Based on interview and record review the facility did not ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 2 of 5 residents reviewed for abuse (R4 and R5). Staff documented a resident-to-resident altercation, involving R4 on 8/5/25, which was not reported to the State Agency.Staff documented a resident-to-resident altercation, involving R5 on 8/5/25, which was not reported to the Administrator or State Agency.Evidenced by:The facility policy titled, Abuse, Neglect and Exploitation, revised 6/24/25, includes in part: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.The components of the facility abuse prohibition plan are discussed herein: .VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. On 8/13/25 Surveyors reviewed a progress note for R2, dated and timed 8/5/25 9:09 PM, Author: LPN C (Licensed Practical Nurse). The note contained the following information, in part:.Once supper was over, resident was taken out by staff for a cigarette, upon return her behaviors worsened. She began yelling at R4 to Shut the fuck up. Writer was at med cart when she heard an item fall, resident threw her wander guard in R4's direction, it is unknown if she had the intention to hit him with the object.When resident R5 walked by, she slammed her walker into the chair in front of her and said, I'll kill you.On 8/13/25 at 4:02PM Surveyors interviewed LPN C (Licensed Practical Nurse) via telephone regarding the events she documented on 8/5/25 involving, R2, R4, and R5. During the interview LPN C indicated she recalled the events documented in her note. LPN C indicated that she reported the events between R2 and R4 to NHA A (Nursing Home Administrator) but was only about certain she reported the events between R2 and R5 to NHA A. Surveyor asked LPN C if she should report a potential verbal abuse or threat to the NHA when a resident says, I'll kill you, to another resident. LPN C indicated, it makes sense to report it as abuse, but with R2 it's hard because it's part of her disease.On 8/13/25 at 2:06PM Surveyors interviewed NHA A. Surveyors reviewed the information from the 8/5/25 progress note above with NHA A. During the interview NHA A indicated that LPN C reported to her the events between R2 and R4 and that she did not recall the events between R2 and R5 being reported to her. Surveyor asked NHA A if these events should have been reported to her and to the State Agency as allegations of abuse. NHA A indicated they should have.

Based on interview and record review, the facility did not have evidence that all alleged violations of abuse were thoroughly investigated for 2 of 5 residents reviewed for abuse (R4 and R5). Staff documented an observation of a resident-to-resident altercation, involving R4 on 8/5/25, which was not investigated by the facility. Staff documented an observation of a resident-to-resident altercation, involving R5 on 8/5/25, which was not investigated by the facility. Evidenced by:The facility policy titled, Abuse, Neglect and Exploitation, revised 6/24/25, includes in part: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.The components of the facility abuse prohibition plan are discussed herein: .V. Investigation of Alleged Abuse, Neglect, and Exploitation. A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect, or exploitation occur.On 8/13/25 Surveyors reviewed a progress note for R2, dated and timed 8/5/25 9:09PM, Author: LPN C (Licensed Practical Nurse). The note contained the following information, in part:.Once supper was over, resident was taken out by staff for a cigarette, upon return her behaviors worsened. She began yelling at R4 to Shut the fuck up. Writer was at med cart when she heard an item fall, resident threw her wander guard in R4's direction, it is unknown if she had the intention to hit him with the object.When R5 walked by, she slammed her walker into the chair in front of her and said, I'll kill you.On 8/13/25 at 2:06PM Surveyors interviewed NHA A and reviewed the information from the 8/5/25 progress note above with NHA A. Surveyors asked if the events documented between R2 and R4 and R2 and R5 should have been investigated as allegations of abuse. NHA A indicated they should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law though established procedures for 1 of 17 abuse investigations reviewed involving (R40). Facility became aware of an abuse allegation on [DATE] at 6:15 AM and did not report it to the State Agency until [DATE] at 11:14 AM. Evidenced by: The facility policy, entitled Abuse, Neglect and Exploitation, dated [DATE], states, in part: . Policy: It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . V1I. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . R40 was admitted to the facility on [DATE] and has diagnoses that include, malignant neoplasm of unspecified part of left bronchus or lung (a cancerous tumor that has developed in the left bronchus, one of the large airways in the lungs) and nontraumatic intracranial hemorrhage (bleeding in the brain that occurs without trauma or surgery). R40 admitted to hospice [DATE] and expired [DATE]. Facility Self Report dated [DATE], at 11:14:22 AM, states, in part: . Summary of Incident: Allegation Type: Abuse: Hitting, slapping, threats of harm, assault, humiliation. Name-Affected Person: R40 Name-Accused Person: CNA D (Certified Nursing Assistant) . Date occurred: [DATE]. Time occurred: 06:15 AM . Date discovered: [DATE] . Briefly Describe the incident . R40 recently admitted to the facility. It was reported that resident was reporting pain during cares when CNA D was assisting. CNA D continued cares after resident stated to stop . Explain what steps the entity took upon learning of the incident to protect the affected person and others from further potential misconduct: Upon learning of the incident, investigation was started; CNA D was put on leave. Residents interviewed to determine if they feel their rights are being upheld by CNA D and other staff . On [DATE] at 9:16 AM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A what time the incident was reported to you, and NHA A indicated it should have been between 7:00 AM and 7:30 AM. NHA A indicated LPN E (Licensed Practical Nurse) reported it to her, but NHA A did not have the time documented. Surveyor showed NHA A the Facility Self Report time reported was 6:15 AM and it shows it was reported to the State Agency at 11:14 AM. Surveyor asked when the self-report should have been reported to the State Agency and NHA A indicated within 2 hours. Surveyor asked if it was reported to the State Agency within 2 hours and NHA A indicated no. Surveyor asked the NHA A when should staff report abuse to the facility, NHA A indicated immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to thoroughly investigate an accusation of physical abuse for 1 of 17 residents (R40) reviewed for abuse. Facility became aware of an abuse allegation on [DATE] and did not complete a thorough investigation. Evidenced by: The facility policy, entitled Abuse, Neglect and Exploitation, dated [DATE], states, in part: . Policy: It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse . V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation. 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g. not tampering or destroying evidence). 3. Investigating different types of alleged violations. 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. VI. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: . A. Responding immediately to protect the alleged victim and integrity of the investigation; . C. Increased supervision of the alleged victim and residents . VII. Reporting/Response . 5. Taking all necessary actions as a result if the investigation, which may include, but are not limited to the following: a. Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences. b. Defining how care provisions will be changed and/or improved to protect residents receiving services. c. Training of staff on changes made and demonstration of staff competency after training is implemented. d. Identification of staff responsible for implementation of corrective actions. e. The expected date for implementation; and f. Identification of staff responsible for monitoring the implementation of the plan . R40 was admitted to the facility on [DATE] and has diagnoses that include, malignant neoplasm of unspecified part of left bronchus or lung (a cancerous tumor that has developed in the left bronchus, one of the large airways in the lungs) and nontraumatic intracranial hemorrhage (bleeding in the brain that occurs without trauma or surgery). R40 admitted to hospice [DATE] and expired [DATE]. Facility Self Report dated [DATE], at 11:14:22 AM, states, in part: . Summary of Incident: Allegation Type: Abuse: Hitting, slapping, threats of harm, assault, humiliation. Name-Affected Person: R40 Name-Accused Person: CNA D (Certified Nursing Assistant) . Date occurred: [DATE]. Time occurred: 06:15 AM . Date discovered: [DATE] . Briefly Describe the incident . R40 recently admitted to the facility. It was reported that resident was reporting pain during cares when CNA D was assisting. CNA D continued cares after resident stated to stop . Explain what steps the entity took upon learning of the incident to protect the affected person and others from further potential misconduct: Upon learning of the incident, investigation was started; CNA D was put on leave. Residents interviewed to determine if they feel their rights are being upheld by CNA D and other staff . Resident Interviews conducted by SW G (Social Worker) during investigation, dated [DATE], shows 3 residents voiced CNA D does not respect their wishes and 3 indicate CNA D has disregarded their wishes. 2 of those 3 residents voiced they do not feel safe when CNA D works with them. On [DATE] at 3:30 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and SW G (Social Worker). Surveyor asked SW G if she did touch bases with residents and SW G indicated yes and she would look for them and get them to Surveyor. Surveyor asked what facility has done to ensure residents safety when CNA D returned to work, and SW G indicated the touch bases with residents and CNA D had someone with her the first night she returned to work on [DATE]. SW G indicated she interviewed all residents and followed up with the residents that had voiced concerns regarding CNA D. SW G indicated she also would ask residents in normal conversations during the day but did not document these conversations. SW G indicated she walks by a resident room and asks residents how they are doing but has not charted those. SW G indicates she asks residents if they feel safe and ask if they have any concerns when she completes BIMS (Brief Interview of Mental Status) and PHQ (Patient Health Questionnaire) quarterly and when needed for mood changes. On [DATE] at 9:16 AM, Surveyor interviewed NHA A. Surveyor asked NHA A how the facility ensured safety to all nonverbal residents and NHA A indicated by monitoring for bruises and injuries of unknown origin, watch for more agitation. Surveyor asked NHA A if skin assessments had been completed at time of investigation and NHA A indicated not at time, but they are completed weekly. NHA A indicated the facility should have completed additional skin assessments with nonverbal residents at the time of investigation. Surveyor asked NHA A if this was a complete investigation and NHA A indicated no, it should have included all staff education on abuse and skin assessments on nonverbal residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 3 of 4 residents (R16, R31, and R142) reviewed for falls. R142 sustained a fall on 11/27/24 and the facility failed to find a root cause or implement a new intervention. R31 had several falls, and the facility failed to complete a root cause analysis or implement interventions to prevent additional falls. R16 had several falls, and the facility failed to complete a root cause analysis or implement interventions to prevent additional falls. Findings include: The facility policy, Fall Policy and Procedure, updated 11/2024, indicates, in part: Policy: Staff shall assess for risk, provide preventative measures, and address falls in a safe and professional manner. Procedure: .Fall incident: .7) Documentation: a. Fall note .e. Update fall care plan of immediate intervention . Fall Team Meeting: .2) Fall team is to meet within 72 hours of fall to review fall data and documentation to ensure completion and to review intervention for appropriateness .4) Nurses note is to be completed following the meeting to including: a. Members present b. Root cause c. Intervention: Including all possible interventions noted and reasons for negating or approving of interventions. Example 1 R142 was admitted to the facility on [DATE] with diagnoses that include, in part: Hemiplegia and Hemiparesis (weakness and paralysis on one side of body), Muscle Weakness, Unsteadiness on Feet, and Repeated Falls. R142's admission Minimum Data Set (MDS) dated [DATE] indicates a Brief Interview for Mental Status (BIMS) of 2, indicating R142 has a severe cognitive impairment. R142's care plan includes, in part: --Focus: Potential for falls related to CVA (Cerebral Vascular Accident - Stroke) with right sided weakness, cognitive deficit, communication deficit, functional urinary and bowel incontinence, medications received, intermittent pain, h/o (history of) falls. Date Initiated: 12/4/24. --Goal: The resident will be free of minor injury through the review date. Date Initiated: 12/4/24. --Interventions/Tasks (all indicate date initiated 12/4/24): Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Ensure that the resident is wearing appropriate footwear mobilizing in w/c. Follow facility fall policy. Pt evaluate and treat as ordered or PRN (as needed) The resident uses bed and chair alarm. Ensure the device is in place as needed. --Focus: The resident has limited physical mobility related to CVA (Cerebral Vascular Accident/stroke) with right sided weakness, balance deficit, cognitive impairment. Date initiated 12/4/24. --Goal: The resident will increase level of mobility by [sic] through the next review date. Date initiated: 12/4/24. Revision on 12/10/24. --Interventions/Tasks, in part: .Assistive devices: Hoyer, wheelchair. Date initiated: 12/9/24 . Of note, no interventions indicated a date initiated of 11/27/24, the date R142 sustained a fall, or within 72 hours of the fall. A fall document, dated 11/27/24 at 1:30 PM, titled, #169 Un-witnessed Fall, includes, in part: Nursing description: Resident found on floor next to bed, alarm sounding, resident lying on right side facing bed, no apparent injuries noted. Resident description: Resident Unable to give Description . Injury Type: No Injuries observed at time of incident. Mobility: Wheelchair bound. Of note, there is no information on the document regarding a root cause analysis or the implementation of a new individualized fall intervention(s). A nurse's note, dated 11/27/24 1:35 PM includes the following: Resident found on floor next to bed, alarm sounding, Admin/DON (Director of Nursing), MD, and family aware, no new injuries noted. Resident unable to recall incident. VSS (Vital Signs Stable), will monitor. On 12/12/24 at 7:20 AM, Surveyor observed R142 in bed with her bed in low position. On 12/12/24 at 2:38 PM, Surveyor interviewed CNA T (Certified Nursing Assistant) who indicated she can look at the resident [NAME] or in the electronic record to see what fall interventions are in place for a resident. CNA T indicated that for R142, when she is in bed, she has a bed alarm and they keep her bed in low position. When R142 is in the common area, they keep her by staff. CNA T opened the [NAME] for R142 on the computer and was not able to locate these interventions. On 12/12/24, Surveyor interviewed NHA A (Nursing Home Administrator). NHA A is the interim NHA at the facility and was the DON (Director of Nursing) before her interim NHA status. NHA A indicated that a root cause should be completed for falls and a new intervention put into place and was not. Example 2 R16 was admitted to the facility on [DATE] and has diagnoses that include malignant neoplasm of brain (cancer in the brain) and seizures. Her care plan states, Focus: Potential for falls related to lung cancer with brain metastasis, history of CVA (Cerebrovascular Accident/Stroke), limitations to lower extremities, weakness, balance deficit, intermittent urinary and bowel incontinence, recent history of falls, visual deficit .Goal: resident will be free of falls .Interventions: 1) Assist resident with ambulation and transfers, utilizing therapy recommendations (dated 10/1/24), 2) Determine residents ability to transfer (dated 10/1/24), 3) If fall occurs, alert provider (dated 10/1/24) 4) If resident is a fall risk, initiate fall risk precautions (dated 10/1/24). Recent fall risk assessments conducted on 12/7/24 and 12/10/24 show a score of 16, indicating R16 is at high risk for falls (10 or greater indicates high risk). R16 experienced the following falls: 9/30/24 at 11:10 PM: Unwitnessed in resident room/bathroom 10/25/24 at 5:45 PM: Unwitnessed, found on floor in room near bathroom. 10/31/24 at 11:53 AM: Witnessed near therapy room slide out of her wheelchair. 10/31/24 at 8:46 PM: Witnessed in room sliding out of chair. 11/2/24 at 5:45 PM: Witnessed trying to self-reposition in her wheelchair in the hallway. 12/6/24 at 7:55 PM: Unwitnessed, found on floor sitting near her bed. None of these falls resulted in significant or major injuries. Additionally, a progress note dated 11/6/24 at 5:56 PM states, Resident's alarm started going off ran into room to find resident sitting on the foot part of recliner, she had scooted to the end and was going to try to get up. She did not fall. She continually is getting up unassisted. She takes her alarm off, and we have caught her several times tonight get up without assist. The fall reports for these falls do not include any interventions, immediate or otherwise. The facility was unable to provide documentation or record of Interdisciplinary Team (IDT) meetings or documentation detailing a root cause analysis, how the facility will help address R16's unique needs and her continued falls. Additionally, Fall risk precautions, as mentioned in R16's care plan, are not detailed. Example 3 R31 was admitted to the facility on [DATE] and has diagnoses that include dementia. His care plan states, Potential for falls related to dementia, self-care deficit, weakness, balance deficit, recent history of falls, incontinence, intermittent pain .Goal: will be free of falls (dated 5/21/24) .Interventions: 1) Assist resident with ambulation and transfers, utilizing therapy recommendations (dated 5/21/24), 2) Determine residents ability to transfer (dated 5/21/24), 3) Ensure bed is kept in lowest position (dated 6/21/24), 4) Ensure call light is available to resident (dated 6/12/24), 5) Evaluate fall risk on admission and PRN (as needed) (dated 5/21/24), 6) If fall occurs, alert provider (dated 5/21/24), 7) If fall occurs, initiate frequent neuro (neurological) and bleeding evaluation per facility protocol (dated 5/21/24), 8) If resident is a fall risk, initiate fall risk precautions (dated 5/21/24), 9) Utilize devices as appropriate to ensure safety (dated 6/12/24). On 12/10/24 at 10:07 AM, Surveyor interviewed R31, who was laying in his bed, which was low to the floor with fall mat next the bed. Across the fall mat, R31's wheelchair was facing him. R31 stated that he had, had recent falls but could not remember exactly when. He stated that he sometimes trips over the mat on the floor and that he recently fell from tripping on it. The facility documented the following falls for R31: *10/29/24 at 7:46 PM: Resident had an unwitnessed fall at 1545 (3:45 PM) today in his bathroom. Resident was found sitting on the floor on his buttocks in his bathroom with his back up against the wall. Resident denied hitting his head when he was asked today by this writer. No immediate signs of injury were noted by this writer today. Resident said that the staff could get him up when he was asked by this writer. Resident said he got up by himself and tripped on the fall mat on the floor and slid. Water was on the floor, resident's water mug got knocked over and water got spilled on the floor. Family and DON (Director of Nursing) was updated. *10/31/24 at 6:30 AM: The night shift and day shift were in hall doing walking rounds and resident was resting on bed. At 0635 CNA's went past his room and found resident laying on the floor supine by the closet and sink. He was alert but had blood on floor under his head. Night nurse and this writer went to assess and found a hematoma (collection of blood) on the occipital area (back of head) of head and no laceration, but hematoma had bleeding. Resident was able to speak clearly and was able to state he was walking to get his underwear to change it. {sic} R31 was sent to the hospital after the 10/31 fall, but no significant or major injuries were identified. The fall reports for the 10/29 and 10/31 falls does not include any interventions, root cause analysis, immediate or otherwise. The facility was unable to provide documentation or record of Interdisciplinary Team (IDT) meetings or documentation detailing how the facility will help address R31's unique needs and his continued falls. Additionally, Fall risk precautions, as mentioned in R31's care plan, are not detailed. No documented root cause analysis was sought or identified, nor any resident specific interventions or approaches have been care planned for R31. On 12/12/24 at 5:45 PM, Surveyor interviewed NHA A (Nursing Home Administrator). NHA A is the interim NHA at the facility and was DON before her interim NHA status. NHA A stated that the facility talks about falls at standup but does not document those interactions. NHA A stated that they did not look at any root-cause analysis. When asked how they plan to address R16's falls, NHA A stated, She keeps sliding out of her chair, that is the cause. When Surveyor told NHA A that R31 had stated that he trips on his fall mat, NHA A indicated that the specific fall mat in R31's room can be slippery.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 2 of 2 residents (R35 and R17) reviewed for nutrition. R35's weights were obtained using different methods and therefore it is unclear if they are accurate. R35's physician was not updated on weight gain/loss based on these weights. R17's physician was not updated on a 21 pound weight loss and there was no documentation of trialing supplements with R17. Findings Include: The facility policy, titled, Weight Monitoring, date reviewed 11/2024, indicates, in part: Policy: Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. Compliance Guidelines: .1. The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes: .c. Developing and consistently implementing pertinent approaches. d. Monitoring the effectiveness of interventions and revising them as necessary .4. Interventions will be identified, implemented, monitored and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status .6. Weight Analysis: The newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as: a. 5% change in weight in 1 month (30 days) b. 7.5% change in weight in 3 months (90 days) c. 10% change in weight in 6 months (180) days .7. Documentation: a. The physician should be informed of a significant change in weight .f. Observations pertinent to the resident's weight status should be recorded in the medical record as appropriate . Example 1 R35 was admitted to the facility on [DATE] with diagnoses that include, in part: Alzheimer's Disease, Hypertension, and Gastro-Esophageal Reflux (stomach contents goes up into the food pipe causing irritation). R35's Facility recorded weights include, in part: 12/8/24: 166 lbs (wheelchair) (this is a 5 pound loss) 11/1/24: 171.0 lbs (wheelchair) 10/1/24: 167.4 (Standing) 9/1/24: 171.6 (Standing) (this is a 10.8 pound loss) 8/6/24: 182.4 (wheelchair) 8/1/24: 180.6 (wheelchair) (this is a 13.4 pound or 7.41% gain) 7/1/24: 167.2 lbs (wheelchair) 6/1/24: 169 lbs (Standing) (this is a 8 pound gain) 3/14/24: 161.2 (Standing) . Review of R35's Physician Orders do not reference a weight gain or loss parameter for notification. A 9/15/24 Nutrition/Dietary Note indicates, in part: .On 8/1/24 and 8/6/24 he (R35) had weights documented approximately 180-182#, which was a approximate 13-15# wt gain from the previous month (9/1/24) weight was approximately 171.6#. Writer questioning accuracy of 8/24/24 weights, if accurate though writer unsure of cause of weight gain. Not concerned at this time with weigh [sic] variations as po (oral) intake remains good, fairly stable compared to previous assessment with (outside of 8/24/24 weights) primarily ranging approximately 165-171# since 5/1/24 .No recommended changes to nutritional care plan . On 12/12/24 at 2:47 PM, Surveyor interviewed CNA S (Certified Nursing Assistant) a who indicated the facility electronic health record indicates how a resident should be weighed. CNA S indicated the majority of the residents on the floor (where R35 resides) are wheelchair weights. CNA S showed surveyor a list of residents who are weighed via wheelchair that also includes the weight of the wheelchair that should be subtracted after the weight is obtained. CNA S indicated that the wheelchair weight includes all equipment such as pressure relieving cushions, foot petals, etc. CNA S indicated if a resident's chair changes then the CNAs are to update the list. CNA S indicated the nurse will tell them if they need to complete a re-weight and that either the CNA or the nurse can document the weight in the record. On 12/12/24 at 2:52 PM, Surveyor interviewed RN H (Registered Nurse) who indicated the CNAs bring her the resident weights and if something is funky a re-weight is completed and if it is still funky then it is compared to prior months. If after this anything is still funky then the information goes to the dietician and if it is a major weight loss/gain they are to update the doctor. Surveyor reviewed R35's weights with RN H and asked how you could tell if there was a re-weight. RN H indicated they do not keep the paper that re-weights are documented on. RN H also reviewed R35's orders and did not find an order for when to contact the provider for weight gain/loss. RN H indicated with no order she would contact the physician with a 5 lb. change in resident weight. RN H was unsure if there was a facility policy regarding this. RN H indicated that residents should be weighed consistently by the same method and that R35 is on the list of residents who should be weighed in their wheelchair, and she would expect him to be weighed in his wheelchair. RN H indicated she would have expected a provider notification on 9/1/24 when R35's weight went from 182.4 lb (Wheelchair) on 8/6/24 to 171.6 (Standing) on 9/1/24. On 12/12/24 at 3:39 PM, Surveyor interviewed NHA A (Nursing Home Administrator). NHA A is the interim NHA at the facility and was the DON (Director of Nursing) before her interim NHA status. NHA A indicated resident's weights should be obtained at the beginning of the month and that they need to be weighed the same way. If they are going to use a wheelchair then they need to do that every month. If they are going to use the shower chair, then use that every month. Otherwise, there can be discrepancies. Surveyor reviewed R35's weights with NHA A. NHA A indicated there is no way to know if the weights are accurate given the different methods the weights were obtained by. NHA A indicated she would expect re-weights to be documented. NHA A indicated she was unsure of the exact facility policy on when to call the physician if an order for weight changes is not given and would check on this. (Please see policy information above that was later provided to surveyor). NHA A indicated she would have expected the physician to have been called, based on the following weight changes: 8/6/24: 182.4 lbs to 9/1/24: 171.6 lbs (Loss of 10.8 lbs. or 5.9%) 7/1/24: 167.2 lbs to 8/1/24: 180.6 lbs (Gain of 13.4 lbs. or 8.0%) 11/1/24: 171 lbs to 12/8/24: 166 lbs (Loss of 5 lbs. or 2.9%) No further documentation or provider notification for these weights was provided by the facility. Example 2: R17 was admitted to the facility on [DATE] and has diagnoses that include unspecified dementia without behavioral disturbance. Her most recent Minimum Data Set (MDS), dated [DATE], includes a Brief Interview for Mental Status (BIMS) score of 01, indicating R17 is severely cognitively impaired. The facility documented the following weights for R17: 10/9/2024 19:05 (7:05 PM) 179.2 Lbs 10/19/2024 20:01 (10:01 PM) 179.6 Lbs 11/1/2024 12:48 (12:48 PM) 158.4 Lbs 11/6/2024 11:03 (11:03 AM) 161.1 Lbs 12/8/2024 10:18 (10:18 AM) 158.0 Lbs Additionally, on 10/6/2024 at 4:36 PM, the facility's dietician notes R17's hospital weight, prior to discharge to the facility, to be 171.2 lbs. The dietician also noted for R17 on 10/24/24 at 5:21 PM, Resident had been started on Ensure 4oz (TID w/ meals) on 10/8/24, it was discontinued on 10/23 and boost breeze was started in its place. Documentation notes she didn't care for ensure. Documentation does show she has refused frequently for breakfast and lunch, however it also shows she has consumed ~100% of supper ensure. Questioning accuracy. Since starting boost breeze she has averaged ~70% (based on x5 offerings). Meal intakes over the last ~14 days: ~0-25%: x17; ~26-50%: x12; ~51-75%:x8; ~76-100%: x3. 10/19/24 wt 179.6#; 10/9/24 179.2#. Weight has held ~179# since admitting. A nutrition note, entered by DM Q (Dietary Manager), dated 11/6/24 at 12:52 PM states, Resident is not eating well. Trial of Magic cup at noon and supper meals. Pudding cup at all meals. Still getting the wildberry breeze three times daily. Facility was unable to provide any documentation of this trial of R17's Magic Cup. On 12/12/24 at 3:59 PM, Surveyor interviewed DM Q (Dietary Manager) who stated that, although she is not a dietician, the facility's contracted dietician, who is not in the building often, would give her permission to trial nutritional supplements for up to three days. DM Q stated that she remembers the trial for R17 but the dietary department does not track how often they go out or if the supplement was actually consumed. DM Q stated it would be the CNAs (Certified Nursing Assistants) that would track the consumption of the supplements. On 12/12/24 at 4:15 PM, Surveyor interviewed NHA A (Nursing Home Administrator). NHA A is the interim NHA at the facility and was the DON before her interim NHA status. When asked who tracks supplement intake, NHA A stated nursing staff should be documenting, even if it is a trial. When asked if there was documentation of R17's three day trial of the Magic Cup, NHA A stated she was unable to find any documentation of it. Additionally, when asked if R17's physician was made aware of her 21 lb weight loss, NHA A indicated she was unable to find communication of the weight loss. NHA A indicated if the weights are that different back to back, nursing staff should be re-weighing to ensure accuracy, but then the weight loss should be communicated with the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 1 residents (R142) reviewed. R142 did not receive her scheduled Dupilumab (Dupixent) Subcutaneous (under the skin) Solution Auto-Injector 300mg/2ml on 12/6/24. Findings include: The facility policy titled, Medication Errors, date reviewed 11/2024, includes, in part: Policy: It is the policy of this facility to provide protections for the health, welfare, and right of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors . Policy Explanation and Compliance Guidelines: 1. The facility shall ensure medications will be administered as follows: a. According to physician orders .4. The facility will consider factors indicating errors in medication administration, including, but not limited to, the following: a. Medication administered not in accordance with the prescriber's order. Examples include, but not limited to: ii. Medication omission . R142 was admitted to the facility on [DATE] with diagnoses that include, in part: Other Seasonal Allergic Rhinitis, Hemiplegia and Hemiparesis. R142's admission Minimum Data Set (MDS) dated [DATE] indicates a Brief Interview for Mental Status (BIMS) of 2, indicating R142 has a severe cognitive impairment. On 12/10/24 at 11:19 AM, Surveyor contacted R142's Power of Attorney for Health Care (POAHC) due to R142's cognitive status. R142's POAHC indicated that R142 was not receiving her injections of Dupilumab for her eczema since being at the facility and she feels her skin is getting worse and that she is itching her arms again. R142's POAHC indicated that she has talked to the facility about it and they were looking into it but has not been given a definitive answer yet. R142's December Medication Administration Record (MAR) indicates the following, in part: Dupilumab Subcutaneous Solution Auto-Injector 300mg/2ml (Dupilumab) Inject 2ml subcutaneously one time a day every 14 day(s) related to Other Seasonal Allergic Rhinitis with a start date of 12/6/24 AM. (of note: this medication is a biological medication, which are used for inflammatory conditions) Of note, the next dose would not be scheduled for administration until 12/20/24. R142's Physician Orders indicate an order date for the Dupilumab of 11/22/24 and a start date of 12/6/24. On 12/6/24 there is a circled M and N/A written for the 12/6/24 administration time for R142's Dupilumab. It is important to note that the facility had an environmental emergency where residents were relocated to other local facility's from 11/27/24 returning to the facility 12/6/24. Facility staff did provide cares to residents at the other facilitys. On 12/12/24 at 2:41 PM, Surveyor interviewed CNA T (Certified Nursing Assistant) who indicated that R142 does itch her arms a lot. CNA T indicated that R142's daughter said that she was on a medication for it but she (CNA T) was unsure if R142 was on it now and that she thought the facility was checking into it. CNA T indicated that they will let the nurse know and sometimes they will put lotion on but that it doesn't help for long. On 12/12/24 at 3:29 PM, Surveyor interviewed NHA A (Nursing Home Administrator). NHA A is the interim NHA at the facility and was the DON (Director of Nursing) before her interim NHA status. According to the physician order audit details, NHA A entered the Dupilumab order into the facility electronic record. NHA A indicated that if she remembers correctly R142 does have eczema. NHA A indicated the reason the order was put in on 11/22/24 with a start date of 12/6/24 was because she spoke to the hospital, and they said that they gave it the day she left the hospital on [DATE]. NHA A indicated that when the residents were out of the building their medications were sent with them to the other facility's. Surveyor reviewed R142's MAR with NHA A for the 12/6/24 dose of Dupilumab. NHA A indicated agreement that this was not given based on the documentation. NHA A indicated the missed medication was not reported to her. NHA A indicated someone should have reviewed the MARs when residents returned to know if anything was missed and contacted the provider so that it could be rescheduled sooner than the next scheduled dose of 12/20/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 2 R30 was admitted on [DATE] with diagnosis that include Unspecified Dementia, Depression Unspecified, Pain Unspecified, Adjustment Disorder with Mixed Anxiety and Depressed Mood. R30's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/11/24 indicates R30 has significant cognitive impairment with a Brief Interview of Mental Status (BIMS) score of 6 out of 15. R30's Care Plan states in part: --Focus: The resident has impaired cognitive function/dementia or impaired thought processes r/t (related to) diagnosis of Unspecified Dementia, Unspecified Severity, Without behavioral disturbance, Mood Disturbance, and Anxiety. --Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Ask yes/no questions in order to determine the resident's needs . Review medications and record possible causes of cognitive deficit: new medications or dosage increases; anticholinergics, opioids, benzodiazepines, recent discontinuation, omission or decrease in dose of benzodiazepines, drug interactions, errors or adverse drug reactions, drug toxicity. --Focus: The resident uses psychotropic medications r/t adjustment disorder with anxiety and depression. --Interventions: Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness Q-shift (every shift) . Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy. Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of medications. --Focus: The resident has a mood problem r/t diagnosis of Depression and Adjustment Disorder with mixed anxiety and depressed mood. --Goals: The resident will have improved mood state as noted by resident indicating 1 to 2 less episodes of depression and 1 to 2 less episodes of anxiety through the review date. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. R30's December 2024 Physician orders include: *Quetiapine Fumarate Oral Tablet 25 MG (Quetiapine Fumarate). Give 1 tablet by mouth two times a day for Adjustment Disorder with Mixed Anxiety and Depressed Mood. *Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth one time a day related to Adjustment Disorder with Mixed Anxiety and Depressed Mood. *Sertraline HCl Oral Tablet 25 MG (Sertraline HCl) Give 1 tablet by mouth one time a day related to Adjustment Disorder with Mixed Anxiety and Depressed Mood; AND Give 2 tablet by mouth one time a day for Adjustment Disorder with Mixed Anxiety and Depressed Mood. (Of note: R30's Electronic Health Record does not indicate what side effects to monitor for while R30 is taking an antipsychotic, a benzodiazepine, and an antidepressant.) On 12/12/24 at 4:58 PM, Surveyor interviewed CNA J (Certified Nursing Assistant). Surveyor asked CNA J if she knew what side effects of R30's medication she should monitor for. CNA J stated she didn't know but that she would ask the nurse. On 12/12/24 at 4:59 PM, Surveyor interviewed CNA K. Surveyor asked CNA K if she knew what side effects of R30's medication she should monitor for. CNA K stated that R30 gets very anxious so she thought that is what should be monitored for. On 12/12/24 at 5:01 PM, Surveyor interviewed CNA L. Surveyor asked CNA L if she knew what side effects of R30's medication she should monitor for. CNA L stated she did not know but she thought things like anxiety and depression should be monitored for. On 12/12/24 at 5:03 PM, Surveyor interviewed Med Tech M (Medication Technician). Surveyor asked Med Tech M if she knew what side effects of R30's medication she should monitor for. Med Tech M indicated that R30 has seizures and maybe dizziness should be monitored for. Surveyor asked Med Tech M how the CNAs would know what side effects to monitor for so they could let the nurse know. Med Tech M stated the nurses would have to tell them what medication side effects to monitor for. On 12/12/24 at 5:06 PM, Surveyor interviewed RN N (Registered Nurse). Surveyor asked RN N how the staff would know of what medication side effects to monitor for R30. RN N stated they are taught to notify the nurse of any change in behavior that is different from their baseline. On 12/12/24 at 5:11 PM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A how staff would know what side effects to monitor for R30's antipsychotic, antidepressant, and benzodiazepine medications. NHA A indicated that the black box warning is put into their MAR (Medication Administration Record) in PCC (Point Click Care; an electronic health record system). Surveyor asked if that would include specific side effects. NHA A stated no, specific side effects would not be listed on the MAR. NHA A indicated that the nurses on the floor always have drug books available to them and they can reference those. NHA A stated that none of the residents have what medication side effects should be monitored or daily monitoring. R30's comprehensive care plan and documentation did not indicate what side effects of antipsychotic, benzodiazepine, or antidepressive medication R30 should be monitored for, nor was there any documentation to indicate that R30's side effects were being monitored by staff. Based on interview and record review, the facility did not ensure residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 2 of 5 residents reviewed for unnecessary medications (R17 and R30). R17 was taking an antipsychotic medication without appropriate diagnoses and indications for its use. R30's comprehensive care plan and documentation did not indicate what side effects of antipsychotic, benzodiazepine, or antidepressive medication that R30 should be monitored for, nor was there any documentation to indicate that R30's side effects were being monitored by staff. Findings include The facility policy titled, Use of Psychotropic Medication, states, in part: *The indications for initiating, withdrawing, or withholding medications, as well as the use of non-pharmacological approaches, will be determined by: a) Assessing the residents underlying condition, current signs, symptoms, expressions, and preferences and goals for treatment, b) Identification of underlying causes, when possible. *New admissions: the facility shall identify the indication for use, as possible, using preadmission screening and other preadmission data. The physician in collaboration with the consultant pharmacist shall reevaluate the use of the medication and consider whether or not the medication can be reduced or discontinued upon admission or soon after admission. * the effects of the psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as: a) upon physician evaluation (routine and as needed), b) during the pharmacist's monthly medication regimen review, c) during MDS review (quarterly, annually, significant change), and d) in accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the residents comprehensive plan of care. * The resident's response to the medications, including progress towards goals and presence/absence of adverse consequences, shall be documented in the residence medical record. Example 1 R17 was admitted to the facility on [DATE] and has diagnoses that include unspecified dementia without behavioral disturbance, depression, and anxiety disorder. admission medication orders for R17 included Quetiapine (seroquel) 25 mg (milligrams) three times daily for depression. The facility has targeted behaviors for R17 as anxiety (as manifested by fidgeting, repetitive comments, worry, feelings of not knowing what to do), insomnia, and depression. The facility documents on these behaviors each shift. A pharmacy consultant note, dated 10/21/24 at 11:09 AM reads, .noted Seroquel diagnosis is depression .Nursing recommendation to update diagnosis on Quetiapine . A facility progress note for R17, 10/22/24 at 1:42 PM, states, Residents son here to visit over the noon hour. Resident has been eating poorly at meals as she gets distracted very easily and then will state she doesn't care for a lot of the food choices. Has been refusing her supplements as well. Will update provider and she if he wants to order anything for appetite. Will have kitchen send a few different types of supplements to see what she likes. On 10/22/24 at 4:52 PM, R17's physician made an electronic note regarding R17's nutritional status, writing, Omeprazole was started and also Quetiapine was increased, hopefully between these 2 her appetite will be stimulated. An additional progress note made for R17 on 10/23/24 at 8:53 AM reads Received a response from the provider as he was updated on resident's heartburn last week and of her having anxiety episodes intermittently throughout all shifts and at times to the point of making her hyperventilate or get nauseated .Provider did order resident to start on Omeprazole 20mg P.O. daily for GERD (gastroesophageal reflux disease; a digestive disorder that causes heartburn and indigestion), and wants to increase the Seroquel to give 25mg P.O. 3 times daily and 50 mg at night. A pharmacist note to R17's physician, dated 11/25/24, states, Resident had a quetiapine dose increase on 10/23/24 to 25 mg 3 times daily and 50 mg at bedtime. The diagnosis in this order is listed as dementia with behaviors. Per discussion with the psychotropic medication review committee resident does not display harmful behavior, and the quetiapine dose increase was due to increased anxiety symptoms. She does have diagnosis of both depression and anxiety on her chart. Could we have an updated diagnosis for the quetiapine please? The physician, on 12/4/24, responded with a new diagnoses of dementia with agitation and aggression. The facility was unable to provide any documentation that R17 was being monitored for agitation or aggression. On 12/12/24 at 2:16 PM, Surveyor interviewed SW G (Social Worker) who stated that she had not seen any aggression by R17. SW G also stated that, as far as her agitation, R17 gets a bit fidgety but that is specifically addressed in her behaviors being tracked for anxiety. On 12/12/24 at 4:25 PM, Surveyor interviewed NHA A (Nursing Home Administrator). NHA A is the interim NHA at the facility and was DON (Director of Nursing) before her interim NHA status. When asked if depression or dementia were appropriate diagnosis for the use of an antipsychotic, NHA A responded, It depends. When asked if using quetiapine for appetite stimulation was appropriate, NHA A responded, No. R17 is taking quetiapine without an appropriate diagnoses or indications for its use.

Based on observation, interview, and record review, the facility did not ensure drugs and biological's are labeled in accordance with currently accepted professional standards for 2 of 2 Medication carts reviewed and 2 of 2 medication rooms for medication storage. The 2nd floor medication cart had an undated open insulin pen for R34, and expired morphine tablets for R25. The 3rd floor medication cart had a cough syrup for R1 with no open date or expiration date. The 2nd and 3rd floor medication storage rooms had expired stock meds. Evidenced by: The Facility's Policy, entitled Labeling of Medications and Biologicals, dated 1/5/2022 with last revision date of 11/2024 states, in part: All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications . 1. All medications and biologicals will be labeled in accordance with applicable federal and state requirements and current accepted pharmaceutical principles and practices . 9. Labels for medications designed for multiple administration (such as inhalers, eye drops), the label will identify the specific resident for whom it was prescribed . The Facility Policy, entitled, Medication Storage, dated 1/5/2024 with last revision date of 11/2024, states, in part: .It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medications rooms according to the manufacturer's recommendations . 9. Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed . The Facility Policy, entitled, Medication Administration, dated 1/5/2022 with last revision date of 11/2024, states, in part: Medications are administered . in accordance with professional standards of practice . 12. Compare medication source (bubble pack, vial, etc.) with MAR (Medication Administration Record) to verify resident's name, medication name, form, dose, route, and time . 13. Identify expiration date. If expired, notify nurse manager . Example 1 On 12/12/24 at 8:28 AM, Surveyor observed the 2nd floor medication storage room with LPN I (Licensed Practical Nurse). Surveyor found two bottles of Thiamin Vitamin B1 100 mg (milligrams) with an expiration date of 11/2024, one bottle of Super View Healthy Eyes eye vitamins with expiration date of 7/2/24 and a bottle of Paxlovid 300 mg with an expiration date of 11/2024. Surveyor asked LPN I how long medications were good for after the open date. LPN I answered the medications were good for 30 days after opening. Example 2 On 12/12/24 at 8:49 AM, Surveyor observed the 3rd floor medication storage room with LPN I. Surveyor found a box of acetaminophen 650 mg suppositories with an expiration date of 2/2024. LPN I indicated that the last resident to use this medication was over a year ago. Surveyor found a bottle of Vitamin D 10 mcg (micrograms) with an expiration date of 11/2024. Surveyor asked LPN I who was responsible for checking the medication storage rooms for expired medications. LPN I replied that typically the night nurses go through the storage rooms and dispose of expired medications. Example 3 On 12/12/24 at 9:11 AM, Surveyor observed the 2nd floor medication cart with DON B (Director of Nursing). Surveyor noted two bottles of GenTeal eye drops not properly dated with an open date, a box of Hydrocort (hydrocortisone) 25 mg suppositories with an expiration date of 11/2024, a bottle of fish oil capsules not properly dated with an open date, a blister pack of Muccinex removed from the original packaging with no expiration date, a used Lantus insulin pen for R34 with no open date and no expiration date, and morphine sulfate 15 mg tablets for R25 with an expiration date of 9/25/24. DON B indicated that the insulin pens are normally dated when they are first used. Surveyor asked DON B if the nurses administering the medications should be checking the expiration dates. DON B replied yes, but that hospice was responsible for checking the medication cart for expired medications for their patients. Example 4 On 12/12/24 at 9:31 AM, Surveyor observed the 3rd floor medication cart with RN H (Registered Nurse). Surveyor found a bottle of Delsym cough syrup for R1 with no expiration date and not properly dated with an open date. Surveyor asked RN H how long medications were good for after the open date. RN H answered the medications were good for 28 days after opening. On 12/12/24 at 1:47 PM, Surveyor interviewed NHA A (Nursing Home Administrator) regarding medication storage and expiration dates. Surveyor asked NHA A who was responsible for checking medication carts and medication storage rooms for expired medications. NHA A replied that the nurses are responsible for checking for expired medications, and also that the pharmacy comes every three months and does an audit looking for expired medications. Surveyor asked NHA what her expectation was for dating over the counter medications and insulin pens. NHA A stated the nurses were expected to date the bottles when they open them and also date eye drops and insulin. Surveyor asked NHA A how long medications were good for after the open date. NHA A indicated the medications were good until the manufacturer's expiration date. Surveyor asked NHA A if she expected that the medications administered to the residents would be before the expiration date. NHA A replied yes, that would be her expectation.

Based on observation and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 39 residents. Nutritional supplements and food items were observed with improper dates. An employee walked through the kitchen with no hairnet. A scoop was observed inside a container of sugar. Findings include Example 1 On 12/10/24 at 8:48 AM, Surveyor, along with DM Q (Dietary Manager), observed the following in the kitchen's dry storage: *3 bags of unopened pasta with no use by date *28-6 lb. cans of various vegetables and pie fillings with no received or use-by dates At 9:00 AM, Surveyor and DM Q observed the following in the kitchen's main refrigerator: *A container of sunflower seeds with an open/prepared date of 5/17/24 and a use by 10/17/24 *4 thawed nutritional supplements with no thaw dates (manufacturer label states the supplement must be used within 14 days of thawing). At 9:07 AM, DM Q stated that the nutritional supplements need to be thrown away as there is no thaw date and the container of sunflower seeds is past its use-by date and needed to be discarded. Example 2 On 12/10/24 at 9:08 AM, Surveyor, along with DM Q, observed CM R (County Maintenance) walk into the main kitchen without a hairnet. CM R walked through food preparation areas. CM R acknowledged Surveyor at this time indicating that he was not wearing a hairnet and needed one. Example 3 On 12/10/24 at 9:08 AM, Surveyor, along with DM Q, observed a large container of sugar in the facility's main kitchen. Inside the container of sugar a scoop could be seen. At this time, DM Q stated the scoop should not be in there due to potential cross-contamination and infection control standards.

Based on interview and record review, the facility did not identify issues to which quality assessment and assurance activities are necessary or make a concentrated effort to improve facility quality. This has the potential to affect all 39 residents. The facility does not have a Quality Assurance and Performance Improvement (QAPI) system in place and has failed to identify areas needing improvement to develop, implement, monitor, and evaluate action plans to achieve specific goals to improve quality of care. This is evidenced by the following: The facility policy, entitled Quality Assurance and Performance Improvement (QAPI) and dated 1/1/24, states, in part, It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides . The facility will maintain documentation and demonstrate evidence of its ongoing QAPI program. Documentation may include, but is not limited to: . Documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities . Governing oversight responsibilities include but are not limited to: . Ensuring the program is sustained during transitions in leadership and staffing . The facility conducts at least one distinct performance improvement project (PIP) annually that focuses on high risk or problem prone areas. Additional projects may be conducted as needed, and may be clinical or non-clinical in nature . The facility policy, entitled, QAPI Change Process, dated 1/1/24, states, in part: The facility has established and utilizes a systemic approach to performance improvement activities to ensure changes are effective and improvements are sustained . The facility must conduct distinct performance improvement projects, based on the scope and complexity of facility services and available resources, identified in the facility assessment . The facility must conduct at least one improvement project annually that focuses on high-risk or problem-prone areas, identified by the facility through data collection and analysis .: On 12/11/24 at 2:22 PM, Surveyor reviewed the facility QAPI binder. There was no evidence of the facility having a PIP in place to improve quality of care for the residents. On 12/12/24 at 2:06 PM, Surveyor interviewed NHA A (Nursing Home Administrator) regarding the QAPI process and plan. Surveyor asked NHA A how the facility tracked QAPI initiatives. NHA A stated she didn't have an answer for that as she has only conducted one QAPI meeting herself since assuming the role of NHA in October. Surveyor asked NHA A if the facility was currently working on any PIPs. NHA A replied no, they were currently not working on any PIPs. Surveyor asked NHA A if they should be working on a PIP at least annually to ensure quality of care to the residents. NHA A replied yes, they should have a PIP, but with the changes in facility leadership it has been difficult to prioritize the QAPI plan and initiatives. The facility did not follow their QAPI plan to identify at least one improvement project that focused on problem areas to ensure quality of care for their residents.

Based on interview and record review, the facility did not maintain a Quality Assessment and Assurance Committee consisting of at a minimum, the Director of Nursing Services, the Medical Director or his/her designee, at least three other members of the facility's staff one of whom must be the administrator, owner, a board member or other individual in a leadership role, and the Infection Preventionist, which met at least quarterly. This has the potential to affect all 39 Residents residing within the facility. Quality Assurance and Performance Improvement (QAPI) meetings did not consist of the required attendees/members for any of the quarterly meetings in the past year. This is evidenced by: The facility policy, entitled Quality Assurance and Performance Improvement (QAPI) and dated 1/1/24, states, in part, It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides . The QAA (Quality Assessment and Assurance) Committee shall be interdisciplinary and shall consist of a minimum of: i. The Director of Nursing Services ii. The Medical Director or his/her designee; iii. At least three other members of the facility's staff, at least one of which must be the Administrator, Owner, a Board Member, or other Individual in a leadership role; and iv. The Infection Preventionist . On 12/11/24 at 2:22 PM, Surveyor reviewed the facility's QAPI Committee meeting sign in sheets and noted the following: The QAPI meeting attendance sheet dated 11/6/23 did not include the Infection Preventionist (IP). The QAPI meeting attendance sheet dated 1/31/24 did not include the IP. The QAPI meeting attendance sheet dated 4/29/24 did not include the Administrator or IP. The QAPI meeting attendance sheet dated 7/29/24 did not include the IP. The QAPI meeting attendance sheet dated 10/28/24 did not include the IP. On 12/12/24 at 2:06 PM, Surveyor interviewed NHA A (Nursing Home Administrator) regarding the facility's QAPI process and QAA meetings. Surveyor asked NHA A who should be in attendance for the QAPI meetings. NHA A replied the NHA, DON (Director of Nursing), MD (Medical Director), Social Services, Dietary, Activities, Pharmacy, and the MDS (Minimum Data Set) Coordinator. Surveyor asked NHA A if the IP should be in attendance at the meetings. NHA A indicated she was not aware the IP needed to attend the meetings, as infection control is presented by the DON at the meetings. Surveyor reviewed the facility QAPI policy with NHA A. Surveyor asked if, per their policy, the IP should be included in the QAPI meetings. NHA A replied yes, the IP should attend the meetings.

Based on interview and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility does not have a water management plan that identifies all areas where Legionella and other opportunistic waterborne pathogens can grow and spread. This has the potential to affect all 39 residents (R) in the facility. Surveyors observed missing ceiling tiles with water actively dripping from a pipe into a container near residents during the lunch meal. The facility does not have mechanism for tracking Multi-Drug Resistant Organisms (MDRO). The facility's monthly infection control rates were not segregated for specific infection types. The facility could not provide evidence their water management program included: 1) Descriptions of the building water system using text and flow diagrams. 2) Identification of areas where Legionella and other opportunistic waterborne pathogens can grow and spread. 3) Description of where control measures should be applied and how to monitor them. Findings include: The facility policy titled, Infection Surveillance, date reviewed, 10/23/24, indicates, in part: Policy: A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections . Policy Explanation and Compliance Guidelines: .7. The facility will communicate via (specify how, e.g. written reports, staff meetings, etc.) to staff and/or prescribing practitioners information related to infection rates and outcomes in order to revise interventions/approaches and/or re-evaluate medical interventions as indicated. 8. Monthly time periods will be used to capturing and reporting data. Line charts will be used to show data comparisons over time and will be monitored for trends. 9. All resident and infections will be tracked. Separate, site-specific measures may be tracked as prioritized from the infection control risk assessment . The facility policy titled, Infection Prevention and Control Program, date reviewed, 10/23/24, indicates, in part: Policy: The facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted standards and guidelines .3. Surveillance: .b. The infection preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee . The facility policy titled, Water Management Program, date reviewed, 10/23/24, indicates, in part: Policy: It is the policy of this facility to establish water management plans for reducing the risk of legionellosis and other opportunistic pathogens .in the facility's water systems based on nationally accepted standards (e.g., ASHRAE, CDC, EPA). Policy Explanation and Compliance Guidelines: .3. A risk assessment will be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems .4. Data to be used for completing the risk assessment may include but are not limited to: a. Water system schematic/description. b. Legionella environmental assessment .5. Based on the risk assessment, control points will be identified. The list of identified points shall be kept in the water management program binder . The CDC Legionella Toolkit-Version 1.1 - June 24, 2021, Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings. A Practical Guide to Implementing Industry Standards, indicates, in part: Page 4 - Where can Legionella grow and/or spread? . *Water heaters . *Electronic and manual faucets . *Showerheads and hoses . *Ice Machines . Page 8 - Describe Your Building Water Systems Using Text .You will need to write a simple description of your building water system and devices .This description should include details like where the building connects to the municipal water supply, how water is distributed, and where pools, hot tubs, cooling towers, and water heaters or boilers are located . Page 10 - Describe Your Building Water Systems Using a Flow Diagram .In addition to developing a written description of your building water system, you should develop a process flow diagram . Page 11 - Identify Areas Where Legionella Could Grow & Spread .Once you have developed your process flow diagram, identify where potentially hazardous conditions could occur in your building water system . Example 1 On 12/10/24 at 11:18 AM, surveyors observed resident dining at the lunch mealtime in the first-floor dining area. Surveyors observed 5 ceiling tiles missing with exposed pipes, a ladder, a container, and towels placed under the open ceiling with water dripping into the container and debris on the floor. The container the water was dripping into was less than 2 feet from 2 residents sitting at a dining table. There were an additional 5 residents seated at another table near the open ceiling and container collecting the dripping water. On 12/10/24 at 11:30 AM, Surveyors interviewed NHA A (Nursing Home Administrator) in the first-floor dining area. NHA A indicated a pipe started leaking yesterday from a resident room above the dining room that maintenance was currently trying to repair. Surveyor asked NHA A how she would feel if she was one of the residents dining next to this. NHA A indicated not well. Surveyor asked if this could be an infection control issue in a dining area. NHA A indicated it could be and that the residents should have been seated somewhere else. On 12/10/24 at 11:36 AM, staff moved a total of 7 residents to an area away from the open ceiling and dripping water. Example 2 On 12/11/24 and 12/12/24 Surveyor reviewed the infection control program documentation provided by the facility. On 12/12/24 at 10:07 AM, Surveyor met to review the infection control program with LPN I, (Licenses Practical Nurse) who is also the Infection Preventionist (IP) for the facility, and NHA A. NHA A is the interim NHA at the facility and was DON (Director of Nursing) before her interim NHA status. Surveyor asked if the facility has a tracking mechanism for residents who have MDRO's (Multi-Drug Resistant Organisms). LPN I and NHA A indicated with the size of the building they know which residents have MDRO's and were able to list these residents for Surveyor. LPN I and NHA A indicated they do not have an actual mechanism to track these MDROs that others would be able to access. Example 3 On 12/11/24 and 12/12/24 Surveyor reviewed the infection control program documentation provided by the facility. On 12/12/24 at 10:07 AM, Surveyor met to review the infection control program with LPN I, who is also the Infection Preventionist (IP) for the facility, and NHA A. NHA A is the interim NHA at the facility and was DON (Director of Nursing) before her interim NHA status. Surveyor reviewed the monthly IC (Infection Control) rates that were provided by the facility with LPN I and NHA A. The monthly rates provided are for overall infection rates and not segregated for specific infection type. NHA A indicated that she completes the monthly infection rates and only completes overall rates and does not have them by specific infection type. Surveyor asked how they can ascertain an increase in a certain infection type without segregated rates. NHA A indicated they cannot. Example 4 On 12/12/24, Surveyor reviewed the water management documentation provided by the facility. On 12/12/24 at 5:18 PM, Surveyor interviewed NHA A regarding the facility water management program information that had been provided. Surveyor was unable to locate: 1) Descriptions of the building water system using text and flow diagrams. 2) Identification of areas where Legionella and other opportunistic waterborne pathogens can grow and spread. 3) Description of where control measures should be applied and how to monitor them. Surveyor asked NHA A if maintenance was available to speak with as the water management policy indicates the Maintenance Director maintains documentation that describes the facility's water system. NHA A indicated that maintenance was not available at that time. Surveyor reviewed the above items that could not be located in the water management documents provided. NHA A indicated that these things should have been included in the water program and that she will check maintenance to see if she can locate the binder referenced in the policy. Of note, no further documentation related to the water management program was provided to the Surveyor.

Example 2 R2 reported that a Certified Nursing Assistant (CNA) was rough with her. The facility did not report this allegation of abuse to the State Agency (SA) or law enforcement. Grievance Form, dated 2/6/24, states, in part: .CNA was rough with her . On 8/13/24 at 4:45 PM, Surveyor interviewed SSD C (Social Service Director) and asked if a resident states that a CNA was rough with them, could this be considered an allegation of abuse? SSD C stated, it could be, yes. Surveyor asked if R2's concern was potentially abuse. SSD C stated, it could've been. Surveyor asked if this concern met the definition of contacting the state agency or law enforcement. SSD C stated, we didn't feel so at the time, but looking back at it now, we could have updated the state and contacted law enforcement. On 8/13/24 at 5:25 PM, Surveyor interviewed DON B (Director of Nursing) and asked if a resident states that a CNA was rough with them, could this be considered an allegation of abuse. DON B stated, yes. Surveyor asked if the facility would expect that the State Agency and law enforcement be notified with concern of abuse. DON B stated, yes. Example 3 R3 reported that the CNA left her unsupervised in the tub. The facility did not report this allegation of neglect to the State Agency (SA). Grievance Form, dated 5/31/24, states, in part: R3 stated that CNA was not attentive during bathing, she had to request multiple times for assistance, felt CNA was distracted. R3 mentioned that at one point she felt like she could have slipped in the tub unit and asked the CNA to get out of the bath. Employee Disciplinary Form, dated 5/31/24, states, in part: Employee Statement-- .I was over by the sink cutting my nails. I did not know she needed help. On 8/13/24 at 2:00 PM, Surveyor observed the tub/shower room. The bathtub is on the far side of the room, separated from the shower and sink by a wall. Surveyor was unable to visualize the tub when standing near the sink. On 8/13/24 at 4:45 PM, Surveyor interviewed SSD C and asked, if staff needs to supervise residents while they are in the bathtub. SSD C stated, they should, I believe. Surveyor asked SSD C if a resident is unsupervised in the bathtub, could this be considered an allegation of neglect. SSD C stated, yes, it could be. On 8/13/24 at 5:25 PM, Surveyor interviewed DON B and asked if staff need to supervise residents while they are in the bathtub. DON B stated, yes. Surveyor asked if the staff member needs to see the resident during supervision. DON B stated, yes, staff need to have eyes on the resident. Surveyor asked if a staff member is standing near the sink in the tub/shower room, are they able to supervise the resident. DON B stated, no. Surveyor asked if a resident is unsupervised in the bathtub, could this be considered an allegation of neglect. DON B stated, it could be. Surveyor asked if this should have been investigated. DON B stated, yes. Surveyor asked if the facility would expect allegations of neglect to be reported to the SA. DON B stated, yes. Based on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 of 3 sampled residents (R1) and failed to report to the State Agency for 2 of 3 sampled residents (R2, R3). R1 had a sexual abuse allegation reported to the facility. The facility did not report this allegation to law enforcement. R2 reported that a certified nursing assistant (CNA) was rough with her. The facility did not report this allegation of abuse to the State Agency (SA) or law enforcement. R3 reported that the CNA left her unsupervised in the tub. The facility did not report this allegation of neglect to the SA. This is evidenced by: The Facility's Policy and Procedure entitled Abuse, Neglect and Exploitation dated 11/20/23 documents in part: .Crime is defined by law of the applicable political subdivision where the facility is located. A political subdivision would be a city, county, township or village, or any local unit of government created by or pursuant to State law .Sexual Abuse is non-consensual sexual contact of any type with a resident .VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes . Example 1 Per the facility reported incident (FRI), Adult Protective Services (APS) sent an email on 7/26/24 to SSD C (Social Service Director) alleging sexual abuse of R1 by R1's SO (Significant Other) per a Hospital entity. SSD C opened this email 7/29/24 upon returning from vacation and immediately began the investigation process for this allegation of sexual abuse. Per the FRI, the sexual abuse allegation was not reported to law enforcement. On 8/13/24 at 4:57 PM, Surveyor interviewed SSD C. Surveyor asked SSD C if an allegation of sexual abuse is a crime, SSD C stated yes. Surveyor asked SSD C if law enforcement should have been contacted, SSD C said yes, I think we thought they had been, since the allegation came to us from APS. On 8/13/24 at 5:33 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if an allegation of sexual abuse is a crime, DON B stated yes. Surveyor asked DON B if law enforcement should have been contacted, DON B replied if there is a suspicion that sexual abuse has occurred, yes.

Based on interview and record review, the facility did not investigate an alleged violation of abuse or neglect for 2 of 3 sampled residents (R2 and R3). On 2/6/24, the facility became aware of an alleged violation of abuse to R2 and the facility did not conduct an investigation. On 5/31/24, the facility became aware of an alleged violation of neglect to R3 and the facility did not conduct an investigation. Evidenced by: Facility policy entitled, Resident and Family Grievances dated 1/30/2024, states, in part: .Take any immediate actions needed to prevent further potential violations of any resident rights. Report any allegations involving neglect, abuse, injuries of unknown source, and/or misappropriation of resident property immediately to the administrator and follow procedures for those allegations . Facility policy entitled, Abuse, Neglect, and Exploitation dated 11/20/2023, states, in part: .V. Investigation of Alleged Abuse, Neglect and Exploitation A.An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: .4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpertrator, witnesses, and others who might have knowledge of the allegations . Example 1 R2's Grievance Form, dated 2/6/24, states, in part: .CNA (certified nursing assistant) was rough with her .SW (social worker) spoke with resident who was unable to name staff member . On 8/13/24 at 10:16 AM, Surveyor interviewed SSD C (Social Services Director) and asked if there was conversation with the staff working on 2/6/24 to determine which staff member worked with R2. SSD C said, No, because the resident couldn't say who the staff member was. On 8/13/24 at 3:13 PM, Surveyor interviewed SSD C and asked would staff on duty be interviewed if a resident reported a concern but was unable to state name of the involved staff member. SSD C stated, yes, to narrow down who might be responsible for the care of the resident. Surveyor asked if the staff on duty on 2/6/24 should have been interviewed. SSD C stated, after reviewing this again, I should have spoken to everyone individually. I should have interviewed all staff. On 8/13/24 at 4:45 PM, Surveyor interviewed SSD C and asked if a resident states that a CNA was rough with them, could this be considered an allegation of abuse? SSD C stated, it could be, yes. Surveyor asked if this would be investigated to rule out abuse. SSD C stated yes, we talk with the resident for further information and talk with staff. Surveyor asked if staff should have been interviewed regarding R2's report of CNA being rough. SSD C stated, yes. On 8/13/24 at 5:25 PM, Surveyor interviewed DON B (Director of Nursing) and asked if a resident states that a CNA was rough with them, could this be considered an allegation of abuse. DON B stated, yes. Surveyor asked if R2's report of CNA being rough should have been investigated. DON B stated, yes. Surveyor asked if staff and other residents should have been interviewed. DON B stated, yes. Example 2 R3's Grievance Form, dated 5/31/24, states, in part: R3 stated that CNA was not attentive during bathing, she had to request multiple times for assistance, felt CNA was distracted. R3 mentioned that at one point she felt like she could have slipped in the tub unit and asked to get out of bath. Facility Employee Disciplinary Form, dated 5/31/24, states, in part: Employee Statement-- .I was over by the sink cutting my nails. I did not know she needed help. On 8/13/24 at 1:34 PM, Surveyor interviewed R3 and asked about the bath on 5/31/24. R3 stated, the CNA should've been paying more attention to me. She was behind the wall where she couldn't see me. I don't wear a restraining belt, I could have slipped down under the water and she wouldn't have known. On 8/13/24 at 2:00 PM, Surveyor observed the tub/shower room. The bathtub is on the far side of the room, separated from the shower and sink by a wall. Surveyor was unable to visualize the tub when standing near the sink. On 8/13/24 at 2:04 PM, Surveyor interviewed CNA D and asked if residents are allowed to be unsupervised while in the bath tub. CNA D stated, no, you have to keep eyes on them. On 8/13/24 at 4:45 PM, Surveyor interviewed SSD C and asked, if staff needs to supervise residents while they are in the bathtub. SSD C stated, they should, I believe. Surveyor asked SSD C if a resident is unsupervised in the bathtub, could this be considered an allegation of neglect. SSD C stated, yes, it could be. Surveyor asked SSD C if R3's concern of 5/31/24 should have been investigated. SSD C stated, yes. Surveyor asked SSD C if staff and residents should have been interviewed. SSD C stated, yes. On 8/13/24 at 5:25 PM, Surveyor interviewed DON B and asked if staff needs to supervise residents while they are in the bathtub. Surveyor asked if the staff member needs to see the resident during supervision. DON B stated, yes, staff need to have eyes on the resident. Surveyor asked if a staff member is standing near the sink in the tub/shower room, are they able to supervise the resident. DON B stated, no. Surveyor asked if a resident is unsupervised in the bathtub, could this be considered an allegation of neglect. DON B stated, it could be. Surveyor asked if this should have been investigated. DON B stated, yes. Surveyor asked if staff and other residents should have been interviewed. DON B stated, yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure a resident received a complete involuntary discharge notice including the information for the right to appeal the notice for 1 of 1 residents (R1). R1's Power of Attorney (POA) was issued an involuntary discharge notice for R1 that did include all the requirements for an involuntary discharge notice, including the right to appeal to the Division of Quality Assurance and contact information. Findings include: The facility's policy, Transfer and Discharge (Including AMA) states the following: * The facility's transfer/discharge notice will be provided to the resident and the resident's representative and in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: a) the specific reason and basis for transfer discharge b) the effective date of transfer discharge c) the specific location to which the resident is to be transferred or discharged d) an explanation of the right to appeal the transfer or discharge to the state e) the name, address (mailing and e-mail) and telephone number of the state entity which receives such appeal hearing requests f) information on how to obtain an appeal form g) information on obtaining assistance in completing and submitting the appeal hearing request h) The name, address (mailing and email), and phone number of the representative of the office of the State Long-Term Care Ombudsman . * Document the reasons for the transfer or discharge in the resident's medical record, and in the case of necessity for the resident's welfare and the resident's needs cannot be met in the facility, document the specific resident needs that cannot be met, facility attempts to meet the resident needs, and the services available at the receiving facility to meet the needs. Document any danger to the health or safety of the resident or other individuals that failure to transfer or discharge would pose. * Orientation for transfer discharge will be provided and documented to ensure safe and orderly transfer or discharge from the facility, in a form and manner that the resident can understand. Depending on the circumstances, this orientation may be provided by various members of the interdisciplinary team. * The physician shall document medical reasons for transfer or discharge in the medical record, when the reason for transfer or discharge is for any reason other than non-payment of the stay or the facility ceasing to operate. A copy of the physician's order for discharge should be attached to the discharge notice. * For a community discharge, a discharge summary and plan of care should be prepared for the resident. Document in the medical record that written discharge instructions were given to the resident and if applicable, the resident's representative. R1 was admitted to the facility on [DATE] and has diagnoses that include dementia. He has an activated POA. On 12/7/23 at 9:00 AM, NHA A (Nursing Home Administrator) stated to surveyors that she had issued R1 an involuntary discharge notice to R1's POA C (Power of Attorney) on 11/20/23 and R1's son would be picking him up and taking him home. NHA A stated that he is to be discharged by 12/20/23. NHA A provided a copy of the notice of discharge to surveyors. The form indicates it was issued to POA C and the Board of Long-term Care Ombudsmen Program. The form did not include the resident's appeal rights, including the right to appeal to Division of Quality Assurance (DQA), and DQA's contact information in order to make an appeal of the discharge decision. Rather, the form directs POA C to contact NHA. Additionally, the form lists R1's home address as the discharge location and states that reasons for R1 being discharged are: 1) Resident requires a locked unit that the facility cannot provide; 2) The safety of individuals in the facility is engaged due to the clinical or behavioral status of the resident: Aggression towards staff and others; and 3) The health of individuals in the facility would otherwise be endangered. On 12/7/23 at 11:14 AM, Surveyor interviewed POA C, who is also R1's wife. POA C stated that she was notified that the facility would be discharging R1 and she was under the impression that she needed to come and pick him up. POA C confirmed the address listed on the form was her home. POA C stated she thought the facility had done their best with R1 but she could not take care of R1 due to his wandering behaviors, her age, and that she lived alone at their (R1 and POA C's) home. POA C also stated that her sons could not take care of R1 as they work during the day. POA C stated that her plan was to come to the facility with one of her sons, pick R1 up and take him to the VA (Veteran's Administration) hospital ER (Emergency Room) because she had no other options, and the ER would have to take him. On 12/7/23 at 11:40 AM, Surveyor interviewed NHA A to clarify R1's discharge destination. NHA A stated the address on the discharge form was R1 and POA C's home and stated, I don't know what they're going to do when he gets there, but that's where I'm discharging him. On 12/7/23 at 12:09 PM, Surveyor interviewed MD D (Medical Doctor), who is R1's physician. MD D stated that he does not remember signing any discharge orders for R1 nor was aware that R1 was given an involuntary discharge. MD D stated that he was aware of R1's wandering and tendency to hit staff and other residents and that it was difficult for the facility to take care of R1. MD D stated that he did not believe R1 would be an immediate danger to himself or POA C upon returning back to their home, but that it would not be a safe long-term plan. The facility issued an incomplete involuntary discharge notice for R1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's physician was consulted with a deterioration in a pressure injury for 1 of 2 Residents reviewed for pressure injuries (PI) out of a total sample of 15 Residents (R9). R9 was admitted to the facility with a pressure injury to her left elbow and the physician was not notified when the wound was not improving/worsened. This is evidenced by: The facility policy titled Documentation of Wound Treatments, with a reviewed/revised date of 4/12/23, indicates, in part: Policy: The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment. Policy Explanation and Compliance Guidelines: 1. Wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates. 2. The following elements are documented as part of a complete wound assessment: .c. Measurements: height, width, depth, undermining, tunneling . The facility policy titled, Pressure Injury Prevention and Management, with a reviewed revised date of 4/12/23, indicates, in part: .Policy Explanation and Compliance Guidelines: .5. Monitoring .b. The attending physician will be notified of: .ii. The progression towards healing, or lack of healing, of a pressure injuries weekly. iii. Any complication (such as infection, development of a sinus tract, etc.) as needed. R9 was admitted to the facility on [DATE] with diagnoses that include, in part: unspecified dementia, weakness, vitamin deficiency, and hyperglycemia (high blood sugar). R9's admission Minimum Data Set (MDS) dated [DATE] indicates a Brief Interview for Mental Status (BIMS) of 2, indicating severe cognitive impairment. R9's Physician Orders for wound care to left elbow, with a start date of 8/12/23, indicate, in part: .one time a day .cleanse wound and peri wound with Normal Saline, apply moistened aquacel ag (silver) to woundbed, apply bordered foam . R9's Wound - Weekly Observation Tool forms, indicate, in part: 10/10/23: A. Communication 1a. Date MD/Alternate Notified/Last updated: 8/25/23 .4. Details .Area is chronic. B. Observations/Data 1. Location: Left elbow .8. Wound Measurements 10mm (millimeters) x 10mm .D. Evaluation Wound Progress: stable, unchanged . No weekly wound observation tool was provided for 10/17/23. However, progress notes reviewed note a measurement on 10/17/23 of 2 cm (centimeter) x 1 cm (20mm x 10mm). 10/25/23: A. Communication 1a. Date MD/Alternate Notified/Last updated: 8/25/23 .B. Observations/Data 1. Location: Left elbow .8. Wound Measurements 20mm x 10mm .D. Evaluation: Wound Progress: Stable, unchanged-continuing to monitor weekly . 11/2/23: A. Communication 1a. Date MD/Alternate Notified/Last Updated: 11/2/23 . B. Observations/Data 1. Location: Left elbow .8. Wound Measurements 20mm x 10mm .D. Evaluation: Wound Progress: Documentation is Blank . On 11/9/23 at 11:20 AM, Surveyor interviewed RN H (Registered Nurse) and asked when a provider should be contacted if a wound is not improving. RN H indicated she did not know if there was a specific time. RN H indicated if it isn't healing, if you are doing a wound round and notice it isn't doing well, then let them know. Surveyor asked RN H if she provides wound care for R9's left elbow. RN H indicated that it is a PM treatment, it was here on admission, and it has stalled out and it just doesn't heal. RN H added that MD I (Medical Doctor) looks at it when he does rounds and he says to just continue the current treatment. Surveyor asked RN H if she could provide documentation where the MD was contacted or observed wound during rounds regarding no improvement. RN H checked for documentation in R9's record and was unable to locate documentation of this. Surveyor reviewed R9's wound measurements with RN H from 10/2 to 11/2 and asked if she would expect a call to be made to the doctor as it was not improving. RN H indicated, yes, I think our rule of thumb is after two weeks. On 11/9/23 at 2:36 PM, Surveyor interviewed MD I via telephone. Surveyor asked MD I if he would have expected a call regarding R9's left elbow wound if it was not improving since 10/2/23. MD I indicated he saw R9 on Monday and did not look at the wound. MD I indicated that would be reasonable and if it hasn't improved in 2 weeks, then he would expect a call. On 11/9/23 at approximately 11:15 AM, Surveyor interviewed DON B (Director of Nursing) and asked when staff should contact the provider regarding a wound. DON B indicated if there is a change, if it seems infected, if it's worsening, if they don't feel the treatments are working. Surveyor asked when staff should contact the doctor if the wound isn't improving. DON B indicated staff should call as soon as they make that determination. R9 had left elbow pressure injury measurements that worsened between 10/10/23 and 10/17/23. R9's pressure injury measurements also remained unchanged from 10/17/23 through 11/2/23 without notification to the provider so that a decision could be made on whether to change treatment course.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to protect the resident's (R35's) right to be free from physical abuse by R33. R33 has a history of striking residents. The facility failed to put aggressive measures in place to prevent R33 from physical abusing R35. R33 entered R35's room and willfully hit R35 in the chest. The facility failed to protect R35 by not providing adequate supervision. Evidenced by: The facility's policy, entitled Abuse, Neglect, and Exploitation revision date 7/24/23, states: 5. Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect such as: a. Aggressive and/or catastrophic reactions of residents; b. Wandering or elopement-type behaviors; c. Resistance to care; d. Outbursts or yelling out; and e. Difficulty in adjusting to new routine or staff. VI. Protection of Resident. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation .A. Responding immediately to protect the alleged victim and integrity of the investigation; B. Examining the alleged victim for any signs of injury including a physical examination or psychosocial assessment if needed; C. Increased supervision of the alleged victim and residents; D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; . VII. Reporting/Response a. Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; b. Defining how care provision will be changed and/or improve to protect residents receiving services; c. training of staff on changes made and demonstration of staff competency after training is implemented. R33 was originally admitted to the facility on [DATE] and was recently readmitted on [DATE] from the Dementia Stabilization Unit (DSU) where he was seen for aggressive behaviors. R33 has diagnoses that include: unspecified dementia moderate with agitation, unspecified dementia moderate with other behavioral disturbances, anxiety disorder unspecified, pain unspecified, other hereditary and idiopathic neuropathies. R33's Minimum Data Set (MDS) assessment, dated 7/26/23, indicated R33 has clear speech and is understood when speaking. R33 scored a 1 out of 15 on his Brief Interview of Mental Status (BIMS) assessment indicating that R33's cognition is severely impaired. The MDS also shows R33 has disorganized thinking and behavioral symptoms of wandering. On 9/19/23 R33 was admitted to a DSU for a short term stay due to aggressive behaviors that facility staff was having difficulty controlling, medication changes, non-pharmacological interventions, and for assistance to buffer R33's care plan. R33 was discharged from the DSU on 10/5/23 and returned to the facility. R33's discharge paperwork included a Behavior Support Plan dated 10/4/23 states . In his first 24 hours here at the DSU, R33 had a difficult time. He was very confused and became angry frequently. Overtime, with getting to know him and his responses, along with some medication changes, this has improved . Behaviors. R33 has shown his anger on several occasions during his stay. his anger seems to be directly preceded by his confusion. we have seen this occur when someone approaches him quickly, questions his ability for him to take care of himself, move too quickly or telling him No. All staff have found success and talking very calmly, asking him permission to approach, listening to him, giving him choices . it is important to remember that R33 is on his own schedule, and to honor that. It is important to read R33's mood .R33 . likes watching YouTube videos about farming in Wisconsin. he also enjoys westerns, [NAME] Bond movies, and Gunsmoke. he has been interested in the [NAME] show . R33's Care Plan initiated on 10/16/23, states: Risk for wandering/elopement identified. Interventions include clearly identify resident's room and bathroom, identify if there is a certain time of day wandering attempts occur. Resident does not harm self or others. Interventions include if wandering or pacing, initiate visual supervision during acute episode, maintain consistent schedule with daily routine, minimize environmental stimuli, monitor for cognitive, emotional, or environmental factors that may contribute to violent behaviors. Monitor resident for signs/symptoms of agitation. Provide clear, simple instructions. Provide reorientation to situation, utilize calming touch. Targeted behavior 2: aggressive behavior. Targeted behavior 5: wandering. Interventions include aggressive behavior nonpharmacological intervention. Behavior intervention 2: walk with him, hands off, talk about farming, grain bins, validate what he is saying, even if difficult to understand that must be frustrating, I can see why you might be upset. Behavior intervention 3: Do not direct with hands on, you can reach out with open hand he takes it, but hand on arm can trigger. Resident has motion sensor alarm on his door to indicate anyone entering and leaving room. Alarm sounds in hallway. Wander/exit seeking non-pharmacological interventions. Behavior intervention 1: attempt to redirect (state, I know your legs get tired from farming; maybe you could sit down for a bit). Behavior intervention 3: Check environment- he gets overwhelmed with a lot of noise, states he gets headaches, attempts to leave the area. Wandering/entering (other resident's rooms) non-pharmacological interventions. Behavior intervention 1: Redirect to his own room or recliner in his room; do not put hands on; he can feel threatened. Behavior interventions 3: State calmly, oh, that room belongs to someone, we just had to move them, are you looking for your room? Or did you need to find the bathroom, snack, recliner, etc.? Care Conference was held on 10/31/23 at 1:00 PM. Care conference notes states .Can become aggressive based on approach. Confused and forgetful .Aware of previous resident to resident interactions . Care conference notes indicated that Administration, SW G (Social Worker) and RR O (Resident Representative) in attendance. On 10/26/23 at 7:30 PM, the following progress note was entered into R33's medical record, R33 walked into room ### tonight after supper with no clothes on. The CNA assisted R33 out of room ### and explained to him why he could not be in that room. On 11/9/23 at 10:51 AM, Surveyor interviewed R35's RR O (Resident Representative). RR O indicated that R35 would not be okay with another resident entering his room naked. R33's Medication Administration Record (MAR) indicates Lorazepam 0.5 MG was administered to R33 at 8:00 PM, for agitated and has a lot of anxiety, no non-pharmacological interventions documented. On 10/27/23 at 11:36 AM, the facility submitted a self-report to the State Agency (SA) indicating that on 10/26/23 at the estimated time of 8:00 PM, R33 was reported to have entered R35's room. Yelling was overheard. Staff entered room and were able to redirect R33 back to his room. R35 stated during investigation that R33 had hit him but had not stated this to staff after incident was discovered. Staff did not see any physical contact. On 11/9/23 at 9:38 AM, Surveyor and DON B (Director of Nursing) reviewed R33's elopement risk assessment dated [DATE]. R33's elopement risk assessment states, is the resident's wandering behavior likely to affect the safety or well-being of others? The facility indicated yes. Is the residents wandering behavior likely to affect the privacy of others? The facility indicated yes. DON B stated, This is the first I have seen it. Abnormal assessments should be reported to me by staff completing assessments. DON B indicated that she tries to review the 24-hour report daily. DON B indicted that the 24-hour report includes progress notes, behavior notes, PRN medication notifications, and assessments. On 11/9/23 at 11:40 AM, surveyor and NHA A (Nursing Home Administrator) reviewed R33's elopement risk assessment dated [DATE]. NHA A stated, Indicates R33's wandering is likely to affect the privacy, safety, and well-being of others, and the behavior is a pattern. On 11/8/23 at 1:39 PM, Surveyor interviewed CNA M (Certified Nursing Assistant) regarding her knowledge of R33's behavior history. CNA M stated, R33 has a history of history of hitting other residents. CNA M indicated that R33 it not on 1:1 supervision (1 staff member supervising 1 resident), but he used to be. CNA M indicated that when R33 is agitated she implements 1:1. Surveyor asked CNA M if the facility has staffing to allow for 1:1s with R33, CNA M indicated no. On 11/8/23 at 2:14 PM, Surveyor interviewed CNA N regarding R33. CNA N indicated that R33 often thinks the facility is his home adding that R33 gets very confused and upset when he sees other men (in his home). CNA N indicated that R33 does not like other men. CNA N indicated that R33 has a history of becoming combative. CNA N stated that R33 frequently goes into R35's room. On 11/9/23 at 9:04 AM, Surveyor interviewed RN H (Registered Nurse) regarding her knowledge of R33's behavior history. RN H indicated that R33 tends to sundown in the evenings and R33 gets busier after supper and wanders by self-propelling in his wheelchair and ambulating independently. RN H stated, R33 get angry when he is unable to communicate his bathroom needs and when he wets his brief. On 11/8/23 at 9:34 AM, Surveyor interviewed SW G (Social Worker) regarding R33's behavior history. SW G indicated that R33's dementia has gotten worse since his admission. SW G indicated that R33 was previously on 15 minute 1:1 supervision, and it was previously care planned. SW G indicated that when R33 is close to another resident staff try to be close to R33. SW G indicated that she does not know if extra staff has been added to allow for R33 to receive increased supervision. On 11/9/23 at 11:40 AM, Surveyor interviewed NHA A (Nursing Home Administrator) regarding her knowledge of R33's supervision. NHA A indicated that the facility tries to supervise R33 as much as they can. NHA A stated, I don't have the staff to do a 1:1 for R33. On 11/8/23 at 1:39 PM, Surveyor interviewed CNA M regarding the incident between R33 and R35 that occurred on 10/26/23. CNA M indicated that she was on the other end of the hallway helping another resident when the incident occurred, adding that she responded to R35's room at the end of the incident. CNA M indicated that when she got to R35's room, she saw CNA N and an agitated R33 who was wearing a shirt and pull up brief, in R35's room. CNA M stated that she and CNA N got R33 out of R35's room and R33 back into his room. On 11/8/23 at 2:14 PM, Surveyor interviewed CNA N regarding the incident between R33 and R35 on 10/26/23. CNA N indicated that she had assisted R33 to bed, and about thirty minutes later she was in another resident's room that was three rooms down from R33 and R35's rooms, when she heard yelling. CNA N indicated that she was unable to see inside R35's room from her location at the time. CNA N indicated that as she was responding to the incident when she encountered RN E in the hallway. CNA N indicated that RN E stated, so you have everything under control, and RN E turned around and walked back down the hall to the med cart. CNA N indicated she continued to hear yelling coming from R35's room. When she responded to the incident R33 was standing in the doorway of R35's room, naked. As CNA N responded she continued to hear yelling between R33 and R35. CNA N stated that when she arrived to the incident R35 was standing in front of R33, within an arm's length apart. R35 was yelling at R33, asking R33 where his clothes were. CNA N stated, R33 was mumbling and stuttering, when R33 is very upset he stutters. CNA N indicated that she entered R35's room and asked R35 to step back, R35 complied. CNA N indicated that she asked R33 what was going on, R33 stated that there was a man in his house, and he needed help. CNA N indicated that she offered to help R33 get some clothes on. CNA N indicated that CNA M had just reported back to duty after taking a break and provided her with assistance. CNA N indicated that CNA M got R33's wheelchair from his room, and herself and CNA M took R33 to his room. Surveyor asked who stayed with R35 following the incident, CNA N stated, No one stayed with R35. CNA N indicated that she and CNA M assisted resident with getting dressed and offered R33 to sit in his recliner or in his bed, R33 choose to get into bed. CNA N indicated that when she exited R33's room, R35 was standing alone in the hallway, waiting outside R33's room. CNA N stated that R35 stated, next time I see him acting like that I am going to take him to the ground. CNA N stated that she stayed with R35 for five minutes. CNA N stated that R35 didn't know what was going on. Surveyor asked CNA N if she reported the incident to RN E, CNA N indicated that she did report her knowledge of the incident to RN E during the shift as well as the other nurse on duty on the third floor. CNA N stated that she did not observe RN E assess R33 or R35 following the incident. CNA N indicated that she worked the night shift that evening and typed up a statement of the incident. CNA N indicated that she received a phone call from SW G on 10/27/23, SW G requested a statement of the incident from CNA N. CNA N indicated that she provided a copy of the incident statement to DON B, SW G, and NHA A on 10/31/23 at 1:30 PM. CNA N indicated that R33 and R35 both have motion sensors in the doorway to their rooms. CNA N indicated that there is a pod that sounds in the CNA station/room, as well as in the doorway of resident's rooms that the motion sensors have been installed. CNA N indicated that she is not able to hear them depending on her location in the facility, CNA N. CNA N indicated that she cannot hear the alarms while working many areas of the unit including, in the dayroom when there is background noise in the dayroom, in other residents' rooms, and from the opposite hallway. CNA N indicated that the motion sensors activate when someone walks under the sensor that is placed above the doorway of resident's room. CNA N indicated that when a sensor alarm sounds, she has to listen for the alarm, and search the hallways to determine the location of the sounding alarm, adding that she often goes into the CNA station/room to use the pods to determine the location of the sounding alarm. CNA N indicated that R33 had a motion sensor installed in his room on the second floor and a motion sensor was installed in R33's new room when he moved to the third floor after his DSU discharge adding that R35's sensor alarm was installed a few weeks after R35's admission. On 11/8/23 at 4:22 PM, Surveyor interviewed RN E regarding R33. RN E stated there was an incident between R33 and R35 that occurred on 10/26/23. RN E indicated that before 7 PM, she was at the nurses' station when she heard yelling. RN E saw CNA N by the nurse's station. From her location, RN E indicated she was not able to see R33, R35, or inside R35's room, adding that she went to check it out. RN E indicated that when she arrived at the source of the yelling in R35's room she observed R33 standing in the doorway of R35's, R35 was standing 2-3 feet away from R33 facing R33 and the doorway part way open. RN E indicated that CNA N entered R35's room first and then she followed, R33 and R35 were yelling at one another. RN E indicated that CNA N stayed in R35's room while she walked across the hall to R33's room to get R33's wheelchair. RN E indicated that she returned to R35's room with R33's wheelchair. RN E indicated that when she returned to the room R33, R35, and CNA N were in the same spot as when she left. RN E indicated that she handed R33's wheelchair to CNA N who assisted R33 to sit in his wheelchair and she escorted R33 to his room. Surveyor asked RN E what care she provided for R33 following the incident, RN E stated, R33 stated he was okay. RN E indicated she did not ask R33 any questions regarding the incident stating, R33 was upset. Surveyor asked RN E if she completed an assessment on R33 following the incident, RN E stated that she had not, adding that she should have assessed R33 right away. Surveyor asked RN E what care she provided for R35 following the incident, RN E stated, I did nothing, R35 said nothing to me or other staff the rest of the night, R35 was upset. RN stated, R35 was mad that R33 was in his room and I should have asked R35 if he was okay, I should have asked if R33 struck out at him. RN E stated that, I just didn't think of it, when Surveyor asked her why a skin assessment was not completed for R35 after the altercation. RN E indicated that she should have completed skin assessment on R35 right away. RN E indicated she completed an assessment the following day after SW G had prompted and requested her to complete a skin assessment for R35. On 11/8/23 at 9:34 AM, Surveyor interviewed SW G regarding R33. SW G indicated that that R33's DSU care plan is referenced in R33's care plan and posted. SW G indicated that she observes and reeducates staff, discussed R33's wandering/exit seeking in staff trainings, and she models to staff how to interact with R33. SW G indicated that visual supervision is eye on resident at all times, visual supervision can be from another room, as long as staff can see resident. Surveyor asked SW G about the incident that occurred between R33 and R35 on 10/26/23. SW G indicated that the incident was reported to her after 9:30 AM, on 10/27/23 by a floor nurse, stating that the story varied. SW G indicated that she met with R35 following receiving the report of the incident. SW G indicated that R35 reported to her that R33 had walked into his room, swung open the door and hit him in the chest, and then R33 got on the floor. SW G indicated that she interviewed the staff that was working on the third floor at the time of the incident and no staff reported R35 being hit. Surveyor asked SW G about R33's interventions. SW G indicated that R33's interventions work if they are being put into place. SW G indicated that the facility held an all staff meeting last week. The topics discussed included abuse and neglect, and the results from the 10/16/23 state survey. SW G indicated that the facility held dementia training last week. On 11/9/23 at 9:38 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what her expectations were for a resident who has a history of wandering into other residents' rooms. DON B indicated that residents will be monitored, assessed, the facility will look for routines and patterns and use that information to come up with a care plan that includes interventions. Surveyor asked DON B how the facility staff is made aware when a resident's care plan is updated, or changes have been made to residents' interventions. DON B indicated that the residents care plan reflects the changes and staff can see the changes. DON B indicated that she tries to review the 24-hour report daily. DON B indicted that the 24-hour report includes progress notes, behavior notes, PRN (as needed) medication notifications, and assessments. Surveyor asked DON B about the incident that occurred between R33 and R35 on 10/26/23. DON B indicated that she was made aware of the incident about 9:30 AM on 10/27/23. On 11/09/23 at 3:06 PM, Surveyor observed the CNA and nurse stations/rooms. Surveyor was unable to locate R33's DSU behavior support plan interventions referenced as being posted in R33's care plan. On 11/09/23 at 3:13 PM, Surveyor interviewed SW G regarding how care plan changes are relayed to the floor nursing staff, especially regarding the DSU behavior support plan that is referenced in R33's care plan. At 3:20 PM surveyor requested SW G to show were R33's DSU behavior support plan interventions referenced as being posted in R33's care plan is posted at. SW G was unable to located R33's DSU behavior support plan interventions in the nurses' station and asked RN E for assistance at 3:30 PM, R33's DSU behavior support plan interventions were in a pile of papers clipped together in a plastic desktop file. The facility provided surveyor with attendance records for the 11/1/2023 dementia care workshop. 8 staff attended the 11:45 AM workshop, 4 staff attended the 2:15 PM workshop for a total of 12 staff. 9% of the staff working at the facility received the dementia training. The facility provided Surveyor with staff list attendance records for the 11/2/2023 staff in-service where attendees received abuse/neglect training. 22 staff attended the 7:00 AM in-service, 15 staff attended the 2:00 PM in-service for a total of 37 staff attending the in-service. The facility staff lists 86 staff, the facility contracts 42 staff for a total of 128 staff. 32% of the staff working at the facility received the abuse/neglect training. The facility failed to protect R35 from physical abuse when R33 willfully hit R35 in the chest.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours to the state agency for 1 (R35) of 3 allegations of abuse. -The facility failed to identify and report an incident an alleged violation involving potential abuse immediately, but not later than two hours, to the administrator as well as the state survey agency. The facility's policy, entitled Abuse, Neglect, and Exploitation revision date 7/24/23, states: Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. V. Investigation of Alleged Abuse, Neglect and Exploitation. A. An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse neglect or exploitation occur. B. Written procedures for investigations include1. identifying staff responsible for the investigation .4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Book a scene the investigation on determining if abuse, neglect, and/or mistreatment has occurred, the extent, and cause; and 6. provide incomplete and thorough documentation of the investigation. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the administrator, state agency, adult Protective Services (APS) and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but no later than two hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury .5. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following: a. Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; b. Defining how care provision will be changed and/or improve to protect residents receiving services; c. training of staff on changes made and demonstration of staff competency after training is implemented; R33 was originally admitted to the facility on [DATE] and was recently readmitted on [DATE] from the Dementia Stabilization Unit where he was seen for aggressive behaviors. R33 has diagnoses that include unspecified dementia moderate with agitation, unspecified dementia moderate with other behavioral disturbances, anxiety disorder unspecified, pain unspecified, other hereditary and idiopathic neuropathies. R33's MDS (Minimum Data Set) assessment, dated 7/26/23, indicated R33 has clear speech and is understood when speaking. R33 scored a 1 out of 15 on his BIMS (Brief Interview of Mental Status) assessment indicating that R33's cognition is severely impaired. The MDS also shows R33 has disorganized thinking and behavioral symptoms of wandering. On 10/26/23 at 7:42 PM, the following progress note was entered into R33's Electronic Medical Record (EMR): the resident walked into the room ### tonight after supper and had no clothes on. The CNA (Certified Nursing Assistant) assisted resident out of room ### and explained to him why he could not be in that room. This writer got residents wheelchair and CNA took care of resident. On 10/27/23 at 6:59 PM, the following progress note was entered into R35's medical record, . This writer checked over R35's back, arms, and shoulders tonight and no bruising was noted by this writer from when another resident (R33) went into his room last night on the PM shift around 7:00 PM. R35 did not voice any concerns to this writer tonight about getting hit by the resident (R33) that came into his room last night . On 10/27/23 at 11:36 AM, the facility submitted a self-report to the State Agency (SA) indicating that on 10/26/23 at the estimated time of 8:00 PM, R33 was reported to have entered R35's room. Yelling was overheard. Staff entered room and were able to redirect R33 back to his room. R35 stated during investigation that R33 had hit him but had not stated this to staff after incident was discovered. Staff did not see any physical contact. (It is important to note the alleged abuse incident was not reported immediately to NHA A (Nursing Home Administrator) or the State Agency. On 11/8/23 at 1:39 PM, Surveyor interviewed CNA M regarding the incident between R33 and R35 that occurred on 10/26/23. CNA M indicated that she was on the other end of the hallway helping another resident when the incident occurred, adding that she responded at the end of the incident. CNA M indicated that when she got to R35's room CNA N was already in the room. CNA M indicated that R33 was in R35's room adding that R33 was agitated. CNA M stated that she and CNA N got R33 out of R35's room and R33 back into his room. CNA M she reported the incident to RN E during that shift. On 11/8/23 at 2:14 PM Surveyor interviewed CNA N regarding R33. CNA N indicated that R33 has a history of becoming combative. CNA N stated that R33 frequently goes into R35's room. CNA N indicated that she had assisted R33 to bed, and thirty minutes later while she was in another resident's room that was three rooms down from R33 and R35's rooms when she heard yelling. CNA N indicated she continued to hear yelling, coming from R35's room when she responded R33 was standing in the doorway of R35's room. As CNA N responded she continued to hear yelling between R33 and R35. CNA N stated that R35 was standing in front of R33, within an arm's length apart. R35 was yelling at R33 asking R35 where his clothes were. Surveyor asked CNA N if she reported the incident to RN E the RN on duty. CNA N indicated that she did report her knowledge of the incident to RN E during the shift and to another nurse working on the third floor. CNA N indicated that she received a phone call from SW G (Social Worker) on 10/27/23, SW G requested a statement of the incident from CNA N. CNA N indicated that she provided a copy of the incident statement to DON B (Director of Nursing), SW G, and NHA A (Nursing Home Administrator) on 10/31/23 at 1:30 PM. On 11/8/23 at 4:22 PM, Surveyor interviewed RN E regarding R33. RN E indicated that R33 will go into other resident rooms. Surveyor asked RN E if she was aware of the incident between R33 and R35 that occurred on 10/26/23. RN E indicated that before 7 PM, she was on way to nurses' station when she heard yelling. RN E saw CNA N by the nurse's station. From her location, RN E indicated she was not able to see R33, R35, or inside R35's room, adding that she went to check it out. RN E indicated that when she arrived at the source of the yelling in R35's room she observed R33 standing in the doorway of R35's room. R35 was standing 2-3 feet away from R33, facing R33, and the doorway part way open. RN E indicated that CNA N entered R35's room first and then she followed, R33 and R35 were yelling at one another. RN E indicated R35 was upset. RN E stated, R33 was mad that R35 was in his room. I should have asked R35 if he was okay, I should have asked if R33 struck out at him. RN E stated that I just didn't think of it Surveyor asked RN E when she should report incidents that involve possible abuse, RN E indicated that incidents that involve possible abuse should be reported within 30 minutes to NHA A or DON B (Director of Nursing), RN E stated, I should have reported this right away. On 11/8/23 at 9:34 AM, Surveyor interviewed SW G (Social Worker) regarding the incident between R33 and R35. SW G indicated that she was not working at the time of the incident on 10/26/23 and was not informed of the incident until 10/27/23 around 9:30 AM. Surveyor asked SW G what facility staff member is responsible for overseeing investigations at the facility. SW G indicated that she was and NHA A and DON B step in in her absence. Surveyor asked SW G about the incident that occurred between R33 and R35 on 10/26/23. SW G indicated that the incident was reported to her after 9:30 AM on 10/27/23 by a floor nurse, stating that the story varied. SW G indicated that she met with R35 after she was informed of the incident. SW G indicated that R35 reported to her that R33 had walked into his room, swung open the door and hit me in the chest. SW G indicated that she interviewed staff that was working at the time of the incident and no staff reported R35 being hit, SW G indicated RN E was not told about the incident. Surveyor asked SW G what she would have expected staff to do after responding to the incident between R33 and R35 on 10/26/23. SW G indicated that she expected that the staff would report the incident to the NHA A or DON B to allow for the facility to begin the reporting and investigation process. SW G indicated that she would have expected that the police had been called. SW G indicated that with the history between R33 and R35 facility should have asked more questions after responding to the incident. On 11/9/23 at 9:38 AM, Surveyor interviewed DON B regarding the incident that occurred between R33 and R35 on 10/26/23. DON B indicated that she tries to review the 24-hour report daily. DON B indicted that the 24-hour report includes progress notes, behavior notes, PRN medication notifications, and assessments. DON B indicated that she was made aware of the incident until about 9:30 AM on 10/27/23, after floor staff verbally reported the incident to management. DON B indicated that she would have expected for staff to have notified her right away, assess the situation, and if contact was made the nurse should have completed a skin assessment. DON B indicated that she would expected R35 to have been interviewed regarding the incident right away. On 11/9/23 at 11:40 AM, Surveyor interviewed NHA A regarding staff reporting abuse and potential for abuse. NHA A indicated once residents' safety is assessed staff is expected to report to herself or DON B, staff has been instructed to call myself or DON B when we are not in the facility. NHA A indicated that staff should be reporting the incident to the police department. NHA A indicated that following reporting and notifications the facility begins an investigation. Interviews are conducted with residents and written statements are required from and provided by staff involved. The interdisciplinary team reviews the investigation to see if the incident was a process issue. Once investigation is completed findings are reported to the State Agency. Surveyor asked NHA A what her expectation was for the staff involved in the incident that occurred between R33 and R35 on 10/26/23. NHA A indicated that she would expect for DON B or herself to have been notified as soon the staff was finished ensuring the safety of R33 and R35. Surveyor disclosed that RR O had reported that he had not received notification of the incident that occurred between R33 and R35 on 10/26/23; however, he was aware of a prior incident that a facility nurse had mentioned in passing. NHA A stated, that is alarming, indicating that she expects family to be notified right after facility management. NHA A indicated that she would have expected for RN E to have viewed this incident as potential abuse, and followed the facilities abuse policy and reported to herself or DON B. Facility staff failed to immediately notify NHA A and State Agency of an allegation of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure all alleged violations of abuse were thoroughly investigated to prevent further abuse for 1 of 3 resident's (R33) reviewed for of abuse. The facility failed to complete a thoroughly investigation into the incident between R33 and R35 that occurred on 10/26/23. Evidenced by: The facility's policy, entitled Abuse, Neglect, and Exploitation revision date 7/24/23, states: Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. IV. Investigation of Alleged Abuse, Neglect and Exploitation. A. An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse neglect or exploitation occur. B. Written procedures for investigations include1. identifying staff responsible for the investigation .4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Book a scene the investigation on determining if abuse, neglect, and/or mistreatment has occurred, the extent, and cause; and 6. provide incomplete and thorough documentation of the investigation. Responding immediately to protect the alleged victim and integrity of the investigation. R35 was readmitted to the facility on [DATE] and has diagnoses that include vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R35's most recent Minimum Data Set (MDS) assessment, dated 10/9/23, indicates. R35 scored a 06 out of 15 on his Brief Interview for Mental Status (BIMS) assessment indicating that R35 's cognition is severely impaired. Progress notes date 10/26/23 state R33 walked into room ### tonight after supper and had no clothes on. The CNA (Certified Nursing Assistant) assisted R33 out of room ### and explain to him why he could not be in that room. This writer got R33's wheelchair. The CNA took care of R33. On 10/27/23 at 11:36 AM, the facility submitted a self-report to the SA indicating that on 10/26/23 at the estimated time of 8:00 PM, R33 was reported to have entered R35's room. Yelling was overheard. Staff entered room and were able to redirect R33 back to his room. R35 stated during investigation that R33 had hit him but had not stated this to staff after incident was discovered. Staff did not see any physical contact. The facility provided Surveyor with the self-reported incident investigation documentation. A grievance form dated 10/26/23, was completed by SW G (Social Worker) on behalf of resident. Person making complaint in relationship to resident: self-reported altercation with another resident. R33. Grievance form indicated that R35 stated (I was) in (my) room, in my chair, he (R33) came to door, nothing on came by table, didn't say anything, he pushed door, swung into me, not sure if he saw me, swung door open again, R33 took a swing hit (my) chest. I did not tell nurses that he connected with me. I don't remember if I called for a nurse or if they were just walking by. On 10/27/23 at 6:59 PM, the following progress note was entered into R35's medical record, . This writer checked over R35's back, arms, and shoulders tonight and no bruising was noted by this writer from when another resident (R33) went into his room last night on the PM shift around 7:00 PM. R35 did not voice any concerns to this writer tonight about getting hit by the resident (R33) that came into his room last night . On 11/8/23 at 4:22 PM, Surveyor interviewed RN E (Registered Nurse) regarding R33. RN E stated there was an incident between R33 and R35 that occurred on 10/26/23. RN E indicated that before 7 PM, she was on way nurses' station when she heard yelling. RN E saw CNA N by the nurse's station. From her location, RN E indicated she was not able to see R33, R35, or inside R35's room, adding that she went to check it out. RN E indicated that when she arrived at the source of the yelling in R35's room she observed R33 standing in the doorway of R35's room with not clothes on, R35 was standing 2-3 feet away from R33 facing R33 and the doorway part way open. RN E indicated that CNA N entered R35's room first and then she followed, R33 and R35 were yelling at one another. RN E indicated that CNA N stayed in R35's room while she walked across the hall to R33's room to get R33's wheelchair. and RN E indicated that she returned to R35's room with R33's wheelchair. RN E indicated that when she returned to the room R33, R35, and CNA N were in the same spot as when she left. RN E indicated that she handed R33's wheelchair to CNA N who assisted R33 to sit in his wheelchair and she escorted R33 to his room, adding that CNA N was the only other staff that responded to the incident and assisted R33, following R33 leaving the room. Surveyor asked RN E what care she provided for R33 following the incident, RN E stated, R33 stated he was okay. RN E indicated she did not ask R33 any questions regarding the incident stating, R33 was upset. Surveyor asked RN E if she completed an assessment on R33 following the incident, RN E stated that she had not, adding that she should have assessed R33 right away. Surveyor asked RN E what care she provided for R35 following the incident, RN E stated, I did nothing, R35 said nothing to me or other staff the rest of the night, R35 was upset. RN E stated, R35 was mad that R33 was in his room. I should have asked R35 if he was okay, I should have asked if R33 struck out at him. RN E stated that, I just didn't think of it, when Surveyor asked her why a skin assessment was not completed for R35 after the altercation. RN E indicated that she should have completed skin assessment on R35 right away. Surveyor asked RN E if she reported the incident to management, RN E stated, No, I should have reported it right away, within 24 hours. Surveyor asked RN E when she should report incidents that involve possible abuse, RN E indicated that incidents that involve possible abuse should be reported within 30 minutes to NHA A or DON B, RN E stated, I should have reported this right away. RN E indicated she completed an assessment the following day after SW G had prompted and requested her to complete a skin assessment for R35. Surveyor asked RN E about abuse and dementia training that she had recently received from the facility. RN E indicated that she had attended an in-service the prior week and she had received handouts for different types of abuse. On 11/8/23 at 9:34 AM, Surveyor interviewed SW G regarding the incident between R33 and R35 that occurred on 10/26/23 and investigations. Surveyor asked SW G about the incident that occurred between R33 and R35 on 10/26/23. SW G indicated that the incident was reported to her after 9:30 AM, on 10/27/23 by a floor nurse, stating that the story varied. SW G indicated that she met with R35 following receiving the report of the incident. SW G indicated that R35 reported to her that R33 had walked into his room, swung open the door and hit him in the chest, and then R33 got on the floor. SW G indicated that she interviewed the staff that was working on the third floor at the time of the incident and no staff reported R35 being hit, SW G indicated that the incident was not reported to RN E. Surveyor asked SW G what she would have expected staff to do after responding to the incident between R33 and R35 on 10/26/23. SW G indicated that she expected that the staff would report the incident to the NHA A (Nursing Home Administrator) or DON B (Director of Nursing) to allow for the facility to begin the reporting and investigation process. SW G indicated that she would have expected that the police had been called. SW G indicated that she would have expected for RN E to have completed a skin check. SW G indicated that with the history between R33 and R35 facility should have asked more questions after responding to the incident. SW G indicated that in this situation she did not expect for the staff to complete a skin sweep. SW G indicated that a progress note should have been put into the medical record that night. SW G indicated that the facility held an all staff meeting last week. On 11/9/23 at 10:46 AM, Surveyor interviewed SW G regarding investigations. On 11/9/23 at 9:38 AM, Surveyor interviewed DON B regarding facility investigations and the incident between R33 and R35 that occurred on 10/26/23. DON B indicated that she was made aware of the incident about 9:30 AM on 10/27/23. Surveyor asked DON B if she expects verbal interviews and conversations to be completed after the staff written statements and residents safety interviews are completed and documented as part of the investigation process, DON B indicated it depends, and sometimes interviews provide second validations. Surveyor showed DON B a written statement that was provided to the Surveyor in the self-reported incident investigation documentation. DON B indicated that the statement appears to be R35's account of the incident, adding that the handwriting looks to belong to SW G. Surveyor and DON B reviewed other statements and identified there were no follow up interviews documented. Surveyor asked DON B if she felt that this was a thorough investigation. DON B stated, No, I do not. adding that the written staff statements don't match. On 11/9/23 at 11:40 AM, Surveyor interviewed NHA A regarding facility investigations and the incident between R33 and R35 that occurred on 10/26/23. Surveyor and NHA A reviewed the CNA M's written statement that was provided to the Surveyor in the self-reported incident investigation documentation. NHA A stated, To me, that is not a valid statement, adding that her expectation in the situation would have been for SW G to have completed and documented follow up interview/conversations. The facility provided Surveyor with attendance records for the 11/1/2023 dementia care workshop. 8 staff attended the 11:45 AM workshop, 4 staff attended the 2:15 PM workshop for a total of 12 staff. 9% of the staff working at the facility received the dementia training. The facility provided Surveyor with staff list attendance records for the 11/2/2023 staff in-service where attendees received abuse/neglect training. 22 staff attended the 7:00 AM in-service, 15 staff attended the 2:00 PM in-service for a total of 37 staff attending the in-service. The facility staff lists 86 staff, the facility contracts 42 staff for a total of 128 staff. 32% of the staff working at the facility received the abuse/neglect training.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that a discharge summary, with a recapitulation of the resident's stay, includes, but is not limited to: diagnosis, course of illness/treatment or therapy, pertinent lab, radiology, and consultant results was developed for 1 of 14 sampled residents (R37) reviewed for discharge summary/recapitulation. R37 did not have a recapitulation of his stay. Evidenced by The facility's policy, entitled Transfer and Discharge ., dated 4/10/23, states in part; . 14. Anticipated Transfers or Discharges . b. A member of the interdisciplinary team completes relevant sections of the Discharge Summary. The nurse caring for the resident at the time of discharge is responsible for ensuring the Discharge Summary is complete and includes, but not limited to, the following: i. A recap of the resident's stay that includes diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. ii. A final summary of the resident's status. iii. Reconciliation of all pre-discharge medications with the resident's post-discharge medications . iv. A post discharge plan of care that is developed with the participation of the resident, and the resident's representative(s) which will assist the resident to adjust to his or her new living environment . R37 was admitted to the facility on [DATE] and was discharged to another facility per family request on 9/26/23. R37's record review of a discharge summary progress note dated 9/26/23 indicated current vital signs and breakfast intake, bowel status, transportation of daughter's arrival, personal belongings, discharged paperwork signed and copies of paperwork of history and physical, physician orders, vaccination record and power of attorney documentation. R37's record review indicates a signed discharge instruction form dated 9/26/23 indicated diagnosis, orientation, a urology follow up appointment, current diet, activity, and a treatment. The facility did not have or provide surveyors with a recapitulation of R37's stay that includes, but is not limited to: diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, consultation results, most recent comprehensive assessment, identification and demographic information, cognitive patterns, communication, vision, mood and behavior patterns, psychosocial well-being, physical functioning and structural problems, continence, disease diagnosis with health conditions, dental and nutritional status, skin conditions, activity, medications, special treatments or procedures, and a discharge care plan. On 11/8/23 at 4:13 PM, Surveyor interviewed SW G (Social Worker) and DON B (Director of Nursing) together regarding R37's discharge. SW G indicated she handles the SW information of sending the face sheet and any progress notes the receiving facility will ask for. DON B indicated the nurse that is scheduled will send the physician orders and any other requests the facility has. On 11/08/23 at 4:45 PM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor reviewed the findings of the discharge instruction form and the discharge progress note with NHA A. NHA A indicated to the Surveyor she does not have a recapitulation and will be doing it going forward.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 6 residents (R33 & R34) reviewed for supervision and accidents out of a total sample of 14. R33 had 9 falls since August 1, 2023. Facility did not identify root/cause for these falls. No new interventions or care plan updates were added with these 9 falls. R34 is known to be exit-seeking and staff did not monitor him. Evidenced by: The facility policy, entitled Fall Policy and Procedure, dated 3/2019, states, in part: . Policy: Staff shall assess for risk, provide preventative measures, and address falls in a safe and professional manner. Procedure: Fall risk assessment: . 2. Upon assessment, staff will provide needed intervention to prevent fall. Intervention is added to care plan . Example 1 R33 was admitted to the facility on [DATE], and has diagnoses that include unspecified dementia, moderate, with agitation, unspecified dementia, moderate, with other behavioral disturbance, and anxiety disorder. R33's Quarterly Minimum Data Set (MDS) Assessment, dated 7/26/23, shows R33 has a Brief Interview of Mental Status (BIMS) score of 1 indicating R33 has severe cognitive impairment. Section GG indicates R33 requires supervision with ambulating and requires partial to moderate assistance with transferring from sit to stand position. R33's Care Plan states, in part: . Focus: Risk for Falls Date Initiated: 10/16/23 Revision on: 11/8/23. Goal: Resident will be free of falls Date Initiated: 10/16/23 Target Date: 11/15/23 Interventions: -Assist Resident with ambulation and transfers, utilizing therapy recommendations Date Initiated: 10/16/23 -Determine Residents ability to transfer Date Initiated: 10/16/23 -Evaluate fall risk on admission and PRN (as needed) Date Initiated: 10/16/23 -If fall occurs, alert provider Date Initiated: 10/16/23 . Focus: ADL (activities of daily living) Performance Date Initiated: 11/7/23 Revision on: 11/8/23 Goal: The resident will maintain current level of function in through the review date. Date Initiated: 11/7/23 Revision on: 11/7/23 Target Date: 11/15/23. Interventions: Important to note . does not include how resident ambulates or transfers . Falls in August 2023 include: Fall 8/14/23 10:30 AM Incident Location: Lounge Incident Description: CNA (Certified Nursing Assistant) made writer aware that resident was on the floor in the TV lounge area. Writer went to lounge area and observed resident in sitting position in front of the recliner noted. Resident Description: Resident unable to give description. Immediate Action Taken Description: Head to toe assessment, pain assessment, ROM (range of motion), skin assessment, education on alternate ways to reach staff if in the common area . Injuries Observed at Time of Incident . No injuries observed at time of incident. Level of Pain: Numerical: 4 LOC (level of consciousness): Alert Mobility: Ambulatory without assistance Mental Status: Oriented to Person Predisposing Physiological Factors: confused, gait imbalance, impaired memory. Predisposing Situation Factors: ambulating without assistance . Fall 8/21/23 8:24 AM Incident Location: Resident's room. Incident Description: When passing resident room noticed resident on the floor on his left side, noticed bruise on the right hand, no c/o (complaints of) pain at this time. Resident Description: Resident unable to give description. Immediate Action Taken Description: Certified Nursing Assistants (CNAs) helped resident to the bed. Injuries Observed at Time of Incident . No injuries observed at time of incident. Level of Pain: PAINAID 4 LOC (level of consciousness): Alert Mobility: Ambulatory without assistance Mental Status: Oriented to Person Injuries Report Post Incident: Injury Type: Bruise Injury Location: 29) Right hand (back) . Predisposing Environmental Factors: None Predisposing Physiological Factors: confused, gait imbalance, impaired memory. Predisposing Situation Factors: Active Exit Seeker, wanderer, ambulating without assistance . Fall 8/26/23 11:05 AM Incident Location: Resident's room. Incident Description: Resident was transferring by himself, fell on the floor, noticed when he was laying on his right side, some c/o pain on the right side. Resident Description: Resident unable to give description. Immediate Action Taken Description: resident was helped to the w/c (wheelchair) by 2 CNAs, vs (vital signs), neuro checks checked . Injuries Observed at Time of Incident . No injuries observed at time of incident. Level of Pain: PAINAD:2 LOC (level of consciousness): Alert Mental Status: Oriented to Person Predisposing Environmental Factors: None Predisposing Physiological Factors: confused, gait imbalance, weakness/fainted. Predisposing Situation Factors: ambulating without assistance . Fall 8/29/23 5:10 AM Incident Location: Dining room. Incident Description: Resident was attempting to transfer himself from chair, got up and fell onto the floor, residents assessed for injuries, no apparent injuries noted. Doctor updated by fax and DON (director of nursing) and family notified. Resident Description: Resident unable to give description. Immediate Action Taken Description: resident assessed for injuries . Injuries Observed at Time of Incident . No injuries observed at time of incident. Level of Pain: LOC (level of consciousness): Alert Mobility: Ambulatory without assistance Mental Status: Oriented to Person Predisposing Environmental Factors: None Predisposing Physiological Factors: gait imbalance, impaired memory, weakness/fainted Predisposing Situation Factors: ambulating without assistance . Fall 8/30/23 6:11 PM Incident Location: Dining room. Incident Description: Resident ambulating pushing wheelchair (w/c) in common area following dinner. Checking doors and railings as he believes he is home. Alert with confusion as baseline. Resident then noted to lose balance and fall to his back, not hitting head, appeared to fall slowly with no new apparent injury. Old bruising noted to right hip from previous fall, no hip rotation, no leg shortening noted denies headache, got up and put in recliner in common area. Resident Description: Resident unable to give description. Immediate Action Taken Description: Resident assessed and put in recliner in common area . Injuries Observed at Time of Incident . No injuries observed at time of incident. Level of Pain: PAINAD:1 LOC (level of consciousness): Alert Mobility: Ambulatory without assistance Mental Status: Oriented to Person Predisposing Environmental Factors: None Predisposing Physiological Factors: confused, gait imbalance. Predisposing Situation Factors: ambulating without assistance . Other Info: resident is impulsive and does become agitated when staff attempts to assist him . Falls in September 2023 include: Fall 9/11/23 10:22 PM Incident Location: Dining room. Incident Description: Resident got out of wheelchair while unlock. Wheelchair rolled away from resident. Resident fell on floor on his right side. Resident has bruising on hips from previous falls. Resident Description: Resident unable to give description. Immediate Action Taken Description: Resident assessed for injuries, no apparent injuries, resident transferred back to wheelchair by two CNAs and nurse. Injuries Observed at Time of Incident . No injuries observed at time of incident. Level of Pain: PAINAD:4 LOC (level of consciousness): Alert Mobility: Ambulatory without assistance Mental Status: Oriented to Person Predisposing Physiological Factors: gait imbalance, impaired memory Predisposing Situation Factors: ambulating without assistance . Falls in October 2023 include: Fall 10/20/23 5:58 AM Incident Location: Resident's room. Incident Description: Called to resident's room by Certified Nursing Assistant (CNA) he was sitting on his knees with his face down blocking the door. Tried to redirect him to move so we could get inside the room, this took a while because he just got more agitated. He was left alone, and we went back, and CNA was able to get in the room. CNA tried several times to assist him from the floor and he would become very combative kicking, swinging his feet, and hollering at staff. Called the nurse from the 2nd floor to assist with assessment of resident because he was very combative. We were eventually able to assist him to his wheelchair, dressed him and brought him out of his room. Tried to get vitals with resident being combative. Maintenance came so I could get his vitals. Attempted to get them again with him becoming combative again. Resident Description: Resident unable to give description. Immediate Action Taken Description: Resident was assessed with both active and passive ROM. Skin was assessed for injuries with none noted. Notified DON, faxed doctor and notified POA (power of attorney) VS BP (blood pressure): 157/80 Resp (respirations): 20 Pulse: 89 Temp: 98.2 . Injuries Observed at Time of Incident . No injuries observed at time of incident. Level of Pain: Numerical: 0 LOC (level of consciousness): Alert Mobility: Wheelchair bound. Mental Status: Oriented to Person Predisposing Environmental Factors: None Predisposing Physiological Factors: impaired memory Predisposing Situation Factors: none . Fall 10/24/23 6:22 PM Incident Location: Hallway Incident Description: CMA (Certified Medication Aide) was monitoring the resident, he was trying to stand up out of his wheelchair and when he stood up the wheelchair moved backwards, and he lost his balance. He fell on his buttock and did not hit his head. Resident Description: Resident unable to give description. Immediate Action Taken Description: Resident was assisted back into his chair, unable to use Hoyer as resident becomes combative. Vitals were taken and neuros assessed. No skin alterations noted . Injuries Observed at Time of Incident . No injuries observed at time of incident. Level of Pain: LOC (level of consciousness): Alert Mobility: Ambulatory without assistance Mental Status: Oriented to Person Injuries Report Post Incident: Injury Type: Hematoma Injury Location: 17) Right elbow Predisposing Environmental Factors: None Predisposing Physiological Factors: confused, gait imbalance, impaired memory. Predisposing Situation Factors: wanderer, ambulating without assistance . Fall 10/27/23 1:44 PM Incident Location: Hallway Incident Description: This writer was called up to third floor for a fall. Resident was found by staff in the hallway on his knees. Resident was holding on to the handrail in the hall with staff around him. Resident Description: Resident unable to give description . Immediate Action Taken Description: Resident assessed for injuries, no apparent injuries, resident transferred back to wheelchair by two CNAs and nurse. Injuries Observed at Time of Incident: Injury Type: Abrasion Injury Location:37) Right Knee (front) Level of Pain: 0 LOC (level of consciousness): Lethargic (drowsy) Mobility: Ambulatory with assistance Mental Status: Oriented to Person Predisposing Physiological Factors: gait imbalance, impaired memory, weakness/fainted Predisposing Situation Factors: wanderer, ambulating without assistance . On 11/9/23 at 4:33 PM, Surveyor interviewed DON B (Director of Nursing) and asked if DON B could indicate the root cause of R33's fall on 8/29/23. DON B indicated self-transfer. Surveyor asked DON B why was R33 self-transferring and DON B indicated she did not know. Surveyor asked what intervention was put into place for R33 after the fall and DON B indicated none. Surveyor asked DON B if there should have been, and DON B indicated yes. Surveyor asked DON B for the fall 8/26/23, what was the root cause and intervention put into place. DON B indicated same as for fall 8/29/23 - none. DON B indicated all the falls for R33 will be the same without root cause or new interventions. Surveyor asked DON B if the fall care plan should be updated after a resident falls to prevent further falls or fall with injury, DON B indicated yes. Surveyor asked DON B who can update the care plan and DON B indicated herself or staff. Example 2 The facility's policy titled, Elopements and wandering Residents, states the following: *The facility is equipped with door locks and alarms to help avoid elopements. *Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. *Adequate supervision will be provided to help prevent accidents or elopements. R34 was admitted to the facility on [DATE] and has diagnoses that include dementia in other diseases classified elsewhere, moderate, with agitation, and sensorineural hearing loss, bilateral (hearing loss in both ears). R34's Minimum Data Set (MDS), dated [DATE], indicates that R34 has a Brief Interview for Mental Status (BIMS) score of 3 indicating that R34's cognition is severely impaired. R34's Wandering/Elopement Care Plan, dated 10/16/23, states, Monitor location of where resident is while he is up moving around. Additionally, R34's care plan indicates he wears a wanderguard on his right ankle. Facility progress notes for R34: *9/29/23: At 3:35 PM, this writer got a call from dietary staff stating that resident was wandering around down here. in the basement. This writer and another nurse went to the basement to assist the resident back up to his room. Upon entering the dining area in the basement this writer observed the resident attempting to turn off the alarm to the patio door by deactivating the switch with the pole located near the door, staff does this to allow residents out onto the patio during activities. The wanderguard door unlocked and resident exited the facility . Resident encouraged around the building and back into the facility .Resident returned back into facility safely at 3:45 PM *9/30/23: At 3:00 PM, resident went to the stairway door, he attempted to enter door code several times unsuccessfully; then he just held the door until it opened up; he then proceeded down the stairway until he reached the second floor; at that time he then exited the building through the side exit door .nurse along with CNA (Certified Nursing Assistant) followed resident closely as he walked through the parking lot and across the street into the neighbor's yard; staff attempted unsuccessfully to redirect resident back into the facility; he was eventually redirected back toward the facility by staff .will continue to monitor. *10/30/23 at 9:23 PM: Has been restless but redirected frequently away from the exit doors after setting off the door alarms then walks away. It is a repeated behavior he does daily throughout the shifts. *11/2/23 at 10:24 AM: Resident has been wandering and has just started to go to the exits and set alarm off. Was easily redirected and is sitting 1:1 at present with this writer. *11/7/23 at 6:13 PM: Resident wandering hallways most of the shift. This writer was with resident 1:1 as resident was exit seeking. This writer placed self between resident and doors when resident would walk up to door. Resident would stand by door entering random numbers on the wandergaurd keypad for a few minutes, not attempting to remove this nurse from in front of the door. No injuries occurred during any of these events. On 11/9/23 at 4:42 PM, Surveyor observed R34 walking up and down the halls on his wing, trying to open every door that was closed. Surveyor conducted the following staff interviews on 11/9/23: *4:49 PM: RN E (Registered Nurse) stated that R34 had already gotten into the stairwell twice during the afternoon shift. The first time, staff observed him and went with him to redirect, but the second time, the staff heard the alarm and went to the stairwell on the end of the hall and R34 had made it down a flight of stairs before the staff found him and redirected him back to the unit. *4:58 PM: CNA J (Certified Nursing Assistant) stated it is hard to keep an eye on R34 and the staff cannot do so at all times. CNA J stated that if the staff are helping or providing cares to another resident, the nurses are to watch the halls. *5:01 PM: CNA K stated it is hard to monitor R34 at all times and she hasn't found anything that works very well. Both CNA J and CNA K stated R34 had been in the stairwell twice during the afternoon shift on 11/9/23, once unsupervised. The facility was aware that R34 was exit seeking and had gotten out of the building multiple times, but did not have a plan to ensure he was monitored at all times and he was found unsupervised in the stairwell at the end of the hall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review. The facility did not ensure that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence for 1of 3 resident's (R33) reviewed for bowel and bladder program. Staff did not remove gloves per standards of practice when providing catheter care for 1 of 1 residents with a catheter R2. The facility failed to implement and conduct a toileting program for R33 after an assessment indicated that R33 is categorized as being a candidate for scheduled toileting. Staff did not remove gloves per standards of practice when providing catheter care for 1 of 1 residents with a catheter R2. Findings include: The facility policy, entitled Preventing Bowel Constipation or Obstruction dated 12/13 states, Policy: To assure adequate bowel movements for residents in order to prevent discomfort or complications from constipation or bowel obstruction. Procedure: 1. Bowel diary assessment will be completed upon admission, readmission, quarterly, annually and upon significant change of condition . R33 was admitted to the facility on [DATE] and has diagnoses that include: unspecified dementia moderate with agitation, unspecified dementia moderate with other behavioral disturbances, anxiety disorder unspecified, pain unspecified, and other hereditary and idiopathic neuropathies. R33's Minimum Data Set (MDS) assessment, dated 7/26/23, R33's Brief Interview for Mental Status (BIMS) scored a 1 out of 15, indicating that R33's cognition is severely impaired. Section H shows that that R33 has not had a trial of a toileting program, nor is R33 on a current toileting program. R33 is frequently incontinent with his bowel and bladder. R33's Care Plan initiated on 10/16/23, states: Risk for wandering/elopement identified. Ask if he is looking for a bathroom. Behavior intervention 2: Ask if you can help him to the bathroom in the morning and after meals. Behavior Intervention 3: redirect to bathroom areas . Behavior intervention 2: Asking if there is a need, . looking for a toilet, food. R33's progress notes from 10/23/23 to 11/9/23 include the following notes: on 10/25/23, at 7:23 AM, the following progress note was entered into R35's medical record, At 7:00 AM R33 was being checked on and (R33) found sitting on buttocks leaning against his bed. R33 was incontinent of a large amount of urine on bed and on the floor. Resident had probably slipped off edge of bed due to urine on floor and was unable to get up per self. On 11/6/23 at 7:13 PM, the following progress note was entered into R35's medical record, Around supper time tonight R33 got up in his wheelchair he was by room ###. R33 went into the doorway of room ### and urinated on (the) resident's floor. On 11/9/23 at 3:06 PM, Surveyor observed R33's room. R33's room door and bathroom are not clearly labeled. Surveyor observed a sign to the left of resident door affixed to the wall with resident room number, under the sign was R33's name displayed in a standard signage font. On 11/8/23 at 1:39 PM, Surveyor interviewed CNA M (Certified Nursing Assistant) regarding R33. CNA M indicated that R33 will have behaviors, get agitated; she tries to pin point what R33 needs, such as food, to use the bathroom, or pain relief adding CNA M indicated that R33 is not on a toileting program and is frequently incontinent. On 11/9/23 at 9:04 AM, Surveyor interviewed RN H (Registered Nurse) regarding R33 bowel and bladder patterns. RN H stated, R33 doesn't tell when he has to use the bathroom, adding that R33 get angry when he is unable to communicate his bathroom needs and when he wets his brief. On 10/27/23 at 11:36 AM, the facility submitted a self-report to the State Agency (SA) indicating that on 10/26/23. The Misconduct Incident Report for the incident states, Resident one (R33) had a urinary incontinent issue that had woken him up prior to the incident. The facility provided Surveyor with the self-reported incident investigation documentation. CNA N written statement, with no date states, R33 was returned to his room, his clothes were on the floor along with his dirty pullup (brief) .I personally feel that because R33 had an incontinent episode, this provoked him to become frustrated and was just trying to get help. On 11/9/23 at 9:38 AM, Surveyor and DON B (Director of Nursing) reviewed R33's bowel and bladder assessment completed on 10/22/23, DON B indicated that the assessment shows R33 is categorized as being a candidate for scheduled toileting (timed voiding). DON B indicated that the assessment shows R33 is not always, but at least daily voids appropriately without incontinence. DON B indicated that the assessment shows R33 is incontinent of stool 1-3 times a week. DON B indicated that the assessment shows R33 is unable to transfer to the toilet independently, R33 is confused and needs prompting and that R33 sometimes is mentally aware of the need to toilet. Surveyor asked how often she reviews the facilities nursing documentation. DON B indicated that the was not aware of data collected in R33's bowel and bladder assessment completed on 10/22/23. Surveyor asked DON B what was done with the data collected in the assessment, DON B stated, Nothing, R33 is not on a scheduled program for bowel and bladder. DON B indicated that she was unaware of a bowel/bladder diary assessment, DON B indicated that R33 should be on a toileting program. DON B indicated that floor nursing staff that completed R33's bowel and bladder assessment on 10/22/23 should be using their judgement, and relaying the data collected in assessment to her. R33 has a history of agitation when incontinent. The facility failed to implement and conduct a toileting program for R33 even though the facility had completed an assessment that categorized R33 as being a candidate for scheduled toileting. Example 2 On 11/8/23 at 7:50 AM, Surveyor observed catheter care with CNA C (Certified Nursing Assistant). CNA C washed hands and put on gloves. CNA C cleaned down the shaft of the penis and from the tip of the penis down the catheter tubing. CNA C then picked up a clean towel and dried R2's peri-area and down catheter. CNA C did not remove gloves and wash or sanitize hands when going from dirty to clean. Surveyor asked CNA C if she should have washed her hands when going from dirty to clean. CNA C stated, Yes, I should have changed gloves and washed hands after cleaning R2's peri-area. On 11/9/23 at 1:59 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what her expectation was for hand hygiene during catheter care. DON B stated, staff should be changing gloves after cleaning and before moving onto something else. Surveyor asked DON B if the expectation was to remove gloves and wash hands going from dirty to clean, to which DON B stated yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure prescribing provider evaluated the resident and documented a clinical rationale for extending as needed (PRN) anti-psychotic medication beyond 14 days for 1 resident (R33) of 5 residents reviewed for unnecessary medications. The facility failed to implement and document nonpharmacological interventions before administering PRN psychotropic medications to R33. Facility administered PRN Lorazepam past the 14-day limitation, failed to follow the facility's use of psychotropic medication policy, evaluate the effects of PRN psychotropic medication use and respond to/provide reasoning for not following Dementia Stabilization Unit (DSU) recommendations to decrease R33's PRN psychotropic medication. Findings include: The facility policy, entitled Use of Psychotropic Medication, dated [DATE], states: Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). 4. The indications for use of any Psychotropic drug will be documented in the medical record. 9. PRN orders for all Psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record and for a limited duration ( .14 days). a. if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the residents' medical record and indicate the duration for the PRN order. R33 was admitted to the facility on [DATE] and has diagnoses that include: unspecified dementia moderate with agitation, unspecified dementia moderate with other behavioral disturbances, anxiety disorder unspecified, pain unspecified, and other hereditary and idiopathic neuropathies. R33's most recent completed Minimum Data Set (MDS) assessment, dated [DATE], indicates R33 has clear speech, is able to be understood when speaking. R33 Brief Interview for Mental Status (BIMS) scored a 1 out of 15 indicating that R33's cognition is severely impaired. Section N shows R33 is not receiving medications in the high-risk drug classes including antipsychotic, antianxiety, antidepressant and opioid. R33's Care Plan initiated on [DATE], states: .The resident has impaired cognitive function/dementia or impaired thought process r/t (related to) dementia, psychotropic drug use, short term memory loss. Cannot always communicate his needs; forgets his limitations. Interventions include communication: use the resident(s) preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions-turn off TV radio close door etc. The resident understands consistent, simple, directive sentences. provided the resident with necessary cues-stop and return if agitated. Cue and reorient and supervise as needed . R33's current physician orders as of [DATE] includes Lorazepam Oral Tablet 0.5 MG give one tablet by mouth two times a day related to Alzheimer's Disease, Unspecified. and Lorazepam Oral Tablet 0.5 MG give one tablet by mouth every four hours as needed for anxiety .Start Date [DATE]. R33's Medication Administration Record (MAR) printed on [DATE], indicates R33's PRN Psychotropic drug order for Lorazepam Oral Tablet 0.5 MG give one tablet by mouth every four hours as needed for anxiety .Start Date [DATE] was administered on at 12:30 AM, 36 days after PRN Psychotropic drug was ordered. The facility administered PRN psychotropic drug Lorazepam to R33 for 22 days without renewing the Psychotropic drug order. R33's progress notes from [DATE] to [DATE] indicate that PRN psychotropic drug Lorazepam was administered to R33 8 times; the 8 times Lorazepam was administered to R33 the facility failed to implement and document nonpharmacological interventions that have been attempted, and the target symptoms for monitoring before staff administered the psychotropic drug. R33's Progress Notes: *[DATE] at 12:34 AM, PRN Lorazepam administered to R33 restless and swinging at the staff. *[DATE] at 11:43 PM, PRN Lorazepam administered to R33 *[DATE] at 11:51 PM, PRN Lorazepam administered to R33 *[DATE] at 5:28 PM, PRN Lorazepam administered to R33. This writer gave resident a PRN Lorazepam 0.5 MG tablet at this time for increased anxiety and restlessness. *[DATE] at 11:25 PM, Lorazepam administered to R33. Restlessness and anxiety. *[DATE] at 1:26 PM, Lorazepam administered to R33. Resident has been wandering in w/c (wheelchair) and is freq (frequently) attempting to stand per (by) self, gave PRN Lorazepam. *[DATE] at 10:00 PM, PRN Lorazepam administered to R33. Restlessness and anxiety. *[DATE] at 12:30 AM, Lorazepam administered to R33. He is getting anxious at this time. R33's progress note entered on [DATE] at 10:17 AM, states: R33 has been very restless this shift. R33 has been redirected many times by different staff. (R33) wants to stand up from w/c (wheelchair) but not stable on his feet. resident was given a PRN Ativan (It is important to note that Lorazepam is the generic drug for Ativan) which has seemed to help the resident some. R33's MAR printed on [DATE] indicates R33's PRN Psychotropic drug order for Lorazepam Oral Tablet 0.5 MG give one tablet by mouth every four hours as needed for anxiety .Start Date [DATE] was administered once to R33 at 11:51 PM on [DATE]. The facility documentation of PRN Lorazepam administered to R33 is conflicting. It is unknown if PRN Lorazepam administered to R33 during the day shift on [DATE]. On [DATE] R33 was admitted to a Dementia Stabilization Unit (DSU) for a short term stay due to aggressive behaviors that facility staff was having difficulty controlling, needing medication studied and changed, and for assistance to buffer R33's care plan and R33's non-pharmacological interventions. R33 was discharged from the DSU on [DATE] and returned to the facility. R33's discharge paperwork included a Behavior Support Plan dated [DATE] states .In his first 24 hours here at the DSU, R33 had a difficult time. He was very confused and became angry frequently. Overtime, with getting to know him and his responses, along with some medication changes, this has improved . Behaviors. R33 has shown his anger on several occasions during his stay. His anger seems to be directly preceded by his confusion . Medication upon arrival in the DSU R33 was on Lorazepam 0.5 MG (Microgram) 4 times per day. This was recently cut back to two times per day with positive results. R33 is more confused when he is tired and seems that the Lorazepam was causing more confusion. The less frequent Lorazepam has successfully kept his more extreme behaviors down, while not tiring him out to the point of increased confusion . On [DATE] at 4:22 PM, Surveyor interviewed RN E (Registered Nurse) regarding R33. RN E indicated that she has been employed at the facility for 12 years. RN E indicated that R33 gets agitated. RN E indicated that R33 tends to wander by walking and self-propelling in his wheelchair thought his day. RN E indicated that R33 will go into other residents. rooms. Surveyor asked RN E about R33's medications, behaviors, and use of PRN Lorazepam. Surveyor asked RN E if she implemented and documented nonpharmacological interventions before administering PRN Lorazepam to R33, RN E stated, Sometimes I do, sometimes I don't. On [DATE] at 2:28 PM, Surveyor interviewed SW G (Social Worker) regarding PRN psychotropic drug orders. SW G indicated that PRN psychotropic drug orders cannot exceed 14 days. Surveyor asked SW G how the facility ensures that pharmaceutical interventions are used only when clinically indicated, at the lowest dose, for shortest duration, and closely monitored. SW G indicated that when she sees that R33 gets a PRN Lorazepam she makes an effort to look at R33's progress notes to see what data is listed. SW G indicated that nonpharmacological interventions are not being implemented and documented before facility is administering PRN psychotropic drugs to R33, stating, That is an issue. SW G indicated that she creates the care plans for psychotropic drug use. SW G was unable to explain to the Surveyor the process facility uses to audit the facilities compliance for implementing and documenting nonpharmacological interventions before administering PRN psychotropic medications to facility residents. On [DATE] at 9:38 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what the facility expectations are for the use of PRN psychotropic medications. DON B indicated that she expects that staff to implement and document nonpharmacological interventions before administering PRN psychotropic medications to facility residents. DON B indicated that she tries to review the 24-hour report daily. DON B indicted that the 24-hour report includes progress notes, behavior notes, PRN medication notifications, and assessments. Surveyor asked DON B to review R33's PRN psychotropic drug Lorazepam medication administration notes in R33's Medical Record from [DATE] to date ([DATE]). Surveyor asked DON B if she has identified a pattern, DON B stated, Yes. DON B indicated that nonpharmacological interventions are not being implemented documented before administering PRN psychotropic drugs to R33. DON B was unable to explain to the Surveyor the process facility uses to audit the facilities compliance for implementing and documenting nonpharmacological interventions before administering PRN psychotropic medications to facility residents. DON B indicated that R33 was sent to a DSU to get his medications managed, DON B and Surveyor reviewed R33's DSU Behavior Support Plan. DON B indicated that the DSU recommended that R33 receive less Lorazepam. R33's DSU Behavior Support Plan states, Medication upon arrival in the DSU R33 was on Lorazepam 0.5 MG 4 times per day. This was recently cut back to two times per day with positive results. R33 is more confused when he is tired and seems that the Lorazepam was causing more confusion. The less frequent Lorazepam has successfully kept his more extreme behaviors down, while not tiring him out to the point of increased confusion. DON B and Surveyor reviewed R33's MAR from [DATE] to [DATE], (7 days) R33 received PRN Lorazepam 7 times. Surveyor and DON B discussed the days reviewed resident continues to receive Lorazepam 0.5 MG on average 3 times per day, despite R33's success with a lowered dose. Surveyor asked DON B if the facility should be following DSU's recommendations to lower the Lorazepam dose. DON B stated ideally, we should attempt the recommendations. On [DATE] at 11:40 AM, Surveyor interviewed NHA A (Nursing Home Administrator) regarding facility expectations for the use of PRN psychotropic medications. Surveyor informed NHA A of the DON B's identification of a pattern of facility staff administering PRN psychotropic medications to R33 without implementing and documenting nonpharmacological interventions before administering PRN psychotropic medications to R33. NHA A stated, Not okay in my book. NHA A indicated that the expectation is facility staff implement and document nonpharmacological interventions before administering PRN psychotropic medications to residents. Surveyor and NHA A reviewed R33's DSU Behavior Support Plan. Surveyor asked NHA if the facility should have responded to DSU Behavior Support Plan following assessment and implement or provide reasoning for not implementing R33's DSU Behavior Support Plan. NHA A stated, Yes, and indicated that the DSU Behavior Support Plan, including medication changes made, should have been discussed with R33's Medical Doctor, following that discussion the facility should had made and followed a plan. The facility is not implementing and documenting nonpharmacological interventions before administering PRN Lorazepam, administered PRN Lorazepam past the 14-day limitation, and did not document resident's provider-evaluated resident for appropriateness of continued administration of the PRN Lorazepam. The facility failed to address DSU's recommendation to decrease PRN Lorazepam use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 4 errors in 27 opportunities that affected 2 out of 5 residents (R7 & R25) included in the medication pass task, which resulted in an error rate of 14.81%. Staff mixed R7's Valproic Acid, clonidine, and tizanidine together and administered through R7's gastrointestinal tube (g-tube). R25 received senna plus and R7's physician order was for senna. Evidenced by: Example 1 The facility policy, entitled Medication Administration via Enteral Tube, dated 1/1/23, states, in part: . Policy: It is the policy of this facility to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practice guidelines . Policy Explanation and Compliance Guidelines: . 6. Each medication will be administered separately, not combined, or added to an enteral feeding formula . 9. Procedure: a. Verify physician orders for medication and enteral flush amount . i. Flush enteral tube with at least 15mL (milliliters) of water prior to administering medications unless otherwise ordered by prescriber . m. Flush the tube with a final flush of at least 15 mL of water to ensure drug delivery and clear the tube . The facility policy, entitled Crushed Medications, dated 2/23/23, states, in part: . Policy: Medications shall be crushed in accordance with standards of practice for safety and accuracy in medication administration . Policy Explanation and Compliance Guidelines: . 3. Medications shall be crushed in accordance with physician orders and mixed in an appropriate medium (i.e., applesauce, pudding, jelly, juice, water, etc.) . 7. Medications administered via feeding tube will be crushed individually and administered one at a time . The facility policy, entitled Medication Administration, dated 6/19/23, states, in part: . Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection . Policy Explanation and Compliance: . 11. Compare medication source (bubble pack, vial, etc.) with MAR (medication administration record) to verify resident name, medication name, form, dose, route, and time . 14. Administer medication as ordered . The facility policy, entitled Flushing a Feeding Tube, dated 2/1/23, states, in part: . Policy: It is the policy of this facility to ensure that staff providing care and services to the resident via a feeding tube are aware of, competent in and utilize facility protocols regarding feeding nutrition and care. Feeding tube care and services will be provided in accordance with resident needs and professional standards of practice . Policy Explanation and Compliance Guidelines: R7 was admitted to the facility on [DATE], and has diagnoses that include: dysphagia (difficulty or discomfort in swallowing, as a symptom of disease) following cerebral infarction (also called ischemic stroke, occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following a cerebral infarction, and Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar. With type 2 diabetes, the body either doesn't produce enough insulin, or it resists insulin). R7's Quarterly Minimum Data Set (MDS) Assessment, dated 8/18/23, shows R7 has a Brief Interview of Mental Status (BIMS) score of 9, indicating R7 has moderate cognitive impairment. R7's physician's orders, dated 11/1/23, states, in part: . NPO diet, NPO texture, NPO consistency . Order Date: 7/21/23 . Clonidine Tab 0.3 mg (milligrams) Give 1 tablet via G-Tube three times a day related to Essential (primary) hypertension . Order Date: 6/26/23 . Tizanidine Tab 2 mg Give 1 tablet via G-Tube three times a day related to Muscle spasm . Order Date: 6/26/23 . Valproic Acid Oral Solution 250 mg/ml (Valproate Sodium) Give 5 mL via G-Tube in the afternoon for bipolar disorder Administer three times daily via G-Tube as scheduled . Order Date: 8/2/23 . R7's November MAR includes: Valporic Acid Oral Solution 250 MG/ML (Valprorate Sodium) Give 5 mL via G-Tube in the afternoon for Bipolar disorder Administer three times daily via G-Tube as scheduled. Start Date: 8/2/23. Clonidine Tab 0.3mg Give 1 tablet via G-Tube three times a day related to Essential (primary) hypertension Start Date: 8/1/23. Flush G-Tube with 60cc before and after each feeding and medication administration three times a day for Feeding Start Date: 8/1/23. Tizanidine Tab 2mg Give 1 tablet via G-Tube three times a day related to Muscle Spasm Start Date: 8/1/23. On 11/7/23, at 11:44 AM, Surveyor observed RN H (Registered Nurse) measure out 5 mL of valproic acid into a medication cup and pour it into a drinking cup. RN H poured approximately 3 mL water into the drinking cup. RN H crushed the clonidine 0.3 mg tablet and the tizanidine 2 mg tablet and poured them into the drinking cup with the valproic acid. RN H added 30 mL water into the drinking cup and mixed. RN H added 90 mL of water from R7's sink into a graduated cylinder. RN H poured medications from drinking cup into the syringe and unclamped extender tubing. RN H clamped the tubing and added 30 mL of water into the syringe and unclamped extender tubing for flush. RN H indicated the 30 mLs for the flush is the first 60 mLs combined with the medications. RN H then connected the tube feeding. On 11/8/23, at 2:41 PM, Surveyor interviewed DON B (Director of Nursing) and asked what the process is for administering medications through a G-Tube. DON B indicated there must be an order to crush the medications. If there is no order to mix the medications, the medications must be administered separately. The G-Tube should be flushed before and after medications administered. DON B indicated, for example the order is for 60 ccs before and after. Surveyor asked DON B if the water includes the water mixed with the medications and DON B indicated no, flush would be 60 ccs then administer the medications then flush with another 60 ccs of water. Surveyor informed DON B of medication administration observation with the amount water used for flushing for R7. On 11/9/23, at 9:19 AM, Surveyor asked DON B if she would consider mixing medications together without an order to do so a medication error and DON B indicated yes. Surveyor informed DON B of medication administration observation of R7's medications being mixed and administered. Surveyor asked DON B if she would expect physician orders to be followed and DON B indicated yes. DON B agreed it was a medication error. Example 2 R25 was admitted to the facility on [DATE] and has diagnoses that include dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), Type 2 Diabetes Mellitus, and hypertension (a condition in which the force of the blood against artery walls is too high). R25's Quarterly Minimum Data Set (MDS) Assessment, dated 8/8/23, shows R25 has a Brief Interview for Mental Status (BIMS) score of 13 indicating R25 is cognitively intact. R25's physician orders, dated 11/1/23, states, in part: . Senna Tab 8.6mg Give 1 tablet orally two times a day for constipation. Order Date: 2/23/22 . R25's November MAR includes: -Senna (sennosides 8.6 mg) Tab 8.6mg Give 1 tablet orally two times a day for Constipation Start Date: 8/1/23 On 11/7/23, at 8:20 AM, Surveyor observed RN H administer Senna Plus (docusate sodium 50mg and sennosides 8.6mg)1 tablet to R25 during medication administration. On 11/9/23, at 9:19 AM, Surveyor interviewed DON B and asked if Senna Plus was administered and the physician's order was for senna, would you consider this a medication error. DON B indicated yes. Surveyor asked DON B if she expects physician orders to be followed and DON B indicated yes. Surveyor informed DON B of R25 being administered Senna Plus.

Based on observation, interview, and record review, the facility did not ensure that food was stored, distributed, and served in accordance with professional standards for food service safety. This has the potential to affect all 36 residents residing at the facility. Surveyor observed: -Undated, unlabeled, uncovered, expired ready to eat foods and beverages in the refrigerator. -Undated, unlabeled, uncovered, expired food, and improper storage of food in freezer -Cross Contamination -Towel Drying clean/sanitized dishes and wetsacking dishes (process of placing wet dishes in to storage) -Facility staff filling out 3 Compartment Sinks Part Per Million (PPM) Log before processes had begun. -Not taking/documenting food temps -Improper hand hygiene -Improper sanitization of food prep surfaces and kitchen cart The facility policy, entitled Dishwashing dated 3/2019, states Dishwasher Operation. 1. Turn on dishwasher, booster heater, add soap dispenser. 2. Prepare items for cleaning. scrape, rinse, or soak items before washing. Presoak items with dried on-food. 3. Loading dish racks. Use the correct dish racks. Load them so the water spray will reach all surfaces. Never overload dish racks. 4. Run dishwasher until sanitizing thermometer reaches a minimum of 180 degrees. 5. Load rack into dishwasher and allow running full cycle. Checking temperature gauges. Wash cycle is 160 degrees. Rinse cycle sanitizing 180 degrees. 6. Drying items. Air-dry all items. never use a towel to dry items. You could contaminate them. 7. If working on the dirty end of the dish room, ensure proper hand washing before touching clean dishes. 8. Keeping the machine clean. when dishwashing is completed drain and clean baskets in dishwasher, turn off dishwasher, booster heater hand soap dispenser .Manual Dishwashing .1. Clean and sanitize each sink and drain board. 2. Fill the first sink with detergent and water. the water temp must be at least 110 degrees3. Fill the second sink with clean water. Items must be rinsed prior to sanitizing. 4. fill the third sink with water and sanitizer to correct concentration. Use chem strip as indicated on package 200 to 300 PPM. Water at 70 to 100 degrees . Storing Tableware and Equipment. Storage. Store tableware and utensils at least 6 inches off the floor. protect them from dirt and moisture . Trays and carts. Clean and sanitize trays and carts used to carry clean tableware and utensils. Check them daily, and clean as often as needed. The facility policy, entitled Dietary Policy for Date Marking Food, dated 5/18/21, states, Purpose: To ensure the safety and health to residents and coworkers. to follow the health policies provided in the 2017 FDA (Food and Drug Administration) Food Code . C) Criteria for Refrigerator Storage . c. All foods are covered, and raw meat items are stored below cooked items. D. Ready-to eat are labeled with the date which the food should be consumed or discarded. Foods not labeled are discarded . e. Follow food storage time-line chart and followed. [sic] F. Refrigerator is cleaned weekly and inspected on a regular basis . *** kitchen staff will apply an open/expiration label for staff to document dates on at the time of opening . D. Criteria for freezer storage. C. A freezer food storage timeline chart is in place and followed . e. Freezers are cleaned and inspected on a regular basis. Facility policy, entitled Hand Hygiene dated 4/12/22, states, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff in all locations within the facility . Policy Explanation and Competence Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice .5. Hand hygiene technique when using soap and water: a. Wet hands with water. b. Apply to hands the amount of soap recommended by the manufacturer. c. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. d. Rinse hands with water. e. Dry thoroughly with a single-use towel. f. Use clean towel to turn off the faucet. 6. Additional considerations: a. the use of gloves does not replace hand hygiene. if your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . Example 1: On 11/6/23 at 9:31 AM, Surveyor and DM P (Dietary Manager) observed 6 bottles of prepared iced coffee in the refrigerator unlabeled, and without a prep or expiration date. On 11/7/23 at 8:11 AM, Surveyor observed a post-it note on the left side of the tray that the iced coffee was stored on in the refrigerator indicating to use the bottles on the left first. On 11/8/23 at 3:43 PM, Surveyor interviewed DM P regarding refrigerated storage. DM P indicated that fluids and drinks in the refrigerator should be labeled and dated. DS T (Dietary Services) indicated that she should have all the bottles of coffee labeled and dated. On 11/6/23 at 9:35 AM, Surveyor and DM P observed undated, unlabeled, and expired foods in the refrigerator. DM P indicated one container that is unlabeled and undated contained tomato soup, another container that was unlabeled and undated contained bean soup, 2 ready to eat fruit cups with an expiration date of 11/5/23, and a container of cream of mushroom soup with an expiration date of 10/29/23 should all be thrown away due to improper storage and being expired. Example 2: On 11/6/23 at 9:49 AM, Surveyor and DM P observed food storage in the freezer. DM P indicated that a smoked ham sealed in plastic appeared to have been thawed and refrozen and showed signs of freezer burn. Surveyor observed frost on the ham inside the packaging. DM P indicated that she is going to throw the smoked ham away. Surveyor and DM P observed a gallon of ice cream, box of cookies, box of whipped topping, and two containers of sherbet on the lowest left side shelf upon entering the freezer. Surveyor and DM P observed meats including meat balls, Italian roast beef, and ham on the shelf's above. DM P indicated that the gallon of ice cream, box of cookies, box of whipped topping, and two containers of sherbet should not be stored under meat. Inside the freezer was a rolling cart with leftovers and packages of food being stored on it. Surveyor and DM P observed the contents of the cart and found a bag of left over buns not labeled or dated, a labeled container of left-over solid pumpkin with a 6/24/23 prepared date and no use by date; a plastic bag of sealed hash browns was not labeled or dated; container of left-over tator tot casserole with a 10/18/23 prepared date and a use by date 10/26/23 (expired); container of left-over country vegetables with a 10/30/23 prepared date and no use by date; container of left-over beef broth with a 8/23/23 prepared date, no use by date; two unlabeled sealed bags of French toast, no received date, no expiration/use by date; sealed unlabeled bag of Salisbury steak no received on date, no expiration/use by date; sealed unlabeled bag of meat balls, no received on date, no expiration/use by date; sealed unlabeled bag of chicken nuggets, no received on date, no expiration/use by date; unlabeled Ziploc bag of pepperoni prepared date 4/20/23, no use by date, and an unlabeled Ziploc bag of dumplings, no prepared or used by date. A container labeled leftover squash was observed to have food expanding outside of container with surface of food with ice crystals and airtight lid off. DM P indicated that food stored in the freezer should be in airtight containers. DM P indicated that the container was labeled with a 8/18/23 put in date. DM P indicated that she is not sure how long the squash is good for. DM P indicated that the kitchen staff tries to use food up fast, stating, DM P I would say its good for a month. DM P indicated that all the contents of the freezer should be labeled with contents, put in/prepared date. Surveyor asked DM P what will be done with the food that is not labeled with contents, put in/prepared date, DM P stated I'm gonna get rid of (the) food. Example 3: On 11/7/23 at 8:24 AM, Surveyor observed the facility dishwashing process. Surveyor observed DA R (Dietary Aide) to have gloves on and move from the dirty end of the dishwasher line to the clean end of the dishwasher line. DA R opened the dishwasher and used a gloved hand to remove the clean dishes/rack from the dishwasher, and DA R touched the clean dishes while wearing the gloves used while handling dirty dishwashing items. On 11/7/23 at 8:30 AM, Surveyor reported improper dishwashing observations to DA R. DA R stated, I should not been on the clean side of the dishwasher, I touched the clean tray. I touched fork . I should have washed my hands. Example 4: On 11/7/23 at 8:36 AM, on the clean end of the dishwasher. Surveyor observed DA S place plastic handled cups upside down, that were dripping water (wetstacking). Surveyor observed DA S wetstacking dishes in a cabinet. Surveyor observed DA S wiping down dishes as well as soaking up water that had collected on the dishes with a towel. Surveyor and DA S observed the inside of the cups that were placed in cabinet to be wet on the inside of the cups. Surveyor asked if the cups should be put into storage when they are wet. DA S stated, Cups should be dried, they should sit longer to dry. Surveyor asked why is it important for dished to be dried before putting dishes away, DA S indicated cups can get moldy, DA S stated The residents could get severely sick. Surveyor shared observations with DA S of her towel drying clean and sanitized dishes. DA S indicated that she should not be using a towel to dry the dishes, DA S indicated that bacteria could grow on the towel, and it could cross contaminate. DA S stated, The residents could catch the bacteria or cross contamination could occur. On 11/8/23 at 3:43 PM, Surveyor interviewed DM P regarding wetstacking and towel drying dishes. DM P stated, They (dishes) need to air dry, indicating dishes should not be wet-stacked. Surveyor asked if towel drying dishes is acceptable. DM P stated, No. Example 5: On 11/6/23 at 10:15 AM, Surveyor and DM P reviewed the 3 Compartment Sink PPM Log for 11/2023. Entries for lunch (dinner) and supper were already filled in. DM P indicated that lunch (dinner) and supper entries for 11/6/23 should not be documented as the meals have not yet occurred. Example 6: On 11/6/23 at 10:20 AM, Surveyor and DM P reviewed the Daily Food Temperatures Log for 11/2023. The facility did not document food temps for 11/2/23 breakfast, 11/2/23 dinner, 11/3/23 breakfast, 11/3/23 dinner, 11/3/23 supper, 11/4/23 for breakfast, 11/4/23 for dinner, 11/5/23 for breakfast, and for 11/5/23 for dinner. The facility failed to document the temperature for 9 of 15 meals reviewed. Example 7: On 11/6/23 at 10:02 AM surveyor observed DM P take a tissue out of her pocket. DM P blew their nose and put the dirty tissue back into her pocket. DM P touched a bag of marshmallows contaminating the food packaging. On 11/6/23 at 10:09 AM, Surveyor reported improper hand hygiene observation to DM P. DM P stated, I should have went and washed my hands. On 11/7/23 at 8:18 AM, Surveyor observed DA R (Dietary Aide) demonstrate the facility dishwashing process. Surveyor observed DA R take the bottom of her apron with bare hands and lift the apron up to her face, wipe her nose using the apron, and continue with dishwashing process. On 11/7/23 at 8:30 AM, surveyor reported observation of improper hand hygiene to DA R. DA R stated, Well I didn't want to use any other part of apron .I should of washed hands after wiped nose. I should be changing my apron. On 11/8/23 at 7:49 AM, Surveyor observed DS Q (Dietary Staff) handling raw hamburger in mixer. DS Q removed gloves and performed hand hygiene; DS Q applied soap and rubbed hands for 9 seconds and dried. DS Q obtained new gloves and began to re-apply gloves and dropped a glove on the floor. DS Q picked glove up off the floor, went to the trash can lifted the dirty lid to the trash bin, threw away the glove. (It is important to note hand hygiene should have been performed). DS Q grabbed another glove, applied gloves, and continued to prepare food. Preparing the raw meatloaf, DS Q took the raw meat from the stand mixer and placed it into sheet pans. DS Q removed gloves, touched and lifted the dirty lid of garbage and threw away gloves. (it is important to note hand hygiene should have been performed). DS Q obtained and placed more raw hamburger into the stand mixer and set metal bin (that raw hamburger was being stored in) into the sink. DS Q removed gloves touched and lifted the lid of trash bin and disposed of soiled gloves. (It is important to note hand hygiene should have been performed). DS Q went to the sink and rinsed the dirty pan that raw hamburger was in. DS Q placed the pan on a cart with other dishes and wheeled the cart over to the 3-compartment sink area. DS Q placed all dishes from the cart on the dirty side of the 3-compartment sink. DS Q returned cart to the sink area and rinsed hands using the food prep sink for three seconds (It is important to note hand hygiene should have been performed for a minimum of 20 seconds). DS Q used a paper towel to dry hands and then used the dirty paper towel to wipe down the cart. Surveyor observed DS Q dip a washcloth into sink one, of the 3-compartment sink containing detergent and water, DS Q used a washcloth to wipe down the cart. From initial kitchen tour on 11/6/23 at 9:31 AM to 11/8/23 at 7:20 AM, Surveyor observed two posters to the right of the facilities kitchen hand washing station posted on the wall. Poster one dated 2008 states, Scrub hands for at least 10 to 15 seconds. Poster two with no date states, Wash hands for 20 seconds. On 11/8/23 at 3:43 PM, Surveyor interviewed DM P regarding hand hygiene (hand washing) expectations in the kitchen. DM P indicated that hand hygiene should be completed every time you turn around, you need to wash hands. DM P was uncertain of exact time staff should be washing hands, DM P stated, I would go with 20 seconds. Surveyor interviewed DM P regarding sanitation of kitchen workspace surfaces. DM P indicated that staff uses a towel and premixed cleaner in a designated bucket and spray sanitizer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility does not have a system for preventing, identifying, reporting, investigating, and controlling infections and communicable disease for all residents. This has the potential to affect the census of 36 and 1 of 7 hand hygiene opportunities. Staff returned to work too early with gastrointestinal (gs) symptoms (sx) and COVID per Centers for Disease Control and Prevention (CDC) guidelines. 2 staff and 3 residents (R4, R3, R12) with positive COVID were not included on the staff line lists for surveillance. 7 residents (R4, R12, R3, R15, R18, R29, R1) were allowed off isolation for COVID too early per CDC guidelines. Resident and staff line lists were not complete with well dates and return to work dates. COVID testing was not initiated with outbreak. Facility did not test appropriately per CDC guidelines during testing or to conclude outbreak status. Medical Director was not notified when outbreak began. Staff did not perform glucometer check per standards of care. Infection Control Policies were not revised annually. Staff did not complete appropriate hand hygiene while performing cares for R24. Evidenced by: The facility policy, entitled Infection Surveillance, dated 6/7/22, states, in part: . Policy: A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infection. Definitions: Infection surveillance refers to an ongoing systemic collection, analysis, interpretation, and dissemination of infection-related data . Policy Explanation and Compliance Guidelines: 1. The Infection Preventionist and/or designee serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee, and public health authorities when required . 4. The CDC's NHSN (National Healthcare Safety Network) Definitions will be used to define infections . 5. Surveillance activities will be monitored facility-wide . 7.All resident infections will be tracked. Separate, site-specific measures may be tracked as prioritized from the infection control risk assessment. Outbreaks will be investigated. 8. Employee, volunteer, and contract employee infections will be tracked, as appropriate, such as influenza or gastrointestinal infection breaks. 9. Data to be used in the surveillance activities may include, but are not limited to: . h. Documentation of signs and symptoms in clinical record . The facility policy, entitled COVID-19 Prevention, Response and Reporting, dated 6/1/23, states. In part: . Policy: It is the policy of this facility to ensure that appropriate interventions are implemented to prevent the spread of COVID-19 and promptly respond to any suspected or confirmed COVID-19 infections. COVID-19 information will be reported through the proper channels as per federal, state and/or local health authority guidance . Policy Explanation and Compliance Guidelines: . 13. The facility will perform viral testing for SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) as per national standards such as CDC recommendations. (See Infection Prevention and Control Program Policy and information below for testing recommendations) . 22. Duration of Transmission- Based Precautions for Residents with SARS-CoV-2 infection: . c. Discontinuation of transmission-based precautions on SARS-CoV-2 infection is as follows: i. Symptom Based Strategy A. Residents with mild to moderate illness who are not moderately to severely immunocompromised: a) At least 10 days have passed since symptoms first appeared and b) At least 24 hours have passed since last fever without the use of fever-reducing medications and c) Symptoms (e.g., cough, shortness of breath) have improved B. Residents who were asymptomatic throughout their infection and are not moderately to severely immunocompromised: a) At least 10 days have passed since date of their first positive viral test C. Residents with severe to critical illness who are not moderately to severely immunocompromised: a) At least 10 and up to 20 days have passed since symptoms first appeared and b) At least 24 hours have passed since last fever without the use of fever reducing medications and c) Symptoms (e.g., cough, shortness of breath) have improved d) The test-based strategy as described for moderately to severely immunocompromised residents can be used to inform the duration of isolation . 27. Responding to a newly identified SARS-CoV-2 infected HCP (Healthcare Personnel) or resident: . b. A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed. c. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based approach (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contact cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission . 28. The Infection Preventionist, or designee, will monitor and track COVID-19 related information to include, but not limited to: a. The number of residents and staff who exhibit signs and symptoms of COVID-19. b. The number of residents and staff who have suspected or confirmed COVID-19 and date of confirmation . The facility policy, entitled Coronavirus Testing, dated 4/12/22, states, in part: . Policy: The facility will implement testing of facility residents and staff, including individuals providing services under arrangement and volunteers, for COVID-19 . Policy Explanation and Compliance Guidelines: . 3. Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test as soon as possible . Testing of Staff and Residents with COVID-19 Symptoms or Signs . 2. The criteria for healthcare personnel returning to work using a symptom-based strategy consists of: a. Healthcare personnel with mild to moderate illness who are not moderately to severely immunocompromised: i. At least 7 days if a negative antigen or NAAT (Nucleic Acid Amplification Tests) is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7) have passed since symptoms first appeared and ii. At least 24c hours have passed since last fever without the use of fever-reducing medications and iii. Symptoms (e.g., cough, shortness of breath) have improved. b. Healthcare personnel who were asymptomatic throughout their infection and are not moderately to severely immunocompromised: i. At least 7 days if a negative antigen or NAAT is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or a positive test at day 5-7) have passed since the date of their first positive viral test . Testing of Staff and Residents in Response to an Outbreak: 1. A new COVID-19 infection in any staff or any nursing home onset COVID-19 infection in a resident will trigger an outbreak investigation . 2. Upon identification of a single new case of COVID-19 infection in any staff or residents, testing will begin immediately. 3. Outbreak testing will be performed either through contact tracing or broad-based (e.g., facility-wide) testing. 4. In a broad-based approach, perform testing for all residents and HCP on the affected unit(s), regardless of vaccination status, immediately (but generally not earlier than 24 hours after the exposure, if known) and, if negative, again 5-7 days later. 5. If no additional cases are identified during the broad-based testing, room restriction and full PPE (personal protective equipment) use by HCP caring for residents who are not up to date with all recommended COVID-19 vaccine doses can be discontinued after 14 days and no further testing is indicated. 6. If additional cases are identified, testing should continue affected unit(s) or facility-wide every 3-7 days in addition to room restriction and full PPE used for care of residents who are not up to date with all recommended COVID-19 vaccine doses, until there are no new cases for 14 days . Documentation of Testing: 1.The facility will demonstrate compliance with the testing requirements by doing the following: a. For symptomatic residents and staff, document: i. Date and time of the identification of signs or symptoms ii. Date when testing was conducted. iii. Date when results were obtained. iv. Actions the facility took based on the results. b. Upon identification of a new COVID-19 case in the facility (i.e., outbreak), document: i. Date the case was identified. ii. Date other staff and residents were tested. iii. Dates that staff and residents who tested negative are retested. iv. Results of all tests c. For staff routine testing, document: i. The facility's level of community transmission ii. The corresponding testing frequency indicated (e.g., every week) iii. Date each level of community transmission was collected. iv. Date(s) that testing was performed for staff who are not up to date. v. Results of each test . The facility policy, entitled Blood Glucose Monitoring, dated 1/1/23, states, in part: . Policy: It is the policy of this facility to perform blood glucose monitoring to diabetic residents as per physician's orders . Procedure: . 6. Select the puncture site. 7. Clean the intended site with alcohol pad and allow to dry completely . 9. Collect blood sample from the fingertip using the single use, auto-disabling lancet on the side of resident's fingertip. Puncture the skin with a quick, continuous, and deliberate stroke. 10. If required by the facility, wipe away the first drop of blood using a gauze pad . The facility's policy, entitled Hand Hygiene, dated 4/12/23, states, in part: . Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility . Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table . Hand Hygiene Table: Condition .Either Soap and Water or Alcohol Based Hand Rub . -Before performing invasive procedures -Before applying and after removing PPE, including gloves -Before preparing or handling medications . -Before performing resident care procedures . -After handling items potentially contaminated with blood, body fluids, secretions, or excretions -When, during resident care, moving from a contaminated body site to a clean body site -After assistance with personal body functions . R4 was admitted to the facility on [DATE] and has diagnoses that include: anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar. The body either doesn't produce enough insulin or it resists insulin), and Major Depressive Disorder (clinical depression that includes persistent sadness and losing the ability to find pleasure in activities). R3 was admitted to the facility on [DATE] and has diagnoses that include Major Depressive Disorder and Osteoarthritis (type of arthritis that occurs when flexible tissues at the ends of bones wears down). R12 was admitted to the facility on [DATE] and has diagnoses that include hypertension (a condition in which the force of the blood against the artery walls is too high) and coronary atherosclerosis (Starts when fats, cholesterols and other substances collect on the inner walls of the heart arteries. The buildup is called plaque and causes the arteries to narrow, blocking blood flow). R1 was admitted to the facility on [DATE] and has diagnoses that include peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). R29 was admitted to the facility on [DATE] and has diagnoses that include chronic obstructive pulmonary disease (COPD; a common lung disease causing restricted airflow and breathing problems) and hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone). R18 was admitted to the facility on [DATE] and has diagnoses that include spinal stenosis (spinal narrowing) and Type 2 Diabetes Mellitus. R15 was admitted to the facility on [DATE] and has diagnoses that include cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) and hypertension. August Staff Line Lists: Two staff members had symptoms of GI, and both returned to work 24 hours after last symptom. Note: According to CDC guidelines staff should return 48 hours after last symptom. One staff member had no date of last symptom documented with a return-to-work date of 8/12/23. Type of Illness was listed as sick and sx listed was upset stomach. September Staff Line Lists: Two staff members had Health Issues documented for symptoms. One staff member was positive for COVID on 9/4/23. Date of last symptom was 9/3/23. Returned to work on 9/6/23. Note: Per CDC guidelines should remain off for 10 days after sx onset or positive test. October Staff Line Lists: One staff member had GI sx of diarrhea. Date of last sx was 10/2/23. Returned to work 10/3/23. Per CDC guidelines staff with GI sx should remain off work 48 hours after last sx. One staff member tested positive for COVID on 10/6/23 and returned to work on 10/11/23. This staff member was not included on the October staff line list. No date of last sx or sx listed. Note: Per CDC guidelines should remain off for 10 days after sx onset or positive test. One staff member tested positive for COVID on 10/14/23 and returned to work on 10/23/23. This staff member was not included on the October staff line list. No date of last sx or sx listed. Note: Per CDC guidelines should remain off for 10 days after sx onset or positive test. One staff member tested positive for COVID on 10/22/23. Date last sx was 10/27/23. Returned to work on 10/28/23. Note: Per CDC guidelines should remain off for 10 days after sx onset or positive test. One staff member was positive for COVID on 10/23/23. Date of last sx was 10/26/23. Returned to work on 10/27/23. Note: Per CDC guidelines should remain off for 10 days after sx onset or positive test. One staff member tested positive for COVID on 10/25/23. Date of late sx was 10/27/23. Returned to work on 10/30/23. Note: Per CDC guidelines should remain off for 10 days after sx onset or positive test. According to October Outbreak Timeline two staff members were positive of COVID but not on staff line list. August Resident Line List: R37 has no well date. Date of Illness lists 9/1/23 and type of illness lists urethral. Sx lists infection, pain and swelling. R27 has no well date. Date of Illness lists 9/1/23 and type of illness lists skin. Sx lists increased drainage and pain at g-tube (gastrointestinal tube) site. R13 has no Date of Illness, Symptoms, Well Date, or Precaution End Date. Type of illness lists c-diff (clotridoides difficile colitis which is inflammation of the colon caused by bacteria Clostridium difficile) and precaution start date lists 8/15/23. R8 has no well date. Date of Illness lists 8/17/23 and type of illness lists UTI (urinary tract infection). Sx lists no sx. R24 has no Date of Illness Date or a Well Date. Type of illness lists UTI and sx lists confusion, Urinary Tract Infection (UTI) and emergency room visit. Precaution start date lists 8/31/23. September Resident Line List: R3 has no well date. Date of illness lists 9/21/23 and type of illness lists tooth infection. R14 has no well date. Date of illness lists 9/24/23 and type of illness lists URI (upper respiratory infection). Sx lists congestion and rhonchi. R4 has no Date of Illness, Treatment or Well Date. Type of illness lists UTI and sx lists spasms. R27 has no date of Illness or Well Date. Under date of illness, it lists skin. Sx lists drainage and pain at GI-tube site. R9 has no well date or precaution end date. Date of illness lists 9/7/23 and type of illness lists wound. Precaution start date lists 9/7/23. R17 has no well date, date of illness or type of illness. Sx lists [sic]. October Resident Line List: R2 has no well date. Date of illness lists 10/27/23. Type of illness lists UTI. Sx lists hematuria (blood in urine, [sic]). R1 has no well date. Date of illness lists 10/27/23 and type of illness lists respiratory virus. Sx lists covid + and confusion. Precautions start date lists 10/27/23 and precautions end date lists 11/6/23. R13 has no well date. Date of illness lists 9/29/23 and type of illness lists cellulitis (a bacterial skin infection). Sx lists red, swelling and pain. R12 has no well date. Date of illness lists 10/6/23 and type of illness lists UTI. Sx lists confusion. Precaution start date lists 10/6/23. R18 has no well date. Date of illness lists 10/14/23 and type of illness lists UTI. Sx lists painful urination. Precautions start date lists 10/14/23. R13 has no well date. Date of illness lists [sic] and type of illness lists cellulitis. Sx lists right lower extremity swollen, weeping. Precautions start date lists 10/17/23. R15 has no well date or precautions end date. Date of illness lists 10/18/23 and type of illness lists covid. Sx lists cough. Precautions start date lists 10/18/23. R18 has no well date or precautions end date. Date of illness lists 10/18/23 and type of illness lists covid. Sx lists weakness and fever. Precautions start date lists 10/18/23. R8 has no well date. Date of illness lists 10/21/23 and type of illness lists UTI. Sx lists increased confusion. R10 has no well date or precaution end date. Date of illness lists 10/21/23 and type of illness lists c-diff. Sx lists loose stools. Precautions start date lists 10/21/23. R4 is not on the resident line list for positive COVID. According to the October Outbreak Timeline R4 was positive for COVID on 10/8/23. R4 was on the second floor. No sx listed. According to the Facility October Outbreak Timeline R4 tested positive for COVID on 10/8/23 and placed on isolation precautions until 10/14/23. R4 was then allowed out of his room with a surgical mask on until 10/19/23. Of note: Per CDC guidelines residents are to be on isolation precautions from day of positive covid test or day sx start for 10 days. R3 & R12 (2nd floor) were not on the resident line list for COVID. According to the October Outbreak Timeline R3 & R12 were both positive for COVID on 10/13/23 and placed on isolation precautions until 10/19/23. Then R3 & R12 were allowed to come out of their rooms with surgical masks on until 10/24/23. Of note: Per CDC guidelines residents are to be on isolation precautions from day of positive covid test or day sx start for 10 days. Facility COVID testing documentation shows: -10/6/23- 11 staff were tested with one positive. Of note the facility did not complete contact tracing and did not test the residents until 10/8/23. -10/8/23 All residents on 2nd and 3rd floors were tested and R4 was the only positive resident. R4 was on the 2nd floor. -Undated- Ten staff were tested and all negative. -10/9/23- Kitchen Staff (10) Tested and all were negative. -10/9/23-10 Staff were tested and were all negative. -10/13/23- 2nd floor residents were tested with R3 & R12 were the only positives. R3 and R12 were on the 2nd floor. -10/18/23- 3rd floor residents were tested and were all negative; 4 staff were tested and were negative. 2nd floor residents were tested and shows R18 & R15 (2nd floor) were positive on 10/17/23. -10/31/23- shows the 3rd floor residents were tested and all negative. Of note: Testing is not accurate for the floors being tested. The Facility October Outbreak Timeline shows: 10/6/23- Staff member had sx (symptoms) of COVID and tested positive for COVID. Sx started 10/5. Immediately sent home. Able to come back to work 10/11 and mask for remaining 5 days. Health Dept aware. Of note, health care personnel are to remain off work for 10 days after testing positive for COVID or can return in 7 days with two negative tests. 10/8/23- Floor nurse COVID tested R4 related to sx of COVID. R4 tested positive for COVID. R4 placed on isolation in room and allowed to come out on 10/14/23 and mask until 10/19. Residents should remain in isolation precautions for 10 days. 10/8/23- Health Department was notified. Families were notified of COVID positive. All residents were tested for COVID, and all other residents remained negative. 10/13/23- 5-day COVID testing for residents. R12 & R3 tested positive for COVID . R12 & R3 were placed on isolation in room until 10/19/23 and mask until 10/24/23. All other residents remain negative. Residents should remain in isolation precautions for 10 days. 10/14/23- Staff member had sx of COVID at home and self- tested. Nurse tested positive for COVID. Nurse was excused from work until 10/23. Health Department was notified. Families were notified of COVID positive. Health care personnel should remain off work for 10 days or may return in 7 days with two negative tests. 10/17/23- R18 & R15 was tested for COVID related to have sx of COVID. Both residents came up positive. R18 & R15 were placed on isolation in room until 10/23/23 and mask until 10/28/23. Health Department was notified. Families were notified of COVID positive. 10/18/23- 5-day COVID testing for all currently negative residents. All residents remain negative currently. 10/21/23- R29 was tested related to having sx of COVID. R29 had a positive COVID result. R29 was placed on isolation in room until 10/26 and mask until 10/31. Residents should remain in isolation precautions for 10 days. Staff member tested for COVID related to sx and tested positive. Staff was sent home immediately and returned to work 10/27. Staff should not return for 10 days or 7 days if two negative tests. Health Department was notified. Families were notified of COVID positive. 10/22/23- Staff member had sx of COVID and tested positive. Staff was immediately sent home and was able to return to work 10/28. Staff should not return for 10 days or 7 days if two negative tests. Health Department was notified. Families were notified of COVID positive. 10/23/23- All currently COVID negative residents were tested. All residents remained negative. 10/24/23- Resident was tested for COVID related to sx and had a positive COVID test. Resident was isolated to room until 10/29 and mask until 11/3. Residents should remain in isolation for 10 days. Health Department was notified. Families were notified of COVID positive. Staff member started having sx of COVID at the end of her shift. Staff Member tested for COVID and had a positive test result. Staff Member was immediately sent home and was able to return to work 10/30. Staff should not return for 10 days or 7 days if two negative tests. Infection Control Policies were not reviewed annually as evidenced by: - Hand Hygiene `Date Revised- 4/12/22 -Antibiotic Stewardship Program Date Revised- 4/12/22 -Infection Surveillance Date Revised- 6/7/22 -COVID-19 Antigen Testing Date Revised 4/12/22 -Coronavirus Testing Date Revised- 4/12/22 -Legionella Surveillance Date Revised- 6/7/22 -Pneumococcal Vaccine (Series) Date Revised- 6/7/22 -Influenza Vaccination Date Revised- 4/12/22 -Infection Preventionist Date Revised- 6/7/22 On 11/7/23 at 11:28 AM, Surveyor observed RN H (Registered Nurse) check R7's blood sugar. RN H wet a Kleenex with water and wiped R7's finger with it prior to poking finger with lancet and taking blood sample. Surveyor asked RN H what facility procedure states for checking blood sugars. RN H indicated you can use an alcohol wipe to cleanse finger prior to taking blood sample. Surveyor asked what the best practice would be, and RN H indicated an alcohol wipe. On 11/8/23 at 9:49 AM, Surveyor interviewed IP L (Infection Preventionist). Surveyor asked IP L when the COVID outbreak started, and IP L indicated 10/6/23 with a staff member. Surveyor asked if testing began, and IP L indicated no because it was staff. IP L indicated staff get tested if they have symptoms of COVID and the nurse on the floor typically tests them. Surveyor asked IP L how RTW (return to work) dates are determined, and IP L indicated DON B (Director of Nursing) generally deals with that but typically staff are out for 5 days and then can return and wear a mask for 5 days. Surveyor asked IP L on 10/8/23 when R4 turned up positive who got tested and IP L indicated all residents and no staff. Surveyor asked if R4 should be on the resident line list and IP L indicated yes and R4 is not on the line list. Surveyor asked if staff member should be on the staff line list and IP L indicated DON B completes the staff line lists and IP L completes the resident line list. IP L indicated she would expect to see the staff member on the staff line list. Surveyor asked when testing days are and IP L indicated every three days. Surveyor asked if R12 and R3 are on the resident line list and IP L indicated no. Surveyor asked IP L if she would expect to see them on the resident line list being COVID positive and IP L indicated yes. Surveyor asked IP L, looking at the resident and staff line lists should all lines be completed, and IP L indicated yes. Surveyor asked if the Well Dates should be completed, and IP L indicated yes. Surveyor asked IP L if the dates on the testing documentation and the resident line list should be the same for R18 and R15 and IP L indicated yes. Surveyor asked IP L which date would be correct as testing documentation states R18 and R15 are positive on 10/17/23 and the resident line lists indicate R18 and R15 are positive on 10/18/23. IP L indicated she was not here that day but 10/18 routinely tested everyone. IP L indicated she wasn't sure if they were symptomatic on the 17th and that is why they got tested but IP L believes the line list should say 10/17/23. IP L indicated facility tests every 3 days if positive shows and if no positive they change to test every 5 days. Surveyor asked IP L if a staff member who tested positive on 10/14/23 should be on the staff line list and IP L indicated yes. Surveyor asked if the staff member is on the line list and IP L indicated no. Surveyor asked IP L, looking at the staff line list it shows a staff member last day worked 10/22/23 and date of illness 10/23/23. The facility October Outbreak Timeline lists the staff member as testing positive for COVID on 10/21/23. IP L indicated the dates are not consistent and should be. IP L indicated timeline is not consistent with the testing dates. IP L indicated the facility does not document negative or positive results for staff we just notify public health. Surveyor asked IP L if the fa

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that grievances were filed per facility policy for 1 of 1 sampled residents (R3). Findings include: The facility policy, entitled Resident and Family Grievances, dated 1/30/23, stated in part, Policy Explanation and Compliance Guidelines: . SW F, SW (Social Worker) has been designated as the Grievance Official .The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion .issuing written grievance decisions to the resident .The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form . The Grievance Official, or designee, will keep the resident apprised of progress towards resolution of the grievances .In accordance with the residents right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation . R3 was admitted to the facility on [DATE] and has diagnoses that include unspecified atrial fibrillation (irregular and often very rapid heart rhythm) and chronic obstructive pulmonary disease, unspecified (chronic inflammatory lung disease that causes obstructed airflow from the lungs). R3's Minimum Data Set (MDS) annual assessment, dated 8/15/23, indicates that R3 has a Brief Interview for Mental Status (BIMS) score of 13 indicating that R3 is cognitively intact. On 9/12/23 at 11:26 PM, Surveyor interviewed R3 who indicated that another resident has been coming into his room without R3's permission. R3 stated that he gets mad when the other resident comes into his room. R3 indicated that he told facility staff that another resident has been coming into his room without R3's permission. R3 indicated that he told facility staff that he did not want this other resident in his room, that it made him mad when the other resident comes into his room. R3 stated I told staff he (the other resident) can't come in my room; I don't want him in my room. Resident stated he was unsure of what staff did to resolve issue. On 9/12/23 at 3:10 PM Surveyor interviewed R3 who indicated that he told a nurse about the other resident that has been coming into his room without R3's permission a few weeks ago. R3 indicated that this nurse assisted him by filling out a grievance form. R3 indicated that the facility staff did not follow up with him. (It is important to note that R3 has a private room without a roommate.) R3's progress note entered by RN G (Registered Nurse) on 8/28/23 at 5:30 PM states, in part, Resident told the CNA (Certified Nursing Assistant) tonight that another resident has been going into his room the last 2 days. The CNA reported resident's concern to this writer today. Filled out a concern form and put it under the DON's (Director of Nursing) door tonight. This writer left a message for ., DON, today on her desk phone regarding resident's concern that was voiced to the CNA today. Record Review of facility staffing entitled, Daily Staffing 8/28/2023 and interviews determined that CNA referenced in above progress note entered by RN G on 8/28/23 at 5:30 PM to be CNA H, other resident was determined to be R6. R6's Behavior Monitoring and Interventions Report dated 9/13/23 includes data from 8/1/23 to 9/13/23. R3's Behavior Monitoring and Interventions Report indicated that R3 was Entering Other Resident's Room/Personal Space on 8/1/23, 8/6/23, 8/21/23, 8/22/23, 8/27/23, 8/28/23, and again on 8/28/23. On 9/13/23 at 9:43 AM, Surveyor observed R6 exiting another resident's room, other resident was not in room. On 9/13/23 at 10:40 AM, Surveyor interviewed RN G. RN G indicated that a CNA had reported to her that R3 had voiced a concern regarding an unwanted resident entering his room. RN G indicated that CNA had slipped a completed concern form regarding R3's voiced concern under DON B's office door. Surveyor asked RN G if she knew the identity of unwanted resident entering R3's room, RN G stated, R6. RN G indicated she left DON B a voicemail regarding R3's voiced concern. On 9/13/23 at 4:03 PM, Surveyor interviewed CNA H who indicated she had filled out a grievance form on behalf of R3 regarding his voiced concern of an unwanted resident entering his room. CNA H indicated that she reported R3's voiced concern to the RN. Filled out a grievance form and had placed the completed grievance form under DON B's office door. Surveyor asked CNA H if she knew the identity of unwanted resident entering R3'S room, CNA H stated, R6. On 9/12/23 at 3:27 PM, Surveyor interviewed SW F (Social Worker), who indicated that she had not received a grievance filed by/or on behalf of R3. On 9/13/23 at 1:35 PM, Surveyor interviewed DON B. Surveyor asked DON B if she had received a grievance filed by/or on behalf of R3. DON B stated, not that I can think of. Surveyor asked DON B to read R3's progress note entered by RN G on 8/28/23 at 5:30 PM regarding R3's voiced concern of an unwanted resident entering his room. After reading the progress note, DON B stated she doesn't remember receiving R3's grievance form that was slid under her door by CNA H. DON B indicated that she doesn't recall receiving the voicemail left by RN G regarding R3's voiced concern of an unwanted resident entering his room. DON B stated, I could have missed it, this nurse (RN G) leaves lots of voicemails. The facility staff were aware R3 voiced a grievance of an unwanted visitor in his room. The facility failed to follow up on R3's grievance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure adequate supervision to prevent accidents and hazards for 1 of 1 resident reviewed (R6). -R6 left 3rd floor 2 times using the staircase without complete supervision. -R6 eloped from the building -R6 left 3rd floor 1 time using elevator unsupervised. -R6 left 3rd floor 1 time using unknown route. -R6 wandered into other residents' room [ROOM NUMBER] times. -R6 hit staff or was physically aggressive towards. Findings include: R6 was admitted to the facility on [DATE] and has diagnoses that include dementia in other diseases classified elsewhere, moderate, with agitation, sensorineural hearing loss, bilateral (hearing loss in both ears). R6's Minimum Data Set (MDS) admission assessment, dated 7/3/23, indicates that R6 has a Brief Interview for Mental Status (BIMS) score of 3 indicating that R6's cognition is severely impaired. R6's Care Plan, dated 7/28/23, states: -I do not like being told what to do, I get aggressive, and headstrong. -Basic care needs .I need help with bathing with bathroom use. Because I .get confused dementia behavioral issues. I show this by .being combative at times acting out physically acting out verbally . Approach .Please know where I am at all times to ensure my safety and others related to my forgetfulness . -I wear a Wanderguard (medical alert systems for wandering patients) on my right ankle. I cannot go outside without being accompanied by staff or family. I have the potential to wander into other people's room when I am looking for my room. -Mental well-being . I have the potential to feel anxious scared angry confused or forgetful .When I feel this way I: pace, yell, shout, or scream. May be disruptive, might have mood swings .may make threats push or grab .Targeted behavior 1: Increased agitation manifested in yelling, forcefully moving/shoving furniture (more noticeable in the evening). Behavior intervention 1: Attempt to redirect me. Tell me that the elevator it's not working if I . wish to leave the floor or walk with me . Wandering with possible exit seeking .Walk with me if exit seeking; attempt to redirect . Remind me that the elevator may not be working or that we can't get transportation right now . R6's behavior monitoring notes the following: -8/1/23 Entering Other Resident's Room/Personal Space -8/2/23 Elopement, Exit Seeking -8/6/23 Entering Other Resident's Room/Personal Space, Elopement, Exit Seeking -8/15/23 Elopement, Exit Seeking -8/18/23 Elopement, Exit Seeking -8/19/23 Elopement, Exit Seeking -8/20/23 Elopement, Exit Seeking -8/21/23 Entering Other Resident's Room/Personal Space, Elopement, Exit Seeking -8/21/21 Elopement, Exit Seeking -8/22/23 Express Frustration/Anger at Others, Entering Other Resident's Room/Personal Space, Elopement, Exit Seeking -8/23/23 Express Frustration/Anger at Others, Exit Seeking -8/24/23 Elopement, Exit Seeking -8/25/23 Elopement, Exit Seeking -8/27/23 Entering Other Resident's Room/Personal Space, -8/28/23 Entering Other Resident's Room/Personal Space, -8/28/23 Entering Other Resident's Room/Personal Space, -8/29/23 Physically Aggressive Towards Others, Elopement, Exit Seeking -9/9/23 Hitting Others, Physically Aggressive Towards Others, Express Frustration/Anger at Others, Threating Others, Elopement, Exit Seeking -9/10/23 Elopement, Exit Seeking -9/10/23 Grabbing Others, Hitting Others, Physically Aggressive Towards Others, Cursing at Others, Express Frustration/Anger at Others, Threating Others, Elopement, Exit Seeking -9/12/23 Elopement, Exit Seeking R6's progress notes for the last month from 8/14/23 to 9/13/23 includes: -R6's progress note dated 8/16/23 8:55 PM states .This writer heard the alarm sound to the elevator .CNA (Certified Nursing Assistant) told this writer that resident went down on second floor . - R6's progress note dated 8/19/23 4:38 PM states .Resident has been wandering around the third floor today .Resident did walk through the doors today and he was going towards the elevator . - R6's progress note dated 8/22/23 5:35 PM states Resident has been wandering at times tonight. Resident had a small outburst today . - R6's progress note dated 8/23/23 5:41 PM states .Resident was down by the door at the end of the hall, and he was able to open the door .This writer seen the resident go through the door .resident was walking down the stairwell . - R6's progress note dated 8/29/23 10:01 AM states Resident has been following staff 1:1 more and has been picking up items laying around the unit and putting them in his room or will be noted carrying them around. He had three tv remotes yesterday and was wandering into various resident rooms that are empty . - R6's progress note dated 8/29/23 6:47 PM states resident has been attempting to leave the floor using stairway door, elevator, got angry when (staff) tried to redirect multiple times . one time on (going) downstairs .CNA and activity lady caught him from (the) down stair . {sic} - R6's progress note dated 9/2/23 8:55 PM states Resident is starting to ramp up again and following staff on med pass and CNA bed checks . - R6's progress note dated 9/4/23 11:00 AM states . (Resident) Did follow residents onto the elev (elevator) . - R6's progress note dated 9/10/23 4:13 PM states .Resident was found walking outside of the building . - R6's progress note dated 9/10/23 8:10 PM states .resident got outside but they got him back in .It was reported that resident had left the floor again tonight . - R6's progress note dated 9/10/23 6:13 PM states Around the time of 3:45 PM, fire door alarm began ringing writer and third floor CNA erupt through door. Third floor CNA grasped the fire exit door .as resident fell against door. This writer observed the resident swing his left fist backwards making contact with the third floor CNA in the face. On 9/13/23 at 3:55 PM, Surveyor interviewed LPN I (Licensed Practical Nurse) who indicated that R6 wanders into other residents' rooms and wherever he wants, adding that's what he does. LPN I indicated that when R3 wanders into areas that he should not be in, she redirects him by having him sit and watch television with other residents, encourages resident to have conversations with other residents, or offers drinks and snacks. LPN I indicated that R6 has hit, shoved, and yelled at staff. During the interview at 4:01 PM, Surveyor observed R6 getting into the staff elevator unsupervised, alarms sounded. LPN I left interview to assist R6 off the elevator. On 9/13/23 at 4:37 PM, Surveyor interviewed DON B (Director of Nursing) regarding R6's wandering and behaviors. DON B indicated that she expects staff to know where wandering residents are at. DON B indicated that R6 has hit staff. DON B indicated that there is not a potential for R6 to hurt other residents, adding that R6 has hurt staff during altercations when R6 was being redirected. R6's behavior monitoring and progress notes indicate R6 has wandering behaviors, has eloped from the facility and been found by staff, exited the floor via the stairwell and has been found by staff, wanders into other residents' rooms which has upset other residents, and has been physically aggressive toward staff. The facility has failed to ensure R6 has adequate supervision to prevent accidents and hazards. Cross Reference: F585

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure the provision of pharmaceutical services (including procedures that assure that accurate acquiring, receiving dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 2 residents reviewed (R4). R4 did not receive all medications as ordered on 9/10/23 and 9/11/23. This is evidenced by: The facility policy titled, Medication Errors, with a reviewed/revised date of 6/12/23, indicates, in part: .Policy Explanation and Compliance Guidelines: .8. If a medication error occurs, the following procedure will be initiated: a. The nurse assesses and examines the resident's condition and notifies the physician or health care practitioner as soon as possible .c. Document actions taken in the medical record. d. Once the resident is stable, the nurse reports the incident to the appropriate supervisor and completes the incident or occurrence report . R4 was admitted to the facility on [DATE] with diagnoses that include, in part: Chronic Systolic Congestive Heart Failure, Left Bundle Branch Block (a disruption of the heart's electrical impulse system), and Localized Edema. R4's Significant Change Minimum Data Set (MDS) with a target date of 3/6/23, documents a Brief Interview of Mental Status (BIMS) score of 14, indicating R5 is cognitively intact. R4 was seen in the emergency department on 9/9/23 with decreased urine output and resident reported slight increase in leg swelling and shortness of breath. R6 was discharged from the emergency room back to the facility with the following medication orders, in part: Spironolactone (diuretic) 25mg a day. R4's Medication Administration Record (MAR) documents the following, in part: Spironolactone Oral Tablet .Give 25mg by mouth one time a day related to Chronic Systolic (Congestive) Heart Failure. The doses are scheduled for AM. The dose for 9/10/23 is signed out as administered. The dose for 9/11/23 indicates to see charting and is initialed by RN E (Registered Nurse). R4's Progress notes, indicate the following, in part: 9/9/23 9:11 PM: Orders received from ED (Emergency Department) reviewed: Spironolactone [sic] 25mg PO (by mouth) daily . 9/10/23 6:55 PM: Resident continues with edema to BLE (Bilateral lower extremities). Resident encouraged to elevate legs to help reduce swelling. 9/10/23 10:28 PM: Resident monitored for med change-new med not delivered yet by pharmacy and not in contingency, bilat (bilateral) pedal edema, resident encouraged to elevate legs, does not appear to be in resp distress, denies SOB (Shortness of Breath), denies pain/disc Lungs Clear. (Of note, this documentation is after the AM dose is documented as administered.) 9/11/23 Administration Note: .Spironolactone Oral Tablet Give 25 mg by mouth one time a day .n/a (not available). This note is signed by RN E. On 9/13/23 at 8:27 AM, Surveyor interviewed RN E and asked what the process is for medication errors. RN E indicated she would tell her supervisor, call the doctor, and follow the orders given, fill out a form and she believed it had to be signed by whoever is making the report, the NHA (Nursing Home Administrator), DON (Director of Nursing), the doctor, and you would notify the resident or the representative. On 9/13/23 at 10:00 AM, Surveyor interviewed RN E and reviewed R4's MAR and verified she had documented it was not administered on 9/11/23. RN E indicated that it was her documentation and that the spironolactone was not administered because the medication was not at the facility. RN E added that the pharmacy had called her on 9/11/23 and told her that the spironolactone would come Monday night and that she faxed the physician to inform him it couldn't start until Tuesday. Surveyor asked how the medication could have been administered on 9/10/23 if the facility did not have it. RN E indicated she felt that person may have charted it in error. Surveyor asked RN E what the process is if a medication is needed and is not delivered by pharmacy and is not in contingency. RN E indicated the pharmacy and the doctor should be called. Surveyor asked RN E if the pharmacy can be called on the weekend to have medications delivered. RN E indicated, probably. Surveyor asked RN E if there should be documentation in the progress notes if she was unable to get the medication. RN E indicated yes. Surveyor asked RN E if there was documentation of this in the progress notes. RN E indicated there was not. On 9/13/23, the facility provided a copy of the fax that was sent to the provider for R4. The fax is dated and timed, 9/11/23 at 12:50 PM. The fax documents, in part: Concern - Resident was prescribed on 9/9 Spironolactone 25mg a day .medication not started yet, not available from pharmacy. The physician response on 9/12/23 at 8:41 AM documents, in part: .Start the spironolactone 25mg daily. On 9/13/23 at 1:13 PM, Surveyor interviewed DON B and asked if a missed medication dose is considered a medication error. DON B indicated it is. Surveyor asked DON B what the expectation is of staff if a medication isn't given. DON B indicated they should notify the resident or POA (Power of Attorney) if activated, notify the doctor, notify her, and the NHA. Surveyor asked if the provider should be notified by fax or telephone. DON B indicated if it is a weekend or after hours it should be a phone call. Surveyor asked DON B if this should be documented. DON B indicated it should be documented in the progress notes. Surveyor asked DON B when she would have expected staff to contact the physician regarding R4's medications not being available. DON B indicated for sure by the 10th. (Of note, 9/10/23 was a Sunday.) R4 was prescribed Spironolactone 25mg and this was not administered as ordered due to facilities inability to obtain the medication. The facility staff did not immediately contact the physician regarding the inability to administer Spironolactone resulting in R4 not receiving medication timely and a medication error.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not maintain medical records on each resident that are complete and accurately documented in accordance with accepted professional standards and practices in 1 of 2 residents reviewed (R5). R5's Medication Administration Record (MAR) had documentation of medication administration that did not occur. This is evidenced by: The facility policy titled, Medication Errors, with a reviewed/revised date of 6/12/23, indicates, in part: .Policy Explanation and Compliance Guidelines: .7. To prevent medication errors and ensure safe medication administration, nurses should verify the following information: a. Right medication, dose, route, and time of administration. b. Right resident and right documentation . On 9/12/23 Surveyors requested a list of medication errors from the facility. The facility provided a copy of R5's MAR for 9/1/23 - 9/30/23. The PM dose of metoprolol was highlighted for 9/1/23 through 9/10/23. No Medication Error report was provided by the facility. R5 was admitted to the facility on [DATE] with diagnoses that include, in part: Essential Hypertension (high blood pressure), Chronic Atrial Fibrillation (irregular heartbeat), and Chronic Systolic Congestive Heart Failure. R5's quarterly Minimum Data Set (MDS) with a target date of 8/7/23, documents a Brief Interview of Mental Status (BIMS) score of 15, indicating R5 is cognitively intact. R5 was hospitalized on [DATE] and discharged back to the facility on 8/15/23 with the following medication change, in part: Metoprolol Succinate XL 24 hr., 25mg tablet, take 0.5 (one-half) tablet by mouth once daily. Reason: High Blood pressure Disorder. R5's MAR documents the following, in part: Metoprolol Suc tab 25mg ER, give 0.5 tablet orally two times a day related to Essential (primary) hypertension. Start date: 8/15/23 4:00PM. D/C (Discontinue) Date: 9/11/23 4:00PM. The doses are scheduled as AM and PM. All doses starting from 8/15/23 PM through 9/11/23 AM are signed out as being administered to R15. On 9/13/23 at 1:13 PM, Surveyor interviewed DON B and asked what information she could provide as to the metoprolol order for R5 and how the error was discovered. DON B indicated the following: On Monday, 9/11/23, a nurse was passing medications and couldn't find the PM medication card for R5's metoprolol and asked me to come and help her look. We looked through the entire cart and I was like, how are they charting it and all the sudden we have a missing card. I pulled up his hospital transfer orders from 8/15/23 and I found the orders and it was only supposed to be given one time a day and, in the computer, it said twice a day. DON B indicated R5 was only getting it once per day even though it was being documented twice daily. Surveyor asked DON B how she knew R5 was not getting the dose twice a day. DON B indicated that they did not have the medication to give. They did not have a PM medication card and only had the AM medication card which did say do administer once daily. Surveyor asked DON B if the staff should have been documenting that the PM dose was given if it wasn't. DON B indicated, no. On 9/13/23 at approximately 1:50 PM, DON B provided an Items to be returned to pharmacy form which indicated that metoprolol doses had been returned to the pharmacy for R5 due to an order change. Facility staff were signing out R5's MAR incorrectly from 8/15/23-9/11/23. The facility was able to determine no medication error occurred, but facility staff were incorrectly documenting in the MAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interview, and record review, the facility did not ensure an allegation of physical abuse was reported to law enforcement for 2 Residents (R) (R1 and R2) of 6 sampled residents. On 6/14/23, R2 entered R1's room and hit R1 in the head with a plastic water mug. The facility did not report the physical assault to law enforcement. Findings include: The facility's Resident Abuse, Neglect, Mistreatment, Exploitation, +Misappropriation (sic) of Property, and Injuries to a Resident of Unknown Source, dated 12/20/22, contained the following information: [NAME] Manor (herein referred to as entity) will not tolerate misconduct by any person who has access to clients served at the entity, and is under the entity's operational control. [NAME] Manor will take all reasonable measures to ensure client safety and security .12. If at any point during an investigation the Administrator/designee has reasonable grounds to believe that a crime has been committed (all cases of sexual abuse, cases of serious theft or physical/mental harm) or that another agency could more readily obtain sufficient evidence to show reasonable cause, the appropriate law enforcement officials will be promptly contacted . On 6/26/23, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses to include Parkinson's disease and diabetes mellitus. R1's Minimum Data Set (MDS) assessment, dated 6/26/23, contained a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R1 had no cognitive impairment. On 6/26/23, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses to include dementia with behavioral disturbance. R2's MDS assessment, dated 5/3/23, contained a BIMS score of 00 out of 15 which indicated R2 had severe cognitive impairment. On 6/26/23, Surveyor reviewed the facility's investigation of a resident-to-resident altercation between R1 and R2 on 6/14/23 that contained the following information: R2 entered R1's room and when asked to leave, a physical interaction occurred. R1 and R2 were separated and both residents were assessed. R1 was interviewed about the altercation and stated R1 was in bed watching television when R2 entered R1's room. R1 told R2 to get the f*** out. R2 did not leave and R1 repeated the statement. R2 approached R1 and hit R1 in the head with a hard plastic water mug that was next to R1's bed. Staff removed R2 from the room. R1 was upset and frustrated regarding the altercation and stated the bump and small red abrasion the right side of R1's forehead was from the incident. The following interventions were initiated: R1 was offered and declined a room change. R1 stated R1 did not want to move, and did not want to cause issues for R2. The facility looked at medication adjustments, and different placements for R2, including changing rooms and/or moving to a different facility. Other interventions included redirection and the use of staff that R2 liked to help with redirection. The investigation stated staff education was completed. On 6/26/23 at 10:58 AM, Surveyor interviewed R1 who stated R1 was in bed when the altercation occurred. R1 liked to leave the door open, but stated the door was partially closed and R2 snuck in. R1 told R2 to get the f*** out. R1 stated R2 struck R1 with a water mug similar to a mug next to R1's bed. Surveyor noted the cup was a hard plastic covered mug with a handle. R1 considered striking back at R2, but thought R1 would get in trouble. When R1 yelled, staff entered the room, called R2 Grandpa, and calmed R2 down. R1 stated R1 had injuries on the head, hand, and arm, and thought R2 struck R1 on the knee also. When R1 asked Nursing Home Administrator (NHA)-A if R1 would get in trouble if R1 struck back at R2, R1 indicated NHA-A said R1 could have struck back because it would have been considered self-defense. R1 stated R1 felt safe and saw R2 wander the hallway; however, the facility had a watch group and staff redirected R2. R1 stated if R2 struck R1 again, R1 would beat the f*** out of R2. R1 wondered why nothing was done with R2, why R2 wasn't moved away from R1's room (R1 and R2 lived next door to each other), and/or why R2 wasn't moved to the 2nd floor. R1 stated R1 was asked to move, but R1 liked R1's room and didn't want to move. A nursing note in R1's medical record contained the following information: R1 was laying in bed on 6/14/23 at approximately 7:45 PM. Another resident entered R1's room, took R1's water cup, hit R1 on the right side of the head and caused a raised area with a skin tear. Staff heard R1 call out and ran to R1's room. R1 denied a headache and shortness of breath and asked that the 'SOB (son of bitch) bastard not be allowed in R1's room. Tylenol was administered, ice was applied to R1's head and emotional support was provided. On 6/26/23 at 1:08 PM, Surveyor interviewed NHA-A who verified the police were not notified when R2 assaulted R1. On 6/26/23 at 2:05 PM, Surveyor interviewed R1 who verified staff did not offer to call the police. R1 stated if staff had offered to call the police, R1 would have wanted the police called.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interview, and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 2 Residents (R) (R1 and R2) of 6 sampled residents. On 6/14/23, R2 entered R1's room and hit R1 in the head with a hard plastic water mug. During the investigation, the facility did not interview other residents to determine if other residents experienced or witnessed abuse. Findings include: The facility's Resident Abuse, Neglect, Mistreatment, Exploitation, +Misappropriation (sic) of Property, and Injuries to a Resident of Unknown Source, dated 12/20/22, contained the following information: [NAME] Manor (herein referred to as entity) will not tolerate misconduct by any person who has access to clients served at the entity, and is under the entity's operational control. [NAME] Manor will take all reasonable measures to ensure client safety and security, and will promptly investigate all reports/allegations of client rights violations, abuse .4. All investigation and assessments will be recorded in the nursing notes .5. For the Nursing Home, the Administrator/Social Services Supervisor or designee will complete the investigation .The policy did not indicate other residents would be interviewed to determine if they had concerns or experienced similar treatment. On 6/26/23, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses to include Parkinson's disease. R1's Minimum Data Set (MDS) assessment, dated 6/26/23, contained a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R1 had no cognitive impairment. On 6/26/23, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses to include dementia with behavioral disturbance. R2's MDS assessment, dated 5/3/23, contained a BIMS score of 00 out of 15 which indicated R2 had severe cognitive impairment. On 6/26/23, Surveyor reviewed the facility's investigation of a resident-to-resident altercation between R1 and R2 that occurred on 6/14/23. The investigation contained the following information: R2 went into R1's room and when asked to leave, a physical interaction occurred. R1 was upset and frustrated, and had a small abrasion on R1's forehead. R1 and R2 were separated and assessments were completed. R1 stated R1 was in bed watching television when R2 entered R1's room. R1 told R2 to Get the f*** out. When R2 did not leave, R1 repeated the statement. R2 then approached R1 and hit R1 in the head with a water mug. Staff removed R2 from R1's room. R1 stated the bump on R1's head was from the incident. The following interventions were initiated: R1 was offered and declined a room change. The facility looked at medication adjustments and different placement for R2, which included changing rooms and moving R2 to a different facility. Redirection by using staff R2 liked was encouraged. The investigation indicated staff education was competed and the above interventions were discussed. Surveyor noted the investigation did not include interviews with other residents. On 6/26/23 at 10:58 AM, Surveyor interviewed R1 who indicated R1 was lying in bed on the date of the incident. R1 liked to leave the door open, but stated the door was partially closed and R2 snuck in. R1 told R2 to get the f***out. R2 then struck R1 with a water mug similar to a mug on the table next to R1. Surveyor noted the mug was a hard plastic covered mug with a handle. R1 stated R1 thought about striking R2 during the incident, but thought R1 would get in trouble. R1 yelled, staff entered the room, called R2 Grandpa and calmed R2 down. R1 stated R1 had injuries on R1's head, hand, arm, and stated R1 was struck on the knee also. R1 asked Nursing Home Administrator (NHA)-A if R1 would get in trouble if R1 struck back at R2 and was told R1 could have struck back because it would have been considered self-defense. R1 stated R1 saw R2 wander the hallway since the incident but felt safe because the facility had a watch group and redirected R2. R1 stated if R2 struck R1 again, R1 would beat the f*** out of R2. R1 wondered why nothing was done with R2, and why R2 wasn't moved away from R1's room (R1 and R2 resided next door to each other) and to the 2nd floor. R1 stated R1 was offered a room change, but liked R1's room did not want to move. On 6/26/23 at 11:17 AM, Surveyor interviewed Registered Nurse (RN)-C who indicated R2 was aggressive at times and seemed to pick someone's room and then keep going that way. During the interview, an alarm sounded. RN-C stated the alarm was on a resident's door and activated when someone entered or exited the room. RN-C stated 2 residents had door alarms requested by family due to R2's wandering. RN-C indicated R4 had a door alarm because R2 entered R4's room and scared R4. RN-C indicated R5 had a door alarm per R5's family's request. RN-C was unaware of an incident between R2 and R5. On 6/26/23 at 12:36 PM, Surveyor interviewed CNA-E who was aware of the incident between R1 and R2 on 6/14/23. CNA-E was not aware of any interventions added to R2's plan of care following the incident and did not receive education after the altercation. On 6/26/23 at 1:01 PM, Surveyor interviewed R5's Guardian (GD)-F regarding the alarm on R5's door. GD-F stated GD-F observed R2 wander up and down the halls which made GD-F nervous. GD-F visited R5 on 6/16/23 and observed R2 in the room next to R5 with R2's pants down. (The resident who resided in the room was not in the room at the time). GD-F yelled to staff who redirected R2. GD-F indicated staff were busy helping residents and did not see R2 enter the room. GD-F said staff indicated R2 was trying to find a bathroom, but GD-F was uncomfortable because R5 couldn't call for help if something happened. GD-F indicated it was almost impossible for staff to have eyes on R2 at all times and requested a door alarm for R5. On 6/26/23 at 1:08 PM, Surveyor interviewed NHA-A who verified residents (except R1) were not interviewed during the investigation. On 6/26/23 at 3:20 PM, Surveyor interviewed R4's Family Member (FM)-G who was visiting R4. When Surveyor asked FM-G about the alarm on R4's door, FM-G indicated the alarm was added approximately two weeks ago and stated R2 wandered and it made FM-G uncomfortable. FM-G stated FM-G observed R2 push an empty wheelchair down the hall. While FM-G used the bathroom in R4's room, FM-G heard voices outside the bathroom door. FM-G exited the bathroom and saw R2 next to R4's bed. FM-G stated R4 was asleep, but woke up and was scared that R2 was in the room. On 6/26/23, Surveyor reviewed R4's medical record and noted a progress note, dated 5/25/23, that contained the following information: Writer received a phone call from (FM-G) with a concern that another resident wandered into R4's room. Writer notified upcoming shift. Left voicemail for Social Worker and Director of Nursing (DON). On 6/26/23 at 3:40 PM, Surveyor observed R2 ambulate independently in the hallway. R2 walked down the left side of the hallway, held the railing, and carried a blanket. At that time, Surveyor observed R3 sitting in R3's doorway as R2 ambulated toward R3's room. On 6/26/23 at 3:43 PM, Surveyor observed R2 enter an empty room with an open door on the left side of the hallway. Surveyor observed CNA-H walk down the hall and enter the same room. CNA-H attempted to verbally redirect R2. On 6/26/23 at 3:44 PM, R2 and CNA-H exited the room and ambulated across the hallway. Surveyor observed R2 open the closed door of an empty room on the same side as R3's room. On 6/26/23 at 3:45 PM, Surveyor observed R3 back into R3's room as R2 and CNA-H ambulated past R3's room. Surveyor observed R3 come back into the hallway and sit in R3's doorway when CNA-H and R2 entered R2's room. On 6/26/23 at 3:50 PM, Surveyor observed CNA-H guide R2 to a recliner in the lobby. On 6/26/23 at 3:56 PM, Surveyor interviewed CNA-I and CNA-J who indicated they regularly worked the PM shift and were familiar with R2. CNA-I indicated CNA-I heard in shift report on 6/15/23 and from other CNAs about the altercation between R1 and R2. CNA-I and CNA-J stated staff indicated in report that R2 was on edge, had exit seeking behaviors, and was aggressive. CNA-I indicated R2's aggressive behaviors in the evening were hit or miss. CNA-I indicated R2 entered other resident rooms since the incident between R1 and R2, but was not verbally or physically aggressive. CNA-I and CNA-J were aware of topics R2 liked to discuss, but were not aware of any updates or changes to R2's plan of care and were not provided education following the incident between R1 and R2. CNA-J indicated staff were told to keep an eye on R2; however, CNA-I and CNA-J indicated there were times during the PM shift where R2 could be unsupervised when staff provided meals and cares between 5:00-7:30 PM. CNA-J indicated staff tried to keep R2 in the lobby on the PM shift, but R2 ambulated independently. CNA-J verified there were other residents in the lobby with R2 at times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, and record review, the facility did not ensure a safe environment that was free from abuse for 1 Resident (R) (R1) of 6 sampled residents and had the potential to affect 19 residents who resided on R2's unit. On 6/14/23, R2 entered R1's room and hit R1 in the head with a hard plastic covered water mug. Prior to the incident, R2 was involved in multiple instances of physical abuse involving other residents and staff. Staff were not monitoring R2's whereabouts and did not update the care plan after the incident with R1 to protect the residents on the unit. R1 stated R1 would beat the f*** out of R2 if R2 came into R1's room again. Two residents (R4 and R5) had alarms on their doors because they were afraid of R2 entering their rooms. Findings include: The facility's Resident Abuse, Neglect, Mistreatment, Exploitation, +Misappropriation (sic) of Property, and Injuries to a Resident of Unknown Source, last reviewed on 12/20/22, contained the following information: [NAME] Manor (herein referred to as entity) will not tolerate misconduct by any person who has access to clients served at the entity, and is under the entity's operational control. [NAME] Manor will take all reasonable measures to ensure client safety and security . On 6/26/23, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses to include Parkinson's disease. R1's Minimum Data Set (MDS) assessment, dated 6/26/23, contained a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R1 was cognitively intact. R1's medical record indicated R1 was responsible for R1's healthcare decisions. On 6/26/23, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses to include dementia with behavioral disturbance. R2's MDS assessment, dated 5/3/23, contained a BIMS score of 00 out of 15 which indicated R2 had severe cognitive impairment. R2's Power of Attorney for Healthcare (POAHC) document, dated 11/22/22 and activated 2/6/23, indicated R2's POAHC was responsible for R2's healthcare decisions. R2's plan of care contained the following interventions, dated 5/24/23: Attempt to redirect me from exits or other rooms; do not come toward me quickly; follow my usual routine - reorient me unless doing so makes me agitated; give me time and approach me later. Targeted behaviors included: Wandering-entering other rooms .redirect to R2's room or recliner (offer hand but do not put hands on R2); use calm tones and take R2's lead (example: I need groceries, you say we have those delivered here, can I help you make a list?); state this is so and so's room, are you looking for yours? On 6/26/23, Surveyor reviewed the facility's investigation of a resident-to-resident altercation between R1 and R2 that occurred on 6/14/23. The investigation contained the following information: R2 went into R1's room and when asked to leave, a physical interaction occurred. R1 was upset and frustrated, and had a small abrasion on the forehead. R1 and R2 were separated and assessments were completed. R1 was interviewed about the altercation. R1 stated R1 was in bed watching television when R2 entered R1's room. R1 told R2 to get the f*** out. When R2 did not leave, R1 repeated the statement. R2 then approached R1 and hit R1 on the head with a hard covered plastic water mug. Staff quickly removed R2 from R1's room. R1 stated the bump on R1's head was from the water mug, and the marks on R1's hands were from the incident. R1 had a small red abrasion on the right side of R1's forehead. The following interventions were initiated: R1 was offered and declined a room change. R1 stated R1 did not want to move and did not want to cause issues for R2. The facility looked at medication adjustments and different placement for R2, which included changing rooms and moving to a different facility. Redirection and using staff R2 liked to help with redirection was encouraged. Staff education was completed and the above interventions were discussed. Surveyor reviewed R1's medical record which contained a note with the following information: 6/14/23 .R1 was in bed on 6/14/23 at approximately 7:45 PM - another resident entered R1's room, took R1's water cup, hit R1 on the right side of the head, and caused a raised area with a skin tear. Staff heard R1 call out, and ran to the room. R1 denied a headache and shortness of breath and asked that the SOB (son of bitch) bastard not be allowed in R1's room. Tylenol was administered, ice was applied to R1's head and emotional support was provided. Director of Nursing (DON) and Nursing Home Administrator (NHA) were notified. R2's physician was notified of the incident on 6/15/23. Surveyor noted R1 also had a history of being physically aggressive to other residents and staff. On 6/26/23 at 10:58 AM, Surveyor interviewed R1 who indicated R1 was in bed at the time of the altercation. R1 liked to leave the door open, but stated the door was partially closed and R2 snuck in. R1 told R2 to get the f***out. R1 said R2 struck R1 with a water mug similar to a cup on the table next to R1. Surveyor noted the cup was a hard plastic covered mug with a handle. R1 stated R1 thought about striking R2 during the altercation, but thought R1 would get in trouble. R1 stated when R1 yelled, staff entered the room, called R2 Grandpa and calmed R2 down. R1 stated R1 had injuries on R1's head, hand, and arm, and R2 also struck R1 on the knee. R1 asked NHA-A if R1 would get in trouble if R1 struck R2 and was told R1 could have struck R2 because it would have been considered self-defense. R1 stated R1 felt safe. R1 stated R2 still wandered the hallways; however, the facility had a watch group and redirected R2. R1 stated if R2 struck R1 again, R1 would beat the f*** out of R2. R1 wondered why nothing was done with R2, and why R2 wasn't moved away from R1's room (R1 and R2's rooms were next to each other) and/or moved to the 2nd floor. Staff asked if R1 wanted to change rooms. R1 liked R1's room and did not want to move. On 6/26/23 at 12:32 PM, Surveyor interviewed Registered Nurse (RN)-K via phone. RN-K verified RN-K was the nurse on duty during the altercation between R1 and R2 on 6/14/23. RN-K indicated RN-K was giving a CNA shift report when they heard yelling from R1's hallway. RN-K and the CNA entered R1's room, saw the water mug in R2's hand, and heard R1 state, You hit me. RN-K observed a scratch on R1's head. On 6/26/23 at 12:48 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-L who verified CNA-L and RN-K heard screaming and found R2 in R1's room. CNA-L verified R1 was in bed and stated, By the time I got down there, (R1's) bed was full of water. I don't know how many times (R1) was hit by (R2). Basically, (R1) was yelling at (R2) to get out of the room. CNA-L stated R2 threw a water mug across the room over CNA-L's head and tried to grab R1's eyeglasses from a table. CNA-L stated CNA-L called R2 Grandpa which seemed to calm (R2) down and R2 was removed from R1's room. Surveyor noted R2's plan of care did not contain an intervention to call R2 Grandpa. On 6/26/23 at 1:08 PM, Surveyor interviewed NHA-A who verified there were no interventions implemented following the altercation between R1 and R2 to ensure other residents were safe from R2 and R2 was safe from other residents. On 6/26/23 at 1:14 PM, Surveyor interviewed DON-B who stated when RN-K called DON-B on the evening of 6/14/23 to report the incident between R1 and R2, DON-B told staff to make sure residents stay separated. Know where (R2) is at and do 15 minute checks. Surveyor noted R2's plan of care did not contain an intervention for 15 minute checks. On 6/26/23 at 2:17 PM, Surveyor interviewed RN-C and asked if 15 minute checks were implemented following the incident between R1 and R2. RN-C indicated 15 minute checks were not implemented and stated staff tried to keep R2 in the main area and keep eyes on R2. Surveyor noted R2's plan of care was not updated following the altercation with R1 on 6/14/23. Earlier in the day on 6/14/23, R2 had another incident of physical aggression. On 6/26/23 at 11:36 AM, Surveyor interviewed Housekeeper (HK)-D who stated HK-D cleaned R3's room and stepped out of the room with R3's wheelchair. A CNA was walking down the hall with R2 when R2 attempted to enter R3's room and use the bathroom. HK-D stated R3 was behind the door and if R2 pushed the door open, the door would hit R3. HK-D put HK-D's foot in front of R3's door so R2 could not open the door. HK-D indicated R2 was agitated and said R2 was going to get that son of a bitch. HK-D stated R2 swung at HK-D and mule kicked the CNA. A progress note on 6/14/23 at 12:51 PM indicated R2 was very aggressive that morning, hit staff, entered other resident rooms, and refused care. Staff had difficulty calming R2. Staff did not update the care plan or implement new interventions to protect residents following the incident, which was followed later in the day with the incident with R1. On 6/26/23 at 12:36 PM, Surveyor interviewed CNA-E who usually worked the AM shift and was aware of the altercation between R1 and R2 on 6/14/23. CNA-E trained new staff on the 6/14/23 AM shift and indicated one staff stated they were pushed into a door frame by R2. CNA-E trained another new staff on 6/15/23 who stated R2 was aggressive with them during cares. CNA-E was not aware of any changes to R2's plan of care following the altercation with R1 and stated staff tried to be with R2 as much as possible. Surveyor reviewed other documentation and through interviews confirmed prior incidents of abuse by R2. Surveyor reviewed a facility-reported incident (FRI) submitted to the State Agency (SA) on 4/19/23. The FRI indicated R2 swatted at R7 who attempted to hit R2. The facility's investigation indicated R2 was standing in R2's doorway on 4/19/23 when R7 walked down the hall. R2 became agitated that R7 was near R2's room, exchanged words with R7 and began to swat at R7 who swatted back. Staff reported contact was made three times each between R2 and R7 in the face/chest area before staff separated the residents. R7 stated R2 hit R7 on the cheek and R7 attempted to hit R2 in the face. R2 and R7 were assessed and no injuries were noted. The investigation indicated staff would continue to monitor R2 and R7 for additional interactions. Surveyor also reviewed a FRI submitted to the State Agency on 5/3/23 that indicated a possible resident-to-resident interaction occurred between R2 and R8. The facility's investigation indicated R8 reported R2 entered R8's room and hit R8. The investigation indicated R8 reported to a CNA on 5/3/23 at approximately 11:00 AM that R2 came into (R8's) room and beat (R8) up. R8 repeated the same allegation to a Social Worker during an interview on 5/3/23. During the interview, R8 also stated R2 hit R8 in the face, knocked R8's glasses off, and had done so at least 3 times in the past. An interview with another CNA indicated when they responded to R8's call light, R8 was attempting to call 911 because (R2) assaulted (R8). R8 had dried blood and a small scratch near R8's left eyebrow. The investigation indicated the allegation of physical abuse was not substantiated due to conflicting interviews and staff would continue to monitor R2 and R8. The investigation indicated R2's movement around the facility was monitored due to dementia and potential exit seeking and staff were keenly aware of R2's movements. On 6/26/23 at 3:20 PM, Surveyor interviewed R4's Family Member (FM)-G who was visiting R4. Surveyor noted R4 was asleep at the time of the interview and most of the afternoon. When Surveyor asked about the alarm on R4's door, FM-G indicated the alarm was put on R4's door because R2 wandered and it made us uncomfortable. FM-G stated FM-G observed R2 push an empty wheelchair down the hallway approximately two weeks ago. FM-G used the bathroom in R4's room; however, shortly after entering the bathroom, FM-G heard voices in R4's room. FM-G exited the bathroom and saw R2 next to R4's bed. FM-G stated R4 was asleep, but woke up and was scared. FM-G stated, After that, we had the alarm put on the door. A progress note in R4's medical record, dated 5/25/23, contained the following information: Writer received a phone call from R4's daughter who was concerned that another resident wandered into R4's room. Writer notified upcoming shift and left voicemail for Social Worker and DON. On 6/26/23 at 1:01 PM, Surveyor interviewed R5's Guardian (GD)-F who indicated GD-F observed R2 wander up and down the halls which made GD-F nervous. GD-F visited R5 on 6/16/23 and observed R2 in the room next to R5 with R2's pants down. (The resident who resided in the room was not in the room at the time). GD-F yelled down the hall to staff who redirected R2. GD-F indicated staff were busy helping other residents and did not see R2 enter the room. Staff told GD-F that R2 tried to find a bathroom, but GD-F was uncomfortable because R5 could not call for help if something happened. GD-F stated it's almost impossible for staff to have eyes on R2 at all times and requested an alarm on R5's door. GD-F said R2 didn't enter R5's room or have an incident with R2, but GD-F did not want anything to happen to R5. On 6/26/23 at 11:17 AM, Surveyor interviewed RN-C who indicated R2 was aggressive at times and seemed to pick someone's room and then tend to keep going that way. During the interview, Surveyor heard an alarm. RN-C stated the alarm was on a resident's door and activated when someone entered or exited the room. RN-C stated 2 residents had door alarms requested by family due to R2's wandering. RN-C indicated R4 had a door alarm because R2 entered R4's room and scared R4. RN-C indicated R5 had a door alarm per R5's family's request. RN-C indicated the only intervention RN-C was aware of following the altercation between R1 and R2 was the addition of lorazepam (generic name for Ativan) PRN (as needed). RN-C indicated a combination cream Ativan/Haldol/Benadryl (known as ABH cream; used to treat delirium) was prescribed prior to the altercation on 6/14/23. Progress notes following the incidents on 6/14/23 indicated the following: A progress note on 6/17/23 at 2:21 PM indicated the on-call physician was asked for an order due to R2's increased agitation, wandering, exit seeking and yelling at residents. R2 was redirected multiple times before the physician was called and R2's agitation worsened throughout the morning. A progress note on 6/17/23 at 7:57 PM indicated R2 wandered for an hour or two, periodically showed signs of agitation and aggression and peered in resident rooms. On 6/17/23, the physician added an order for Ativan (a sedative medication used to treat anxiety) 0.5 milligrams by mouth every 4 hours as needed for agitation. On 6/26/23, Surveyor reviewed R2's June 2023 Medication Administration Record (MAR) which indicated R2 received as needed doses of Ativan once daily on 6/17/23, 6/18/23, 6/19/23, 6/21/23, and 6/23/23. R2 received four doses of Ativan on 6/25/23. R2 was administered ABH cream (0.25 milliliters topically 4 times daily PRN) four times daily with the exception of 6/24/23 when three doses were administered. Two doses were administered on 6/26/23 when Surveyor reviewed R2's MAR. During the investigation, Surveyor made the following observations: On 6/26/23 at 3:40 PM, Surveyor observed R2 ambulate independently in R2's hallway. R2 walked down the left side of the hallway, held the railing, and carried a blanket. Surveyor observed R3 sitting in R3's doorway when R2 ambulated toward R3. On 6/26/23 at 3:43 PM, Surveyor observed R2 enter an empty room with an open door on the left side of the hallway. Surveyor observed CNA-H enter the room and attempt to verbally redirect R2. On 6/26/23 at 3:44 PM, Surveyor observed R2 exit the empty room and ambulate across the hallway with CNA-H. Surveyor observed R2 open the closed door of an empty room on the same side of the hallway as R3. On 6/26/23 at 3:45 PM, Surveyor observed R3 back into R3's room when R2 and CNA-H ambulated past R3's room. When CNA-H and R2 entered R2's room, Surveyor observed R3 come back into the hallway and sit in R3's doorway. On 6/26/23 at 3:48 PM, Surveyor observed CNA-H and R2 exit R2's room and ambulate toward the lobby. On 6/26/23 at 3:50 PM, CNA-H guided R2 to a recliner in the lobby. On 6/26/23 at 3:53 PM, Surveyor interviewed CNA-H who indicated it was CNA-H's first shift on the unit and 7th day at the facility. CNA-H stated CNA-H heard about R2 from other staff and knew there was an incident. CNA-H was unaware of R2's care plan interventions and stated CNA-H was told to keep an eye on R2. On 6/26/23 at 3:56 PM, Surveyor interviewed CNA-I and CNA-J who regularly worked the PM shift and were familiar with R2. CNA-I heard in shift report on 6/15/23 and from other CNAs about the incident between R2 and R1. CNA-I also asked R1 about the incident because R1 had a shiner. CNA-I was told R1 screamed, clawed back and scratched R2 and a CNA pulled R2 out of the room and kept R1 and R2 separated. CNA-I and CNA-J indicated in shift report, CNA-I and CNA-J were told R2 was on edge, had exit seeking behaviors, and was aggressive. CNA-I indicated R2's aggressive behaviors in the evening were hit or miss and R2 wandered more than R2 was aggressive. CNA-I verified R2 entered other resident rooms and empty rooms since the altercation between R1 and R2, but was not aggressive or verbal. CNA-I and CNA-J were aware of topics R2 liked to discuss, including farming, but were not aware of any updates or changes to R2's plan of care following the incident with R1. CNA-J stated staff were told to keep an eye on R2. CNA-I and CNA-J agreed there were times during the PM shift when R2 was unsupervised. CNA-I and CNA-J indicated staff provided meals and cares between 5:00-7:30 PM and it was likely R2 could be unsupervised for a period of time. CNA-J indicated on the PM shift, staff tried to keep R2 in the lobby; however, R2 ambulated independently. CNA-J indicated there were other residents in the lobby when R2 was there. CNA-J stated one resident had an electric wheelchair that beeped and annoyed R2. CNA-I and CNA-J indicated there were usually 2 to 4 staff on the PM shift and sometimes night shift came in early to help. When asked about residents with door alarms, CNA-I and CNA-J said family members complained about R2 wandering so staff keep an eye on who goes in and out of those rooms. CNA-J also indicated CNA staff aren't asked for intervention ideas following incidents and altercations.

Based on interview and record review, the facility did not ensure 5 CNAs (Certified Nursing Assistants) (CNA-N, CNA-E, CNA-O, CNA-P, and CNA-J) of 5 CNAs employed by the facility received 12 hours per year of in-service training. This practice had the potential to affect multiple residents in the facility. CNA-N was hired on 8/21/14. CNA-N did not have 12 hours of in-service training during the most recent anniversary of hire year. CNA-E was hired on 5/28/96. CNA-E did not have 12 hours of in-service training during the most recent anniversary of hire year. CNA-O was hired on 7/27/21. CNA-O did not have 12 hours of in-service training during the most recent anniversary of hire year. CNA-P was hired on 4/23/19. CNA-P did not have 12 hours of in-service training during the most recent anniversary of hire year. CNA-J was hired on 2/1/20. CNA-J did not have 12 hours of in-service training during the most recent anniversary of hire year. Findings include: The facility's Emergency Preparedness Training and Testing Program policy, last reviewed 6/7/22 contained the following information: The staff training/education and competencies that are necessary to provide the level and types of support and care needed for the resident population .training topics (this is not an inclusive list): .Required in-service training for nurse aides. In-service training must: Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year. Include dementia management training and resident abuse prevention training. Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff. For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired. On 7/6/23, Surveyor reviewed documents that indicated the following: ~ CNA-N received 2 of the required 12 hours of in-service training. ~ CNA-E received 3 of the required 12 hours of in-service training. ~ CNA-O received 3 of the required 12 hours of in-service training. The documentation did not indicate the numbers of hours of in-service training CNA-P and CNA-J received. On 7/6/23 at 2:39 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified NHA-A and Director of Nursing (DON)-B were responsible for keeping track of whether or not CNAs obtained the required 12 hours of in-service training. NHA-A indicated in July of 2022, the facility identified a concern that staff did not attend required in-services and stated, We started making in-service attendance requirement at 80 percent. NHA-A verified the requirement meant staff must attend at least 80 percent of in-services provided by the facility. NHA-A indicated the facility generally provided monthly in-services and allowed one hour of credit for each; however, the facility did not provide in-services for months and stated, I can't penalize them (CNAs) for the ones I didn't do. NHA-A stated the facility kept track of attendance by looking at sign-in sheets but did not have a process for tracking attendance, such as a spreadsheet. NHA-A indicated CNA-P received a couple hours of in-service training because CNA-P was in college and doesn't work much. NHA-A indicated CNA-J was in a high school school-to-work program and the facility did not have documentation of in-service hours for CNA-J.

Based on interview and record review, the facility did not provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 3 residents (R2). R2 did not receive scheduled medications following admission to the facility. Evidenced by: The facility policy Medication Administration, dated 1/5/23, states, as follows: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards or practice 1. Keep medication cart clean, organized and stocked with adequate supplies. Review MAR (Medication Administration Record) to identify medicaiton to be administered. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. Correct any discrepencies and report to nurse manager. R2 was admitted to the facility 4/27/23 at 10:45 AM, with diagnoses including, but not limited to: chronic obstructive pulmonary disease (COPD), mitral insufficiency (mitral valvue of the heart does not close properly), panlobular emphysema (type of emphysema that affects a specific part of the lungs), and hypoxemia (low oxygen) R2's Physician Orders, signed 4/27/23, documented the following scheduled medications: 1. Albuterol-Ipratropium Bromide 2.5 mg - 0.5 mg (milligrams) / 3 ml (milliliters) inhalation solution; Inhale 3 milliliters inhalation 2 times a day for shortness of breath; Quantity 60 2. Budesonide 0.5 mg/2 ml Inhalation suspension; Inhale 2 milliliters Inhalation 2 times a day for shortness of breath; Quantity 60 3. Citalopram Hydrobromide 10 mg oral tablet; Take 0.5 (5 mg) tab oral once a day for depression; Quantity 15 4. Senna Plus 50 mg - 8.6 mg oral tablet; Take 1 tab oral 2 times a day for constipation; Quantity 60 5. Furosemide 20 mg oral tablet; Take 1 ab oral once a day for edema; Quantity 30 6. Mirtazapine 7.5 mg oral tablet; Take 1 tab oral once a day (at bedtime) for sleep; dose 100 mg Quantity: 60 7. Prednisone 10 mg oral tablet; Take 1 tab oral once a day for COPD (Chronic Obstructive Pulmonary Disease); Quantity 30; (dose: 100 mg) Qantity: 60 8. Trazadone 50 mg oral tablet; Take 2 tabs oral once a day (at bedtime) for sleep; (dose:100 mg) Quantity: 60 9. Seroquel 25 mg oral tablet; Take 1/2 tab orally once a day (in the evening) for agitation; Give between 4-6 pm. (Dose: 12.5 mg) Quantity: 15 tablets 10. Loratadine 10 mg oral tablet; Take 1 tab orally nce a day for seasonal allergies; Quantity: 30 11. Polyethylene gycol powder 17 gms(grams) (1 capful) By mouth; daily for constipation; with 8 oz (ounce) water, may repeat if no BM after 6 hours 1st dose. #1 bottle. R2's Medication Administration Record (MAR) documents the following medication administration: 1. Albuterol-Ipratropium Bromide - Use contents of one vial via nebulizer twice daily. Diagnosis: Dyspnea (Scheduled AM and PM) 4/27/23: PM dose not administered 4/28/23: None administered On 4/28/23 at 2:24 AM, R2's Progress Note documents the following: .Hospice RN (Registered Nurse) indicated that she would make sure that the scheduled Hospice RN visit on 4/28/23 at 10:00 am - that they would bring his meds/nebulizer and MARS/TARS (Medication Administration Record/Treatment Administration Record). 4/29/23 PM dose not administered On 4/29/23 at 5:52 PM, R2's Progress Note documents the following: When this writer went to give resident his routine nebs (nebulizers) today it was noted that resident did not have a nebulizer machine in his room This writer circled (On the MAR indicating medication not administered) resident's routine nebs tonight as we do not have a neb machine for him. 2. Budesonide Suspension 0.5 mg/ 2 mg - Inhale 2 ml PO twice daily. Dx: Dyspnea (Scheduled AM and PM) 4/27/23: PM dose not administered 4/28/23: None administered 4/29/23 PM dose not administered On 4/29/23 at 5:52 PM, R2's Progress Note documents the following: When this writer went to give resident his routine nebs (nebulizers) today it was noted that resident did not have a nebulizer machine in his room This writer circled (On the MAR indicating medication not administered) resident's routine nebs tonight as we do not have a neb machine for him. 3. Citalopram 10 mg - Take 0.5 tablet (5mg) PO daily. Diagnosis: Depression (Scheduled AM) 4/28/23: None administered 4. Senna Plus 8.6 - 50 mg - Take 1 tab PO twice daily (stock) (Scheduled AM and PM) 4/27/23: PM dose not administered 4/28/23: None administered 5. Furosemide 20 mg - Take 1 tab PO daily. Diagnosis: Edema (Scheduled AM) 4/28/23: None administered 6. Mirtazapine 7.5 mg - Take 1 tab at bedtime (Scheduled HS - bedtime) 4/27/23: None administered 4/28/23: None administered 4/29/23: None administered 4/30/23: None administered 7. Prednisone 10 mg - Take 1 tab PO daily (Scheduled AM) 4/28/23: None administered 8. Trazadone 100 mg - Take 1 tab at bedtime (Scheduled HS - bedtime) 4/29/23: None administered 4/30/23: None administered 9. Seroquel 25 mg - Take 0.5 mg (12.5 mg) PO in the evening. (Scheduled 4:00 PM) 4/27/23: None administered 4/28/23: Medication administered 4/29/23: None administered 4/30/23: None administered 5/1/23: None administered 5/2/23: None administered 10. Loratadine - Take 1 tab PO daily (Scheduled AM) 4/28/23: None administered 11. Clearlax Powder - Mix 17 gm (1 capful) in 8 oz of liquid and drink PO daily. (Scheduled AM) 4/28/23: None administered On 6/15/23 at 12:05 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B what is the process for processing physician-ordered medications. DON B stated, when a resident gets admitted , the nurses will fax the orders to the pharmacy. The pharmacy uses the orders to create the MAR. The pharmacy brings the MARs and the medications. Surveyor asked DON B were there any issues with R2 receiving ordered medications. DON B stated, pharmacy said R2 passed (5/3/23) before they could get them done and printed. Surveyor asked DON B if the facility completed medication errors for R2's missed medications. DON B stated, no, there probably are not any. Surveyor asked DON B, who's responsibility is it to complete medication errors reports. DON B stated, it is her responsibility. Surveyor asked DON B, did you complete medication errors reports for R2's missed medications. DON B stated, No, they did not tell me he (R2) missed them. Surveyor asked DON B, do you expect residents medications to be ready and available upon admission. DON B stated, Yes. Surveyor asked DON B, would you expect staff to notify you when a resident's medications are not available. DON B stated, Yes. Surveyor asked DON B, why is this important. DON B stated, staff should be going by (administering) what's ordered by the physician. Surveyor asked DON B, did staff notify the physician of the (above referenced) medication errors. DON B stated, no. Surveyor asked DON B, would you expect the physician to be notified. DON B stated, yes. Surveyor asked DON B, what is your expectation of steps to be completed when there is a medication error. DON B stated, she expects staff take vitals, notify the resident and/or activated power of attorney and physician. DON B added, she expects staff to notify her, follow the steps the physician indicates, DON B will sit down with staff and go over the information, educate on medication error policy, and provide a written test to the staff member.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized in accordance with accepted professional standards and practices in 1 of 3 residents reviewed (R1). There is no documentation in R1's Medication Administration Record (MAR) regarding updated orders for supplemental oxygen. Evidenced by: R1 was admitted to the hospital on [DATE] and discharged on 5/20/23 with the following orders, in part: Active Problems: Acute on chronic respiratory failure with hypoxemia (low level of oxygen). Acute on Chronic Hypoxic and Hypercapneic (high carbondioxide level/retention) respiratory failure. Continue O2 to keep sats 89-90%. Continue BiPAP 10/5 if able to tolerate. R1 was admitted to the hospital 5/23/23 and discharged [DATE] with the following orders: Oxygen administration: Titrate oxygen per facility policy, procedure or guidelines. Mode: Nasal canula Flow (LPM (Liters per minute): 3 R1's MAR documents the following: O2 (oxygen) per nasal canula 2L titrate to keep O2 89-90%. There was no documentation in R1's medical record that his 3 liter oxygen order was transcribed into the MAR. On 6/15/23 at approximately 3:00 PM, Surveyor spoke with DON B (Director of Nursing). DON B stated the oxygen order should be updated in R1's MAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not return funds within 30 days of discharge for 2 of 3 residents (R1 & R3). R1 was admitted to the facility on [DATE] and discharged on [DATE]. R1 had funds at the facility which the facility failed to return to family within 30 days of discharge. R3 was admitted to the facility on [DATE] and discharged on [DATE]. R3 was private pay the entire stay at the facility. R3 had funds at the facility which the facility failed to return to family within 30 days of discharge. This is Evidenced by: The facility policy entitled, Resident Personal Funds, with revision on [DATE], states, in part: . Conveyance upon Discharge, Eviction, or Death 1. Upon the discharge, eviction, or death of a resident with a personal fund deposited with the facility, the facility will convey within 30 days the resident's funds and a final account of those funds to the resident, or in the case of death, the individual or probate jurisdiction administering the resident's estate, in accordance with State law . Example 1 R1 had expired on [DATE]. On [DATE] FM C (Family Member) had written the facility a check for approximately $21,167.00 to be applied towards R1's outstanding balance. Within a short span of time from the date of receiving the check from FM C, the facility received a check from R1's Long Term Care Private Insurance. The facility cashed the check and applied it to the remaining balance. As of approximately [DATE] the balance had been paid in full leaving a credit to the family. As of [DATE], the facility still owes FM C an outstanding balance. Example 2 R3 had expired on [DATE] and had a balance owed of $5847.15. The check for $5847.15 was sent out to R3's family on [DATE]. On [DATE], at 12:00PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked should FM C have received the outstanding balance owed within 30 days of receiving the Long-Term Care Insurance check and balance paid in full and NHA A indicated yes. Surveyor asked NHA A should outstanding balances owed after a resident discharge be returned within 30 days and NHA A indicated yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, facility staff did not provide care and treatment in accordance with professional standards of practice for 1 of 2 sampled residents (R15). R15 was admitted to the facility on [DATE] with diagnoses including, but not limited to: diabetes mellitus type 2, chronic kidney disease and cognitive impairment. R15 developed a facility acquired ulceration to his right fourth toe (6/1/22). The facility was not completing daily diabetic foot checks, a nursing standard of practice. In addition, the facility is not measuring nor assessing this area. This is evidenced by: The facility policy, Skin Integrity - Foot care, updated 6/7/22, indicates in part, the following: Policy Explanation and Compliance Guidelines: 1. The facility will provide foot care and treatment in accordance with professional standards of practice, including the prevention of complications from the resident's medical conditions. a. The facility will utilize a systemic approach for the prevention and management of foot ulcers, including efforts to identify risk; stabilize, reduce, or remove underling risk factors; monitor the impact of the interventions; and modif the interventions as appropriate. 2.b. The comprehensive assessment process will be utilized for identifying additional risk factors or conditions that increase risk for impaired skin integrity of the foot. Examples include, but are not limited to: diabetes, peripheral vascular disease, peripheral arterial disease, venous insufficiency, peripheral neuropathy, and lack of sensation in feet. According to American Medical Doctors Association - The Society for Post-Acute and Long-Term Care Medicine - Pressure Ulcers - Clinical Practice Guideline - http:// www.amda.com/ tools/ guideline.cfm#pressureulcer .to the extent feasible, caregivers should educate patients about daily foot care (e.g., washing, moisturizing), nail care, and about the importance of avoiding walking barefoot, avoiding foot trauma, and promptly telling a caregiver about foot pain or changes in the appearance of the feet . Treatment of foot problems in patients with diabetes is generally stratified into three broad risk categories: at-risk foot; current mild foot, ankle, or heel infection or ulcer; and limb-threatening foot, ankle, or heel infection or ulcer . Risk Category: At-risk foot (patients who smoke; have vascular insufficiency, neuropathy, retinopathy, nephropathy, history of ulcers or amputations, structural deformities, infections, skin/nail abnormality; are on anticoagulation therapy; cannot see, feel, or reach their feet.) Treatment Plan: · Refer for podiatric care at least annually and as needed for specific foot problems · Train caregivers to perform daily foot care and inspection · To the extent feasible, train patients to perform daily foot care and inspection . The facility's policy, Skin and Wound Care Program, updated 1/22/22, indicates in part, the following: The facility shall ensure that a skin and wound care program will be maintained to preserve skin integrity, prevent pressure injuries, promote comfort and mobility and prevent infection. Licensed Nursing Staff - 3. Monitor, measure and document altered skin integrity issues on all residents. R15 was admitted to the facility on [DATE] with diagnoses including, but not limited to, diabetes mellitus type 2, chronic kidney disease and cognitive impairment. R15's MDS (Minimum Data Set) assessment dated [DATE] notes a BIMS (Brief Interview for Mental Status) score of 9/15 indicating R15 is moderately cognitively impaired. Section M (Skin), indicates R15 has one (1) stage 1 pressure injury. R15's Comprehensive Care Plan includes in part: (Date Initiated: 3/24/22) I like to reposition frequently. I have the potential to bruise easily have a skin injury because I am a diabetic, have poor tissues perfusion sometimes get confused or can't remember things can't move around well on my own lose control of my bladder and/or bowels. I show this by having an existing skin injury, damp skin, poor skin turgor. I need my nurses to .check my skin weekly My goal is to keep my skin healthy and intact, have my skin heal. Goal time: two weeks R15's CNA [NAME] indicates in part: Skin Care: Make sure that the skin between my toes is dry. I have decreased feeling in my feet so remind me to position myself up in bed so that my feet aren't rubbing the footboard. On 6/1/22 DON B (Director of Nursing) sent a fax to R15's Physician that indicates the following: .R15's right foot has sore under 4th toe. Can we have an order for Betadine on all sores/open areas on feet and non-adherent gauze between toes, border foam on right toe and lightly wrap right foot. Change daily and PRN (as needed). On 6/2/22 NP D (Nurse Practitioner) noted, Ok to continue with orders as requested for wound care. On 7/28/22 R1's Orthopedic Surgeon diagnosed R15 with diabetic ulcer. It is important to note, the facility was not completing nor documenting daily diabetic foot checks until 7/1/22 (one month after the wound was first noted). On 9/28/22 at 2:02 PM and 2:40 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B if staff were completing daily diabetic foot checks prior to discovering the open area on R15's foot on 6/1/22. DON B stated, No. Surveyor asked DON B, should staff have been completing daily diabetic skin checks for R15 since admission. DON B stated, yes. Surveyor asked DON B, why is it important for staff to complete daily diabetic foot checks. DON B stated, because just like R15 a lot of diabetic residents have diabetic neuropathy and can't feel a sore/wound. DON B indicated to Surveyor that she is responsible for completing weekly wound rounds at the facility. DON B is not Wound Care Certified. Surveyor asked DON B, should R15's wound have been monitored, measured and assessed weekly. DON B stated, she was not aware his wound should have been monitored, measured, and assessed weekly. Surveyor asked if there was any training completed regarding R15's wound. DON B stated, no. On 9/28/22 at 3:16 PM, Surveyor spoke with Physician E. Surveyor asked Physician E, when did the facility first notify you of R15's wound to his right foot fourth toe. Physician E stated, 6/1/22. Physician E stated, R15 has neuropathy and his circulation is not there. Surveyor asked Physician E was the wound avoidable. Physician E stated, no.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 (R89) of 2 residents reviewed for accidents of a total sample of 12 residents. R89 was known to wander, did not have a plan of care for his wandering, and wandered into other resident rooms. Findings include R89 was admitted to the facility on [DATE] and has diagnoses that include Dementia without behavioral disturbance. His most recent MDS (Minimum Data Set), dated 9/6/22, shows a BIMS (Brief Interview for Mental Status) score of 00, indicating R89 is severely cognitively impaired. The facility documented the following progress notes on R89: *8/31/22 at 8:34 PM: Resident having extreme wandering this evening. He was found in several other patient rooms, attempting to get out of doors and located in therapy room and supply office. He was difficult to re-direct wanting to go home to find his wife. *9/3/22 at 11:25 PM: Resident was up wandering at times tonight. Staff continue to monitor for resident's safety. *9/9/22 at 6:51 PM: Resident came up to this writer and told this writer that a man was in her bed. This writer walked down with resident and got R89 up off of resident's bed. The resident got a little upset about him being in her bed. Both residents were redirected by the writer. This writer walked R89 up the hallway with his walker. 9/10/22 at 10:31 PM: This writer noted that the resident was in the kitchenette tonight by himself. 9/18/22 at 12:52 AM: R89 went into another resident's room tonight and that resident became upset that R89 was in his room. This writer assisted resident out of the room and CNAs came down and got resident into bed in his room. Staff to continue to monitor resident. On 9/26/22 at 11:49 AM, Surveyor interviewed R6 who stated that his neighbor (R89) had come into his room the night before and sat on his bed while he (R6) was laying in the bed. R6 stated R89 did not have any pants on and would not leave despite many attempts to tell him to leave and yell at him. R6 stated he had to push R89 for him to leave. R6 stated that CNAs (Certified Nursing Assistants) came and escorted R89 away. R6 stated to Surveyor that he did not like it that another resident came into his room and he Was not a homosexual and did not want R89 that close to him without pants on. R6 did not know the time of the incident and did not remember the CNA that came into the room to escort R89 away. On 9/27/22 at 4:05 PM, Surveyor interviewed RN C (Registered Nurse) who stated he recalled the incident on 9/25/22. RN C stated R89 had wandered into R6's room and sat on his bed. RN C stated that R89 did not have pants on but did have a brief on. RN C stated he did not witness the event, but a CNA came and notified him of what had happened. RN C stated he put in an incident note about the event. No incident note was found or provided to Surveyors. R89 does not have a care plan addressing his wandering, how the staff will respond to the wandering or how the staff will protect other residents from R89's unwanted wandering into their rooms. On 9/28/22 at 8:46 AM Surveyor interviewed DON B (Director of Nursing), who stated that there was no note documenting R89's wandering into R6's room. DON B also stated that she would expect there to be an incident report so that staff could talk to R6 and see if there are any additional interventions, they could put in place to prevent any future altercations with R6 and other residents. On 9/28/22 at 1:36 PM, Surveyor interviewed NHA A (Nursing Home Administrator). NHA A stated the facility does not have a wandering or elopement assessment for R89 as he hadn't yet been at the facility for 30 days. NHA A also stated that R89's wife had told the facility at the time of admission that he (R89) had been wandering a lot. The facility was aware R89 was wandering into other resident rooms but did not reassess or reevaluate R89 and care plan his wandering to prevent future wandering, accidents and resident to resident altercations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure drug regimens are free from unnecessary psychotropic medications for 1 out of 5 residents (R27) reviewed for unnecessary medications out of a total sample of 18. -R27 is currently on Seroquel for hallucinations. Seroquel is an antipsychotic used to treat certain mental/mood conditions. Facility could not provide persistent behavior documentation to support Seroquel use. -The facility has not completed an annual GDR. This is Evidenced by: The facility policy, entitled Gradual Dose Reduction of Psychotropic Drugs, dated 6/10/22, states, in part: . Policy: Residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs . Policy Explanation and Compliance Guidelines: 1) Reducing the need for and maximizing the effectiveness of medications shall be considered for all residents who use psychotropic drugs. Therefore, dose reductions and behavioral interventions are part of medication management. This policy pertains to gradual dose reductions . 2) After the first year, a GDR (gradual dose reduction) will be attempted annually, unless clinically contraindicated . R27 was admitted to the facility on [DATE] and has diagnoses that include Unspecified dementia without behavioral disturbance, Hallucinations, Mood disorder due to known physiological condition with depressive features and other psychotic disorder not due to a substance or known physiological condition. R27's MDS (minimum data set) Quarterly Assessment, dated 7/25/22, indicated R27 has a BIMS (Brief Interview of Mental Status) score of 12 indicating that R27 is moderately impaired cognitively. R27's physician orders, dated 9/21/22, states, in part: . Quetiapine Tab (tablet) 25 mg (milligrams) Generic For: Seroquel Take 0.5 tablet (12.5mg) PO daily . Hallucinations . Quetiapine Tab 25mg Generic For: Seroquel Take 1 Tablet PO (by mouth) at bedtime .Hallucinations . R27's medication administration record for January 1, 2022 - September 27, 2022, shows R27 received Quetiapine 12.5mg daily in AM and Quetiapine 25mg daily at bedtime. R27's behavior documentation for hallucinations shows: January 2022- 0 documented episodes of hallucinations February 2022- 0 documented episodes of hallucinations March 2022- 0 documented episodes of hallucinations April 2022- 0 documented episodes of hallucinations May 2022- 3 documented episodes of hallucinations June 2022- 0 documented episodes of hallucinations July 2022- 0 documented episodes of hallucinations August 2022- 0 documented episodes of hallucinations September 2022- left blank R27's GDR (Gradual Dose Reduction), dated 5/26/22, states, in part: . R27 has taken Quetiapine 12.5mg po in the morning and 25mg at bedtime for hallucinations/agitation for the past year. She is due to be evaluated for a possible gradual dose reduction attempt. Per monthly psychotropic medication review with Social Services, R27 has not had any hallucinations or agitation documented since the beginning of 2022. We recommend trying a small dose reduction at this time and continued monitoring. Decrease to Quetiapine 12.5mg po bid (2 times a day) (am & hour of sleep) ___x___ . Signed by Physician and dated 5/26/22 . Of Note- The following noted from facility under physician signature: 5/26/22: Resident is still own decision maker and does not want to do trial reduction of medication as she still has hallucinations at night . On 9/28/22, at 1:49 PM, Surveyor interviewed DON B (Director of Nursing) and asked what diagnosis is R27 receiving Seroquel and DON B indicated hallucinations. Surveyor asked DON B looking at the behavior charting for R27 from January through September with 3 episodes documented for hallucinations, does this support the use of Seroquel for hallucinations. DON B indicated no. Surveyor asked DON B by R27 declining GDR 5/26/22 if that was an acceptable standard of practice. DON B indicated her practice has always been to go with what the physician recommends. DON B indicated the facility should have attempted the decrease in the Seroquel to try it and if R27 continued with hallucinations the facility could have the prior dose put back into place. Surveyor asked DON B if there should have been a GDR and DON B indicated yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility does not follow a nationally recognized standard of practice for infection control or monitoring antibiotic use and they do not have protocols in place to obtain cultures and other reports to ensure residents are receiving the correct antibiotic for 2 of 3 residents (R91 and R14) reviewed for infections. R91 was started on an antibiotic and the facility failed to update the physician about her negative urinalysis and continued antibiotic use. R14 was started on a prophylactic antibiotic without a clinical indication. Evidenced by: The facility's policy titled, Antibiotic Stewardship Program, dated 1/3/22, states in part: .4. The program includes antibiotic use protocols and a system to monitor antibiotic use. a. Antibiotic use protocols: i. Nursing staff shall assess residents who are suspected to have an infection and complete an SBAR (Situation, Background, Assessment, Recommendation) form prior to notifying the physician. ii. Laboratory testing shall be in accordance with current standards of practice .iv. The Loeb Minimum Criteria are used to determine whether to treat an infection with antibiotics . Example 1 R91was admitted to the facility on [DATE] with diagnoses that include congestive heart failure, major depressive disorder, chronic kidney disease stage 3, anemia, insomnia, and falls. R91 was on July's line list as having a UTI (Urinary Tract Infection) and was placed on an antibiotic. On 7/19/22, R91 had a fall, and was noted to have increased confusion; MD (Medical Doctor) was updated, and UA (Urine Analysis) was ordered. Urine sample was obtained and sent to the lab. R91 was sent to the ER (Emergency Room) on 7/20/22 for evaluation and treatment. R91's UA resulted while she was in the hospital. Culture results obtained by the facility state: 50,000 to 100,000 CFU (Colony Forming Unit) per ML (milliliters) of Granulicatella Adiacens NO FURTHER WORK UP! (Possible Pathogen). R91 returned to the facility on 7/21/22 with diagnoses of acute on chronic anemia, SOB (Shortness of Breath), and weakness. Additionally, R91 returned to the facility on Cephalexin 500mg BID (twice a day) x7 days. It is important to note that there was no culture and sensitivity performed on R91's UA. Example 2 R14 was admitted to the facility on [DATE] with diagnoses that include dementia without behavioral disturbance, epilepsy, major depressive disorder, chronic kidney disease stage 3b, personal history of urinary tract infections, and overactive bladder. On 8/26/22 facility staff updated R14's MD that R14 was being negative, sarcastic, and rude, R14's MD ordered a UA. On 8/27/22 facility staff obtained the urine sample and sent it to the lab, MD gave an order to start Bactrim DS for 3 days initially, then changed to a total of 5 days, ending on 9/1/22. Urine culture resulted as >100,000 CFU per ML Proteus Mirabillis. On 9/13/22 R14 had an unresponsive episode with possible seizure activity. Facility staff updated the MD and R14 was sent to the ER. R14 returned to the facility later that day with a diagnosis of a probable UTI (Urinary Tract Infection) and was started on Bactrim BID x 7 days. On 9/19/22 facility nurse documented that they received an order from R14's MD stating that R14 is to be placed on a prophylactic antibiotic for recurring UTIs- Cephalexin 250mg (milligrams) daily; MD's note indicates that he consulted with a urologist, but the urologist never saw R14 in the facility or in the clinic. On 9/28/22 at 9:40 AM, Surveyor interviewed NHA A (Nursing Home Administrator) and DON B (Director of Nursing). Surveyor asked DON B if R91 met criteria for a UTI, DON B stated that R91 was having urgency and frequency, but she did not meet criteria. Surveyor asked what the facility's protocol (i.e., push fluids, monitor intake and output) was for a resident that was experiencing urinary changes, DON B stated that they don't really have one and the nurses just call the doctor. Surveyor asked DON B if R91's UA met criteria for a UTI, DON B stated no. Surveyor asked DON B if anyone had had a conversation with the MD about R91 having a negative UA and not meeting the criteria for an antibiotic, DON B stated no. Surveyor asked DON B and NHA A if R14 met criteria for a UA on 8/26/22 with her only documented symptoms were negative, sarcastic, and rude, NHA A and DON B stated no and that was R14's personality. Surveyor asked DON B if R14 had been seen by the urologist prior to starting the prophylactic antibiotic, DON B stated no, but she will follow up with R14's HCPOA (Healthcare Power of Attorney). Surveyor asked DON B if staff has had a conversation with R14's MD about the use of prophylactic antibiotics, DON B stated no.

Based on record review and interview, the facility did not offer each resident pneumococcal immunizations, and the resident's medical record does not include documentation the resident either received, refused, or was educated on the risks and benefits of the influenza and pneumococcal immunization for 2 of 5 residents (R87 and R90) reviewed for immunizations. R87 did not receive the pneumococcal vaccine. R90 did not receive the pneumococcal vaccine. This is evidenced by: The facility's policy titled Pneumococcal Vaccine (Series), last reviewed 6/7/22 states in part, .1. Each resident will be assessed for pneumococcal immunization upon admission .2. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated, or the resident has already been immunized .4. The resident/ representative retains the right to refuse the immunization. A consent form shall be signed prior to the administration of the vaccine and filed in the individual's medical record . Example 1: R87's medical record has no evidence or documentation to show that R87 or their representative was provided education, risks vs. benefits, or side effects regarding the pneumococcal vaccination in order to make an informed choice about receiving/declining the pneumococcal vaccination. There is no evidence of R87 declining the pneumococcal vaccination. Example 2: R90's medical record has no evidence or documentation to show that R90 or their representative was provided education, risks vs. benefits, or side effects regarding the pneumococcal vaccination in order to make an informed choice about receiving/declining the pneumococcal vaccination. There is no evidence of R90 declining the pneumococcal vaccination. On 9/27/22 Surveyor requested from DON B (Director of Nursing) vaccine declination forms for R87 and R90. On 9/28/22, DON B provided Surveyor with signed consent forms for R87 and R90 dated 9/27/22. On 9/28/22 at 1:37 PM, Surveyor interviewed DON B. Surveyor asked DON B what her expectations were for obtaining vaccination consents or declinations? DON B stated that they should be obtained on admission but realized that the consents are not in the admission packets, so she is changing that process. Surveyor asked DON B if the consents should have been obtained prior to 9/27/22? DON B stated yes.

Based on interview and record review, the facility did not ensure that a resident's medical record included documentation that indicates the resident or resident representative was provided education regarding the benefits and potential side effects of the COVID-19 vaccine, and that the resident (or representative) either accepted, received, or declined the COVID-19 vaccine for 2 of 5 residents (R20 and R23) reviewed for COVID-19 vaccinations. This is evidenced by: The Centers for Medicare and Medicaid Services (CMS) Quality, Safety & Oversight Group (QSO) Memo (Ref: QSO-21-19-NH) released on May 11, 2021, addresses the Interim Final Rule related to COVID-19 Vaccine Immunization Requirements for Residents and Staff, which includes requirements for educating residents or resident representatives and staff regarding the benefits and potential side effects associated with the COVID-19 vaccine, and offering the vaccine. Additionally, the facility must maintain appropriate documentation to reflect that the facility provided the required COVID-19 vaccine education, and whether the resident or staff member received the vaccine. According to the facility's vaccination tracking log, R20 and R23 are unvaccinated for COVID-19. Example 1: R20's medical record has no evidence or documentation to show that R20 was provided education, risks vs. benefits, or side effects regarding the COVID-19 vaccination in order to make an informed choice about receiving/declining the vaccination. There is no evidence of R20 declining the COVID-19 vaccination. Example 2: R23's medical record has no evidence or documentation to show that R23 was provided education, risks vs. benefits, or side effects regarding the COVID-19 vaccination in order to make an informed choice about receiving/declining the vaccination. There is no evidence of R23 declining the COVID-19 vaccination. On 9/28/22 at 1:37 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what her expectations were for obtaining vaccination consents or declinations? DON B stated that they should be obtained on admission but realized that the consents are not in the admission packets, so she is changing that process. Surveyor asked DON B if she had any COVID-19 vaccine declination forms for R20 and R23? DON B stated that she was unable to find any COVID-19 declination forms.