both incidences happened about a month ago and both were reported to the administrator and the SW. The resident was asked if the administrator asked for specific details. The resident stated that both the administrator and SW did talk to her and ask questions, but she didn't know if anything was written down. The resident stated that she could not remember what the SW had said to her about the incidences. The resident again stated that the CNA had been working her since it was reported. On 03/19/19 at 11:00 AM, the administrator was asked for any information regarding any allegations of abuse, complaints and/or concerns regarding this resident. The administrator was asked to check with the SW for any type of documentation or information regarding abuse or mistreatment for this resident. On 03/19/19 at 12:33 PM, the administrator presented a folder with a typed document from the DON (director of nursing). The administrator stated that he was aware of the alleged sexual assault and that this was the investigation. The investigation was reviewed. The investigation folder contained one typed document by the DON. The information documented, 03/06/19 Insurance representative along with ED [executive director] came to my office r/t [related to] conversation she [sic] had with [name of resident] .reported to her [sic] that she was taken to the shower the prior evening and raped by 5 women .I was here on 03/05/19, at appox 2 PM .resident was sitting at the nurse's station after returning from an appointment .eczema looked considerably worse .asked the assigned CNA to shower her .[name of resident] did not want to take shower .but did agree .[name of CNA #1] with assistance of [name of CNA #2] completed .shower .put to bed .diagnoses of bipolar and anxiety .over the past months has become more confused .[name of resident] was drowsy, but able to put words together that made sensible sentences .asked .anything strange happened in the last couple of days .you heard about my shower .specifically what happened .a lot of women raped me .strange women .explained I needed more details .was not able to provide any .explained that CNA #1 gave her shower with assist of CNA #2 .explained that what she is reporting is just not possible .you know me I probably dreamed it .starting to slur her words a little and was having hard time keeping her eyes open. I told her I'd let her rest, to let staff know if she wanted to talk more later and I would come back at that time the conversation ended . No other information was provided regarding this incident. The resident's CCP (comprehensive care plan) was reviewed and documented, .requires mechanical lift with 2 staff .totally dependent on staff for catheter/incontinence care .if exhibits behaviors (hypersexual conversation, request to speak to male staff members, suspicions of others, resistive to care, ask staff for money, paranoia, mood swings, states staff is outside of her room talking about her) make sure she is safe and re-approach later . On 03/20/19 at 4:44 PM, the administrator and DON were made aware of concerns regarding this incident in a meeting with the survey team. The administrator stated that he knows his residents pretty well and felt like if he thought something like that had actually occurred he would have reported it. The administrator was made aware that this was an allegation of abuse and that abuse allegations are not only investigated or reported if the allegation actually happened. The administrator was made aware that this was an allegation of abuse made a resident of this facility. The DON and administrator both stated that this resident has been known to say things that weren't true. The administrator and DON were made aware that this was an allegation of abuse and should have been reported. The administrator stated, It was not a reported FRI [facility reported incident], but stated that he has since been educated. A policy on abuse was requested at this time. The policy Policies and Procedures Subject: Resident Abuse was presented and reviewed and documented the following: .policies and procedures to protect these rights to establish a disciplinary policy, which results in fair and timely treatment of occurrences of resident abuse .No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment .against any resident .abuse .physical abuse .verbal abuse .sexual abuse .neglect .questions may arise as to what actions constitute abuse of a resident. Any action that may cause actual physical, psychological or emotional harm .non-action, which results in emotional, psychological .all employees have a duty to respect the rights of all residents, to treat them with dignity and to prevent others from violating their rights .Any employee, who witnesses or has knowledge of an act of abuse or an allegation of abuse .is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator and to other officials in accordance with State law .An employee shall be deemed to have violated his obligations .if he does any of the following: fails to report an incident of abuse witnessed by or known .incomplete report of abuse .monitor residents at risk .all reported events .will be investigated .once an allegation of abuse is reported, the executive director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations .recognizes that preliminary reports of abuse can sometimes be clouded by biases and other factors that are relevant and need to be explored during a full investigation in order to obtain a clear picture of what actually happened .immediately upon an allegation of abuse or neglect, the suspect(s) shall be segregated from residents pending the investigation of the allegation .the clinical nurse in charge of director of clinical services shall perform and document a thorough nursing assessment and notify the attending physician .and incident report shall be filed .report the results .to the executive director .including to the State Survey Agency, within 5 working days . The resident's clinical record did not reveal any additional information or documentation regarding this incident. No evidence of any type of mental and/or physical assessment had been completed for this resident, as a result of the alleged sexual assault allegation. The administrator and DON stated that they were unaware of an allegation by Resident #8 of a CNA stating that she was going to punch the resident in the face. The administrator stated that he would speak with the resident regarding that allegation. No further information and/or documentation was presented prior to the exit conference on 03/21/19 to evidence that the facility staff implemented and followed policies and procedures for the prevention of abuse regarding an allegation of sexual abuse by Resident #8.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review and facility document review, the facility staff failed to report an allegation of sexual abuse to the state agency and/or officials in accordance with State law. Findings include: Resident #8 was admitted to the faintly on 05/30/17. Diagnoses for this resident included, but were not limited to: MS (multiple sclerosis), depression, anxiety, seizure disorder, bipolar disorder, neurogenic bladder, hypothyroidism, and hemiplegia. The most recent MDS (minimum data set) was an annual assessment dated [DATE]. This MDS documented the resident with a cognitive score of 13, indicating the resident was cognitively intact for daily decision making skills. This resident was assessed as requiring extensive assistance for most all ADLs (activities of daily living) with assistance of one staff and required total assistance for transfers and bathing with assistance of two staff. On 03/19/19 at 10:50 AM, Resident #8 was interviewed and stated that she had two complaints. The resident stated first, that an aide had stated to her that she was going to punch the resident in the face. The resident stated that she didn't know why the aide said that to her, but stated that maybe it was dominance and stated that the aide has continued working and providing care for her. The resident stated that she doesn't like to have this aide care for her due to what has happened in the past. The resident then stated that she was also sexually assaulted by those girls in the shower room, by 5 or 6 girls, including the girl that stated that she was going to punch her in the face. The resident stated that she had reported it to the administrator the following day and the incident happened on the 3-11 shift. The resident could not remember the date, but did state that it was about a month ago. The resident also stated that she also reported it to the SW (social worker). The resident called the administrator and SW by name, but stated that she did not remember the CNA's name (s) that assaulted her, but stated what she thought the name was. The resident again repeated that it was on the 3-11 shift and that she really didn't want to take a shower that day, but ended up going and that is what happened. The resident gave the name again for the CNA that she alleged was going to punch her in the face, which was also was one who was involved in the sexual assault (per the resident). The resident stated that she was not absolutely sure if that was her name, but it was something like that. The resident was asked if she went to the hospital after reporting that she was sexually assaulted, the resident stated, No. The resident was asked if anyone assessed or examined her after this was reported, the resident stated, No. The resident described the CNA by age, gender and race. The resident stated that she did not know how long the CNA has been at the facility, but stated .probably longer than me. The resident stated that the CNA works with her often. The resident stated that this incident happened about a month ago. The resident was asked what the administrator said to her when this was reported. The resident stated that when she reported that the CNA voiced punching her in the face, the administrator stated, we can't have that and that was about it. The resident stated that both incidences happened about a month ago and both were reported to the administrator and the SW. The resident was asked if the administrator asked for specific details. The resident stated that both the administrator and SW did talk to her and ask questions, but she didn't know if anything was written down. The resident stated that she could not remember what the SW had said to her about the incidences. The resident again stated that the CNA had been working her since it was reported. On 03/19/19 at 11:00 AM, the administrator was asked for any information regarding any allegations of abuse, complaints and/or concerns regarding this resident. The administrator was asked to check with the SW for any type of documentation or information regarding abuse or mistreatment for this resident. On 03/19/19 at 12:33 PM, the administrator presented a folder with a typed document from the DON (director of nursing). The administrator stated that he was aware of the alleged sexual assault and that this was the investigation The investigation was presented and consisted of a folder, which contained one typed document by the DON. The information documented, 03/06/19 Insurance representative along with ED [executive director] came to my office r/t [related to] conversation she [sic] had with [name of resident] .reported to her [sic] that she was taken to the shower the prior evening and raped by 5 women .I was here on 03/05/19, at appox 2 PM .resident was sitting at the nurse's station after returning from an appointment .eczema looked considerably worse .asked the assigned CNA to shower her .[name of resident] did not want to take shower .but did agree .[name of CNA #1] with assistance of [name of CNA #2] completed .shower .put to bed .diagnoses of bipolar and anxiety .over the past months has become more confused .[name of resident] was drowsy, but able to put words together that made sensible sentences .asked .anything strange happened in the last couple of days .you heard about my shower .specifically what happened .a lot of women raped me .strange women .explained I needed more details .was not able to provide any .explained that CNA #1 gave her shower with assist of CNA #2 .and explained that what she is reporting is just not possible .you know me I probably dreamed it .starting to slur her words a little and was having a hard time keeping her eyes open. I told her I'd let her rest, to let staff know if she wanted to talk more later and I would come back at that time the conversation ended . No other information was provided regarding this incident. On 03/20/19 at 4:44 PM, the administrator and DON were made aware of concerns regarding this incident in a meeting with the survey team. The administrator stated that he knows his residents pretty well and felt like if he thought something like that had actually occurred he would have reported it. The administrator was made aware that this was an allegation of abuse and that abuse allegations are not only investigated or reported if the allegation actually happened. The administrator was made aware that this was an allegation of abuse made a resident of this facility. The DON and administrator both stated that this resident has been known to say things that weren't true. The administrator and DON were made aware that this was an allegation of abuse and should have been reported. The administrator stated, It was not a reported FRI [facility reported incident], but stated that he has since been educated. A policy on abuse was requested at this time. The policy Policies and Procedures Subject: Resident Abuse was presented and reviewed and documented the following: .policies and procedures to protect these rights to establish a disciplinary policy, which results in fair and timely treatment of occurrences of resident abuse .No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment .against any resident .abuse .physical abuse .verbal abuse .sexual abuse .neglect .questions may arise as to what actions constitute abuse of a resident. Any action that may cause actual physical, psychological or emotional harm .non-action, which results in emotional, psychological .all employees have a duty to respect the rights of all residents, to treat them with dignity and to prevent others from violating their rights .Any employee, who witnesses or has knowledge of an act of abuse or an allegation of abuse .is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator and to other officials in accordance with State law .An employee shall be deemed to have violated his obligations .if he does any of the following: fails to report an incident of abuse witnessed by or known .incomplete report of abuse .monitor residents at risk .all reported events .will be investigated .once an allegation of abuse is reported, the executive director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations .recognizes that preliminary reports of abuse can sometimes be clouded by biases and other factors that are relevant and need to be explored during a full investigation in order to obtain a clear picture of what actually happened .immediately upon an allegation of abuse or neglect, the suspect(s) shall be segregated from residents pending the investigation of the allegation .the clinical nurse in charge of director of clinical services shall perform and document a thorough nursing assessment and notify the attending physician .and incident report shall be filed .report the results .to the executive director .including to the State Survey Agency, within 5 working days . No further information and/or documentation was presented prior to the exit conference on 03/21/19 to evidence that the facility staff reported an allegation of sexual assault to the state agency or that the information was reported within the appropriate timeframe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review and facility document review, the facility staff failed to thoroughly investigate an allegation of sexual abuse for one 19 residents in the survey sample, Resident #8. Findings include: Resident #8 was admitted to the faintly on 05/30/17. Diagnoses for this resident included, but were not limited to: MS (multiple sclerosis), depression, anxiety, seizure disorder, bipolar disorder, neurogenic bladder, hypothyroidism, and hemiplegia. The most recent MDS (minimum data set) was an annual assessment dated [DATE]. This MDS documented the resident with a cognitive score of 13, indicating the resident was cognitively intact for daily decision making skills. This resident was assessed as requiring extensive assistance for most all ADLs (activities of daily living) with assistance of one staff and required total assistance for transfers and bathing with assistance of two staff. On 03/19/19 at 10:50 AM, Resident #8 was interviewed and stated that she had two complaints. The resident stated first, that an aide had stated to her that she was going to punch the resident in the face. The resident stated that she didn't know why the aide said that to her, but stated that maybe it was dominance and stated that the aide has continued working and providing care for her. The resident stated that she doesn't like to have this aide care for her due to what has happened in the past. The resident then stated that she was also sexually assaulted by those girls in the shower room, by 5 or 6 girls, including the girl that stated that she was going to punch her in the face. The resident stated that she had reported it to the administrator the following day and the incident happened on the 3-11 shift. The resident could not remember the date, but did state that it was about a month ago. The resident also stated that she also reported it to the SW (social worker). The resident called the administrator and SW by name, but stated that she did not remember the CNA's name (s) that assaulted her, but stated what she thought the name was. The resident again repeated that it was on the 3-11 shift and that she really didn't want to take a shower that day, but ended up going and that is what happened. The resident gave the name again for the CNA that she alleged was going to punch her in the face, which was also was one who was involved in the sexual assault (per the resident). The resident stated that she was not absolutely sure if that was her name, but it was something like that. The resident was asked if she went to the hospital after reporting that she was sexually assaulted, the resident stated, No. The resident was asked if anyone assessed or examined her after this was reported, the resident stated, No. The resident described the CNA by age, gender and race. The resident stated that she did not know how long the CNA has been at the facility but stated .probably longer than me. The resident stated that the CNA works with her often. The resident stated that this incident happened about a month ago. The resident was asked what the administrator said to her when this was reported. The resident stated that when she reported that the CNA voiced punching her in the face, the administrator stated, we can't have that and that was about it. The resident stated that both incidences happened about a month ago and both were reported to the administrator and the SW. The resident was asked if the administrator asked for specific details. The resident stated that both the administrator and SW did talk to her and ask questions, but she didn't know if anything was written down. The resident stated that she could not remember what the SW had said to her about the incidences. The resident again stated that the CNA had been working her since it was reported. On 03/19/19 at 11:00 AM, the administrator was asked for any information regarding any allegations of abuse, complaints and/or concerns regarding this resident. The administrator was asked to check with the SW for any type of documentation or information regarding abuse or mistreatment for this resident. On 03/19/19 at 12:33 PM, the administrator presented a folder with a typed document from the DON (director of nursing). The administrator stated that he was aware of the alleged sexual assault and that this was the investigation. The investigation was reviewed. The investigation folder contained one typed document by the DON. The information documented, 03/06/19 Insurance representative along with ED [executive director] came to my office r/t [related to] conversation she [sic] had with [name of resident] .reported to her [sic] that she was taken to the shower the prior evening and raped by 5 women .I was here on 03/05/19, at appox 2 PM .resident was sitting at the nurse's station after returning from an appointment .eczema looked considerably worse .asked the assigned CNA to shower her .[name of resident] did not want to take shower .but did agree .[name of CNA #1] with assistance of [name of CNA #2] completed .shower .put to bed .diagnoses of bipolar and anxiety .over the past months has become more confused .[name of resident] was drowsy, but able to put words together that made sensible sentences .asked .anything strange happened in the last couple of days .you heard about my shower .specifically what happened .a lot of women raped me .strange women .explained I needed more details .was not able to provide any .explained that CNA #1 gave her shower with assist of CNA #2 .explained that what she is reporting is just not possible .you know me I probably dreamed it .starting to slur her words a little and was having hard time keeping her eyes open. I told her I'd let her rest, to let staff know if she wanted to talk more later and I would come back at that time the conversation ended . No other information was provided regarding this incident. There were no employee statements. There was no information and/or documentation of any type of mental and/or physical assessment completed on this resident. The resident's CCP (comprehensive care plan) was reviewed and documented, .requires mechanical lift with 2 staff .totally dependent on staff for catheter/incontinence care .if exhibits behaviors (hypersexual conversation, request to speak to male staff members, suspicions of others, resistive to care, ask staff for money, paranoia, mood swings, states staff is outside of her room talking about her) make sure she is safe and re-approach later . On 03/20/19 at 4:44 PM, the administrator and DON were made aware of concerns regarding this incident in a meeting with the survey team. The administrator stated that he knows his residents pretty well and felt like if he thought something like that had actually occurred he would have reported it. The administrator was made aware at that this was an allegation of abuse and that this investigation did not include specific details and did not evidence that the resident was protected from abuse during the time of investigation. The DON and administrator both stated that this resident has been known to say things that weren't true. The administrator and DON were made aware that complete and thorough investigation was not completed for this resident regarding an allegation of sexual abuse. A policy on abuse was requested at this time. The policy Policies and Procedures Subject: Resident Abuse was presented and reviewed and documented the following: .policies and procedures to protect these rights to establish a disciplinary policy, which results in fair and timely treatment of occurrences of resident abuse .No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment .against any resident .abuse .physical abuse .verbal abuse .sexual abuse .neglect .questions may arise as to what actions constitute abuse of a resident. Any action that may cause actual physical, psychological or emotional harm .non-action, which results in emotional, psychological .all employees have a duty to respect the rights of all residents, to treat them with dignity and to prevent others from violating their rights .Any employee, who witnesses or has knowledge of an act of abuse or an allegation of abuse .is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator and to other officials in accordance with State law .An employee shall be deemed to have violated his obligations .if he does any of the following: fails to report an incident of abuse witnessed by or known .incomplete report of abuse .monitor residents at risk .all reported events .will be investigated .once an allegation of abuse is reported, the executive director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations .recognizes that preliminary reports of abuse can sometimes be clouded by biases and other factors that are relevant and need to be explored during a full investigation in order to obtain a clear picture of what actually happened .immediately upon an allegation of abuse or neglect, the suspect(s) shall be segregated from residents pending the investigation of the allegation .the clinical nurse in charge of director of clinical services shall perform and document a thorough nursing assessment and notify the attending physician .and incident report shall be filed .report the results .to the executive director .including to the State Survey Agency, within 5 working days . The resident's clinical record did not reveal any nursing notes, any type of mental and/or physical assessment had been completed for this resident as part of the investigation for an allegation of sexual assault. The SW (social worker) was interviewed on 03/21/19 at 9:45 AM. The SW stated that he had no knowledge of any sexual abuse allegations for Resident #8 until Tuesday (the day the survey team entered the facility), which was reported to him by the administrator. The SW stated that he had no knowledge of this resident alleging that a CNA was going to punch her in the face until last evening. No further information and/or documentation was presented prior to the exit conference on 03/21/19 to evidence that a complete and thorough investigation was completed for an allegation of sexual abuse by Resident #8.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, the facility staff failed to issue written notice of the bed-hold policy at the time of transfer for one of 19 residents in the survey sample. No written bed-hold notice was provided when Resident #109 was transferred to the hospital. The findings include: Resident #109 was admitted to the facility on [DATE] and was discharged to the hospital on 3/28/18. Diagnoses for Resident #109 included hip fracture, high blood pressure, peripheral vascular disease and diabetes. The minimum data set (MDS) dated [DATE] assessed Resident #109 with moderately impaired cognitive skills. Resident #109's clinical record documented the resident was sent to the emergency room on 3/28/18 due to an altered mental status. The clinical record documented no written notification to the resident or her responsible party concerning the bed-hold policy. On 3/21/19 at 10:30 a.m., the director of nursing (DON) was interviewed about any bed-hold notification for Resident #109 on 3/28/18. After searching the clinical record, the DON stated she did not find any bed-hold policy notification to Resident #109 or her representative at the time of transfer. The facility's policy titled Bed Hold (revised 11/1/17) documented, Resident or Resident Representative will be notified on admission, and at the time of transfer (to the hospital or therapeutic leave) of the bed hold policies, according to Federal and/or State requirements .At the time of transfer to the hospital or therapeutic leave, the center will provide a copy of notification of bed hold . This finding was reviewed with the administrator and director of nursing during a meeting on 3/21/19 at 4:50 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to ensure a PASARR (preadmission screening and resident review) was completed prior to admission to the facility for one of 19 residents in the survey sample, Resident 8. Findings include: Resident #8 was admitted to the faintly on 05/30/17. Diagnoses for this resident included, but were not limited to: MS (multiple sclerosis), depression, anxiety, seizure disorder, bipolar disorder, neurogenic bladder, hypothyroidism, and hemiplegia. The most recent MDS (minimum data set) was an annual assessment dated [DATE]. This MDS documented the resident with a cognitive score of 13, indicating the resident was cognitively intact for daily decision making skills. This resident was assessed as requiring extensive assistance for most all ADLs (activities of daily living) with assistance of one staff and required total assistance for transfers and bathing with assistance of two staff. During clinical record review for Resident #8, no preadmission screening of any kind could be located. On 03/19/19 at 3:00 PM, the Administrator and DON (director of nursing) were asked for the assistance in locating a PASARR for Resident #8. On 03/19/19 at 4:07 PM, the DON and administrator came in and presented an evaluation (not a PASARR). The DON was made aware that this was not a PASARR and was asked for a Level I PASARR, this would determine if a Level II was required. The DON stated, I know what a PASARR is. The DON stated that she would find it. On 03/20/19 at 8:50 AM, the administrator presented a PASARR for Resident #8. The PASARR was dated 03/19/19, completed the day before by the DON. The PASARR was not complete. The PASARR (Level I) question #5 was not completed to indicate if this resident was to be referred for a Level II or not. On 03/21/19 at 3:00 PM, the administrator and DON were made aware that the PASARR was not completed for this resident prior to admission and was completed on 03/19/19, but was still not complete. The PASARR did not answer the question whether the resident should or should not be referred for a Level II. No further information and/or documentation was presented prior to the exit conference on 03/21/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #29 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included sepsis, type 2 diabetes, hypertension, malnutrition, acute gastritis, stage IV pressure wound, multifactoria dementia, deafness requiring cochlear implant, hepatitis C, and chronic obstructive pulmonary disease (COPD). The most recent minimum data set (MDS) dated [DATE], a quarterly assessment, assessed Resident #29 as being severely cognitively impaired with a score of 03 out of 15 for daily decision making. The state agency received 2 facility reported incidents (FRI) regarding Resident #29 being found outside. The first FRI was dated June 5, 2018 documented the following: [Resident #29] was found on ground, outside, beside wheelchair. Resident sent to hospital via 911. The second FRI was dated November 28, 2018. On 03/20/19, Resident #29's clinical record was reviewed. An readmission assessment was completed on 04/09/18 at 17:30 p.m. and documented the following under the elopement risk evaluation: 1. Is resident cognitively impaired? Response: Yes 2. Is resident independently mobile (ambulatory or wheelchair)? Response: Yes 3. Does resident have poor decision making skills? Response: Yes 4. Has resident demonstrated exit-seeking behaviors? Response: Yes 5. Does resident wander oblivious to safety needs? Response: Yes 6. Does resident have a a history of elopement? If yes, # of times, if known ___ (left blank). Response: Yes 7. Does resident have the ability to exit the facility? Response: Yes The elopement risk evaluation documented the following: YES to questions 4, 5, or 6 automatically place the resident AT RISK. Based on potential risk factors above, resident is determined to be AT RISK for elopement. Response: Yes .If it is determined that the resident has eloped, implement care plan immediately to ensure resident's safety. Report all residents AT RISK to the Director of Clinical Services and on the 24-Hour Report. Resident #29's care plan which were in place at the time of the readmission [DATE] were reviewed and documented the following: Focus: [Resident #29] has inappropriate behaviors. AEB (as evidenced by) sexually inappropriate behavior, other behaviors include hitting, refusing care, yelling, attempt to elope. Date initiated 02/13/2018. Revision on 10/18/2018. Goals: [Resident #29] will not display inappropriate sexual behaviors towards staff through next review. Date initiated: 02/13/2018. Revision on 10/18/18. Interventions: Wander Guard protocol. Date initiated 06/26/2018. Revision on 10/18/18. There were no person centered interventions regarding elopement risk or supervision. The intervention for wander guard protocol was not initiated until 06/26/18, after the elopement risk assessment on 04/9/18 which documented Resident #29 as at risk for elopement, and after the resident was found outside with injury on 06/05/18. On 03/21/19 at 10:30 a.m., the director of nursing (DON) was interviewed regarding the lack of person centered interventions regarding Resident #29 for elopement risk, wandering and supervision. The DON stated Resident #29 had always been allowed to go outside unsupervised as the facility had a discussion with his sister about letting him go outside because he enjoyed the sunny weather. The DON stated Resident #29 was safe to be outside alone and he would let himself in/out of the patio door. The DON was interviewed regarding the re-admission assessment on 04/09/18 which assessed Resident #29 as an elopement risk. The DON stated Resident #29 was an elopement risk, however, at the time of the assessment he had not tried to elope. The DON was asked to review the care plan which was initiated on 02/13/18 with a focus area documenting Resident #29's behaviors that included attempted to elope. The DON stated the nurse who completed the readmission assessment on 04/09/18 was no longer employed at the facility and there should have been a care plan to address the elopement, wandering and supervision. The DON stated she did update the care plan to include the wander guard after the June 5, 2018 incident when Resident #29 was found outside alone on the ground. These findings were discussed during a meeting on 03/21/19 at 4:50 p.m., with the Administrator, Director of Nursing and Nurse Consultant.3. Resident #59 admitted to the facility on [DATE]. Diagnoses included, but were not limited to: anemia, thyroid disorder, osteoarthritis, MS (multiple sclerosis), anxiety disorder, depression, neuralgia, neuritis, chronic pain syndrome, intractable migraines, and opioid abuse. An annual MDS (minimum data set) dated 05/30/18 documented the resident was a score of 15 for cognition, indicating the resident was cognitively intact for daily decision making skills. The resident was documented with a score of 23 [range 0-27] for total severity of mood and was also assessed on this MDS as having potential for self harm. The resident was extensive assist with most ADLs (activities of daily living) with at least one person assist. The resident triggered for cognition, ADL function, urinary, mood, psychosocial, behavior, falls, nutrition, psychotropic drug use, and pain in the CAAS (care area assessment summary) section of this MDS. A quarterly assessment dated [DATE] was reviewed and documented the resident's cognitive score of 15 (intact for daily decision making skills) and the total mood score was 20. A significant change assessment dated [DATE] documented the resident with a cognitive score of 15 indicating the resident was intact for daily decision making skills. The total severity score for mood on this MDS was scored 16. The resident was also documented as having delusions and verbal behaviors toward others, with the presence of overall behavioral symptoms as worse. The resident was assessed as requiring limited assistance with at least one person assist for most ADLs (physical improvement from last MDS assessment). A complaint investigation was completed on Resident #59 on 03/19/19 through 03/21/19. An allegation within the complaint alleged that Resident #59 injured self (10/27/18) with a disposable razor that was not a facility issued item, 911 was called and the resident was taken to the hospital and then readmitted back to the facility on [DATE]. Resident #59's closed clinical records were reviewed. The resident's physician order sheet and interim plan of care dated 08/17/17 (original admission) was reviewed and documented, the resident as having .vitamin B 12 deficiency, opioid abuse, MS, migraines, GERD, anxiety, major depressive disorder, hypothyroidism, chronic pain syndrome, osteoporosis, neuralgia and neuritis. The treatment/care plan was to: adjust to nursing facility placement for long term care .regular diet .may participate in activity and general conditioning program as desired, may attend religious and social activities without limitations or precautions unless otherwise notes . The resident's POS (Physician order set) for 10/01/18 through 10/31/18 were reviewed and documented, .CPR .Regular mechanical soft diet .PAPER PLATES AND PLASTIC UTENSILS ONLY .bed against the wall . A review of the clinical record revealed one psychiatric consult dated 02/06/18. This consult documented, .seen evaluated .follow up depression last seen Nov. 2017 .today she looks much brighter than at previous visits . sleep: ok food: if you can call it food! .sitting up in bed .pleasant and cooperative with good eye contact .MOOD: 'This isn't any way to live' .looks brighter today .continue current meds. if depression symptoms persist, could increase .[wellbutrin 150 mg ER] to BID .can also consider trial of [effexor XR] in lieu of [zoloft] .discuss pt status with POA .signature of psychiatry/neurobehavioral services. On 03/21/19 at 9:45 AM, the SW (social worker) was interviewed regarding Resident #59. The SW was asked about the MDS information for this resident. The SW stated that if a resident answers the last question in that section with yes, then that triggers a response for the following question which asked if staff or provider were informed that there is a potential for resident self harm. The SW stated that is why that is marked yes, indicating that staff and/or the provider were made aware of this information. The SW was asked if this information should be care planned for the resident. The SW stated that it should be and thought it was for this resident. The SW was asked for the CAAS (care area assessment summary) worksheets for mood and behavior for the MDS assessments. The SW presented CAAS worksheet for the annual MDS assessment and for the significant change MDS assessment. The CAAS worksheet dated 05/30/18 documented, .psychosocial well being .The resident has a actual problem .often declines activities .depression .decline in ADL's .Mood or behavior problem that impacts interpersonal relationships .falls, pain .care planning for this problem, what is the overall objective: improvement .Describe impact of this problem .include complications and risk factors and the need for referral to other health professionals: Is a referral to another discipline warranted? No .Mood State: Resident has had thoughts that he/she would be better off dead, or thoughts of hurting him/herself as indicated by: Thoughts that you would be better off dead, or of hurting yourself in some way .yes .Analysis of Findings: has a actual problem with feeling hopeless .reported that at times she feels that she would be better off dead due to her illness .Relapse of an underlying mental health problem .Psychiatric disorder, anxiety, depression, manic depression .pain .mental health and health issues contribute to thoughts of not living. The resident is often observed throughout the day in bed in and out of sleep .Mood State- care planning for this problem, what is the overall objective: improvement Behavioral Symptoms .has a actual problem with rejecting ADL care .needs several prompts and encouragement from staff for bathing and dressing .Seriousness of the behavioral symptoms: Resident is immediate threat to self - IMMEDIATE INTERVENTION REQUIRED .Resident's behavior status, care rejection, or wandering has worsened since last assessment .At times the resident has thoughts of being better off dead. The resident has a dx [diagnosis] of MS which contributes to feelings of hopelessness, stressed that she gets sad when she thinks about being 'crippled up in the bed' .Care plan consideration Will behavioral symptoms- functional status be addressed in the care plan? Yes .Improvement .Referral to Other Disciplines: Is a referral to another discipline warranted? No . The CAAS worksheet dated 08/17/18 documented, .psychosocial well being .verbal behavioral symptoms .actual problem with verbal behavior when she is unable to get her way .curses and calls staff names .has thrown food tray on the floor and thrown objects Depression .Mood or behavior problem that impacts interpersonal relationships .overall objective: improvement .minimize risks .Describe impact of this problem .include complications and risk factors .Is a referral to another discipline warranted? No .Mood State: has actual problem with regulating her mood .depression and anxiety .stressed that the pain caused by her MS and inability to walk makes her sad .Delusions .antipsychotics .improvement, slow or minimize decline .minimize risks .Care plan consideration Will Mood State- functional status be addressed in the care plan? Yes .Improvement .Is a referral to another discipline warranted? No .Referral: No . The resident's CCP (comprehensive care plan) was reviewed prior to self harm incident (10/27/18) and documented, .is dependent on staff for activities, cognitive stimulation, social interaction .engage in activities .explain the importance of social interaction, encourage participation .in room visits .music .provide a calm non rushed environment .reality orientation .report c/o [complaints of] pain, discomfort .or any other c/o that interferes with resident's ability to participate .to the nurse .needs assistance/escort to and from activity .impulsive behavior .history of throwing glass plates when she becomes upset .psychotropic med use .adaptive equipment .walker/wheelchair .anticipate and meet the residents needs .keep needed items .in reach .medication as ordered .[name of resident] needs a safe environment .Resident to received plastic silverware and Styrofoam plates/bowls for all meals .keep call bell in within easy reach .medication as per physician order .monitor and report restlessness, agitation, confusion .monitor and report to MD [medical doctor] s/sx [signs and symptoms] of depression. Obtain order for mental health consult if needed .monitor and report medication side effects and effectiveness every shift .ADL-Observe skin for redness, open areas, scratches, cuts, bruises and report changes to nurse .bathing: provide resident with a sponge bath when a shower can not be tolerated .provide the resident with assistance to bathe daily and as needed .psychoactive use .antidepressant .depression .antipsychotic .depression .antianxiety .anxiety/agitation . non drug interventions- monitor behavioral symptoms and side effects such as appetite changes, memory impairment .antidepressants: report .signs and symptoms of depression or problematic side effects to practitioner .antipsychotic- monitor behavioral symptoms . evaluate medication response and resident's response quarterly .if side effect present report to practitioner .medication as ordered .non drug interventions-see behavior care plan .educate patient .on consequences of poor behavior choices/non compliance .encourage group activities .encourage resident to express feelings .monitor for increase in behaviors or unsafe behaviors and report to physician as needed .impaired thought processes .monitor and report to MD any changes in cognitive function, specifically changes in decision making ability, memory, recall, and general awareness .distress of yelling out when she is not due for pain medications, emotional distress .throwing items and cursing staff and c/o chronic unrelieved pain .anticipate the resident's need for pain relief .assess coping strategies .attempt non pharmacological interventions .distraction .express feelings .monitor and report to nurse resident complaints of pain or requests for pain treatment .monitor and report to .nurse .mood/behavior changes, more irritable, restless, aggressive, squirmy, constant motion .psych consult as needed . No information and/or documentation regarding the resident's thoughts of death or thoughts/risks of self harm were found anywhere on the resident's CCP. The nursing notes were reviewed for this resident for 2018. A nursing note dated 10/25/18 (no time stamp) documented, At approximately 10 AM this writer was alerted to the front lobby where I was met by a police officer, patient had called 911 stated that she was ringing her call light since 8:15 with no answer. Escort police officer X 3 to patients room patient stated that she had migraine [sic] and nurse would not provide me [sic] with medications for my migraine this nurse offered PRN [as needed] Zomig - schedule excedrine patient refused stated, 'your not a nurse your uneducated go back to school, I'm gonna sue the doctor for malpractice police officer talked with patient to .while offered to send patient to ER [emergency room] patient refused MD notified no new medication order per MD narcotic not appropriate for migraines - patient had requested 'strong' pain medication patient refused am medications - prior to police arrival patient had thrown tray across room when asked why she stated 'I can't eat that' per CNA [certified nursing assistant] statement she had placed breakfast tray in at approximately 8:00 AM and had been in room X 2 between then and 9:30 and nurse (LPN) stated that she had also been in patients room between those times patient aware of no new medications patient told this RN to get out of my room again stated that she was going to sue the MD no further behaviors this shift . 10/27/18 at 3:45 PM staff reported resident requested to see nurse this nurse responded immediately to find resident cutting L [left] wrist inner with shaving razor this nurse repeatedly asked resident to stop she stated 'no I want morphine' this nurse removed razor from resident and applied towel with pressure to L inner wrist resident attempted to kick this writer yelling 'I have to wait 20 more minutes before I can have my medicine and I don't want to wait' staff stayed 1:1 with resident while this nurse called 911 for transport to ED [emergency department], ADON [assistant director of nursing], notified immediately of incident, MD notified . On 03/21/19 at approximately 11:30 AM, the administrator, DON and corporate nurse were made aware of serious concerns with Resident #59 in a meeting with the survey team. The facility staff were made aware of the lack of interventions and/or services provided to prevent accidents/self harm for this resident. The facility staff were made aware that this resident had been identified by facility staff as a high risk for self harm in May of 2018, as documented above, and no new interventions were developed and/or implemented for the prevention of accidents, the resident's CCP did not address these concerns. The resident's discharge summary from the hospital dated 10/30/18 documented, .admission Primary diagnosis: Status migrainous, intractable and suicidal ideation .history notable for multiple sclerosis, chronic migraines, depression COPD, opioid use disorder and suicide attempt due to medication overdose who presented to the ED after attempted suicide .onset of a migraine 2 weeks ago .she reports she has not been sleeping for months. She says the pain was so bad that she decided to cut her wrist .she continues to endorse active suicidal ideation .she attributed her suicidal ideation to her intractable severe migraines. Psychiatry evaluated the patient and felt her presentation was consistent with an adjustment disorder with mixed disturbance of emotions and conduct .she denied suicidal ideation when reevaluated by psychiatry on 10/30/18 .cleared for discharge back to her skilled nursing facility .ambulatory referral to [name of psychiatrist] or .may continue to follow with the psychiatrist's at the SNF. No further information and/or documentation was presented prior to the exit conference on 03/21/19 at 6:15 PM to evidence the facility staff developed and/or implemented interventions for the prevention of self harm for Resident #59, after the resident had been identified as having a high mood score and as being identified as a risk for self harm. THIS IS A COMPLAINT DEFICIENCY. Based on observation, staff interview and clinical record review, the facility staff failed to develop a comprehensive care plan for three of 19 residents in the survey sample. 1. Resident #23 had no plan of care regarding use of plastic eating utensils due to unsafe behaviors. 2. Resident #29 had no individualized care plan developed regarding unsafe wandering and elopement prevention. 3. Resident #59 had no comprehensive plan of care regarding suicidal ideation. The findings include: 1. Resident #23 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #23 included dementia, dysphasia, high blood pressure and history of hip fracture. The minimum data set (MDS) dated [DATE] assessed Resident #23 with severely impaired cognitive skills. On 3/19/19 at 12:30 p.m., Resident #23 was observed eating lunch in her room. The resident was using plastic utensils while eating. The meal ticket on Resident #23's lunch tray documented, Plastic Silverware. Resident #23's clinical record documented a dietary slip dated 9/6/18 stating, Please only give plastic utensils. Resident #23's plan of care (dated 3/17/19) included no problems, goals and/or interventions regarding the use of plastic utensils. The care plan listed the resident had paranoid behaviors, aggression and was at times physically abusive to staff. Interventions to minimize behaviors made no mention of plastic eating utensils. This plan of care listed the resident had potential for nutritional problems due to dementia but made no mention of the use of plastic utensils. On 3/21/19 at 8:07 a.m., the dietary manager was interviewed about plastic utensils provided for Resident #23. The dietary manager stated the resident was not safe to have the standard, stainless utensils. The dietary manager stated Resident #23 had attempted to pry towel racks from the wall and had been aggressive with staff using the standard silverware. On 3/21/19 at 8:10 a.m., the licensed practical nurse (LPN #2) caring for Resident #23 was interviewed about the plastic utensils. LPN #2 stated the resident about a year ago tried to stab staff members with the knife from her meal tray. LPN #2 stated the resident also attempted to pry room items with the standard utensils. On 3/21/19 at 8:15 a.m., LPN #3 responsible for care plan development was interviewed about Resident #23. LPN #3 reviewed the care plan and stated she did not see anything on the plan regarding the plastic utensils. LPN #3 stated she was not aware the resident used plastic utensils and did not recall discussing plastic utensils during the last care plan review. These findings were reviewed with the administrator and director of nursing during a meeting on 3/21/19 at 4:50 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to review and revise a comprehensive care plan for one of nineteen residents. Resident #20's care plan was not revised regarding code status. The findings include: Resident #20 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included eczema, bursitis of hip, perforated appendicitis, muscle weakness, chronic bronchitis, dementia with behaviors, depression, hypertension and anorexia. The most recent minimum data set (MDS) dated [DATE], was a significant change and assessed Resident #20 as severely cognitively impaired with a score of 01 out of 15 for daily decision making. Resident #20's clinical record was reviewed on 03/20/18 at 10:00 a.m. Observed on the physician's order form were orders for Do Not Resuscitate - Do Not Intubate, dated 12/22/18. Resident 20's care plans were reviewed and documented the following: Focus - [Resident #20], has advance directives r/t (related to) his choice not to execute advance directives. [Resident #20] is a full code. Date Initiated: 11/28/2018. Created by: [Social Worker]. On 03/21/19 at 9:43 a.m., the social services director (OS #3) was interviewed regarding Resident #20's code status care plan. OS #3 stated Resident #20 code status is currently a DNR (do not resuscitate). OS #3 stated he updates the care plans as soon as he is notified of any changes. OS #3 stated when the code status change was made in December he changed it on his audit sheet, but he never updated the care plan. He stated it was just an oversight. These findings were discussed during a meeting on 03/21/19 at 4:50 p.m., with the Administrator, Director of Nursing and Nurse Consultant.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, clinical record review and staff interview, the facility staff failed to implement a bowel regimen program for one of 19 residents in the survey sample, Resident #26. Resident #26 stated that he had not had a bowel movement in 5 days and was uncomfortable. Findings include: Resident # 26 was admitted to the facility on [DATE]. Diagnoses for Resident #26 included, but were not limited to: atrial fibrillation, high blood pressure, anxiety disorder and depression. The most recent MDS (minimum data set) was a 14 day admission assessment dated [DATE]. This MDS documented the resident with a cognitive score of 14, indicating the resident was cognitively intact for daily decision making skills. The resident also was assessed as requiring supervision with one person physical assist for most all ADL's except bathing, which was extensive assist of person. He was coded a 0 (always continent) for bowel and 1 for urinary (occasional incontinent). On 03/20/19 at approximately 2:30 PM, the resident stated to this surveyor that he had not had a BM (bowel movement) in 5 days and was having problems and he needed help. The resident stated that he needed a suppository and that would help him, but for some reason the staff would not give him one. The resident stated that he had this problem about a month ago, ended up straining to go to the bathroom and went to the hospital for chest pain. Resident #26's clinical records were reviewed and revealed the resident had current orders for Colace 100 mg (milligrams) two caps by mouth once daily for bowel aid, and also a current order for Miralax 17 grams once every day for constipation. The resident's current CCP (comprehensive care plan) documented, .Toilet Use: [name of resident] is able to toilet himself independently/with supervision of staff .notify nursing of incontinent episodes .unobstructed path to bathroom . The resident's MARS (medication administration records) were reviewed and revealed documentation that the above medications were administered per physician's orders. The resident's bowel records were then reviewed for February and March 2019. The resident's bowel records for February documented that Resident #26 did not have a bowel movement for 10 days. During this 10 period there were several blank boxes that did not document anything for this resident regarding a BM. The March 2019 bowel records were then reviewed and documented that the resident went 5 days without a BM. During this time frame, two days were completely blank. Additionally in March it was documented that the resident had not had BM for 8 days (this is the time frame the Resident stated no BM for 5 days); for this time period there were two days without any documentation to reveal if the resident had a BM or not. On 03/20/19 at 10:13 AM, Resident #26 was interviewed. The resident stated that the facility staff finally gave him a suppository yesterday. The resident stated that he did have a BM as result of the suppository and felt better. The resident stated that he gets like that sometimes and he knows what works for him, but feels the staff don't listen. The resident stated that he has a heart condition (atrial fibrillation) and is not supposed to be straining to go to the bathroom. The resident stated that he has had this problem for a long time and is not new. The resident stated that he will tell the staff whether or not he has a BM, if staff ask. The resident then stated if they don't ask, he doesn't always remember to tell them. The resident then stated that, If I go to them and tell them I haven't had a BM, then I haven't had one. The resident stated that they wanted to do things their way. The DON (director of nursing) and administrator were made aware in a meeting with the survey team on 03/20/19 at approximately 3:00 PM of the resident's concerns and documented bowel records. A bowel protocol was requested at this time. The DON stated that this resident can become obsessed with his bowels and further stated that there are blanks on the bowel records. The DON was made aware that this resident is alert and oriented and perfectly capable of knowing when he has had a BM or not and is able to communicate that to nursing staff if the resident is asked. On 03/21/19 at approximately 11:00 AM, the DON presented a BM worksheet. This worksheet documented, .is filled in by nursing assistant each shift .is kept at the desk on a clipboard .accessible to the nursing assistant .Do not leave a blank space .the BM worksheet .identifies the need for additional interventions .If the resident has not had a BM by the third day, he/she is given a laxative or suppository, depending upon the circumstance and physician orders. The nurse checks the resident's order sheet making sure there is laxative or suppository order. The DON stated that, if there is no BM in 3 days, we will use a PRN (as needed) order that is already ordered or notify the physician for the need for an order. The DON stated that this resident has current orders, but does not have a PRN and stated that there are no standing orders that can be used. The DON stated that the resident got a one time order yesterday for the suppository. No further information and/or documentation was presented prior to the exit conference on 03/21/19 at 6:15 PM to evidence that the facility's Bowel Protocol was implemented for Resident #26.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, facility document review and in the course of a complaint investigation, the facility staff failed to ensure supervision for the prevention of accidents for one of 19 residents in the survey sample, Resident #29. Resident #29 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included sepsis, type 2 diabetes, hypertension, malnutrition, acute gastritis, stage IV pressure wound, multifactoria dementia, deafness requiring cochlear implant, hepatitis C, and chronic obstructive pulmonary disease (COPD). The most recent minimum data set (MDS) dated [DATE], a quarterly assessment, assessed Resident #29 as being severely cognitively impaired with a score of 03 out of 15 for daily decision making. The state agency received 2 facility reported incidents (FRI) regarding Resident #29 being found outside. The first FRI was dated June 5, 2018 which resulted in Resident #29 being sent to the local emergency room. The second FRI was dated November 28, 2018. The state agency received a facility reported incident (FRI) on 06/05/18 that documented an injury of unknown origin. The report documented the following: [Resident #29] was found on ground, outside, beside wheelchair. Resident sent to hospital via 911. The follow-up investigation report was received by the state agency on 06/08/18. The follow-up report documented the following: On June 5, 2018, [Resident #29] was found by facility staff on ground, next to his wheelchair. [Resident #29] was assessed by nursing staff and found to be swollen in his left temporal area. No lacerations or contusions were evident. [Resident #29] was transported to a local hospital Emergency Department for evaluation and returned to the facility the same day .An investigation was completed on 6/8/18 to include employee interviews. After investigation, facility determined [Resident #29] injuries were consistent with a fall from a wheelchair. [Resident #29] does not show any signs and symptoms of psychosocial distress. The investigation report was signed by the facility administrator. On 03/20/19 the facility's investigation was reviewed. The investigation documented only one witness statement from the facility's maintenance director (OS #2). The witness statement documented the following: On June 5, 2018, I walked out the patio door and found [Resident #29] laying on the ground by the drink machine. I then went and got the nurse, and brung them to him. The witness statement was signed by the OS #2 and the facility's administrator. On 03/20/19, Resident #29's clinical record was reviewed. An readmission assessment was completed on 04/09/18 at 17:30 p.m. and documented the following under the elopement risk evaluation: 1. Is resident cognitively impaired? Response: Yes 2. Is resident independently mobile (ambulatory or wheelchair)? Response: Yes 3. Does resident have poor decision making skills? Response: Yes 4. Has resident demonstrated exit-seeking behaviors? Response: Yes 5. Does resident wander oblivious to safety needs? Response: Yes 6. Does resident have a a history of elopement? If yes, # of times, if known ___ (left blank). Response: Yes 7. Does resident have the ability to exit the facility? Response: Yes The elopement risk evaluation documented the following: YES to questions 4, 5, or 6 automatically place the resident AT RISK . Based on potential risk factors above, resident is determined to be AT RISK for elopement. Response: Yes . If it is determined that the resident has eloped, implement care plan immediately to ensure resident's safety. Report all residents AT RISK to the Director of Clinical Services and on the 24-Hour Report. Resident #29's care plan which was in place at the time of the readmission [DATE] was reviewed and documented the following: Focus: [Resident #29] has inappropriate behaviors. AEB (as evidenced by) sexually inappropriate behavior, other behaviors include hitting, refusing care, yelling, attempt to elope. Date initiated 02/13/2018. Revision on 10/18/2018. Goals: [Resident #29] will not display inappropriate sexual behaviors towards staff through next review. Date initiated: 02/13/2018. Revision on 10/18/18. Interventions: Wander Guard protocol. Date initiated 06/26/2018. Revision on 10/18/18. There were no person centered interventions regarding elopement risk or supervision. The intervention for wander guard protocol was not initiated until 06/26/18, after the elopement risk assessment on 04/9/18 which documented Resident #29 as at risk for elopement, and after the resident was found outside with injury on 06/05/18. A review of the emergency room visit on 06/05/18 documented the following: .Apparently EMS noted that his pupils [Resident #29] were not reacting, however they are reactive here. I did order the CT which shows no acute abnormality. His sister [name] is now here and states he is aback to his baseline. Therefore we will discharge him back to [name of facility] and she will sign the paperwork to put him back in hospice. She is comfortable with this plan. The emergency room visit was signed by the attending ER physician on 06/05/18 at 20:44 (8:45 p.m.). On 03/21/19 at 10:00 a.m., the maintenance director (OS #2) was interviewed about the FRI which took place on June 5, 2018. OS #2 stated he was going outside on the patio for his smoke break and observed Resident #29 laying on the ground near the soda machine. OS #2 stated there was no one else outside with Resident #29. OS #2 stated Resident #29 did not say how he fell, only said get me up. OS #2 stated he hollered up the hall to the nursing station for a nurse to come and assess Resident #29. On 03/21/19 at 10:30 a.m., the director of nursing (DON) was interviewed about the FRI which took place on 06/05/18. The DON stated she was on vacation when the incident took place. The DON stated Resident #29 had always been allowed to go outside unsupervised as the facility had a discussion with his sister about letting him go outside because he enjoyed the sunny weather. The DON continued and stated Resident #29 was safe to be outside alone and he would let himself in/out of the patio door. The DON was interviewed regarding the re-admission assessment on 04/09/18 which assessed Resident #29 as an elopement risk. The DON stated Resident #29 was an elopement risk; however, at the time of the assessment he had not tried to elope. The DON was asked to review the care plan which was initiated on 02/13/18 with a focus area documenting Resident #29's behaviors that included attempted to elope. The DON stated the nurse who completed the readmission assessment on 04/09/18 was no longer employed at the facility and there should have been a care plan to address the elopement and supervision. The DON stated she did update the care plan to include the wander guard after the June 5, 2018 incident when Resident #29 was found outside alone on the ground. The state agency received a FRI on November 29, 2018 that documented the following incident type: Resident Elopement. The FRI documented the following: [Resident #29] was observed by staff outside of building while on facility property. [Resident #29] immediately assisted back inside by staff without injury or resistance. An assessment was completed by the charge nurse identifying no new signs or symptom of impairments or psychosocial distress The facility's follow-up investigation documented the following: .It was determined [Resident #29] was unsupervised on the enclosed porch area outside. This permitted [Resident #29] to access the front parking lot where he was observed and subsequently returned to the facility. The Director of Nursing immediately began a all staff education initiative on resident supervision when on the porch. Upon return to the floor, an assessment was completed on [Resident #29] by the Charge Nurse identifying no new signs or symptoms of impairments or psychosocial distress. As skin assessment was performed, no marks, bruising/scrapes noted. [Resident 29] did not complain of pain or discomfort. Neurological checks were found to be within normal limits. [Resident was placed on safety checks]. The investigative report was signed by the administrator. A review of the facility's investigation documented the following witness statements from two nurses who were on duty the night of the incident: Nurse #1: 2140 - this nurse administered medication to resident at nurses station. resident self propelled in w/c towards patio door 2141 - alarm at patio door activated, this nurse turned alarm off made visual contact with resident, this nurse advised res (resident) is allowed by facility to be on patio unsupervised 2145 - this nurse walked out front door to facility observed res sitting/scooting around at edge of parking lot. immediately requested assistance from staff. resident assisted in w/c, wheeled inside, assisted to bed, vs/neuro vs done. skin assessment completed. administrator notified. Nurse #2: On Wednesday November 28, 2018 at 2140, [Resident #29] came to the nursing station and headed toward the smoking area as he has always been doing since he has been in the facility. The nurse [Nurse #1] asked me if resident is allowed to go to the smoking area by himself which I responded yes because that is what I was told by [Facility Administrator] back in April this year that the resident is allowed to go there (Smoking Area) alone. Five minutes later, [Nurse #1] saw him at the parking lot attempting to open a car door. He was brought inside without any issues. It was discovered that the resident opened an unlocked door from the smoking area behind the ED's office and went to the parking lot. On 3/21/19, the DON was interviewed about the FRI which took place on 11/28/19 when the resident was found outside in the parking lot at 9:45 p.m. The DON stated [Resident #29] did have the wanderguard in place at the time of the November 28, 2018 incident. She continued and stated Resident #29 was allowed to go outside alone during the day and good weather for brief periods because he enjoyed the sunshine and it helped decrease his behaviors. The DON stated when the resident propels himself to the patio door and activate the alarms, staff generally check to see why the resident wants to go outside which is mostly for smoke breaks and will encourage him to come back inside or provide diversions (i.e. food, soda, etc). However, sometimes staff will deactivate the alarm and allow Resident #29 to go outside if it will de-escalate behaviors. The DON continued and stated the nurse who turned off the alarm and allowed Resident #29 to go outside alone on November 28, 2018 was a relatively new nurse and did not fully utilize her critical thinking skills when she allowed the resident to go outside alone on the patio especially at that time of night. The DON stated based on the investigation Resident #29 was able to open the unlocked patio gate door which leads to the facility parking lot and this is where he was found in the parking lot attempting to open a car door. This resulted in the facility reviewing the outside patio gate door as an exit and now it is pad-locked per the building inspector. Nurse #1 was not available for interview during the survey. Nurse #2 was no longer employed by the facility and not available for interview. These findings were discussed during a meeting on 03/21/19 at 4:50 p.m., with the Administrator, Director of Nursing and Nurse Consultant. This is a complaint deficiency. Based on staff interview, clinical record review, facility document review and in the course of a complaint investigation, the facility staff failed to ensure supervision for the prevention of accidents for one of 19 residents in the survey sample, Resident #29. Resident #29, assessed as an elopement risk was not provided supervision and found outside of the facility on June 5, 2018 and November 28, 2018. Findings include: Resident #59 admitted to the facility on [DATE]. Diagnoses included, but were not limited to: anemia, thyroid disorder, osteoarthritis, MS (multiple sclerosis), anxiety disorder, depression, neuralgia, neuritis, chronic pain syndrome, intractable migraines, and opioid abuse. An annual MDS (minimum data set) dated 05/30/18 documented the resident was a score of 15 for cognition, indicating the resident was cognitively intact for daily decision making skills. The resident was documented with a score of 23 [range 0-27] for total severity of mood and was also assessed on this MDS as having potential for self harm. The resident was extensive assist with most ADLs (activities of daily living) with at least one person assist. The resident triggered for cognition, ADL function, urinary, mood, psychosocial, behavior, falls, nutrition, psychotropic drug use, and pain in the CAAS (care area assessment summary) section of this MDS. A quarterly assessment dated [DATE] was reviewed and documented the resident's cognitive score of 15 (intact for daily decision making skills) and the resident's total mood score was 20, still a high score of depressed mood. Section: D03050. Safety Notification: was blank. A significant change assessment dated [DATE] documented the resident with a cognitive score of 15 indicating the resident was intact for daily decision making skills. The total severity score for mood on this MDS was scored 16. The resident was also documented as having delusions and verbal behaviors toward others, with the presence of overall behavioral symptoms as worse. The resident was assessed as requiring limited assistance with at least one person assist for most ADLs (physical improvement from last MDS assessment). A complaint investigation was completed on Resident #59 on 03/19/19 through 03/21/19. An allegation within the complaint alleged that Resident #59 injured self (10/27/18) with a disposable razor that was not a facility issued item, 911 was called and the resident was taken to the hospital and then readmitted back to the facility on [DATE]. Resident #59's closed clinical records were reviewed. The resident's physician order sheet and interim plan of care dated 08/17/17 (original admission) was reviewed and documented, the resident as having .vitamin B 12 deficiency, opioid abuse, MS, migraines, GERD, anxiety, major depressive disorder, hypothyroidism, chronic pain syndrome, osteoporosis, neuralgia and neuritis. The treatment/care plan was to: adjust to nursing facility placement for long term care .regular diet .may participate in activity and general conditioning program as desired, may attend religious and social activities without limitations or precautions unless otherwise notes . The resident's POS (Physician order set) for 10/01/18 through 10/31/18 was reviewed and documented, .CPR .Regular mechanical soft diet .PAPER PLATES AND PLASTIC UTENSILS ONLY .bed against the wall . No orders for psychiatric services were found. A review of the clinical record revealed one psychiatric consult dated 02/06/18. This consult documented, .seen evaluated .follow up depression last seen Nov. 2017 .today she looks much brighter than at previous visits . sleep: ok food: if you can call it food! .sitting up in bed .pleasant and cooperative with good eye contact .MOOD: 'This isn't any way to live' .looks brighter today .continue current meds. if depression symptoms persist, could increase .[wellbutrin 150 mg ER] to BID .can also consider trial of [effexor XR] in lieu of [zoloft] .discuss pt status with POA .signature of psychiatry/neurobehavioral services. The resident's physician's orders were reviewed from 02/2018 through 10/2018 and did not reveal either of the recommendations were implemented during this time. On 03/21/19 at approximately 9:00 AM, the administrator was asked for the investigation regarding Resident #59's self harm. On 03/21/19 at 9:45 AM, the SW was interviewed regarding Resident #59. The SW was asked about the MDS information for this resident. The SW stated that he completes sections C [cognitive patterns], D [Mood], and E [behavior] on the MDS. The SW was asked about Resident #59's annual MDS assessment dated May of 2018, specifically regarding the resident's high mood score along with documented concerns for self harm. The SW stated that if a resident answers the last question in that section with yes, then that triggers a response for the following self harm question which asked if there is a potential for resident self harm. The SW stated that is why that is marked yes, indicating knowledge of staff and/or the provider of potential for self harm regarding this resident. The SW was asked about the quarterly assessment in July (Mood Score 20) and the significant change assessment in August (Mood Score 16). The SW stated that the resident still had a high mood score, but did not voice hurting herself on those. The SW was asked if this type of information (self harm) should be care planned for the resident. The SW stated that it should be and thought it was for Resident #59. The SW was asked for the CAAS (care area assessment summary) worksheets for mood and behavior for the MDS assessments. The SW presented CAAS worksheet for the annual MDS assessment and for the significant change MDS assessment. The CAAS worksheet dated 05/30/18 documented, .psychosocial well being .The resident has a actual problem .often declines activities .depression .decline in ADL's .Mood or behavior problem that impacts interpersonal relationships .falls, pain .care planning for this problem, what is the overall objective: improvement .Describe impact of this problem .include complications and risk factors and the need for referral to other health professionals: Is a referral to another discipline warranted? No .Mood State: Resident has had thoughts that he/she would be better off dead, or thoughts of hurting him/herself as indicated by: Thoughts that you would be better off dead, or of hurting yourself in some way .yes .Analysis of Findings: has a actual problem with feeling hopeless .reported that at times she feels that she would be better off dead due to her illness .Relapse of an underlying mental health problem .Psychiatric disorder, anxiety, depression, manic depression .pain .mental health and health issues contribute to thoughts of not living. The resident is often observed throughout the day in bed in and out of sleep .Mood State- care planning for this problem, what is the overall objective: improvement Behavioral Symptoms .has a actual problem with rejecting ADL care .needs several prompts and encouragement from staff for bathing and dressing .Seriousness of the behavioral symptoms: Resident is immediate threat to self - IMMEDIATE INTERVENTION REQUIRED .Resident's behavior status, care rejection, or wandering has worsened since last assessment .At times the resident has thoughts of being better off dead. The resident has a dx [diagnosis] of MS which contributes to feelings of hopelessness, stressed that she gets sad when she thinks about being 'crippled up in the bed' .Care plan consideration Will behavioral symptoms- functional status be addressed in the care plan? Yes .Improvement .Referral to Other Disciplines: Is a referral to another discipline warranted? No . The CAAS worksheet dated 08/17/18 documented, .psychosocial well being .verbal behavioral symptoms .actual problem with verbal behavior when she is unable to get her way .curses and calls staff names .has thrown food tray on the floor and thrown objects Depression .Mood or behavior problem that impacts interpersonal relationships .overall objective: improvement .minimize risks .Describe impact of this problem .include complications and risk factors .Is a referral to another discipline warranted? No .Mood State: has actual problem with regulating her mood .depression and anxiety .stressed that the pain caused by her MS and inability to walk makes her sad .Delusions .antipsychotics .improvement, slow or minimize decline .minimize risks .Care plan consideration Will Mood State- functional status be addressed in the care plan? Yes .Improvement .Is a referral to another discipline warranted? No .Referral: No . The resident's CCP (comprehensive care plan) was reviewed prior to self harm incident (10/27/18) and documented, .is dependent on staff for activities, cognitive stimulation, social interaction .engage in activities .explain the importance of social interaction, encourage participation .in room visits .music .provide a calm non rushed environment .reality orientation .report c/o [complaints of] pain, discomfort .or any other c/o that interferes with resident's ability to participate .to the nurse .needs assistance/escort to and from activity .impulsive behavior .history of throwing glass plates when she becomes upset .psychotropic med use .adaptive equipment .walker/wheelchair .anticipate and meet the residents needs .keep needed items .in reach .medication as ordered .[name of resident] needs a safe environment .Resident to received plastic silverware and Styrofoam plates/bowls for all meals .keep call bell in within easy reach .medication as per physician order .monitor and report restlessness, agitation, confusion .monitor and report to MD [medical doctor] s/sx [signs and symptoms] of depression. Obtain order for mental health consult if needed .monitor and report medication side effects and effectiveness every shift .ADL-Observe skin for redness, open areas, scratches, cuts, bruises and report changes to nurse .bathing: provide resident with a sponge bath when a shower can not be tolerated .provide the resident with assistance to bathe daily and as needed .psychoactive use .antidepressant .depression .antipsychotic .depression .antianxiety .anxiety/agitation . non drug interventions- monitor behavioral symptoms and side effects such as appetite changes, memory impairment .antidepressants: report .signs and symptoms of depression or problematic side effects to practitioner .antipsychotic- monitor behavioral symptoms . evaluate medication response and resident's response quarterly .if side effect present report to practitioner .medication as ordered .non drug interventions-see behavior care plan .educate patient .on consequences of poor behavior choices/non compliance .encourage group activities .encourage resident to express feelings .monitor for increase in behaviors or unsafe behaviors and report to physician as needed .impaired thought processes .monitor and report to MD any changes in cognitive function, specifically changes in decision making ability, memory, recall, and general awareness .distress of yelling out when she is not due for pain medications, emotional distress .throwing items and cursing staff and c/o chronic unrelieved pain .anticipate the resident's need for pain relief .assess coping strategies .attempt non pharmacological interventions .distraction .express feelings .monitor and report to nurse resident complaints of pain or requests for pain treatment .monitor and report to .nurse .mood/behavior changes, more irritable, restless, aggressive, squirmy, constant motion .psych consult as needed . No information was on the resident's CCP regarding any self harm, or statements of the resident stating, being better off dead', and there were no interventions to address these identified concerns. None of the information from the above MDS and/or CAAS Worksheets regarding this resident's risk for self harm was incorporated in any way into the resident's CCP. The progress and nursing notes were reviewed for this resident for 2018 and included the following: A progress note dated 06/01/18 documented, .continues to display inappropriate behaviors at times, she throws her food tray and other objects on the floor when she is unable to get her way, when upset .verbally abuses staff by cursing and calls them names based on skin color .prefers to lay in bed most of the day, struggles with staying safe .has had a few falls .signature of [social worker]. A progress note dated 07/12/18 documented, .threw food tray full of food onto floor, when given medications she throw back [sic] at nurse .attempted to pinch/punch and bite nurse and CNA that was assisting back into her w/c. [name of resident] propels to the nursing station and made allegations of sexual assault .[name of resident] started chasing female nurse in w/c which led to the sheriff department being called .investigate allegations of sexual assault .[name of resident] she struggle with [sic] recalling the behavior she displayed and stated she never said anybody sexually assaulted her .new med order for Ativan 1 mg will continue to monitor .SW A progress note dated 08/17/18 documented, Significant change .alert and oriented with some forgetfulness/confusion is able to recognize some staff by name, able to make needs known all needs met by nursing .often observed in bedroom by choice, this is often due to depression .Significant change due to ongoing behavior issues .SW A nursing note dated 09/8/18 documented, resident came out of room and demanded Tylenol. she then made rude statements and became agitated. Redirecting her didn't help .made paranoid statements about the Tylenol .went back to room and then came back out and accused us [staff] of removing pictures from her room . A nursing note dated 10/25/18 (no time stamp) documented, At approximately 10 AM this writer was alerted to the front lobby where I was met by a police officer, patient had called 911 stated that she was ringing her call light since 8:15 with no answer. Escort police officer X 3 to patients room patient stated that she had migraine [sic] and nurse would not provide me [sic] with medications for my migraine this nurse offered PRN [as needed] Zomig - schedule excedrine patient refused stated, 'your not a nurse your uneducated go back to school, I'm gonna sue the doctor for malpractice police officer talked with patient to .while offered to send patient to ER [emergency room] patient refused MD notified no new medication order per MD narcotic not appropriate for migraines - patient had requested 'strong' pain medication patient refused am medications - prior to police arrival patient had thrown tray across room when asked why she stated 'I can't eat that' per CNA [certified nursing assistant] statement she had placed breakfast tray in at approximately 8:00 AM and had been in room X 2 between then and 9:30 and nurse (LPN) stated that she had also been in patients room between those times patient aware of no new medications patient told this RN to get out of my room again stated that she was going to sue the MD no further behaviors this shift . A nursing note dated 10/27/18 at 3:45 PM documented staff reported resident requested to see nurse this nurse responded immediately to find resident cutting L [left] wrist inner with shaving razor this nurse repeatedly asked resident to stop she stated 'no I want morphine' this nurse removed razor from resident and applied towel with pressure to L inner wrist resident attempted to kick this writer yelling 'I have to wait 20 more minutes before I can have my medicine and I don't want to wait staff stayed 1:1 with resident while this nurse called 911 for transport to ED [emergency department], ADON [assistant director of nursing], notified immediately of incident, MD notified . On 03/21/19 at approximately 11:30 AM, the administrator, DON and corporate nurse were made aware of serious concerns with Resident #59 in a meeting with the survey team. The facility staff were made aware of the lack of interventions and/or services provided to prevent accidents/self harm for this resident. The facility staff were made aware that this resident had been identified by facility staff as having a high mood score for depression and as being a risk for self harm in May of 2018, with no interventions developed or implemented for the prevention of accidents/self harm for this resident. The staff were asked for assistance in providing any, and all additional information or documentation regarding Resident #59. The investigation for this incident was again requested at this time. An investigation was presented at approximately 3:00 PM regarding Resident #59. The investigation was reviewed and documented that the resident was observed cutting her wrists with a disposable shaving razor. EMS was called and transported the resident to the emergency department. The summary documented that first aid was provided prior to the resident leaving the facility and staff remained with the resident until EMS arrived. The summary documented that an investigation was completed on 10/30/18 to include employee interviews and medical review. The root cause analysis in the summary documented it was determined that the cause of the resident's behavior was a reaction to the attending physician's decision to not use narcotics and that the resident has a history of engaging in attention seeking behavior. The actual investigation documented several witness statements from staff, including a statement from licensed practical nurse (LPN) #8. The statement by LPN #8 documented, Somewhere in 2017 during the last quarter of the year made a statement that she would rather die than not have her hydrocodone pain medicine. She only made it once and never repeated it. This was reported to the, then DON who instructed this nurse not to worry about it .[LPN #8]. A statement by CNA #2 documented, .realize something was wrong with [name of Resident #59] wrist while we were trying to put gloves on she was continuously using the shaving stick cutting on her wrist faster and faster .manage to take it away after putting her gloves on .[CNA #2]. It was documented within the investigation that razors were found in patients room that were not facility issued or acquired. The investigation did not determine where the razor(s) came from or how the resident obtained the razor. The investigation did not have a statement from the resident. The resident was a 15 cognitively, but was not interviewed regarding the event. The resident was not interviewed prior to leaving the facility for the emergency department and was not interviewed after readmission to the facility. At approximately 3:30 PM, the survey team met with the administrator, DON and corporate nurse. They were again made aware of concerns of actual harm of this resident. The facility staff were also made aware that the investigation was not complete and accurate. The facility staff were asked how the resident got the razor or where did she get it from. The facility staff did not provide information on where or how the resident obtained a razor. The facility staff were asked if the resident was interviewed and the staff did not provide a response. No statements were found for Resident #59. On 03/21/19 at 4:49 PM, the survey team again met with the corporate nurse, administrator and DON. No other information or documentation was presented for this resident regarding this incident or investigation. The corporate nurse stated that there were no other psych consults found for this resident. On 03/21/19 at 5:20 PM, the administrator stated that the MD (medical director) may have information regarding Resident #59. The administrator and MD met with the survey team at this time. The MD stated that the resident did not like getting medications other than narcotics and that the resident had an opioid addiction at one time due to chronic pain. The MD stated, We'd [the

2. During a medication pass and pour observation on 03/20/19 at 8:16 AM, LPN (Licensed Practical Nurse) #1 prepared medications for Resident #43 which included one EC (enteric coated) 81 mg (milligram) ASA (aspirin) tablet. LPN #1 then removed two bottles of eye drop medications from the medication cart, including Prednisone 1%. LPN #1 took the medications into the room and informed the resident that she would first administer one of the eye drops, then administer the pills and then administer the other eye drops. The LPN took the first bottle of eye drops and administered one drop into each eye. The resident then took the pills, including the ASA 81 mg EC tablet and then the LPN administered the second bottle of eye drops, Prednisone 1%, administering one drop into each eye. LPN #1 washed her hands and then exited the room. On 03/20/19 at 8:33 AM, a medication reconciliation was completed. Resident #43's current physician's orders were reviewed and revealed an order for: Aspirin 81 mg chewable tablet and Prednisone 1% eye drop solution- one drop in the right eye. On 03/20/19 at 9:00 AM, LPN #1 was interviewed regarding Resident #43. LPN #1 was made aware that she administered the resident an enteric coated Aspirin and the resident's order was for an Aspirin 81 mg chewable tablet. LPN #1 looked at the physician's order and then went to the MAR (medication demonstration record) and stated, Yes, I did and further stated that almost all of the residents on her hall who receive Aspirin, receive the Aspirin EC and only a couple get the chewable. LPN #1 was then made aware of administering the resident Prednisone 1% eye drops in both eyes, when the physician's order was for one drop in the right eye only. LPN #1 stated, I did, I don't even have to look, I know I'm only suppose to give one, that was all me, I was nervous. The administrator and DON (director of nursing) were made aware in a meeting with the survey team on 03/20/19. A policy on medication administration was requested at this time. A policy on General Dose Preparation and Medication Distraction was presented and reviewed. The policy documented, .facility staff should verify that the medication name and dose are correct .verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route .at the correct time, for the correct resident confirm that the MAR reflects the most recent medication order . No further information and/or documentation was presented prior to the exit conference on 03/21/19 at 6:15 PM. Based on observation, staff interview and clinical record review, the facility staff failed to ensure a medication error rate of less than 5 percent. Medication pass observations revealed three errors out of 39 opportunities resulting in a 7.6 % error rate. The findings include: 1. A medication pass observation was conducted on 3/20/19 at 8:00 a.m. with registered nurse (RN) #1 administering medications to Resident #18. During this observation, RN #1 administered the medication Carbamazepine 200 mg (milligrams) to Resident #18. Resident #18's clinical record documented a physician's order dated 5/31/17 for Carbamazepine 400 mg to be administered each day at 8:00 a.m. for treatment of a seizure disorder. On 3/20/19 at 8:50 a.m., RN #1 was interviewed about the Carbamazepine administered to Resident #18. RN #1 reviewed the physician's order and stated the resident had two orders for the Carbamazepine with 400 mg to be given at 8:00 a.m. and 600 mg to be given at 8:00 p.m. RN #1 at this time reviewed Resident #18's medication supply cards in the cart. Resident #18 had a card of Carbamazepine 400 mg and another card supplied with Carbamazepine of 200 mg. These findings were reviewed with the administrator and director of nursing during a meeting on 3/20/19 at 4:50 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for one of 19 residents in the survey sample. Resident 109's closed clinical record did not include records of treatments/dressing changes provided for wound care and the resident's bathing records were incomplete. The findings include: Resident #109 was admitted to the facility on [DATE] and was discharged to the hospital on 3/28/18. Diagnoses for Resident #109 included hip fracture, high blood pressure, peripheral vascular disease and diabetes. The minimum data set (MDS) dated [DATE] assessed Resident #109 with moderately impaired cognitive skills. a) Resident #109's closed clinical record documented the resident was admitted to the facility with a surgical wound on her left hip, a pressure ulcer to the sacrum and chronic wounds on toes of her left foot. The record documented a physician's order dated 3/10/18 for a Hydrogel dressing to the web of her left toes to be changed daily, barrier cream to pressure ulcers and clean, dry dressing on the left hip surgical incision. A physician's order dated 3/12/19 documented treatment orders for the pressure ulcers to include Santyl ointment to wound right of the sacrum every day and barrier cream each shift to wound left of sacrum. Resident #109's clinical record documented no treatment records for the dressing changes and topical medications to the pressure ulcers as ordered. On 3/21/19 at 11:25 a.m., the director of nursing (DON) was interviewed about any treatment records for Resident #109. After reviewing the closed clinical record, the DON stated she did not find the treatment record for Resident #109. The DON stated she had no idea what happened to the records. The DON stated she followed the resident's wound but did not know what happened to the record documenting the dressing changes/treatments. b) Resident #109's bathing records were requested in response to a complaint investigation. The DON presented a copy of bath records by shift during Resident #109's stay. There were no entries on 33 out of 54 shifts listed on the report from 3/11/18 through 3/28/18. On 3/21/19 at 3:45 p.m., the DON was interviewed about the missing bath records for Resident #109. The DON stated the aides were expected to enter activities of daily living information including bathing data into their tracking system at the end of each shift. The DON stated their tracking system had codes for entering showers, bed baths and partial baths for residents. The DON stated the bathing records for Resident #109 were incomplete as not all shifts entered information as required. These findings were reviewed with the administrator and DON during a meeting on 3/21/19 at 4:50 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a medication pass and pour observation on 03/20/19 at 8:00 AM, LPN (Licensed Practical Nurse) #1 prepared medications for Resident #24. LPN #1 prepared the medications for this resident, which included one Spiriva 18 mcg (microgram) capsule for inhalation. LPN #1 removed the box from the medication cart, removed one package (containing one capsule), applied gloves and opened up the individual package. LPN #1 dropped the capsule onto a piece of paper that was laying on top of the medication cart. LPN #1 picked up the capsule and again, dropped the capsule on top of the piece of paper laying on the medication cart. LPN #1 picked up the capsule, inserted it into the dispensing inhaler and administered the medication to the resident. LPN #1 was made aware of dropping the capsule (Spiriva) on the med cart, landing on top of a piece of paper twice during medication preparation. LPN #1 stated, Yes, I did. The administrator and DON (director of nursing) were made aware in a meeting with the survey team on 03/20/19. A policy on infection control practices for handling medications during medication administration was requested at this time. A policy on General Dose Preparation and Medication Distraction was presented and reviewed. The policy documented, .facility staff should not touch the medication when opening a bottle or unit dose package .if a medication which is in a protective container is dropped, facility staff should discard it .if a medication which is not in a protective container is dropped .staff should discard it No further information and/or documentation was presented prior to the exit conference on 03/21/19. Based on observation, staff interview and facility document review, the facility staff failed to follow infection control practices regarding hand hygiene during housekeeping; failed to implement infection control protocols for the prevention of Legionella and other water borne pathogens; and failed to follow infection control protocols during medication administration. A housekeeping staff member failed to perform hand hygiene after glove removal between cleaning of resident rooms and offices. The facility had no evidence of implementing maintenance and service items required in their water management program for the prevention of Legionella and other water borne pathogens. During a medication pass observation, a nurse dropped a medication on the top of the cart and then administered the medication to a resident. The findings include: 1. On 3/19/19 at 11:15 a.m., a housekeeping staff member was observed with gloves on, sweeping the floor in room [ROOM NUMBER]. The housekeeper went into the resident's bathroom, flushed the toilet and emptied the trash from the room. The housekeeper handled the keys on her cart prior to removing her gloves. Without performing any hand hygiene, the housekeeper proceeded to the MDS office, put on new gloves and emptied the trash can from the office. The housekeeper changed her gloves and then went into room [ROOM NUMBER]. The housekeeper swept the floor and emptied trash cans in this room. The housekeeper changed her gloves and then went into room [ROOM NUMBER] and cleaned/swept the room. The housekeeper performed no hand hygiene after any glove removal. On 3/21/19 at 8:53 a.m., a housekeeper was interviewed about their protocol for hand hygiene when cleaning rooms. The housekeeper stated gloves were to be on before entering resident rooms. The housekeeper stated after cleaning and emptying trash, she removed and discarded gloves before leaving the room. The housekeeper stated she had been instructed to wash hands or use hand sanitizer before going to the next room. On 3/21/19 at 9:17 a.m., the housekeeping director was interviewed. The housekeeping director stated that housekeepers were expected to perform hand hygiene after glove removal and before leaving rooms during cleaning. The housekeeping director stated employees were expected to wash hands or use hand sanitizer and all of the housekeeping staff had training about hand hygiene. The facility's policy titled General Hospitality Services Policies (11/30/2014) documented the policy objective was to provide clean, contamination-free surroundings for residents, visitors, and personnel. A clean environment is essential in preventing transmission of infection in the facility .Environmental Services will adhere to Standard precautions and Transmission-based Precautions as indicated .Gloves, i.e., utility gloves, will be worn . The facility's policy titled Personal Protective Equipment - Using Gloves (9/1/17) documented gloves were used to prevent the spread of infection and to protect hands from potentially infectious material and documented, Wash hands after removing gloves (Note: Gloves do not replace handwashing.) . These findings were reviewed with the administrator and director of nursing during a meeting on 3/21/19 at 4:50 p.m. 2. The facility's protocols for the prevention of Legionella and other water borne pathogens were reviewed on 3/21/19. The facility's policy titled Water Management Program (8/1/17) documented, This center will provide a source of domestic water supply, as safe as possible, to all residents, staff, and visitors .will strive to eliminate the source of, or distribution of, unacceptable levels of preventable contamination (including but not limited to legionella, cryptosporidium, arsenic) within its water and HVAC systems. The policy listed the following preventive maintenance items as interventions for prevention of Legionella and other water borne pathogens: Daily water temperature checks; preventive maintenance of all hot water mixing valves; operational checks of water circulation pumps; cleaning of A/C drain lines and condensation pans; maintenance of all roof drains and any pitch pans; daily disinfection of installed drinking fountains; and routine maintenance of in-line water filters, water softeners including ice machines. The policy required the establishment of safety control limits such as temperatures and disinfectant levels with ongoing monitoring compared to established control limits with action taken for results not meeting established guidelines. On 3/21/19 at 11:15 a.m., the facility's maintenance director was interviewed regarding evidence of maintenance and testing for prevention of Legionella as listed in their policy. The maintenance director stated, We don't test for that [Legionella]. The maintenance director stated he had not set up anything different from what he had been doing prior to the Legionella requirements. The maintenance director stated he checked daily water temperatures and there was a diagram showing the water flow throughout the facility but he had no further testing results or preventive maintenance records regarding Legionella prevention. On 3/21/19 at 2:50 p.m., evidence of the preventive maintenance and testing required in their Water Management Program was requested from the administrator. On 3/21/19 at 4:00 p.m., the administrator presented daily water temperature checks and stated he had no other documented evidence of Legionella prevention. The administrator stated, The other items we do but we don't have documentation. Other than the daily water temperature checks, no other evidence was presented indicating implementation of the facility's Water Management Program for prevention of Legionella. These findings were reviewed with the administrator and director of nursing during a meeting on 3/21/19 at 4:50 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review, the facility staff failed to ensure an accurate meal ticket for one of 19 residents in the survey sample. In addition, the facility failed to ensure a system for printing meal tickets in the facility that accurately reflected physician ordered therapeutic diets, food allergies and resident preferences. Resident #23, served a puree diet, had a meal ticket for a mechanical soft diet. The ticket documented the resident was served ground pork when puree turkey was actually served. The ticket indicated ground pork was served when ticket instructions stated No Pork. The facility had an unresolved issue with inaccurate meal tickets since April 2018. The findings include: 1. Resident #23 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #23 included dementia, dysphagia, high blood pressure and history of hip fracture. The minimum data set (MDS) dated [DATE] assessed Resident #23 with severely impaired cognitive skills. On 3/19/19 at 12:30 p.m., Resident #23 was observed eating lunch in her room. The resident's food items included a puree white meat, vegetable, rice mixture and bread. Resident #23's meal ticket documented the resident's diet was regular - mechanical soft with instructions printed in bold, NO PORK AND NO SHRIMP. The food items listed on the ticket included ground roasted pork, cheesy rice, sliced cauliflower, ground pineapple tidbits, one square cornbread with 8 ounces of milk. There was no milk served on the lunch meal tray as listed on the ticket. Resident #23's clinical record documented a nutrition assessment dated [DATE] for no pork or shellfish due to religious preferences. The record documented a physician's order dated 3/17/19 for a regular dysphagia puree diet. On 3/19/19 at 12:53 p.m., the licensed practical nurse (LPN #1) caring for Resident #23 was interviewed about the meal ticket for mechanical soft and no pork. LPN #1 stated the resident's preference for no pork or shrimp was due to religious reasons. LPN #1 stated she did not know why the ticket listed pork was served when the ticket stated no pork. LPN #1 stated the resident was ordered a puree diet since her return from the hospital on 3/17/19. On 3/19/19 at 3:07 p.m., the dietary manager was interviewed about Resident #23's meal ticket. The dietary manager stated the meal ticket was inaccurate. The dietary manager stated the posted menu items printed on meal tickets even when preferences or instructions were in conflict with the menu items. The dietary manager stated, I don't know how to take it (menu items) off the ticket. The dietary manager stated Resident #23 was actually served puree turkey for lunch and not ground pork as listed on the ticket. The dietary manager stated, My staff just know to not give her [Resident #23] mechanical soft. The dietary manager stated the meal ticket on Resident #23's tray was not accurate and was printed before the resident went to the hospital. The dietary manager stated she printed tickets ahead and if changes in diets occurred, she was supposed to print a new ticket. The dietary manager stated she did not know why the old ticket was not removed and a new ticket printed after the resident's re-admission on [DATE]. The dietary manager stated she had ongoing problems with printing accurate meal tickets. The dietary manager stated she had reported the problem to corporate and they did not know how to prevent the posted menu items from automatically printing on tickets even when residents had orders, allergies or preferences that required other food items. On 3/21/19 at 8:07 a.m., the dietary manager was interviewed again about the inaccurate meal tickets. The dietary manager stated she had experienced problems with printing accurate meal tickets since April 2018 when she started working at the facility. The dietary manager stated she entered therapeutic diets, allergies and dislikes and they showed on the computer but did not always show and/or print on the actual meal ticket. The dietary manager stated she verbally communicated changes/preferences to the tray line staff but knew the tickets did not always match the orders and/or preferences. The dietary manager presented another example of an inaccurate meal ticket for a current resident. The meal ticket for lunch (3/22/19) documented NO FISH .DISLIKES RICE .FISH .HAM then listed the food items to be served as baked stuffed fish fillet and rice pilaf. This meal ticket for dinner (3/22/19) listed sliced baked ham as the entree. The dietary manager stated again she did not know how to make the tickets print accurately. These findings were reviewed with the administrator and director of nursing during a meeting on 3/21/19 at 4:50 p.m.