**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review, the facility failed to implement its policies and procedures and did not protect 2 of 3 residents from abuse. (R43, R35). R43 was not protected from verbal abuse when Certified Nursing Assistant (CNA) D threatened R43 by stating CNA D would throw R43 over shoulder and carry out of room if R43 didn't do what CNA D wanted R43 to do. R36 was not protected from physical abuse when R35 grabbed R36's walker and then swung at R36, hitting R36 and grabbing R36's wrist. Findings include: Example 1 On 2/17/25, Surveyor reviewed R43's medical record. R43 was admitted on [DATE] with Alzheimer's dementia with delusional thought process. R43's Minimum Data Set (MDS) assessment, dated 10/23/24, had a Brief Interview for Mental Status (BIMS) score of 03 out of 15 which indicated R43 had severe impaired cognition. Surveyor reviewed grievance logs from 08/20/24 to 02/18/25. -On 09/11/24, grievance was filed that R44 reported that CNA D was yelling at R43 to get dressed in R43's pajamas and CNA D would not stop telling R43 to get dressed on 09/10/24. R44 also stated that CNA D said she could throw R43 over CNA D's shoulders if she needed to make R43 put on pajamas. On 02/17/25, Surveyor reviewed R44's medical record. R44 was admitted on [DATE] with status post amputation, diabetes mellitus, and heart failure. R44's Minimum Data Set (MDS) assessment, dated 11/20/24, had a BIMS score of 15 out of 15, which indicated R44 has intact cognition. On 02/19/25 at 11:51 AM, Surveyor interviewed R44 and asked if R44 remembers the event on 09/10/24. R44 indicated that R44 does remember the incident. R44 overheard CNA D speak to R43 with a stern voice and threatened R43. Surveyor asked R44 how CNA D threatened R43. R44 indicated that CNA D was barking orders at R43 about putting boot on and making sure to use walker. R44 indicated that R43 refused to wear the boot and use walker. R44 heard CNA D tell R43 that R43 better do what CNA D is asking or CNA D will throw R43 over CNA D's shoulder and carry R43 out. R44 indicated that CNA D would not give R43 a chance to respond and explain what R43 needed instead. R44 indicated that R44 was scared for R43, so R44 told CNA C. R44 indicated that CNA C told R44 to let the nurse on duty know. R44 stated, I did not know which nurse was on that night, but I told who I could and then the next day a social worker talked to me. R44 clarified that CNA D continued with behavior by walking down the hallway antagonizing R43. Surveyor asked how CNA D antagonized R43. R44 indicated that CNA D would come up to R43, touch R43's shoulders, smile extra big and purposely talk to her. R43 would tell CNA D to get away from R43, but CNA D kept coming up and touching R43's shoulders while smiling big. On 02/19/25 at 11:59 AM, Surveyor was unable to interview R43, due to BIMS of 3. R43 was not protected from verbal abuse from CNA D. Example 2 On 02/17/25, Surveyor's review of R35's medical record discovered a nursing progress note which notes the following: Nurse progress note states: .On 01/28/2025 at 4:38 PM, Late Entry for: 01/27/2025. DATE OF INCIDENT: 01/27/2025, TIME OF INCIDENT: 17:12, INJURY: no apparent injury There was an altercation during supper time. Resident was grabbing at [R36's] walker during supper, [R36] tried to stop him by talking loudly. [R35] grabbed [R36]. [R36] stated if he grabs him again, he was going to, punch him. Staff had intervened. At 4:39PM, Today there was no further altercations between [R35] and [R36], they were kept apart from each other. At 10:13 PM, [R35] was aggressive and combative at the beginning of the shift. Resident was found in another resident's room and will not follow redirection from the CNA. Instead, he swung his hand on the CNA hitting the CNA on the chest . On 02/19/25 at 10:25 AM, Surveyor interviewed R36 and asked R36 if there have been any resident-to-resident altercations that have occurred on the unit. R36 stated, Yes, [R35]! Who has not had an altercation with [R35]. One time [R35] came at me in the dining room, but I put him in his place. I yelled to tell him not to ever touch me again or I'd punch him. Surveyor asked R36 to explain the incident in the dining room with R35. R36 indicated that R35 came at R36 and grabbed R36's walker and then swung at R36 hitting R36 and grabbing R36's wrist. Surveyor asked if R36 was injured. R36 indicated that he was not injured but, R35 is very strong, and it did frighten me. Staff intervened and R36 grabbed walker and went to room. R36 indicated that R36 tends to stay in room more now because R36 doesn't want those interactions with R35 again. R36 indicated that R35 has outbursts all the time in the dining room. R36 indicated that R36 dislikes that kind of aggressive behavior and mostly stays in room because of the outbursts. On 02/20/25 at 8:02 AM, Surveyor interviewed Director of Nursing (DON) B and asked what the expectations are for resident to resident altercations and how residents are protected from abuse. DON B indicated that staff follow facility policy and staff should let DON B, NHA A, or Social Worker I know about any potential verbal or physical abuse. On 02/20/25 at 8:14 AM, Surveyor interviewed Nursing Home Administrator (NHA) A asking NHA A how residents are protected from abuse. Surveyor indicated to NHA A that the incident with R43 was verbal abuse. Surveyor indicated to NHA A that the incident with R36 did in fact happen, R36 was grabbed and hit by R35 which is physical abuse. Surveyor asked NHA A if NHA A thought abuse concerns from R35 had occurred. NHA A indicated that residents were not protected from abuse by not following through on the facility policy. NHA A indicated that everyone should be following the facility policy for abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not report 2 of 3 (R43, R36) potential misconduct incidents to the State's Office of Caregiver Quality (OCQ) via the State's Misconduct Incident Reporting (MIR) system immediately upon learning of the incident. *CNA D threatened R43 by stating CNA D would throw R43 over shoulder and carry out of room if R43 didn't do what CNA D wanted R43 to do. *R35 grabbed R36's walker and then swung at R36, hitting R36 and grabbing R36's wrist. Findings include: Facility policy titled Misconduct Investigation and Reporting, last revised 08/20/24, stated in part, -#4. The staff member must immediately report the incident to the nurse on duty or other supervisory staff. -#5. The nurse/supervisor must notify the Administrator of the alleged incident/complaint immediately after ensuring the safety of the resident. If administrator can't be reached, notify the DON or social services manager. -#19. The Administrator or his designee will immediately notify the DQA of all alleged incidents involving mistreatment, exploitation, neglect, or abuse. CMS defines immediately to be as soon as possible but not to exceed 24 hours after discovery of the incident. If the allegation involves abuse or resulted in serious bodily injury the violation must be reported within 2 hours from when the issue if discovered . Example 1 Surveyor reviewed grievance logs from 08/20/24 to 02/18/25. On 09/11/24, grievance was filed that R44 reported that CNA D was yelling at R43 to get dressed in R43's pajamas and CNA D would not stop telling R43 to get dressed on 09/10/24. R44 also stated that CNA D said she could throw R43 over CNA D's shoulders if she needed to make R43 put on pajamas. Surveyor reviewed facility investigation on the grievance filed and when CNA D was asked about the incident, CNA D did confirm what was said to R43 but CNA D said CNA D was only joking and would never actually do it. On 2/17/25, Surveyor reviewed R43's medical record. R43 was admitted on [DATE] with Alzheimer's dementia with delusional thought process. R43's Minimum Data Set (MDS) assessment, dated 10/23/24, had a Brief Interview for Mental Status (BIMS) score of 03 which indicated R43 had severe impaired cognition. On 02/17/25, Surveyor reviewed R44's medical record. R44 was admitted on [DATE] with status post amputation, diabetes mellitus, and heart failure. R44's Minimum Data Set (MDS) assessment, dated 11/20/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicates R44 has intact cognition. On 02/19/25 at 11:51 AM, Surveyor interviewed R44 and asked if R44 remembers the event on 09/10/24. R44 indicated that R44 does remember the incident. R44 overheard CNA D speak to R43 with a stern voice and threatened R43. Surveyor asked R44 how CNA D threatened R43. R44 indicated that CNA D was barking orders at R43 about putting boot on and making sure to use walker. R44 indicated that R43 refused to wear the boot and use walker. R44 heard CNA D tell R43 that R43 better do what CNA D is asking or CNA D will throw R43 over CNA D's shoulder and carry R43 out. R44 indicated that CNA D would not give R43 a chance to respond and explain what R43 needed instead. R44 indicated that R44 was scared for R43, so R44 told CNA C. R44 indicated that CNA C told R44 to let the nurse on duty know. R44 stated, I did not know which nurse was on that night, but I told who I could and then the next day a social worker talked to me. Surveyor asked R44 if CNA D kept working with R43 with cares and activities throughout the next couple days. R44 indicated to Surveyor that CNA D continued to come into room to assist R43, and CNA D walked down the hallway antagonizing R43. Surveyor asked how CNA D antagonized R43. R44 indicated that CNA D would come up to R43, touch R43's shoulders, smile extra big and purposely talk to her. R43 would tell CNA D to get away from R43, but CNA D kept coming up and touching R43's shoulders while smiling big. Surveyor asked R44 if R44 let any staff members know of the continual approaches from CNA D to R43. R44 indicated that R44 did not let any staff know about the incidents because R44 didn't know if it was ok to after trying to report the verbal abuse and CNA D continually providing care for R43 and R44. On 02/19/25 at 11:59 AM, Surveyor interviewed R43 and asked if R43 can R43 remember any incidents that have caused R43 any mental anguish, or physical harm. R43 stared at Surveyor and had confused look on face. Surveyor was unable to interview R43. Surveyor asked R43 if R43 felt safe in the facility in R43's home. R43 chuckled and stated, Ahh the facility is fine, and my roommate takes care of me as needed. Surveyor could not find any facility documentation of this incident as being reported to the State Agency. Example 2 On 02/17/25, Surveyor's review of R35's medical record discovered a nursing progress note which notes the following: Nurse progress note indicated, .On 01/10/2025 at 5:16 PM, PRN MED GIVEN: hydroxyzine HCl 25MG Tablet (1 tablet / 25mg) given for agitation tried to throw chair in dining room. 6:44PM PRN MED RESULT: at 6:44 PM, Improved but still present. At 9:00 PM BEHAVIOR: abusive behavior wandering behaviors Pushing /Grabbing Behavior occurred. Note: We were trying to direct [R35] over to his food at the table. [R35] did not want to come to the table but was trying to take plates from the dietetic worker instead. As we attempted to guide [R35] to the table, [R35] became agitated and attempted to pick up a chair as if [R35] was going to throw it. It was eased back to floor, and we directed [R35] back to tv area. There are three other residents at this table and two staff trying to feed residents and another resident that was not being too cooperative with eating. It seemed too much activity for [R35] at the time and [R35] got very agitated and angry. I then gave [R35] prn Atarax which had little effect tonight. About 7:30 [R35] grabbed another resident by the wrist and staff intervened before [R35] could hurt the resident. [R35] was angry because this resident grabbed [R35's] blanket [R35] was holding and so [R35] turned around quickly and grabbed her, and staff were standing there when [R35] grabbed her. I turned down lights early this evening to slow things down because residents seemed quite wound up tonight. Will continue to monitor [R35] closely around other residents . Surveyor did not find documentation to support that the facility reported the resident-to-resident altercation to DQA. Surveyor did not find documentation that staff notified a supervisor of the incident which occurred. Nurse progress note indicated, .On 01/28/2025 at 4:38 PM, Late Entry for: 01/27/2025. DATE OF INCIDENT: 01/27/2025, TIME OF INCIDENT: 17:12, INJURY: no apparent injury There was an altercation during supper time. Resident was grabbing at [R36's] walker during supper, [R36] tried to stop him by talking loudly. [R35] grabbed [R36]. [R36] stated if he grabs him again, he was going to, punch him. Staff had intervened. At 4:39PM, Today there was no further altercations between [R35] and [R36], they were kept apart from each other. At 10:13 PM, [R35] was aggressive and combative at the beginning of the shift. Resident was found in another resident's room and will not follow redirection from the CNA. Instead, he swung his hand on the CNA hitting the CNA on the chest . Surveyor did not find documentation to support that the facility reported the resident-to-resident altercation to DQA. Surveyor did not find documentation that staff notified a supervisor of the incident. On 02/19/25 at 10:25 AM, Surveyor interviewed R36 and asked R36 if there have been any resident-to-resident altercations that have occurred on the unit. R36 stated, [R35]! Who has not had an altercation with [R35]?. One-time [R35] came at me in the dining room, but I put him in his place. I yelled to tell him not to ever touch me again or I'd punch him. Surveyor asked R36 to explain the incident in the dining room with R35. R36 indicated that R35 came at R36 and grabbed R36's walker and then swung at R36 hitting R36 and grabbing R36's wrist. Surveyor asked if R36 was injured. R36 indicated that he was not injured but, R35 is very strong, and it did frighten me. Staff intervened and R36 grabbed walker and went to room. R36 indicated that R36 tends to stay in room more now because R36 doesn't want those interactions with R35 again. R36 indicated that R35 has outbursts all the time in the dining room. R36 indicated that R36 dislikes that kind of aggressive behavior and mostly stays in room because of the outbursts. On 02/19/25 at 10:30 AM, Surveyor interviewed CNA F and asked about process to report resident-to-resident altercations to administration. CNA F indicated that CNA F would then report this to CNA F's nurse on duty. On 02/19/25 at 11:27 AM, Surveyor interviewed Licensed Practical Nurse (LPN) G and asked if LPN G reports to the supervisor if there is a resident-to resident altercation. LPN G indicated if it is severe enough and needed more attention than LPN G would report to supervisor. On 02/20/25 at 7:21 AM, Surveyor interviewed Registered Nurse (RN) H and asked RN H what is RN H's process when there is a resident to resident altercation or if there is an incident that happens with a resident. RN H indicated, Of course I intervene and separate the aggressor and the victim or the aggressor and the aggressor, then we document the events very thoroughly in the computer, and then there is follow up on both residents for the next 24 hours. Surveyor asked RN H if RN H reports to the supervisor. RN H indicated that RN H is the supervisor on nights but should be reporting to DON B the next day if it's in the middle of the night. Surveyor asked RN H what is the facility procedure for determining if an incident is verbal or physical abuse? RN H indicated intervening and letting supervisor know when supervisor is available is the appropriate measures. On 02/20/25 at 8:02 AM, Surveyor interviewed Director of Nursing (DON) B and asked what the expectations are for resident-to resident altercations and how are potential abuse concerns handled with staff to resident incidents. DON B indicated that staff follow facility policy and staff should let DON B, NHA A, or Social Worker I know about any incidents that are a concern for potential verbal or physical abuse. DON B said DON B was unaware of some of the incidents since nursing staff did not report these except for the more recent ones that occurred this year. On 02/20/25 at 8:14 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked why facility did not report a few of the incidents of potential verbal and physical abuse concerns from staff to resident involving R43 and then R36 and then resident to resident altercations from R35 to the state. NHA A stated that usually staff report incidents and then between NHA A, DON B, and Social Worker I, us three decide the importance of the complaint and start a proper investigation if it's needed, and then report to state regulatory agency if needed. NHA A indicated that NHA A did not think the incidents with R43 or R36 were considered abuse concerns. Surveyor indicated to NHA A that the incident with R43 had concerns with verbal abuse, and CNA D even admitted to verbally saying the threat to R43 and that she continued to work with R43 and other residents before investigation was complete. NHA A indicated that CNA D was joking, but that NHA A didn't realize CNA D continued to work with R43. Surveyor asked NHA A if NHA A thought that some of the physical abuse concerns from R35 unto another unknown resident on Birchwood was concerning. NHA A indicated that NHA A was unaware of some of the incidents and that staff did not report this to administration. NHA A indicated that everyone should be following the facility policy for misconduct.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon interview, policy review and record review, the facility did not ensure allegations of verbal and physical abuse were thoroughly investigated or prevent further potential abuse from occurring while the investigation was in progress for residents (R) (R43, R36) and other undocumented residents, which has the potential to affect all 19 residents on the Birchwood unit. Facility did not protect R43 when allowing Certified Nursing Assistant (CNA) D to continue to work with R43 when accused of verbal abuse. Facility allowed CNA D to continue to work with R43 during complaints of rough cares was being investigated. This is evidenced by: Facility policy titled Misconduct Investigation and Reporting, last revised 08/20/24, stated in part, .-2. If the issue could be considered verbal, sexual, or physical abuse the staff person is required to take action immediately to protect the resident and/or stop the occurrence. This includes incidents perpetrated by staff. The staff's primary responsibility is to always ensure the safety of the resident. Before all else protect the resident. -7. The building supervisor must take action to protect the resident or other residents who may be at risk while the incident is being investigated (I.e. staff person is sent home on administrative leave, is directly supervised to maintain all resident's safety, or is reassigned to non-resident duties). -#14. Investigation of the incident will proceed with interviews being conducted with residents and staff and information regarding the allegations being collected. The investigation may include documenting each step taken during the internal investigation and any conclusions made. Resident to resident altercation should look for causes or situations that may have contributed to the incident occurring. Misconduct Definitions dated, 07/2024 indicates: 'Abuse' is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, or mental anguish; Verbal abuse involves the use of speech, sound, writing, or gestures when communicating with residents or their families or when within their hearing or sight, regardless of their age ability to comprehend, or disability. Examples include but are not limited to threats of harm or frightening a resident; Physical harm includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. Note the federal definition of abuse indicates that the act needs to be willful and that it needs to have resulted in physical or psychosocial harm to the resident or-if the resident cannot provide a response-would be expected to have caused harm to a reasonable person. Example 1 Surveyor reviewed grievance logs from 08/20/24 to 02/18/25. On 09/11/24, grievance was filed that R44 reported that CNA D was yelling at R43 to get dressed in R43's pajamas and CNA D would not stop telling R43 to get dressed on 09/10/24. R44 also stated that CNA D said she could throw R43 over CNA D's shoulders if she needed to make R43 put on pajamas. Surveyor reviewed facility investigation on the grievance filed and when CNA D was asked about the incident, CNA D did confirm what was said to R43 but CNA D said CNA D was only joking and would never actually do it. On 02/17/25, Surveyor reviewed R43's medical record. R43 was admitted on [DATE] with Alzheimer's dementia with delusional thought process. R43's Minimum Data Set (MDS) assessment, dated 10/23/24, had a Brief Interview for Mental Status (BIMS) score of 03 out of 15, which indicates R43 has severe impaired cognition. On 02/17/25, Surveyor reviewed R44's medical record. R44 was admitted on [DATE] with status post amputation, Diabetes Mellitus, and heart failure. R44's Minimum Data Set (MDS) assessment, dated 11/20/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicates R44 has intact cognition. On 02/19/25 at 11:51 AM, Surveyor interviewed R44 and asked if R44 remembers the event on 09/10/24. R44 indicated that R44 does remember the incident. R44 overheard CNA D speak to R43 with a stern voice and threatened R43. Surveyor asked R44 how CNA D threatened R43. R44 indicated that CNA D was barking orders at R43 about putting boot on and making sure to use walker. R44 indicated that R43 refused to wear the boot and use walker. R44 heard CNA D tell R43 that R43 better do what CNA D is asking or CNA D will throw R43 over CNA D's shoulder and carry R43 out. R44 indicated that CNA D would not give R43 a chance to respond and explain what R43 needed instead. R44 indicated that R44 was scared for R43, so R44 told CNA C. R44 indicated that CNA C told R44 to let the nurse on duty know. R44 stated, I did not know which nurse was on that night, but I told who I could and then the next day a social worker talked to me. Surveyor asked R44 if CNA D kept working with R43 with cares and activities throughout the next couple days. R44 indicated to Surveyor that CNA D continued to come into room to assist R43, and CNA D walked down the hallway antagonizing R43. Surveyor asked how CNA D antagonized R43. R44 indicated that CNA D would come up to R43, touch R43's shoulders, smile extra big and purposely talk to her. R43 would tell CNA D to get away from R43, but CNA D kept coming up and touching R43's shoulders while smiling big. Surveyor asked R44 if R44 let any staff members know of the continual approaches from CNA D to R43. R44 indicated that R44 did not let any staff know about the incidents because R44 didn't know if it was ok to after trying to report the verbal abuse and CNA D continually providing care for R43 and R44. Surveyor reviewed investigation file dated 09/11/24 which indicates Social Worker I interviewed R44 about the events pertaining to CNA D and R43. On 09/12/24, Social Worker I interviewed staff that were on same shift when the incident occurred on 09/10/24. DON interviewed residents on 09/12/24. Surveyor reviewed CNA D's schedule and time punches from 09/01/24-09/14/24. CNA D worked on 09/10/24 on Pineview unit, then on 09/12/24 on Birchwood Unit, and again on 09/13/24 on [NAME] Lane unit. Surveyor did not find in the investigation if facility had removed CNA D from the Pineview unit and supervised CNA D with other residents on other units until investigation was complete to prevent further potential abuse concerns. Surveyor did not find a clear investigation complete date of the incident with R43 and CNA D. Example 2 On 02/17/25, Surveyor reviewed R36's medical record. R36 was admitted on [DATE] with atrial fibrillation, hypertension, and chronic obstructive pulmonary disease. R36's Minimum Data Set (MDS) assessment, dated 01/08/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicates R36 has intact cognition. On 02/17/25, Surveyor reviewed R35's medical record. R35 was admitted on [DATE] with diagnoses including dementia unspecified with behavioral disturbances, cataracts, hypertensive heart disease, and insomnia. R35's Minimum Data Set (MDS) assessment, dated 11/06/24, had a Brief Interview for Mental Status (BIMS) score of 00 which indicated R35 had severe impaired cognition and could not complete the BIMS test. Surveyor reviewed R35's nursing progress notes that indicated, .-On 06/22/2024 at 4:09 PM, Note: [R35] was sitting at the dining table eating and suddenly he yelled at resident across the table who was eating his meal and then kicked the table and was swearing. We were going to remove him from the area but then he continued to eat, and we stayed nearby. When he appeared not to be eating, we offered that he could go watch tv if he wanted to. He got up and started pacing the hallway. After residents were done eating one resident stayed in his chair by the dining room table to watch tv and [R35] came up behind him and hit the back of the chair hard. This frightened the resident in the chair, and he got up with his walker and went to his room . Surveyor did not find documentation that staff notified a supervisor of the incident that occurred, and did not find a proper investigation into the incident. Surveyor did not find a thorough investigation that identified who the affected resident was on Birchwood unit. Nurse progress note indicated, . On 09/16/24 at 9:30 PM, Note: [R35] spent first part of our shift outside. He did not eat much of his supper this evening. Given cold fluids as it was warm outside. Brought him in to get ready for bed but he has been very resistive to cares again his shift. I only now was able to get him to take his medications. Will attempt to change him again when he has had his meds in him for 30 minutes or so. CNA informed me that, [R35] walked by another resident and apparently swung as to hit him but did not. It is very difficult to address his cares even with two staff. Will continue to monitor behaviors and chart . Surveyor did not find a thorough investiation into R35 swinging at another residen. Unable to determine who the affected resident was. Nurse progress note indicated, .On 01/10/2025 at 5:16 PM, PRN MED GIVEN: hydroxyzine HCl 25MG Tablet (1 tablet / 25mg) given for agitation tried to throw chair in dining room. 6:44PM PRN MED RESULT: at 6:44 PM, Improved but still present. At 9:00 PM BEHAVIOR: abusive behavior wandering behaviors Pushing /Grabbing Behavior occurred. Note: We were trying to direct [R35] over to his food at the table. He did not want to come to the table but was trying to take plates from the dietetic worker instead. As we attempted to guide him to his table, he became agitated and attempted to pick up a chair as if he was going to throw it. It was eased back to floor, and we directed [R35] back to tv area. There are three other residents at his table and two staff trying to feed residents and another resident that was not being too cooperative with eating. It seemed too much activity for [R35] at the time and he got very agitated and angry. I then gave him his prn Atarax which had little effect tonight. About 7:30 he grabbed another resident by the wrist and staff intervened before he could hurt the resident. He was angry because this resident grabbed his blanket he was holding and so he turned around quickly and grabbed her, and staff were standing there when he grabbed her. I turned down lights early this evening to slow things down because residents seemed quite wound up tonight. Will continue to monitor him closely around other residents . Surveyor did not find a thorough investigation for R35's physical abuse towards others. The affected resident is not identified. Surveyor did not find documentation that staff notified a supervisor of the incident that occurred. Nurse progress note indicated, .On 01/28/2025 at 4:38 PM, Late Entry for: 01/27/2025. DATE OF INCIDENT: 01/27/2025, TIME OF INCIDENT: 17:12, INJURY: no apparent injury There was an altercation during supper time. Resident was grabbing at [R36's] walker during supper, [R36] tried to stop him by talking loudly. [R35] grabbed [R36]. [R36] stated if he grabs him again, he was going to, punch him. Staff had intervened. At 4:39PM, Today there was no further altercations between [R35] and [R36], they were kept apart from each other. At 10:13 PM, [R35] was aggressive and combative at the beginning of the shift. Resident was found in another resident's room and will not follow redirection from the CNA. Instead, he swung his hand on the CNA hitting the CNA on the chest . Surveyor did not find documentation of a thorough investigation into the incident, nor preventative measures put into place to prevent reoccurrence of incidents. On 02/19/25 at 10:25 AM, Surveyor interviewed R36 and asked R36 if there have been any resident-to-resident altercations that have occurred on the unit. R36 stated, [R35]! Who has not had an altercation with [R35]?. One time [R35] came at me in the dining room, but I put him in his place. I yelled to tell him not to ever touch me again or I'd punch him. Surveyor asked R36 to explain the incident in the dining room with R35. R36 indicated that R35 came at R36 and grabbed R36's walker and then swung at R36 hitting R36 and grabbing R36's wrist. Surveyor asked if R36 was injured. R36 indicated that he was not injured but, R35 is very strong, and it did frighten me. Staff intervened and R36 grabbed walker and went to room. R36 indicated that R36 tends to stay in room more now because R36 doesn't want those interactions with R35 again. R36 indicated that R35 has outbursts all the time in the dining room. R36 indicated that R36 dislikes that kind of aggressive behavior and mostly stays in room because of the outbursts. On 02/19/25 at 10:30 AM, Surveyor interviewed CNA F and asked about process to deal with R35 or any other residents that may have altercations of aggression or explosions. CNA F indicated that CNA F will intervene and separate residents or try to redirect residents. Surveyor asked what CNA F's next process is after intervening and making sure residents are safe. CNA F indicated that CNA F would then report this to CNA F's nurse on duty. CNA F indicated the nurse would do a formal assessment and then monitor going forward. On 02/19/25 at 11:27 AM, Surveyor interviewed Licensed Practical Nurse (LPN) G and asked LPN G what is LPN G's process when there is an altercation between a resident to resident or if there is an incident that happens with a resident. LPN G indicated LPN G will intervene if LPN G observes the resident-to-resident altercation. LPN G would try to redirect R35 or any other resident who is aggressive and acting out. LPN G will then assess both residents and manage the residents' care as appropriate. On 02/20/25 at 7:21 AM, Surveyor interviewed Registered Nurse (RN) H and asked RN H what is RN H's process when there is a resident to resident altercation or if there is an incident that happens with a resident. RN H indicated, Of course I intervene and separate the aggressor and the victim or the aggressor and the aggressor, then we document the events very thoroughly in the computer, and then there is follow up on both residents for the next 24 hours. On 02/20/25 at 8:02 AM, Surveyor interviewed Director of Nursing (DON) B and asked what the expectations are for resident-to resident altercations and how are potential abuse concerns handled with staff to resident incidents. DON B indicated that staff follow facility policy and staff should let DON B, NHA A, or Social Worker I know about any incidents that are a concern for potential verbal or physical abuse. Surveyor asked what the process is for properly investigating and preventing further abuse concerns from happening. DON B indicated that once a concern is reported DON B, NHA A, or Social Worker will open an investigation and interview all staff members involved and remove the staff member accused until investigation is complete. DON B indicated then staff will interview other residents for any concerns and complete a thorough investigation with a resolution plan. Surveyor asked DON B why the complaint of possible verbal abuse was not thoroughly investigated before allowing CNA D to continue to work with R43. DON B indicated that DON B was unaware of all the logistics of the incident and that Surveyor would need to speak with Social Worker I. Surveyor asked DON B about the resident-to-resident and staff altercations that involved R35 on 06/22/24, 09/16/24, 01/10/25, and 01/28/25. DON B indicated that DON B was unaware of some of the incidents since nursing staff did not report these except for the more recent ones that occurred this year. Surveyor asked DON B why proper investigations were not completed for 06/22/24, 09/16/24, 01/10/25 and 1/28/25, to prevent any further potential for physical abuse on the Birchwood unit. Surveyor indicated to DON B that on two different occasions on 06/22/24 and 01/10/25, R35 had resident to resident physical altercations and Surveyor could not find complete documentation of the event, the investigation for it, or who the other resident was that was affected. DON B indicated the investigation was not completed, and staff should have had more thorough documentation so that staff could process what had occurred. DON B indicated the affected residents that were not named in the incidents should have had better follow up as facility policy states to assess and document for the next 24-48 hours on both residents involved in altercation. On 02/20/25 at 8:09 AM, Surveyor interviewed Social Worker I and asked why the complaint of possible verbal abuse was not thoroughly investigated before allowing CNA D to continue to work with R43. Social Worker I indicated that Social Worker I was unaware CNA D continued to work with R43 but that Social Worker I does not make those decisions for staff and DON B makes scheduling decisions. Surveyor asked Social Worker I about the resident-to-resident and staff altercations that involved R35 on 06/22/24, 09/16/24, 01/10/25, and 01/28/25. Social Worker I indicated that Social Worker I was unaware of some of the incidents since nursing staff did not report these except for the more recent ones that occurred this year. Social Worker I indicated that thorough investigations were not completed for R35's incidents. On 02/20/25 at 8:14 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked why facility did not thoroughly investigate the incidents of potential verbal, physical abuse concerns from staff to resident involving R43 and the resident-to-resident altercations from R35. NHA A indicated that NHA A did not think the incidents with R43 or R36 were considered abuse concerns. Surveyor indicated to NHA A that the incident with R43 had concerns with verbal abuse, and CNA D admitted to verbally saying the threat to R43. CNA D continued to work with R43 and other residents before investigation was complete. NHA A indicated that CNA D was joking, but that NHA A didn't realize CNA D continued to work with R43.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not transmit the Minimum Data Set (MDS) assessments within 14 days of completion for 3 residents (R) (R40, R47, and R31) out of 12 sampled residents. R40 had a Quarterly (Q) MDS assessment completed on 10/02/24 and a Quarterly MDS assessment completed on 12/31/25. Both assessments had not been transmitted as of end of survey, 02/20/25. R47 had a Prospective Payment System (PPS) discharge assessment completed 11/08/24 and a Quarterly MDS completed 12/23/24. MDS assessments had not been transmitted. R31 had a Quarterly MDS assessment completed on 10/02/24 and another Quarterly MDS completed on 12/31/24 which were not submitted by the facility. This is evidenced by: The requirements for the RAI are found at 42 CFR 483.20 and are applicable to all residents in Medicare and/or Medicaid certified long-term care facilities. The requirements are applicable regardless of age, diagnosis, length of stay, payment source or payer source. Federal RAI requirements are not applicable to individuals residing in non-certified units of long-term care facilities or licensed-only facilities. §483.20(f)(3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following: (i)admission assessment. (ii) Annual assessment. (iii) Significant change in status assessment. (iv) Significant correction of prior full assessment. (v) Significant correction of prior quarterly assessment. (vi) Quarterly review. (vii) A subset of items upon a resident's transfer, reentry, discharge, and death. (viii) Background (face-sheet) information, for an initial transmission of MDS data on resident that does not have an admission assessment. Example 1 R40 was admitted to the facility on [DATE] with diagnoses including pneumonia, atrial fibrillation, coronary artery disease, hypertension, and diabetes. On 02/19/25 at 7:59 AM, Surveyor reviewed R40's MDS assessments. R40's facility records identified the following: Quarterly (Q)90 was completed on 07/03/24. Status accepted. Q180 was completed on 10/02/24. Status completed. Q270 was completed on 12/31/24. Status completed. The Q180 and Q270 MDS assessments were never transmitted to Centers for Medicare & Medicaid Services (CMS). The Q180 assessment should have been transmitted on or before 10/16/24. Q270 assessment should have been transmitted on or before 01/14/25. R40's quarterly MDS's were marked as completed, but not transmitted or accepted by CMS. Example 2 R47 was admitted to the facility on [DATE] with diagnoses including COVID, atrial fibrillation, heart failure, hypertension, dementia, and diabetes. Surveyor reviewed R47's MDS assessments. R47's facility records identified the following: admission 5 day was completed on 09/23/24. Status accepted. PPS discharge was completed on 11/08/24. Status completed. Q90 was completed on 12/23/24. Status completed. The PPS discharge and the Q90 MDS assessments were never transmitted to Centers for Medicare & Medicaid Services (CMS). The PPS discharge MDS assessment should have been transmitted on or before 11/22/24. Q90 assessment should have been transmitted on or before 01/06/25. R40's PPS discharge and Q90 MDS's were marked as completed, but not transmitted or accepted by CMS. Example 3 R31 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, atrial fibrillation, coronary artery disease, hypertension, and kidney disease. Surveyor reviewed R31's MDS assessments. R31's facility records identified the following: Admission-Not PPS was completed on 06/24/24. Status accepted. Q90 was completed on 10/02/24. Status completed. Q180 was completed on 12/31/24. Status completed. The Q90 and Q180 MDS assessments were never transmitted to Centers for Medicare & Medicaid Services (CMS). The Q90 MDS assessment should have been transmitted on or before 10/16/24. Q180 MDS assessment should have been transmitted on or before 01/14/25. R31's Q90 and Q180 MDS's were marked as completed, but not transmitted or accepted by CMS. On 02/19/25 at 9:09 AM, Surveyor interviewed Medical Records (MR) M who stated that MR M helps with MDS transmissions. MR M was provided a list of the residents above and asked for proof of transmissions for the MDS's completed but not transmitted. At 10:38 AM, MR M stated that the MDS assessments were not completed because those residents were self-pay or on a Medicare Advantage Plan and to speak with Nursing Home Administrator (NHA) A if there are more questions. On 02/19/25 at 1:10 PM, Surveyor interviewed NHA A and asked why the MDS's were not transmitted. NHA A stated it was due to payor source. Surveyor encouraged NHA A to visit chapter 5 of the Resident Assessment Instrument manual and F640 regulation. NHA A stated they will transmit them all from now on.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 2 On 02/17/25, Surveyor reviewed R35's medical record. R35 was admitted on [DATE], with dementia unspecified with behavioral disturbances, cataracts, hypertensive heart disease, and insomnia. R35's Minimum Data Set (MDS) assessment, dated 11/06/24, had a Brief Interview for Mental Status (BIMS) score of 00 which indicated R35 had severe impaired cognition and could not complete the BIMS test. Surveyor reviewed R35's care plan for Alzheimer's disease major neurocognitive disorder due to medical condition with behavior disturbance: -On 11/16/22: Nurse to report any behavioral issues. Has wander management bracelet. -On 02/15/23: After wife visits monitor more closely for wandering or behaviors. -On 02/15/23: If attempt to swing fist may need to leave alone and reapproach later or get alternate staff. -On 02/21/24: Report to nurse if noting any behavioral issues or hitting peers. -On 06/25/24: Night shift to look in on him on rounds x 3. Keep door alarm on so as to alert staff to exiting room. On 1:1 visits as needed. -On 11/16/24: If pacing or restless, trying to go into peer's room offer to take toilet in his room. Redirect away from peers' rooms. -On 01/04/25: Turn on chime on outside door when he goes to bed, to alert staff when R35 exit seeks. -On 01/28/25: If in peers' room or noting to be touching peers, redirect R35. Surveyor reviewed R35's nursing progress notes that indicated, . -On 06/22/2024 at 4:09 PM, Note: [R35] was sitting at the dining table eating and suddenly he yelled at resident across the table who was eating his meal and then kicked the table and was swearing. We were going to remove him from the area but then he continued to eat, and we stayed nearby. When he appeared not to be eating, we offered that he could go watch tv if he wanted to. He got up and started pacing the hallway. After residents were done eating one resident stayed in his chair by the dining room table to watch tv and [R35] came up behind him and hit the back of the chair hard. This frightened the resident in the chair, and he got up with his walker and went to his room . Surveyor did not find documentation that staff implemented any new interventions to increase supervision or provide 1:1 for R35 after the resident altercation on 6/22/24. Nurse progress note indicated, -On 07/26/24: R35 was grabbing, pushing, and swinging. Attempted to put hands around writers' neck while trying to provide cares. Surveyor did not find documentation that staff implemented any new interventions to increase supervision for the other residents on the unit, when R35 exhibited increased aggressive behaviours on 7/26/24. Nurse progress note indicated, . On 09/16/24 at 9:30 PM, Note: [R35] spent first part of our shift outside. He did not eat much of his supper this evening. Given cold fluids as it was warm outside. Brought him in to get ready for bed but he has been very resistive to cares again his shift. I only now was able to get him to take his medications. Will attempt to change him again when he has had his meds in him for 30 minutes or so. CNA informed me that, [R35] walked by another resident and apparently swung as to hit him but did not. It is very difficult to address his cares even with two staff. Will continue to monitor behaviors and chart . Surveyor did not find documentation that staff updated any new interventions to increase supervision or provide 1:1 for R35 to protect other residents on the unit when R35 was observed swinging at another resident on 9/16/24. Nurse progress note indicated, .On 01/10/2025 at 5:16 PM, PRN MED GIVEN: hydrOXYzine HCl 25MG Tablet (1 tablet / 25mg) given for agitation tried to throw chair in dining room. 6:44PM PRN MED RESULT: at 6:44 PM, Improved but still present. At 9:00 PM BEHAVIOR: abusive behavior wandering behaviors Pushing /Grabbing Behavior occurred. Note: We were trying to direct [R35] over to his food at the table. He did not want to come to the table but was trying to take plates from the dietetic worker instead. As we attempted to guide him to his table, he became agitated and attempted to pick up a chair as if he was going to throw it. It was eased back to floor, and we directed [R35] back to tv area. There are three other residents at his table and two staff trying to feed residents and another resident that was not being too cooperative with eating. It seemed too much activity for [R35] at the time and he got very agitated and angry. I then gave him his prn atarax which had little effect tonight. About 7:30 he grabbed another resident by the wrist and staff intervened before he could hurt the resident. He was angry because this resident grabbed his blanket he was holding and so he turned around quickly and grabbed her, and staff were standing there when he grabbed her. I turned down lights early this evening to slow things down because residents seemed quite wound up tonight. Will continue to monitor him closely around other residents . Surveyor did not find documentation that staff updated any new interventions or increased supervision for R35 when he was exhibiting increased unsafe behaviors towards staff and residents on 1/10/25. Nurse progress note indicated, .On 01/28/2025 at 4:38 PM, Late Entry for: 01/27/2025. DATE OF INCIDENT: 01/27/2025, TIME OF INCIDENT: 17:12, INJURY: no apparent injury There was an altercation during supper time. Resident was grabbing at [R36] walker during supper, [R36] tried to stop him by talking loudly. [R35] grabbed [R36]. [R36] stated if he grabs him again, he was going to, punch him. Staff had intervened. At 4:39PM, Today there was no further altercations between [R35] and [R36], they were kept apart from each other. At 10:13 PM, [R35] was aggressive and combative at the beginning of the shift. Resident was found in another resident's room and will not follow redirection from the CNA. Instead, he swung his hand on the CNA hitting the CNA on the chest . Surveyor did not find any new intervention or increased supervision for R35 or 1:1 after R35 grabbed R36's walker and grabbed R36. Interviews: On 02/19/25 at 10:25 AM, Surveyor interviewed R36 and asked R36 if there have been any resident-to-resident altercations that have occurred on the unit. R36 stated, Yes, with [R35]! Who has not had an altercation with [R35]. One time [R35] came at me in the dining room, but I put him in his place. I yelled to tell him not to ever touch me again or I'd punch him. Surveyor asked R36 to explain the incident in the dining room with R35. R36 indicated that R35 came at R36 and grabbed R36's walker and then swung at R36, hitting R36 and grabbing R36's wrist. On 02/19/25 at 10:30 AM, Surveyor interviewed CNA F and asked how CNA F supervises difficult residents that may wander into others' rooms or become aggressive. CNA F indicated that CNA F tries to monitor residents such as R35 from becoming angry and wandering but sometimes CNA F is in rooms taking care of other residents and can't always monitor. On 02/19/25 at 11:27 AM, Surveyor interviewed Licensed Practical Nurse (LPN) G and asked LPN G what is LPN G's process when there is an altercation between a resident to resident or if there is an incident that happens with a resident that may need extra supervision. LPN G indicated LPN G will intervene if LPN G observes the resident-to-resident altercation. LPN G would try to redirect R35 or any other resident who is aggressive and acting out. Surveyor asked LPN G if LPN G does any kind of extra supervision for R35's outbursts. LPN G indicated that LPN G will try to observe from afar while in the common area. Surveyor asked LPN G how LPN G intervenes if R35 is from afar in the common area and R35 is about to swing at another resident. LPN G indicated that LPN G tries to make sure R35 is within close proximity but that is not always feasible when LPN G has to go into other rooms to pass medications. On 02/20/25 at 8:02 AM, Surveyor interviewed Director of Nursing (DON) B and asked what interventions for increased supervsion are in place for R35 due to his aggressive behaviors towards staff and residents. DON B indicated that sometimes staff will keep a close eye on R35 in the common area and kind of perform a 1:1. Surveyor asked DON B to explain what 1:1 means. DON B indicated that 1:1 means there is an actual staff member designated to 1:1 with R35 and staff do not let R35 out of sight. Surveyor asked DON B if 1:1 was utilized on 06/22/24, 09/16/24, 01/10/25, and 01/28/25. DON B indicated that DON B was unsure, but that DON B doubts it since some of these events occurred. Surveyor indicated to DON B that through review of documentation that Surveyor could not find that R35 was 1:1. DON B indicated that R35 was probably not 1:1 as we do not have enough staff to be 1:1 at this time. DON B acknowledged that increased supervision was not provided for R35 to prevent incidents with other residents. Based on observation, interview and record review, the facility did not ensure resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 15 residents (R13, R35) reviewed. R13 was left unattended while connected to mechanical lift equipment. R35 did not have increased supervision to prevent resident to resident altercations after incidents on 06/22/24, 09/16/24, 01/10/25, and 01/28/25. This is evidenced by: Example 1 The Food and Drug Administration (FDA) Safety Information guidance provided in Kwikpoints Patient Lifts Safety Guide, states in part: Do not leave patient unattended while in lift. Never keep patient suspended in sling for more than a few minutes. R13 was admitted to the facility on [DATE] with pertinent diagnoses of spastic quadriplegic cerebral palsy and muscle weakness of extremities. R13's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated that R13 has moderate cognitive impairment that requires cues and supervision and is dependent with assist for chair to bed transfers. On 02/18/25 at 12:45 PM, Surveyor observed R13 in his room, seated in broda chair, with mechanical lift sling positioned under him and attached to mechanical lift. Surveyor looked inside room and did not see a staff member present. On 02/18/25 at 12:51 PM, Surveyor observed Certified Nursing Assistant (CNA) C walking from around the corner of dining area from another resident hallway and enter R13's room. Surveyor observed CNA C check R13's sling attachment to mechanical lift by tugging slightly on sling strap. CNA C then walked to doorway, looked in both directions in hallway, and then returned to resident still suspended in sling attached to mechanical lift. On 02/18/25 at 12:53 PM, Surveyor observed another CNA enter R13's room to assist CNA C with transfer of R13. On 02/18/25 at 1:00 PM, Surveyor interviewed CNA C regarding observation. Surveyor asked CNA C why R13 was left unattended in his room while attached to the mechanical lift. CNA C stated she was waiting for her partner to assist with R13's transfer because he is a two person assist. Surveyor asked CNA C if this was a common practice for residents to be left unattended while connected to lift equipment. CNA C stated no. On 02/19/25 at 12:41 PM, Surveyor interviewed Director of Nursing (DON) B regarding observation and mechanical lift safety. Surveyor asked DON B if it would be an acceptable practice for staff to leave residents unattended while connected to lift equipment. DON B stated that other than an emergent situation, staff would be expected to stay with a resident while lift equipment is being used. Surveyor informed DON B of observation of R13 being left unattended for 6 minutes while attached to the lift machine. DON B stated disappointment and concern that this action could have resulted in harm from entrapment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 2 On 02/18/25 at 8:00 AM, Surveyor observed LPN G administer a Humalog insulin pen into R39's abdomen. Surveyor did not observe an open date or expiration date label on the used Humalog pen. Surveyor did not observe LPN G prime the Humalog insulin pen with 2 units before prepping 6 units into the insulin pen. On 02/18/25 at 8:05 AM, Surveyor interviewed LPN G and asked what LPN G's process is for priming and administering insulin. LPN G indicated that LPN G forgot to prime and should have primed the Humalog insulin pen with 2 units and discard the 2 units first before prepping the 6 units for R39's Humalog insulin. Based on observation, interview and record review, the facility did not ensure a medication error rate of 5% or less. During the medication administration task, Surveyors observed 4 errors out of 35 medication opportunities, resulting in an error rate of 11.4%. This affected 2 out of 4 residents (R) observed for medication administration sample. (R11 and R39) R11 received two insulin injections by using injectable pens that were not primed before administration. R39's insulin was not primed prior to administration of insulin. Findings include: Manufacturer's instructions for Basaglar Kwikpen (insulin glargine) states in part, .Priming your pen: Priming means removing the air from the Needle and Cartridge that may collect during normal use. It is important to prime your Pen before each injection so that it will work correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime your Pen, turn the Dose Knob to select 2 units. Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. If you do not see insulin, repeat the priming steps, but not more than 4 times. If you still do not see insulin, change the Needle and repeat the priming steps . The facility procedure document entitled Insulin Injection, procedure reviewed date 2/25, states, in part, 9. If using an insulin pen, cleanse hub, apply needle, then prime pen with 2 units (dial 2 units\, hold pen upright, flick to bring air bubbles to top, push button all the way until dose returns to zero- you should see drop of insulin at needle tip\, if not change needle and repeat) Turn dial until desired dose. Example 1 R11 was admitted to the facility on [DATE] with a diagnosis including type 2 diabetes mellitus. R11 orders include, Insulin Aspart 100 unit/ML solution, Dose 12 units subcutaneously twice per day AM and noon and (Basaglar Kwik-pen) Insulin Glargine 100units/ml, Dose 18 units subcutaneously daily in the AM. R11 received two insulin injections via injectable pens that were not primed by Licensed Practical Nurse (LPN) J before administration of insulin dose. On 2/18/25 at 7:32 AM, Surveyor observed LPN J remove 2 insulin pens from the med drawer. LPN J dialed the Glargin pen (Basaglar 100units/ml) to 18units and the Aspart pen to 12 units without priming the pens first. Surveyor asked if the insulin pens needed to be primed. LPN J stated these insulin pens did not need to be primed. Surveyor observed LPN J administer the insulins subcutaneously into R11'S abdomen. On 2/18/25 at approximately 8:30 AM, Surveyor interviewed Director of Nursing (DON) B on the type of education and training that has been provided to nursing staff. DON B reported there had been a training on how to use an insulin pen in Dec. 2022. DON B reported her expectation would be that nursing staff prime the insulin pen prior to injecting a resident with insulin. DON B reported awareness of LPN J not understanding the need to prime insulin pens prior to injecting insulin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 2 On 02/18/25 at 8:00 AM, Surveyor observed Licensed Practical Nurse (LPN) G administer a Humalog insulin pen into R39's abdomen. Surveyor did not observe an open date or expiration date label on the used Humalog pen. On 02/18/25 at 8:05 AM, Surveyor interviewed LPN G and asked what LPN G's process is for administering insulin without an open date. LPN G stated, That is a good question. I guess I would figure out when the pen was opened before giving to [R39]. Surveyor asked LPN G was it the correct process to still give the Humalog insulin without an open date to R39. LPN G indicated that LPN G probably should have discarded the Humalog insulin and got another one, but LPN G did not. Based on observation, interview and record review, the facility did not ensure drugs and biologics were stored in accordance with current accepted professional practice. This had the potential to affect 2 out of 2 residents (R) for proper labeling. (R29 and R39) This is evidenced by: According to the Food and Drug Administration (FDA), insulin pens should be discarded 28 days after opening the pen to ensure effectiveness of the medication. According to the American Diabetes Association, insulin products contained in vials or cartridges supplied by the manufacturers (opened or unopened) may be left unrefrigerated at a temperature between 59 and 86 degrees F for up to 28 days and continue to work. After 28 days the insulin should be discarded. On 3/29/21, R29 was admitted to the facility with a diagnosis including type 2 diabetes mellitus. R29's orders included Tresiba FlexTouch/ Insulin Deglu[DATE]u/ml Solution Pen-injector Dose 45 unit subcutaneous twice per day. On 2/19/25 at 10:25 AM, during a tour of medication storage, with Registered Nurse (RN) K, Surveyor observed R29's insulin pen, Tresiba FlexTouch 100u/ml exp 8/31/26, pharmacy label reads, 45 units SQ BID, opened, not refrigerated, and not labeled with an opened date, in the drawer of the medication cart. Surveyor interviewed RN K, who reports she forgot to date it when it was originally opened. RN verbalized understanding that insulin pens should be labeled with an opened-on date when they are taken out of the refrigerator and used within 28 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure residents received appropriate treatment and services to maintain range of motion (ROM). This had the potential to affect four residents (R) reviewed for mobility (R25, R26, R30, and R31). -R25 was not provided restorative services at least three times per week as identified in her care plan. -R26's care plan did not identify the frequency and duration of restorative services needed. -R30 was not provided restorative services daily as identified in her care plan. -R31 was not provided restorative services five times per week as identified in her care plan. This is evidenced by: Per Appendix PP of the State Operations Manual (SOM), regulation F688 reads in part . The facility must develop resident care policies in collaboration with the medical director, director of nurses, and as appropriate, physical/occupational therapy consultant. This includes policies on restorative/rehabilitative treatments/services, based on professional standards of practice. The care plan must identify the type of treatments, frequency, and duration, as well as the measurable objectives and resident goals. Example 1 R25 admitted to facility on 05/13/24, with a diagnosis including arthritis. Minimum Data Set (MDS) assessment confirmed R25 scored 15/15 during Brief Interview for Mental Status (BIMS), indicating intact cognition. R25's MDS assessment completed on 01/24/25 indicated the following changes in functional abilities related to transfers, since admission: -Sit to stand, partial assistance increased to substantial assistance. -Chair to bed, partial assistance increased to substantial assistance. -Toilet transfer, partial assistance increased to substantial assistance. R25's Restorative Aide Program documentation indicated restorative goal to decrease joint pain, risk of falls, and decline in transfers and mobility. GOAL: Participate in restorative services at least three times per week to maintain strength and promote safe transfers and mobility. R25's Restorative Aide Program documentation indicated R25 participated in restorative program as follows: -12/2024, 6 of 31 days. -01/2025, 5 of 31 days. -02/20/25, 5 of 20 days. During the survey period of 02/17/25-02/20/2025, Surveyor did not observe R25 participating in restorative services. On 02/19/25 at 1:46 PM, Surveyor interviewed R25. R25 stated she participates in a restorative program to help strengthen her muscles. R25 reported she is supposed to receive exercises with Restorative Aide (RA) L, three times per week, but sometimes she doesn't come at all. Example 2 R26 was admitted to the facility on [DATE] and diagnoses included muscular dystrophy. MDS assessment confirmed R26 scored 15/15 during BIMS, indicating intact cognition. R26's MDS assessment completed on 01/22/25 indicated R25 is dependent on staff for all transfers. R26's Restorative Aide Program documentation indicated restorative goal to prevent decline, contractures, and falls. GOAL: Participate in exercises and transfers to maintain ability to safely transfer and ambulate with staff assist. (Surveyor noted R26's restorative care plan did not include a frequency or duration). R26's Restorative Aide Program documentation indicated R26 participated in restorative program as follows: -10/2024, 13 of 31 days. -11/2024, 8 of 30 days. -12/2024, 4 of 31 days. -01/2025, 7 of 31 days. -02/2025, 3 of 20 days. During the survey period of 02/17/25-02/20/2025, Surveyor did not observe R26 participating in restorative services. On 02/17/25 at 10:40 AM, Surveyor interviewed R26. R26 stated he had not received his exercise program last week. R26 reported he usually receives exercise program once weekly, but stated twice weekly would be better for him to maintain his abilities. R26 stated he reported this to a nurse sometime this winter but had not received any updates related to frequency of his weekly exercises. Example 3 R30 was admitted to the facility on [DATE]. Diagnoses included osteoarthritis, pain, and history of blood clot in limb. MDS assessment confirmed R30 scored 15/15 during BIMS, indicating intact cognition. R30's MDS assessment, completed on 11/06/2024, indicated R30 requires substantial assistance from staff with all transfers. R30's Restorative Aide Program documentation indicated restorative goal to reduce decline in functional transfers and contracture risk. GOAL: Participate in daily exercises to maintain safe transfer ability. R30's Restorative Aide Program documentation indicated the following: -10/2024, 5 of 31 days. -11/2024, 7 of 30 days. -12/2024, 9 of 31 days. -01/2025, 7 of 31 days. -02/2025, 3 of 20 days. During the survey period of 02/17/2025-02/20/2025, Surveyor did not observe R30 participating in restorative services. On 02/19/25 at 2:04 PM, Surveyor interviewed R30 regarding his restorative services. R30 responded, No, not too much. Not even once a week. I want to be able to transfer and stand. Example 4 R31 was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease and pain caused by compression fractures in back. MDS assessment confirmed R31 scored 13/15 during BIMS, indicating intact cognition. MDS assessment completed on 12/18/24 indicated R31 is dependent on staff for all transfers. Review of previous MDS assessment, completed on 09/18/24, confirmed R31 declined in toileting transfers from substantial assistance to dependent on staff. R31's Restorative Aide Program documentation included goal to reduce decline in range of motion, strength, and mobility. GOAL: Participate in restorative services five times per week to maintain strength and mobility as evidenced by ability to ambulate 50 feet with walker and staff assistance. R31's Restorative Aide documentation included the following: -11/2024, 12 of 30 days. -12/2024, 10 of 31 days. -01/2025, 5 of 31 days. -02/2025, 4 of 20 days. During the survey period of 02/17/2025-02/20/2025, Surveyor did not observe R31 participating in restorative services. On 02/18/25 at 1:00 PM, Surveyor interviewed Physical Therapy Assistant (PTA) O. PTA O reported Certified Nursing Assistant (CNA) tasks and restorative program exercises are separate. CNAs do not complete restorative program exercises; the facility has RA L complete restorative program exercises. The facility has a Restorative Aide Program binder, kept in the therapy department, to document how often services were provided to each resident. PTA O stated RA L's schedule recently changed to part-time schedule. PTA O reported if RA L cannot complete the restorative programs for all the residents, therapy staff try to complete what RA L could not. PTA O confirmed DON B is the 'head' of the restorative program. On 02/18/25 at 1:10 PM, Surveyor interviewed Director of Nursing (DON) B. DON B confirmed she oversees the facility's restorative program. DON B confirmed RA L's schedule was changed to part-time and not available full-time, and the facility was working on a plan to have more than one restorative aide to ensure a full-time schedule for restorative services. DON B confirmed if RA L is not able to complete the services, therapy staff assist with ensuring restorative services are completed. DON B stated the facility would like to offer residents restorative services daily, so the frequency is set as daily in the hopes the resident will participate in services 3-5 days per week. DON B stated the purpose of the restorative program is to maintain or prevent loss of a resident's current functioning. DON B stated each resident's restorative program is reviewed monthly when she changes out the documentation in the Restorative Aide Program binder, and the nurses document in the resident's record. Surveyor requested the facility's policy related to restorative services. Director of Nursing (DON) B reported the facility did not have a Restorative Services Policy. Surveyor reviewed records for R25, R26, R30, and R31. Surveyor was unable to find nursing documentation related to restorative services. On 02/20/25 at 7:04 AM, Surveyor interviewed RA L. RA L confirmed she works every Thursday and Friday and every other weekend. RA L reported there are approximately 13 residents participating in the restorative program, and she tries to get to all residents but sometimes it is difficult due to resident schedules, activities, mealtimes, or resident declination to participate. RA L stated it can be difficult to complete the restorative program as she gets pulled to work on the floor as a CNA a lot. RA L reported on average she works as a CNA about one day per week. RA L confirmed if she is unable to complete restorative exercises with a resident, therapy staff attempt to complete those services with the resident. RA L stated she reports to therapy staff which residents did not receive the services, by writing it on a whiteboard in the therapy department and documenting in the Restorative Aide Program binder. On 02/20/25 at 8:58 AM, Surveyor interviewed Certified Occupational Therapy Assistant (COTA) Q. COTA Q stated therapy staff are responsible for evaluating a resident's level of skill and the nursing department is responsible for putting the evaluations into place and into the plan of care. COTA Q explained CNAs are responsible for completing the functional restorative program tasks, to help residents benefit from participating in independence in daily tasks. The RA is responsible for the Functional Aide Program, which is the restorative exercises recommended by therapy staff. COTA Q stated, If a frequency is not identified, ideally residents would receive restorative services daily, so let's see if we can get to them at least 3 days per week.

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections that has the ability to affect all 50 residents (R). -Facility staff failed to transport linens in a manner to prevent the spread of infection. -Facility staff did not properly doff personal protective equipment (PPE) for a resident on enhanced barrier precautions (EBP). -Facility staff demonstrated poor hand hygiene during medication administration. -Facility staff did not prep skin prior to administering a subcutaneous injection of insulin. This is evidenced by: Example 1 Federal Regulation §483.80(e) Linens state, Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. On 02/17/25 at 10:02 AM, Surveyor observed Nursing Support Aide (NSA) N passing clean linens in the hallway without the clean linen cart being covered. Surveyor asked NSA N if it is normal practice to pass out personal clean linen without them being covered. NSA N stated, Yes. I have not seen the carts covered in a long time. On 02/18/25 at 11:00 AM, Surveyor observed NSA N again passing out clean personal linens on a cart in the hallway without a cover. On 02/18/25 at 1:19 PM, Surveyor interviewed Nursing Home Administrator (NHA) A who stated the towels and bedding linens are sent out and covered all the time. Personal linens are done on each wing on PM and night shifts. They are then put on the carts and in the morning, the aides deliver them to the residents' rooms. NHA agreed that all clean linens should be covered, and NHA A will ensure personal linens are covered as well. NHA added that it probably slipped by us when we changed from sending out all linens to be cleaned, to the facility doing the personal clothing in house. On 02/18/25 at 1:59 PM, Surveyor interviewed Infection Control (IC) P nurse. IC P brought Surveyor to the laundry area and stated the clean linen carts are supposed to be covered. IC P retrieved a cover and placed it on the cart. Example 2 Facility policy titled, Enhanced Barrier Precautions (EBP), with a reviewed date of 10/23/24, stated in part: Policy statement: Rolling Hills Rehabilitation Center will utilize EBP to expand the use of PPE to resident care activities that have high potential for contaminating staff's hand and clothes with blood or bodily fluids . 3. Gown and gloves must be put on before entering room and taken off at room exit . 4. Position a trash can inside the resident room and near the exit for discarding PPE after removal (garbage and PPE removal bins in cupboard outside room), prior to exit of the room . The Centers for Disease Control and Prevention (CDC) guidelines for removal of PPE with EBP precautions states in part: Facilities should remember to have an appropriate disposal container available in the resident room to allow for removal of PPE inside the room. On 02/18/25 at 7:00 AM, Surveyor observed an Enhanced Barrier Precaution (EBP) sign on R2's door. The EBP sign indicated the use of personal protective equipment (PPE) of a gown and gloves be used when providing direct care for the resident. The PPE was stored just outside of R2's room behind closed doors. Underneath the PPE storage area was a separate compartment with a sign that stated 'Garbage.' On 02/18/25 at 9:02 AM, Surveyor observed Certified Nursing Assistant (CNA) C don a gown, gloves, and goggles and enter R2's room to assist R2 with toileting. On 02/18/25 at 9:10 AM, Surveyor observed CNA C exit R2's room wearing the gown, gloves and goggles. Surveyor observed CNA C open the garbage compartment outside of R2's room, remove and dispose of all the PPE she was wearing in garbage, and close garbage compartment door. Surveyor then observed CNA C complete hand hygiene. On 02/18/25 at 9:12 AM, Surveyor interviewed CNA C. Surveyor asked CNA C if it is common practice to remove PPE outside of resident room. CNA C stated yes because that is where the garbage is located. On 02/19/25 at 12:41 PM, Surveyor interviewed Director of Nursing (DON) B regarding EBP. Surveyor asked DON B what the expectation is for staff to don/doff PPE with EBP. DON B stated that staff are expected to don PPE before entering a resident's room and remove PPE just outside of resident's room. Surveyor asked DON B if this expectation met the facility's and current CDC guidelines. DON B stated that she felt this was acceptable as it is just outside of the room. Surveyor asked DON B if just outside the resident room was the same as the facility's policy of before exiting the resident's room. DON B then reluctantly stated that it did not. Surveyor asked DON B if this practice had the potential to transmit infection by staff touching equipment outside of room while wearing the contaminated PPE after providing direct care. DON B stated yes, she could see how that could be a potential concern. Example 3 The facility policy document titled: Hand Hygiene and Gloving, reviewed on 10/23/24, states in part, .All staff are required to wash their hands promptly and thoroughly between resident contacts and after contact with blood, body fluid, mucous membranes, secretions, excretions and equipment or articles contaminated by them. Gloves are also used for the above resident contacts and handwashing must follow both application and removal of gloves. The facility procedure document titled Insulin Injection, procedure reviewed date 2/25, states, in part, C. Injection of Insulin . 1. Take insulin alcohol pad to resident. Wash hands, put on gloves. 2. Cleanse injection site with alcohol pad. Allow to dry before injecting. On 2/18/25 at 7:28 AM, during medication administration pass, Surveyor observed Licensed Practical Nurse (LPN) J apply gloves without using hand hygiene prior to gloving. LPN J obtained a finger stick blood sample for R27. After performing the test, LPN J removed her gloves, did not sanitize or wash her hands and proceeded to move medication cart to the next resident's door. On 2/18/25 at 7:32 AM, Surveyor observed LPN J put on gloves, without hand hygiene prior, and obtain a finger stick blood sample for R11. LPN J then removed her gloves, did not sanitize or wash her hands, removed 2 insulin pens from the medication drawer and administer the insulins subcutaneously into R11's abdomen. LPN J did not use an alcohol pad to cleanse injection site prior to injecting. On 2/18/25 at 7:34 AM, Surveyor interviewed LPN J about hand hygiene practices, and she reported hand hygiene should be performed before and after gloving. LPN J stated, I did not do it, you make me nervous. Surveyor also asked if she used an alcohol wipe on the injection site prior to injecting insulin. LPN stated she did not wipe R11's injection site with alcohol prior to administering insulin. I usually do, I just forgot. On 2/18/25 at approximately 8:30 AM, Surveyor interviewed DON B. DON B reported her expectation would be that staff follow infection control procedures. DON B reported she is aware that LPN J did not follow appropriate infection control practices.

Based on record review and interview, the facility did not conduct a thorough investigation of a resident-to-resident altercation by interviewing all residents who were in area at time of incident, did not provide follow up supervision for 48 hours per facility report to protect other residents, and did not provide staff education following an incident for 1 of 4 residents (R1). This is evidenced by: The facility policy, entitled Misconduct Investigation & Reporting last reviewed on 08/23/11 and states in part under section 14 of policy: All resident witnesses/victims should be interviewed as part of the investigation. Nursing or Social Services will assess the resident(s) and make official entries in client charts indicating any behavioral, emotional or changes from their baseline and recommend follow-up or longer if deemed necessary. R1 was admitted to facility on 03/21/21 and has diagnosis of cerebral vascular accident and aphasia. R1's quarterly Minimum Data Set completed on 06/19/24 indicated that R1 has a Brief Interview for Mental Status (BIMS) score of 6 (moderate cognitive impairment). On 08/20/24 at 8:45 AM, Surveyor reviewed facility investigation that occurred on 05/27/24 of a resident-to-resident altercation. R1 had turned off the TV in the resident living room while other residents were watching it and went back to own room. The TV was turned back on and R1 came back out of own room and got upset at inability to locate the TV remote. R1 threw items off the dining table and grabbed another resident's hand and squeezed it. On 08/20/24 at 8:50 AM, Surveyor requested evidence to support that the facility put interventions into place to prevent further resident abuse from occurring while the investigation was in progress. Surveyor asked for interviews conducted with residents that were witnesses to the event to thoroughly collect evidence to allow the facility to determine what actions are necessary (if any) for the protection of residents and education provided to staff following the incident of the findings. On 08/20/24 at 12:39 AM, Surveyor interviewed Nursing Home Administrator (NHA) A who stated interviews with residents that were witnesses to the event did not occur. The facility did not have evidence of R1's increased supervision for 48 hour per facility report and did not provide education to staff following the incident to prevent further potential abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure adequate supervision to reduce risk of wandering/elopement for 1 of 3 residents (R) reviewed (R1). R1 left the facility without staff's knowledge and was not added to the facility's Wanderer's List for increased supervision after incident per facility policy. This is evidenced by: The facility's policy titled, Wanders-Identification, Observation, and Possible Search For, with most recent revision dated 08/2022 stated in part that required follow up following a wandering/elopement event nursing staff must include resident on Wanderer's List. R1 was admitted to the facility on [DATE] with pertinent diagnoses of hemiplegia (impaired body function) on right side due to cerebral infarction (blood clot in brain) and aphasia (impaired speech). R1's most recent quarterly Minimum Data Set (MDS) dated [DATE] indicated no verbal, physical, or wandering behaviors noted. R1's Brief Interview of Mental Status (BIMS) score was 06 indicating severe cognitive impairment. R1's care plan, dated 07/17/24 (implemented after elopement), states: Problem: Activities of Daily Living/Functional Safety Interventions: Wheelchair to be positioned next to head of bed locked related to self-transfer. If R1 is upset/angry about something, staff to initiate 15-minute checks until anger/upset is resolved. No care plan interventions for wandering/elopement risk for R1 were noted. Surveyor reviewed facility's self-report incident of R1 wandering from facility without supervision that occurred on 07/17/24. Surveyor reviewed R1's medical record for wandering/elopement risk assessment. No risk assessment noted. No prior incidents of elopement or exit seeking noted in the medical record. Following the event the care plan was updated to include implemented safety interventions of 15-minute safety checks and placement of wheelchair next to bed for safety. The Interdisciplinary Team (IDT) met to review incident and determined that R1 was upset about a chair being moved in his room causing R1 to become upset and purposefully leave facility. The IDT determined that R1 was not previously considered at-risk for wandering, had not displayed exit seeking behaviors prior to this incident, and was determined not be at-risk for wandering in the future. The IDT ultimately decided to discontinue the 15-minute safety checks with the exception of re-starting safety checks if R1 becomes agitated/upset again, the facility did not to add R1 to facility's wanderer's list. The facility determined through their investigation the use of other safety supervision interventions (such as a Wanderguard) were unnecessary. On 08/20/24, Surveyor reviewed facility's wanderer's list for residents identified as at-risk for wandering/elopement. R1 was not included on this list. On 08/20/24 at 12:37 PM, Surveyor interviewed Director of Nursing (DON) B and Nursing Home Administrator (NHA) A regarding wandering/elopement risk assessment procedure and R1 not being listed on wanderer's list. Surveyor asked if there was a policy for wandering/elopement risk assessment. DON B stated having no written policy, but current practice is that newly admitted residents are informed of any prior wandering/elopement incidents or at-risk behaviors from transferring facility, if applicable. Additionally, all new admissions are monitored for 72-hours for mood and behavior. This information is assessed by the IDT to determine safety risks (i.e. wandering) and the care plan will be updated with safety interventions. All residents are then routinely monitored by nursing staff documenting any change in mood or behavior which is then assessed during routine IDT meetings or immediately if nurse recognizes a risk to safety. Each resident is assessed individually by the IDT for appropriate safety interventions and not all residents at-risk for wandering will have a Wanderguard applied, as was the case with R1. DON B stated R1 had never showed signs of wandering or exit seeking prior to this event and therefore was never determined to be a risk. DON B and NHA A stated that R1 was assessed by the IDT not to be not appropriate for the wanderer's list or for use of a Wanderguard as this would upset R1 being questioned by staff every time R1 was observed roaming the facility grounds outside of R1's unit and restrict his rights. Surveyor asked DON B and NHA A the purpose of having the wanderer's list. DON B and NHA A both stated that the individuals on the list were at-risk for wandering and provide a picture for quick recognition by staff to intervene if observed attempting to wander or elope. Surveyor asked why R1 was not added to wanderer's list after the wandering event. DON B and NHA A stated that they felt appropriate post-incident safety measures were implemented at the time and it was not necessary, but now recognize R1 should have been added to the list.

Based on observation and interview, the facility did not ensure each resident is treated with dignity in a manner and in an environment that promotes enhancement of his or her quality of life. This occurred for two of three residents (R) being assisted with eating during lunch on the Pine View unit. (R14 and R20) Findings include: On 01/08/24 at 12:35 PM, Surveyor observed Certified Nursing Assistant (CNA) F stand beside R14 while assisting R14 to eat. Surveyor observed CNA F leave R14's side to assist another resident and then came back and stood over R14 and continued to assist R14 with eating. On 01/08/24 at 12:36 PM, Surveyor observed a staff member place a plate of pureed food on the table in front of R20 and walk away. R20 had severely contracted hands and was not able to feed self, but no staff member assisted R20 to eat. CNA F was standing beside R20 feeding another resident at the same table. R20 had eyes open and was looking around the table at other residents who were eating. At 12:52 PM, which was 16 minutes after the food was placed in front of R20, Surveyor observed CNA G stand beside R20, remove R20's face mask and use a clothing protector to wipe R20's face and mouth. CNA G did not speak to R20 and walked away to throw the face mask away. Surveyor observed CNA G walk into another resident's room to answer a call light. At 12:55 PM, CNA G came back to R20 and placed a clothing protector on R20. CNA G stood beside R20 and began spooning food into R20's mouth. CNA G did not speak to R20 while spooning the food and liquids into R20's mouth. At 1:03 PM, CNA G used the clothing protector to wipe R20's mouth and walked away to assist another resident in the dining room. CNA G did not speak to R20 before walking away. At 1:09 PM, CNA G came back to R20's side. CNA G stood beside R20 again and began spooning food and liquids into R20's mouth without speaking to R20. Several times while feeding R20, CNA G took the clothing protector and wiped R20's mouth. At 1:20 PM, CNA G took the clothing protector off R20 and wiped R20's face with the clothing protector. CNA G walked away from R20 without talking to him, threw the clothing protector in a bin and walked out of the dining area after washing hands. On 01/10/24 at 6:13 AM, Surveyor interviewed Director of Nursing (DON) B about the above observations of CNA F and CNA G standing beside residents while assisting them to eat. Surveyor also discussed the observation of CNA G not talking to R20 while assisting, using the clothing protector to wipe R20's face and walking away from R20 without talking to R20. DON stated the staff should have been seated beside the residents while assisting them with eating. DON B stated CNA G should not have used the clothing protector as a napkin and should have been communicating with R20 while assisting with the meal.

Based on observation and interview, the facility did not ensure the privacy and confidentiality of resident medical records. This occurred for 2 of 10 residents (R) during medication administration. (R31 and R13) Findings include: On 01/09/24 at 11:34 AM, Surveyor observed Licensed Practical Nurse (LPN) H carry a medication into R31's room. The MAR was open and visible on top of the medication cart in the hallway. R31's confidential information was visible to anyone passing the cart in the hallway. The cart was left unattended in the hallway while LPN H was in R31's room. On 01/09/24 at 11:39 AM, Surveyor observed LPN H carry medications into R13's room and close the door. The MAR was open and visible on top of the medication cart in the hallway. R13's confidential information was visible to anyone passing the cart in the hallway. The cart was left unattended in the hallway while LPN H was in R13's room. On 01/10/24 at 6:08 AM, Surveyor interviewed Director of Nursing (DON) B about the above observations and asked what the facility policy was for this. DON stated she was not sure if they had a written policy that addressed privacy of medical records during medication administration, but stated the nursing staff should make sure the MAR was not visible on the medication carts when the cart was left unattended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.Staff observed not performing hand hygiene with glove changes during cares. This affected 2 of 5 residents (R) observed for cares. (R13 and R8) Staff observed touching medications with bare hands during medication administration. This affected 2 of 10 residents observed for medication administration. (R150 and R38) Findings include: Facility policy entitled, Hand Hygiene and Gloving, last reviewed 01/2024, states in part: .Use an alcohol-based hand rub in all other recommended situation, as follows, unless hands are visibly soiled: Before and after direct patient contact. Before donning gloves. After contact with patients' intact skin . After removing gloves . Example 1 R13 was admitted to the facility on [DATE] and had the following diagnoses, in part: chronic kidney disease, stage 4; urinary tract infection; and urinary retention. R13's medical record identified R13 had a history of recurrent bladder infections due to obstructive uropathy. The record identified R13 had a suprapubic urinary catheter in place since April 2019. The record showed R13 was most recently treated with antibiotics for a urinary tract infection on 10/30/23. On 01/09/24 at 7:23 AM, Surveyor observed Certified Nursing Assistant (CNA) M provide catheter cares for R13. R13 was seated on the toilet and had already done own personal cares on the top half. CNA M used alcohol-based hand rub and applied gloves. CNA M filled a basin with water at sink and placed clean washcloths in the basin. CNA M wiped the connection between catheter tubing bag tubing with an alcohol wipe and disconnected the tubing. CNA M wiped end of leg bag tubing with an alcohol wipe and attached the leg bag tubing to the catheter. CNA M secured the leg bag to R13's leg. CNA M took gloves off, threw them away, and did not wash hands or use alcohol-based hand rub. CNA M assisted R13 to put brief and pants on legs, and put shoes on. CNA M put clean gloves on, but did not wash hands or use alcohol-based hand rub prior to putting on the gloves. CNA M took a washcloth out of the basin, applied liquid soap, and washed insertion site for suprapubic catheter. CNA M took a clean washcloth from the basin and rinsed the insertion site. CNA M dried the area with a clean towel. CNA M removed gloves after catheter cares. CNA M did not wash hands or use alcohol-based hand rub after removing the gloves. CNA M applied clean gloves and finished assisting R13 with perineal cares. CNA M removed the gloves after finishing the cares and washed hands with soap and water. Example 2 On 01/10/24 at 10:36 AM, Surveyor observed Certified Nursing Assistant (CNA) E clean R8 after a bowel movement (BM). CNA E used hand sanitizer and donned gloves before starting. CNA E removed the bedpan and used clean wipes to remove most of the BM. CNA E brought the bed pan to the bathroom, removed gloves, but did not use hand hygiene before placing clean gloves on. CNA E then used clean towels with warm soap and water to clean the peri area of R8, placed a clean brief and then CNA E removed her gloves, but did not use hand hygiene. CNA E grabbed the sling for the lift to place under the resident, rolled R8 onto the sling, helped get R8 set up into the lift, and then into R8's chair. CNA E used hand sanitizer when completed with cares Hand hygiene needs to be completed once gloves are removed. On 01/10/24 at 3:10 PM, Surveyor interviewed Director of Nursing (DON) B about above observation and asked what the facility policy was for hand hygiene with glove changes during resident cares. DON B stated staff should wash hands or use sanitizer every time they change their gloves. DON B provided the facility policy and procedure for hand hygiene and gloving. Example 3 On 01/09/24 at 7:07 AM, Surveyor observed Licensed Practical Nurse (LPN) H empty a packet of medications into a medication cup on top of the medication cart. One of the pills dropped onto the top of the cart. LPN H picked up the pill with bare hands and placed it in the cup and then carried the medications in to R150's room. LPN H administered the medications to R150. On 01/09/24 at 4:15 PM, Surveyor observed Registered Nurse (RN) L bring a medication cup in to R38's room. As RN L was handing the medication cup to R38, the pill fell out of the cup and onto the bedding. RN L picked up the pill with bare hands and placed it back into the medication cup before giving it to R38. On 01/10/24 at 6:08 AM, Surveyor interviewed DON B about the above observations of nurses touching medications with bare hands during medication administration and asked what the facility policy was for bare hand touching of medications. DON B was not sure if they had a policy about bare hand touching of medications, but stated the nurses observed should have put on a glove or maybe used a tissue to pick up the medication rather than touch it with a bare hand.

Example 2 On 01/09/24 at 12:01 PM, Surveyor observed Dietary Aide (DA) C and D serving lunch on the Birchwood unit. Both DA C and D wore the same gloves during the serving process. This affected 11 of 17 residents (R) on the Birchwood unit. R39, R40, R10, R26, R44, R41, R18, R25, R8, R38 and R17 were observed to eat in the dining room of Birchwood and their meals were impacted by the observations below. DA C picked up a sandwich with her hand and placed it on a plate. With the same hand, DA C grabbed a spatula, touched a meal slip, and touched the counter top. DA C then picked up another sandwich with her hand that had the same contaminated glove on. DA C's gloved hands touched a meal slip, grabbed another sandwich and placed it on a plate, touched a scoop, touched a meal slip and touched the counter top. DA C grabbed a sandwich with her hand to cut it in half with a knife, touched a meal slip, and grabbed another sandwich all with the same contaminated gloves. DA D touched spatulas, scoops, and the counter top all with her gloved hands, then picked up a sandwich with DA D's hand wearing the same gloves. DA C grabbed a sandwich with her hand and passed to DA D who held the sandwich in her gloved hand to cut in half with a knife. Both DA C and DA D were touching handles, the counter top, meal slips and then the sandwich with contaminated gloves. DA C and DA D did not change gloves during the entire meal serving process. Based on observation, interview and record review, the facility did not ensure food was prepared and served in accordance with professional standards for food service safety. Staff touched ready to eat foods with potentially contaminated gloves and did not wash hands between glove changes during two meal service observations on Pine View unit. This affected 10 of 16 residents (R) on the Pine View unit. (R15, R9, R4, R149, R30, R2, R36, R31, R12, and R13). This affected 11 of 17 residents on the Birchwood unit. (R39, R40, R10, R26, R44, R41, R18, R25, R8, R38, R17). This affected 8 residents on [NAME] Lane (R34, R24, R7, R19, R46, R6, R21, and R3). Findings include: Facility policy entitled, Use of Disposable Gloves/Bare Hand Contact with Foods, last reviewed 12/15/22, stated in part: .Rules of Glove Use: Employees are trained to know that gloved hands can become contaminated just like ungloved hands. Hands are washed thoroughly .and dried prior to donning gloves to ensure that gloves are not contaminated by unclean hands .Employees are responsible to wash their hands after removal of gloves to destroy any bacteria that has had time to grow on hands in the warm, moist environment provided by the gloves. Dietary employees will wear gloves in the following specific instances and use is not limited to these instances: -To cover non-infected, bandaged cuts, sores or lacerations on hands, wrists and forearms. -When handling raw food product. -When handling any cooked food product which will not be heated further. -When handling ready-to-eat items (such as cookies, toast, bread, sandwiches, etc. ) .Changing Gloves: Food handler employees are responsible to change gloves whenever an activity or a workstation changes or when the gloves become contaminated or soiled . On 01/09/24 at 8:10 AM, Surveyor observed breakfast service on Pine View unit by Dietary Aide (DA) I. Surveyor observed DA I wash hands and put on gloves. With those gloves on, DA I touched multiple surfaces, including cupboard door and drawer handles, refrigerator door handle, steam table covers, and counter tops. Surveyor observed DA I pick up toast and muffins to place them on resident plates using the same gloved hands that touched multiple potentially contaminated surfaces. Surveyor observed DA I touch toast or muffins with the contaminated gloves to place on R15, R9, R4, R149, R30, and R2's plates. At 8:25 AM, Surveyor observed DA I crack eggs into a frying pan on the stove. DA I removed the gloves, threw away and put on a pair of clean gloves. DA I did not wash hands with soap and water before putting on the clean gloves. DA I touched multiple surfaces with those gloves again during food preparation and service. Then Surveyor observed DA I pick up toast with the same gloves and placed it on R36's plate. On 01/09/24 at 12:06 PM, Surveyor observed DA J wash hands and apply gloves. With those gloves on, DA J took covers off the steam table, took plastic and covers off containers, opened a cupboard door and took out a bowl, and opened drawers and took out utensils. Then with those same gloves that had touched multiple potentially contaminated surfaces, DA J picked up a plate and placed a prepared sandwich on the plate. That plate was placed on R31's room tray. DA J then picked up a sandwich with same gloves and placed it on a plate for R12's room tray. DA J then picked up a sandwich with same gloves and placed it on a plate for R15. DA J then picked up a sandwich with same gloves and placed it on a plate for R13. DA J then picked up a sandwich with same gloves and placed it on a plate for R30. On 01/09/24 at 1:40 PM, Surveyor interviewed DM K and informed about observations of dietary staff touching ready to eat foods with potentially contaminated gloves in all three unit kitchenettes. Surveyor also informed DM K of observation of no hand washing between glove changes during food service. Surveyor asked if dietary staff was following food service standards. DM K stated all staff should be changing contaminated gloves and washing hands between glove changes before touching ready to eat foods. On 01/09/24 at 11:41 AM, Surveyor observed the noon meal on [NAME] Lane. Surveyor observed DM K, DA N, and DA O working in the kitchen area during the meal service. Residents (R) 34, R24, R7, R19, R46, R6, R21, and R3 were observed to eat in the dining room of [NAME] Lane and their meals were impacted by the observations below. Surveyor observed DA O wash hands and place gloves on. With those gloves on, DA O touched multiple surfaces, including cupboard door and drawer handles, steam table cover handles, counter tops, the handle to the garbage can drawer, touched the inside of the garbage bag in order to get saran wrap off of her gloves. DA O was observed to touch ready to eat sandwiches, plating them and then cutting the sandwiches by placing her gloved hand on top of the sandwich to hold it together, DA O touched scoops and utensils while plating foods, and touched plate surfaces with contaminated gloves while plating altered diets. Surveyor observed DM K wash hands and then place gloves on. With those contaminated gloves on DM K was observed getting items out of the refrigerator, obtain items from a drawer, throw something away, get a knife out of the drawer for use cutting sandwiches, obtain more items from the refrigerator, and would assist by putting items on plates, and meal trays. Surveyor observed DA N wash hands and then place gloves on. DA N was observed to touch multiple surfaces, including cabinet handles and surfaces, touching the refrigerator door handles, opened drawers and touched multiple utensils looking for spatulas. DA N was observed to use a spatula to plate fruited jello, and would use DA N's finger to slide the jello into a saucer. At one point DA N was observed to turn on the water, rinse the finger of the gloved hand off under the running water, retrieve an item and then go back to portioning out jello as DA N had been doing, again using her contaminated gloved finger to slide jello from the spatula.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident is free from physical restraints that are not required to treat the resident's medical symptoms for 1 of 1 resident (R36) reviewed for restraints out of a total sample of 16 residents. R36 is unable to self- propel when in his Broda chair. The facility never completed a restraint assessment or assessed R36 for mobility ability while in the Broda chair. This is evidenced by: The facility policy titled, Use of Physical Restraints, Guidelines revised 6/2020, states in part, Definition: Physical Restraint means any article, device or garment used primarily to modify resident behavior by interfering with the free movement of the resident or normal functioning of a portion of the body .Protocols: .All restraint use requires a physician's order. Any staff involved in application of restraints will be trained .Restraints used will be the least restrictive to manage the resident . Example 1 R36 was admitted to the facility on [DATE] and has diagnoses that include anxiety disorder, visual hallucinations, delusional disorder, and dementia. R36's most recent MDS (Minimum Data Set) dated 10/12/22 states that R36 has a BIMS (Brief Interview of Mental Status) of 11 out of 15 indicating that he has moderate impairment. Nurse's notes state that on 10/16/22 at 4:43 PM R36 had a fall and was found lying on his left side. Documentation indicates that he slid out of his wheelchair and that this was his only fall in the last 30 days. Plan was for a safety belt and to have therapy evaluate R36 for a Broda chair. Follow up assessment by the RN (Registered Nurse) states in part Plan of Action: Recommend Broda chair, as he leans forward in his w/c (wheelchair) . On 11/28/22 at 3:36 PM, Surveyor interviewed R36. R36 reported to Surveyor that he doesn't like the chair that he has because he is unable to move himself or reach anything. Surveyor observed that R36 was sitting in a Broda chair with a Roho cushion underneath him and his feet were unable to touch the ground; R36 was wearing socks only. There is not an option for R36 to self-propel the Broda chair. On 11/30/22 at 3:07 PM, Surveyor met with R36. R36 was sitting in the Broda chair with heel protector boots on, allowing his feet to touch the floor. Surveyor asked R36 if he was able to move himself in the chair, R36 stated that he was unable to move because there were no wheels to help. Surveyor asked R36 if he can use his feet to help move, R36 stated that he could not because the boots were too slippery. On 11/30/22 at 3:07 PM, Surveyor interviewed CNA J (Certified Nursing Assistant). Surveyor asked CNA J if R36 was able to move himself in the Broda chair, CNA J stated that if R36 is positioned correctly, he can move back and forth to his drawers. Surveyor asked CNA J if R36 was able to self-propel in his previous wheelchair, CNA J stated yes. Surveyor asked CNA J if R36 can self-propel in the Broda chair, CNA J stated no. On 11/30/22 at 3:16 PM, Surveyor interviewed RN G (Registered Nurse). Surveyor asked RN G why R36 was changed from being in a wheelchair to a Broda chair, RN G stated that R36 had a fall from the wheelchair, so they put him in the Broda chair. Surveyor asked RN G if facility staff ever assessed R36 for positioning in the Broda chair or if they completed a restraint assessment, RN G stated that she did not have therapy assess R36 for positioning in the Broda chair and stated that R36 can move with the wheels on the chair, so it was not a restraint. On 11/30/22 at 3:20 PM Surveyor and RN G went in to R36's room to observe the chair; observation shows that there are no large wheels on the Broda chair for R36 to use to self-propel. Surveyor and RN G asked R36 if he can move himself in the chair, R36 stated that he cannot move the chair. Surveyor asked RN G if R36 can move and is unable to because of the chair, would that be considered a restraint, RN G stated yes. On 12/1/22 at 8:38 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what her expectations were when a resident is switched from a wheelchair to another type of chair, DON B stated that staff should be evaluating the reason for the change, such as safety, mobility, and positioning. Surveyor asked DON B if R36 should have been assessed for positioning and mobility in the Broda chair, DON B stated yes. Surveyor asked DON B if R36 had previously been able to self-propel in the wheelchair and is unable to self-propel in the Broda chair, would that be considered a restraint, DON B stated yes. Surveyor asked DON B if a restraint assessment should have been completed, DON B stated yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure that its medication error rate was 5% or less for 27 medication pass opportunities and 2 of 6 residents observed (R42 and R2). The facility's medication error rate was 11.11% with 3 errors observed for R42 and R2. This is evidenced by: The facility policy, Medication Administration, dated 7/27/17, states in part, as follows: Policy: All medication will be administered in compliance with regulations in a safe manner and following provider orders. General Information: Routine med pass times will be designated as AM (8 AM), Noon (12) PM, 4 PM and HS (7:30 PM or specific per resident preference) in the EMAR (Electronic Medication Administration Record) medications can be administered up to one before and one hour after except meds that specify before or after meals and these should be based on mealtime. Medications with a specific time of administration should be entered for that time in the EMAR med pass times can be individualized based on resident needs. Primary Care Diabetes Society (PCDS) News, dated 11/1/15, states, in part, as follows: PCDS statement on the drawing-up of insulin using insulin syringes from insulin pen cartridges and prefilled pens. Transferring insulin from a pen cartridge or prefilled pen to an insulin syringe is NOT a practice that is endorsed by any of the insulin manufacturers and is an unlicensed activity. This is reflect in comments supplied by [NAME] Lilly and Company. Novo Nordisk and Sanofi to be included as part of this statement, which are presented immediately below Comment from Novo Nordisk - Novo Nordisk places great emphasis on ensuring dosing accuracy through drug formulation, delivery systems and their correct handling by the user. Dosing accuracy and product quality, including stability and sterility, may be compromised when not used according to label instructions. Patients and caregivers should follow the approved instructions for use that are included with the product. Off-label use is strongly discourage, including the use of a syringe for drawing up insulin from Penfill cartridges or from prefilled pens. Example 1 R42's Physician Orders, signed 11/9/22, include, in part, the following medications: Decrease aspart to 10 units with meals + sliding scale. R42's Physician Orders, signed 10/20/22, include, in part, the following medications: Insulin Aspart (Sliding Scale) Directions: 151-200=2 units, 201-250=4 units, 251-300=6 units, 301-350=8 units, Greater than 350 + 10 units On 11/28/22 at 11:51 AM, Surveyor observed LPN C (Licensed Practical Nurse) draw up 20 units of aspart insulin from an insulin pen (Manufacturer Novo Nordisk) with an insulin needle and administer to R42. This resulted in a dosing error. Example 2 R2's Physician Orders, signed 11/9/22, include, in part, the following medications: Januvia (SitaGliptin Phosphate) 50 mg (milligrams) tablet (1 tablet/50 mg) by mouth twice per day AM Supper for: Type 2 Diabetes Mellitus. Metformin HCL ER (Extended Release) 500 mg tablet Extended Release 24 hour Dose (2 tablet/1,000 mg) by mouth twice per day AM PM for: Type 2 Diabetes Mellitus Note, the dinner/supper meal is served beginning at 5:00 PM. On 11/28/22 at 3:48 PM, Surveyor observed LPN F (Licensed Practical Nurse) administer, in part, the following medications to R2: Januvia 50 mg Metformin HCL ER 1,000 mg - The packaging included the following instruction: By mouth twice daily with meals The facility utilizes Wolters Kluwer Nursing 2021 Drug Handbook, documents Metformin Administration: Give drug with meals. This resulted in two timing errors. On 11/30/22 at 1:39 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, if a resident has an insulin pen would you expect the insulin to be administered via the pen versus an insulin needle. DON B stated, I would expect it would be used the way it is directed. DON B added, Typically we would have a reason for that. I would expect the pen to be used. Surveyor asked DON B, are you aware the manufacturer guidelines state to not draw insulin off the pen with an insulin needle. DON B stated, no I was not aware. Surveyor asked DON B, would you expect staff to follow mfg guidelines. DON B stated, Yes Surveyor asked DON B should R42's insulin have been administered via the pen. DON B stated, yes. Surveyor asked DON B, if an order indicates a medication is to be administered with supper do you expect it to be administered with the supper/dinner meal. DON B stated, If the order says with supper it would be with supper. Surveyor asked DON B, should Metformin be administered with a meal. DON B stated, Yes. DON B stated, I would expect R2's Januvia and Metformin to be administered with meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility did not follow their grievance process for 1 of 14 sampled Residents (R13) and 1 of 2 supplemental Residents (R21) or post the appropriate postings for filing a grievance with the potential to effect more than a limited number of residents in the facility. Facility did not post in an accessible area the grievance process, grievance officials name, contact information or ways to submit a grievance anonymously. The facility grievance log was not completed for R13 and R21 who voiced a concern to the facility in August of 2022 regarding not being able to access the sink in the bathroom. Neither R13 or R21's grievances were included on the grievance log, no documentation of following up with R13 or R21 for a resolution or plan of action. This is evidenced by: On 11/30/22 Surveyor Asked for the grievances for R13 and R21. Surveyor was provided the following: (no date and no time) sink access issues - received concerns from (R13) and (21) that they are having difficulty using the bathroom vanity sink. (NHA) went to look at their set up with (SW D) as (R13) is wanting the front board removed from the sink. Upon inspection that apron would still have to remain and does not help with access. Maintenance did remove the diagonal board under the sink in both resident rooms however this did not improve access. (R13) sits very low due to her small stature and short wheelchair. She can get all the way under the sink but still doesn't have enough reach to access the faucet. A higher wheelchair was explored but this interferes with her mobility. We did obtain some lever extenders and spout which helps for (R13). Therapy has worked with her on how to use other adaptive approaches for her supplies. She does need to use a basin to spit into for oral care. R21 sits up higher and with the wheelchair sides pulled up she can get all the way under the sink. She is not able to lean forward due to her mobility issues, so she is not able to reach forward far enough. She was provided with lever extender and spout extender but does not wish to use this. (NHA) contacted the architect for ideas to improve access and information was provided. (Signed by NHA A) (Please note that this information was not added to the grievance log and there is no indication of a date or time that R13 or R21 were provided information on their grievance/concern or R13 of R21 felt the issue was resolved.) NHA A's (Nursing Home Administrator) email to the engineer, dated 8/28/22 at 9:59 PM, with subject Accessible bathroom sink, states in part: .We have several residents who are not able to reach their bathroom sinks. For some it's because they are very short and cannot reach far enough to reach the faucet or handles even when up as close to the sink as possible. Others the apron on the sink is too deep to get up under the sink because of the wheelchair arms .for some a different faucet with a longer spout and perhaps an automatic eye would work. I need some ideas . Example 1: R21 was admitted on [DATE], R21 uses a wheelchair and requires assist with transfers via a lift. R21's MDS (Minimum Data Set) dated 8/24/22 indicates R21 has a BIMS (Brief Interview of Mental Status) of 15 out of 15, indicating she is cognitively intact. On 11/28/22 at 11:59 AM Surveyor interviewed R21. R21 told Surveyor she's not able to get to the bathroom sink to brush her teeth, wash her face, that she can't turn on/off the water. Surveyor asked if she told anyone, R21 stated I told many people Surveyor asked if anyone has come back to discuss her concerns or checked with her to ensure it's been resolved, R21 indicated no one has told her anything or helped with her sink issue. Surveyor observed bathroom, no adaptive equipment on sink. R21 indicated the sink is too high. Example 2 R13 was admitted on [DATE], she's an assist of 1 with transfers and uses a wheelchair. R13's MDS (minimum data set) dated 10/12/22, indicates R13 has a BIMS (brief interview of mental status) of a 15 out of 15 indicating R13 does not have cognitive impairment. On 11/28/22 at 1:20 PM Surveyor spoke with R13 regarding her care. R13 took Surveyor into her bathroom to show Surveyor her sink. R13's sink has adaptive handles on the faucet handles, R13 stated I can't see the mirror, can't get close enough. R13 expressed she must do a warm compress to her eyes each morning and cannot reach the sink well enough to do that, without getting her top all wet in the morning. Surveyor did ask R13 if she has asked staff to help and R13 replied that she doesn't want to ask them the staff are so busy. R13 again said she gets water all over her top. R13 stated staff put up another mirror for her. R13 indicated the sink is too high. Surveyor asked R13 if she told anyone about the sink, she replied I've told everyone. Surveyor asked if anyone has come back to discuss her concerns or checked with her to ensure it's been resolved, R13 indicated no one has told her anything. (R21's bathroom has the same layout as R13's bathroom, both Residents are on the same unit) On 12/1/22 at 8:32 AM Surveyor interviewed SW D (Social Worker) regarding grievance process. SW D indicated it depends on who is reporting the concern. SW D indicated staff are good about reporting missing items and concerns can be reported by anyone. SW D indicated staff will let us know there is a grievance or concern. SW D brought up R13 not being able to access her sink in her room. SW D indicated they did have therapy come in and assess different adaptive equipment/items for the handles on the sink. SW D indicated NHA A was informed and NHA A contacted the contractors to see if they could do anything about it. SW D indicated she was told that R13 did not like the adaptors and tried a different wheelchair, which was unsuccessful. SW D indicated that R21 talked with the ombudsman and was told she didn't want the adaptive equipment because R13 told R21 it didn't work. Surveyor asked SW D if the conversations and follow up was documented somewhere. SW D indicated to ask SW E. SW D showed Surveyor the grievance log on her computer at this time, which has columns for date grievance reported, date/time of incident if known, type of concern, Resident affected, witness(s), concern summary, notifications, findings, resolution/plan. On 12/1/22 at 8:49 AM. Surveyor interviewed SW E regarding grievances. SW E indicated that residents voice a concern by letting staff know, then the staff either call SW E or SW D or send an email. SW E indicated the social worker will go down to speak with them to find out what their concern is, ask questions related to concerns, to see what is going on. SW E brought up R13 and R21's sink. SW E indicated she went to see what the concern was and where to go from there. SW E indicated that staff would type the concern up in an email and send to SW, DON (Director of Nursing) and NHA. DON and NHA would let SW E know if they would want her to do anything further or if they are going to take it over. SW E indicated they would do staff interviews, go around, and talk to different residents to see if they are having similar concerns, gather the information, then come up with a plan of action, such as if more training is needed. SW E indicated with the sink NHA was looking into different options with architects and different adaptive devices. R13 has sink handles and they would type the concern up in the grievance file/log. SW E indicated that R21 voiced concern with her sink access, the facility offered and bought adaptive equipment. SW E indicated they're Working on the design of the sink to see if they can change that. SW E indicated that the under-sink part/panels are one whole piece, so staff are looking at changing the faucet itself, but would need different plumbing and are checking into the cost of that. SW E indicated she is still talking with R21 to see if she wants to try out the adaptive equipment. Surveyor asked for documentation of the conversations they've had with R21. SW E indicated she was told by other staff that R21 did not want the adaptive equipment, SW E has not personally asked R21 or documented having that conversation with R21. Surveyor asked SW E if anyone has followed up with R13 and R21 to see if issue has been resolved? SW E indicated she is waiting to hear from NHA A, of other options we can present before talking with or following up on it. Surveyor asked about a written copy of the grievance or resolution being provided to R13 and R21. SW E responded Not that I know of no. On 12/1/22 at 9:33 AM SW D provided the Grievance log. Surveyor noted the log did not have R13 or R21's concern related to sink issues documented on it. Surveyor interviewed SW D asking if R21 was on the log, and SW D replied No, neither is (R13). (There is no indication of the exact date R13's or R21's grievance was reported, date/time of incident if known, type of concern, Resident affected, witness(s), concern summary, physician, family, or Resident notifications, what the facilities findings were, or the resolution/plan of action was for R13 or R21. No indication of when/if they followed up with R13 and R21 on their specific concern to ensure a common goal or resolution was obtained timely.) On 12/1/22 at 10:28 AM Surveyor asked NHA A for copies of R13 and R21's grievance documentation. NHA A indicated that they did not take it as a grievance, as they started working on it right away. NHA A indicated they contacted their contractors and have had their maintenance personnel trying to come up with a solution. NHA A indicated that R13 received adaptive handles for the faucet handles and R21 currently does not have adaptive equipment on her sink. Example 2: On 11/30/22 & 12/1/22 Surveyor observed the environment for postings related to grievances and state agency contacts. Surveyor was unable to locate any postings related to grievances, grievance official, anonymous submission or where to submit a grievance. On 12/1/22 at 8:22 AM Surveyor interviewed RN H (Registered Nurse) regarding grievances. RN H indicated that if a resident offers a complaint to a CNA (Certified Nursing Assistant) the CNA would bring the concern to a nurse, or a resident can come to a nurse and the nurse will follow up with them or the RN will. RN H indicated the nurse on the unit is always updated and the social worker (SW) of any concern and it goes through the chain of command. RN H indicated they would always let NHA A (Nursing Home Administrator) and one of the SW know. RN H indicated she was not 100% sure who the grievance official is and knew it was either SW D or SW E. Surveyor asked RN H if there was form residents could fill out when they have a grievance. RN H indicated there is a complaint form, but she doesn't know if they've been using it for a while. RN H indicated she usually sends an email as it may be something that needs to be investigated promptly. Surveyor asked how a resident can voice a grievance/concern anonymously. RN H indicated they can tell the SW or NHA that a resident who doesn't want to be named had a concern and indicate what the concern is or pass it on to the next shift that a concern came up and what it was regarding without saying the residents name. On 12/1/22 at 8:32 AM Surveyor interviewed SW D regarding grievance process. SW D indicated it depends on who is reporting the concern. SW D indicated staff are good about reporting missing items and concerns can be reported by anyone. SW D indicated staff will let us know there is a grievance or concern. SW D showed Surveyor the grievance log on her computer at this time, which has columns for date grievance reported, date/time of incident if known, type of concern, Resident affected, witness(s), concern summary, notifications, findings, resolution/plan. Surveyor asked SW D where the grievance process/filing information is located. SW D informed Surveyor it's in the admission packet and should be at the front when you walk in, with the ombudsman information. Surveyor and SW D went to the front door area and SW D was not able to locate the grievance process information or the posting of who the grievance official is. SW D indicated she is the grievance official. Surveyor asked SW D about anonymous grievance. SW D indicated she's never had someone want to submit a concern anonymously, only has had concerns brought up anonymously from the ombudsman. Surveyor asked SW D if there is a process for anonymous grievances, SW D replied, Not that I'm aware of. SW D indicated they used to have a form at the nurses' station and that she's not sure if the forms are used anymore. Surveyor asked if they provide the grievance log to a Resident when they ask for the resolution and grievance information in writing, SW D replied no. Surveyor asked how residents are provided information in writing per request, SW D was unsure. On 12/1/22 at 8:49 AM. Surveyor interviewed SW E regarding grievances. SW E indicated that residents voice a concern by letting staff know, then the staff either call SW E or SW D or send an email. SW E indicated they then go down to speak with them to find out what their concern is, ask questions related to concerns, to see what is going on. SW E indicated that staff would type the concern up in an email and send to SW, DON (Director of Nursing) and NHA. DON and NHA would let SW E know if they would want her to do anything further or if they are going to take it over. SW E indicated they would do staff interviews, go around, and talk to different residents to see if they are having similar concerns, gather the information, then come up with a plan of action, such as if more training is needed. Surveyor asked about submitting anonymously, SW E indicated residents will talk to our ombudsman. Surveyor asked if the facility has an anonymous process to submit a grievance, SW E indicated online, or they can tell us they want to be anonymous. SW E indicated she knows the facility has something online for them to submit. SW E stated, I would think they would have a form to fill out. Surveyor asked how residents are made aware of the grievance process and their right to file one. SW E indicated it's in the admission packet, that they have the policy in the admission agreement with all the numbers for ombudsman, Division of Quality Assurance, who to go to, process. Surveyor asked if it was posted somewhere? SW E took Surveyor to the front door where the ombudsman and DQA info is posted. SW E indicated it was posted when you walk in. SW E indicated that in the old building it was posted on each unit. SW E was unable to locate the posting for filing a grievance or a box at wheelchair height to submit a grievance or an anonymous grievance in writing. Surveyor asked about a written way to voice grievance, SW E indicated she knows the facility had a form, she doesn't know where that is as it's available online. SW E indicated in the old building had a drop box in the front office people could put them in. On 12/1/22 at 9:05 AM Surveyor interviewed Receptionist I in the front office regarding a grievance box. Surveyor asked Receptionist I if there was a grievance box for the residents. Receptionist I stated, not that I'm aware of, only drop box I'm aware of is for payments for when the office is closed. On 12/1/22 at 9:29 AM SW D came to Surveyor and indicated that the facility has a drop box out front that says for late night drops. Surveyor asked if there are forms available for representatives or residents to put a grievance in the box, SW D stated No. Surveyor asked if the box was at height for a Resident to reach, SW D replied no. Surveyors observed the box in foyer with SW D at the front door, the box is at standing height on the wall, residents in a wheelchair would not be able to reach this. On 12/1/22 Surveyor was provided a piece of paper by SW D who indicated the admission packet included Grievance Procedures, that indicates if the resident is dissatisfied with any aspect of (facility name) operation or the care provided, Resident or anyone on Resident's behalf may file a grievance or complaint orally or in writing. You also have the right to file a complaint anonymously. The resident should inform nursing staff, social services, or administrator of their grievance of the designated grievance official If you wish to file anonymously, please submit the complaint in writing and place in the lobby drop box or mail attention to the administrator or grievance officer. (Facility name) agrees to review and investigate the grievance in a timely fashion. The resident or their representative may obtain a written decision regarding their grievance if requested. This information was not posted anywhere for residents to be able to access, based on observation by Surveyors and observation with facility Social Workers. There was no box available at resident wheelchair height for residents who are wheelchair bound to place an anonymous concern into. On 12/1/22 at 10:28 AM Surveyor interviewed NHA A. NHA A indicated that the after-hour box is not low enough for residents to access it, the grievance process is not posted currently, but should be. On 12/1/22 at 11:30 AM, Surveyor observed a mailbox near the front office had been hung in the hallway, at resident height, which the NHA A indicated would be accessible for residents if they wanted to put a grievance in the box. (This box was not previously hung prior to 12/1/22)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 2 The facility did not have a policy and procedure in place regarding motorized assistive devices. R18 was admitted to the facility on [DATE]. Resident uses a motorized wheelchair for independent locomotion. On 11/29/22 from 11:00 AM to 2:00 PM Surveyor observed R18's motorized wheelchair charging in the hallway. Resident room doors near the charging wheelchair were opened and the residents were in their rooms. On 11/29/22 at 3:11 PM R18 indicated his wheelchair was being charged in the hallway, because staff failed to charge it overnight in the designated area. On 11/30/22 at 11:15 AM NHA A (Nursing Home Administrator) indicated staff are not to charge wheelchairs in the hallway. They are to charge them in a hazard room. The facility did not ensure that the resident environment remains as free of accident hazards as possible R18's wheelchair was observed to be charging in the hallway and mechanical lift batteries were noted to be charging in 3 of 3 hallways. Surveyor observed R18's motorized wheelchair (Motorized Assistive Devices) being charged in the hallway and not behind a fire safe door. Surveyor observed 18 stand lift batteries charging in hallway alcoves. Evidenced by The facility does not have a policy and procedure for charging lifts. On 11/30/22 at 11:13 AM, Surveyor observed 18 stand lift batteries (EZ Way Smart Stand and EZ Way Smart Lift) charging throughout the facility on unit alcoves in resident areas: Willow (Alcove 1): 3 Willow (Alcove 2): 3 Pineview (Alcove 1): 4 Pineview (Alcove 2): 2 Birchwood (Alcove 1): 4 Birchwood (Alcove 2): 2 On 11/30/22 at 11:15 AM, Surveyor, NHA A (Nursing Home Administrator), and State Agency Engineer observed lifts charging in the [NAME] hallway. NHA A indicated batteries should not be charged in resident areas and stated she will notify Maintenance immediately to move the batteries to a tub room or Utility room to charge.