Based on observation, staff interview, and policy review the facility failed to ensure clean dressing changes were kept clean for 1 of 1 wound care observation (resident #8). The findings were: 1. Observation on 7/9/24 at 10:12 AM of resident #8 wound care with LPN #1 and LPN #2 showed they performed hand hygiene, and donned gloves and gowns. LPN #2 then closed the curtains, turned on the lights, pulled the supplies out of the storage bag, and opened the dressing packages, and dated the dressing. She then moved the extra gloves twice. The nurses turned the resident to his/her side. LPN #2 removed the old dressing, and cleaned the wound. She then doffed her gloves and donned the gloves she had moved earlier, without performing hand hygiene. 2. Interview with the LPN #2 on 7/9/24 at 10:28 AM revealed the procedure performed was her normal routine when doing a dressing change. She stated she should have used hand sanitizer between dirty and clean. 3. Interview with DON on 7/9/24 at 2:22 PM revealed it is the facility's expectation for staff to do hand hygiene, put on gloves, and complete hand hygiene when they remove their gloves. 4. Review of policy Hand Hygiene revised 1/2024 showed .1. Indications for hand washing and hand antisepsis.I. Decontaminate hands after removing gloves . 6. Other aspects of hand hygiene . D . Gloves do not replace hand hygiene, decontaminate hands after removal of gloves. E. Change gloves during patient care if moving from a contaminated-body site to a clean-body site.

Based on observation, QAPI minutes review, and staff interview, the facility failed to ensure a qualified administrator was able to manage the facility and report to the governing body. The census was 38. The findings were: 1. Observation on 7/10/24 at 9:45 AM of the current open positions showed the nursing home administrator position was included. Further, observations throughout the survey showed no administrator was in the facility. 2. Review of the 5/9/24 and 6/13/24 QAPI committee attendance sign in sheet showed the administrator was not present. 3. Interview with the CEO on 7/8/24 at 1:20 PM revealed the administrator was put on leave. Further, she stated the facility did not have a delegated administrator, and it was a problem and it was something the facility was working on. 4. Interview with the DON on 7/10/24 at 10:09 AM revealed the administrator had been on leave for the last 3 months. 5. Interview with the administrator on leave on 7/10/24 at 3:12 PM revealed the former CEO put her on leave on 4/23/24 and she was told not to enter the building. She stated it was impossible to do the overall management for the facility since she was unable to enter the building or be in contact with staff.

Based on staff interview and review of the Payroll Based Journal (PBJ), the facility failed to ensure the mandatory submission of staffing was submitted to CMS for 1 of 4 quarters reviewed (10/1/23 through 12/31/23). The census was 38. The findings were: 1. Interview with the DON on 7/10/24 at 4:32 PM revealed the staffing was not submitted for the 10/1/23 through 12/31/24 quarter. She stated the data did not get submitted in time so it was missed. 2. Review of the PBJ for 10/1/23 through 12/31/23 showed the facility failed to submit data for the quarter.

Based on observation, QAPI minutes review, job posting review, and staff interview, the facility failed to ensure the QAPI committee included a qualified administrator who attended meetings. The census was 38. The findings were: 1. Observation on 7/10/24 at 9:45 AM of the current open positions showed the nursing home administrator position was included. Further, observations throughout the survey showed no administrator was in the facility. 2. Review of the 5/9/24 and 6/13/24 QA committee attendance sign in sheet showed the administrator was not present. 3. Interview with the CEO on 7/8/24 at 1:20 PM revealed the administrator was put on leave. Further, she stated the facility did not have a delegated administrator, and it was a problem and it was something the facility was working on. 4. Interview with the DON on 7/10/24 at 10:09 AM revealed the administrator had been on leave for the last 3 months. Further interview with the DON on 7/11/24 at 11:29 AM revealed the facility met monthly for QAPI, with all attendees, for facility improvement and to increase communication. 5. Interview with the administrator on leave on 7/10/24 at 3:12 PM revealed the former CEO put her on leave on 4/23/24 and she was told not to enter the building. She stated it was impossible to do the overall management for the facility since she was unable to enter the building or be in contact with staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility investigation report, staff and resident representative interview, review of policy and procedure, review of facility training documentation, and State Survey Agency incident report review, the facility failed to protect the residents right to be free from physical abuse by staff for 1 of 1 sample residents (#23) reviewed for abuse allegations. The findings were: 1. Review of the 2/7/23 quarterly MDS assessment showed resident #23 had a staff assessment which determined the resident was severely cognitively impaired. The resident exhibited physical behavioral symptoms directed toward others; behavioral symptoms not directed toward others; and rejection of care 4 to 6 days of the 7-day look-back period. In addition, the resident exhibited verbal behavioral symptoms directed toward others 1 to 3 days of the look-back period. Review of State Survey Agency incident reports showed an allegation of abuse was reported by the facility on 4/3/23 at 9:33 AM. The following concerns were identified: a. Interview with EVS #1 on 4/12/23 at 9:25 AM revealed she was mopping the dining room floor at the end of the noon meal when she witnessed an incident between NSA #1 and the resident. EVS #1 stated NSA #1 was attempting to remove a soiled clothing protector from the resident; however, the resident was resisting and saying no, no, no. NSA #1 continued to attempt to remove the clothing protector and the resident reached over and grabbed NSA #1's arm. NSA #1 reacted by yelling at the resident You won't treat me like that and slapping the resident's face. EVS #1 stated she was only 10 to 15 feet away and could hear the slap. Afterward, the resident had a stunned expression on his/her face. b. Interview with NSA #2 on 4/12/23 at 4:41 PM revealed she was seated at the computer desk at the back of the dining room at the time of the incident. NSA #2 stated she heard a commotion between NSA #1 and the resident about a clothing protector and witnessed the resident grab NSA #1's arm; however, she did not see or hear a slap. Review of an interview by the facility with NSA #2 dated 4/3/23 and timed 11:45 AM showed [NSA #2] freely gave information that she is very hard of hearing in her left ear which was the ear that was turned towards the event taking place and she was a good 30 feet or more from the occurrence . c. Interview with NSA #1 on 4/12/23 at 8:50 AM revealed she was going to take the resident out of the dining room after the noon meal and attempted to remove her soiled clothing protector. NSA #1 stated the resident resisted the removal of the clothing protector and the NSA tried to trade a clean clothing protector for the soiled one; however, the resident did not want it. NSA #1 stated the resident grabbed her hard leaving a bruise and spit on her. NSA #1 stated she remembered she raised her hand; however, honestly, do not remember making any contact with the resident. NSA #1 stated when the resident was resisting or rejecting care the approach was supposed to be leave the resident alone and that is what I probably should have done. d. Interview with the resident's representative on 4/11/23 at 9:23 AM revealed he was aware of an investigation being conducted related to an incident where an aide allegedly slapped the resident. He thought it might have been a defensive move since the resident did strike out at people and perhaps the aide was not properly trained. The resident's representative stated if the resident was being resistant it was best to leave him/her alone for a few minutes and s/he would forget all about it and be fine. e. Review of a statement provided to the facility from MA #1 dated 4/3/23 and timed 10:30 AM showed she had wheeled the resident out of the dining room after the incident and the resident was pleasant and did not have any marks on his/her face. 2. Interview with the DON on 4/13/23 at 10:58 AM revealed the facility had erred on the side of the resident and had terminated NSA #1's employment. In addition, the facility had an in-service in January 2023 which included abuse and reporting. After the incident occurred the DON went to each staff member and verbally instructed them on abuse and reporting and provided them a copy of the abuse policy. However; review of the Abuse, Prevention of abuse and Abuse reporting policy education form showed only 23 employees had been educated from 4/4/23 to 4/13/23. Review of the personnel roster showed the facility had 128 employees and 6 volunteers. 3. Review of the Abuse/Neglect Policy, last reviewed 9/2022, showed It is the policy of [NAME] County Manor that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, corporal punishment or involuntary seclusion .Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties.

Based on review of facility policies, the review of State Survey Agency incident report logs, and staff interview, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act for 1 of 1 allegations of abuse reviewed. The findings were: 1. Review of the facility's policy Abuse/Neglect Policy, last reviewed 9/2022 showed .a. Employees must always report any abuse or suspicion of abuse immediately to the Administrator or designee .Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located, any reasonable suspicion of a crime against any individual who is a resident of or is receiving care from, the facility, and each covered individual shall report immediately, but not more than 2 hours after forming the suspicion . Review of the State Survey Agency incident report logs showed an allegation of abuse was reported by the facility on 4/3/23 at 9:33 AM. The following concerns were identified: a. Interview with EVS #1 on 4/12/23 at 9:25 AM revealed she had witnessed an incident between resident #23 and NSA #1 which she thought was abusive on 4/2/23 at approximately 1:15 PM in the facility's dining room. EVS #1 stated she did not immediately report the incident; however, she contacted MA #1 later in the afternoon. b. Interview with MA #1 on 4/13/23 at 1:21 PM revealed she had spoken to EVS #1 after 6 PM on 4/2/23 and then spoke with the former DON at approximately 6:50 PM to report the incident. 2. Interview with the DON on 4/13/23 at 10:58 AM confirmed the allegation of abuse occurred on 4/2/23 at approximately 1:30 PM and was witnessed by EVS #1 who did not immediately report the incident because she was afraid of retaliation. The DON stated the incident was first communicated to MA #1 who then informed the former DON. The DON stated the former DON trained her on the use of the State Survey Agency incident reporting database on 4/3/23 and this was when the allegation of abuse was reported. In addition, the DON stated the police were not notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide a written notice of transfer and notify the ombudsman for 1 of 2 sample residents (#90) reviewed for a facility-initiated transfer. The findings were: 1. Review of the medical record for resident #90 showed the resident was hospitalized on [DATE] following an acute change of condition and readmitted to the facility on [DATE]. There was no evidence a written transfer notice had been provided to the resident's representative or the ombudsman had been notified. 2. Interview with the DON on 4/13/23 at 10:32 AM confirmed a written transfer notice had not been provided to the residents representative or the ombudsman notified.

Based on observation, staff and resident interview, and medical record review, the facility failed to ensure 1 of 12 sample residents (#10) had resident-specific care plans that reflected individual needs in all required areas. The findings were: 1. Review of the 2/13/23 quarterly MDS assessment showed resident #10 had a BIMS score of 14 out of 15, indicating the resident was cognatively intact, and had diagnoses which included coronary artery disease, heart failure, anxiety disorder, and an unspecified pulmonary disorder. Further review showed the resident required supplemental oxygen. Review of the physician orders showed the resident was prescribed 3 to 4 liters per minute of continuous oxygen via a nasal cannula every day and night with a start date of 10/7/22. The following concerns were identified: a. Observation on 4/11/23 at 9:58 AM showed the resident was in his/her recliner receiving oxygen through a nasal cannula from a concentrator. Interview with the resident at that time revealed s/he required continuous supplemental oxygen at 3 to 4 liters per minute. The resident stated the nasal cannula hurt his/her nose and s/he would prefer to have an oxygen mask; however, when s/he asked, the facility had refused. b. Review of the resident's care plan, last revised 2/22/23, showed no evidence a person-centered care plan had been developed in regard to the resident's use of supplemental oxygen. c. Interview with the DON on 4/13/23 at 10:46 AM confirmed the care plan did not include the resident's use of supplemental oxygen. In addition, the DON stated she was unaware of the resident's request for an oxygen mask.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to ensure the provision of necessary behavioral health care and services for 1 of 4 sample residents (#27) reviewed for behaviors. The findings were: 1. Review of the [DATE] significant change MDS assessment for resident #27 showed the resident had a BIMS score of 6 out of 15 indicating the resident had severe cognitive impairment. The resident received an antidepressant and antipsychotic on a routine basis, and had diagnoses which included Alzheimer's disease, insomnia, Parkinson's disease, and dementia with behaviors. Review of the [DATE] annual MDS assessment showed the resident received no psychological therapies by a licensed professional during the 7-day look-back period. Review of the [DATE] telehealth visit note showed the resident had depression present, had a good mood and calm behavior with no suicidal thoughts. Review of the care plan initiated on [DATE] showed interventions to Follow-up with psychiatry as needed and to monitor/document and/or notify nurse of any changes in behaviors/mood. The following concerns were identified: a. Review of the [DATE] behavior note timed at 3:52 PM showed When CNA had [him/her] on toilet [s/he] stated [s/he] didn't want to live anymore. b. Review of the [DATE] behavior note timed at 5:45 PM showed staff had reported the resident stated I want to die, and when staff asked why, the resident stated s/he wasdepressed. c. Review of the [DATE] at 5:29 PM health status note showed While [s/he] did not call out for help repeatedly, [s/he] did inform [CNA name] that [s/he] wished [s/he] was dead as [s/he] was placed in [his/her] recliner this morning after breakfast. Further review of the medical record showed no evidence the facility notified the responsible party or physician for further direction. b. Interview with the DON on [DATE] at 11:47 AM revealed the resident often made these statements and confirmed the facility had not appropriately addressed the resident's suicidal ideations. 2. Review of the facility policy titled Suicide Threats which expired in 7/2022 showed the following: 3. A staff member shall remain with the resident until the Nurse Supervisor/ Charge Nurse arrives to evaluate the resident. 4. After assessing the resident in more detail, the Nurse Supervisor/ Charge Nurse shall notify the resident's Attending Physician and responsible party, and shall seek further direction from the physician. 5. All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately. 6. As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. 7. If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review and facility policy review, the facility failed to administer medications as ordered by the prescriber for 1 out of 5 residents (#8) reviewed for medication administration. The findings were: 1. Review of the 3/13/23 annual MDS assessment showed resident #8 was admitted on [DATE] with adequate vision and used corrective lenses. Review of the most current physician orders showed the resident had an order for Refresh Plus Solution 0.5 % (active ingredient of carboxymethylcellulose sodium) eye drops every morning for dry eyes. The following concerns were identified: a. Observation on 4/12/23 at 7:36 AM showed the resident sitting in the dining room, when LPN #1 administered one drop of dry eye relief (active ingredients: glycerin, hypromellose and polyethylene glycol) eye drop solution to both eyes, and stated it was the only drops the resident received. b. Interview with LPN #1 on 4/12/23 at 2:50 PM revealed the facility was using eye relief drops provided from the pharmacy house stock. c. Interview on 4/12/23 at 3:03 PM with the pharmacy consultant confirmed nurses were expected to give the eye drops that had the same ingredients as the eye drops prescribed by the physician. d. Interview on 4/12/23 at 3:55 PM with the DON confirmed the expectation that medication administration was to follow the physician's order. 2. Review of the facility policy titled Medication Administration with an expiration date of 2/2024, showed Nurses will administer medications safely to all residents in accordance with physician's orders. 2. Right drug. B. Each medication will be checked against the medication administration record (MAR) for the 6 R's (not documentation), prior to administration of any medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and medical record review, the facility failed to ensure appropriate behavior monitoring and interventions were in place for 1 of 5 sample residents (#3) reviewed for psychotropic medication use. The findings were: 1. Review of the 11/27/22 MDS assessment showed resident #3 was admitted on [DATE] and had a BIMS score of 2 out of 15 (severe cognitive impairment). The resident exhibited physical behaviors directed toward others 1 to 3 days of the 7-day look-back period; verbal behaviors directed toward others every day of the look-back period; and other behavioral symptoms not directed toward others 1 to 3 days of the 7-day look-back period. These behaviors put the resident at risk for physical illness or injury, interfered with care and social interactions, and put other residents at risk for physical injury. In addition, the resident rejected care 4 to 6 days of the 7-day look-back period. Further review showed the resident received an antipsychotic medication on 7 days of the 7-day look-back period. Review of a physician progress note, dated 11/29/22, showed the resident was agitated and physically aggressive only when cares being provided and had diagnoses which included Alzheimer's disease and unspecified dementia with other behavioral disturbance. Review of the current physician orders showed 25 milligrams of quetiapine (antipsychotic medication) was to be given twice a day with breakfast and lunch and 50 milligrams with dinner. Interview with CNA #1 on 4/12/23 at 9:05 AM revealed the resident only exhibited behaviors when personal cares were being performed; however, the behaviors were improving due to a new medication the resident had started to treat his/her diarrhea. In addition, the CNA stated she distracted the resident by asking about his/her children or animals which helped with behaviors during cares. The following concerns were identified: a. Review of the April 2023 MAR showed the facility was to Observe for Behavior: (Specify) and document if the resident was having behavior. In addition the facility was to document attempted non-pharmacological interventions. There was no evidence medication-specific target symptoms or non-pharmacological interventions had been identified. b. Review of the Psychosocial Well-Being care plan developed on 11/28/22 showed the resident was often physically and verbally aggressive with personal cares, would reject care at times, and would frequently wander. Interventions included administer medications as ordered by the physician, explain to the resident cares as they were occurring, walking, napping, and redirecting as necessary. c. Interview with the DON on 4/12/23 at 9:56 AM confirmed resident-specific target behaviors and non-pharmacological interventions had not been defined.

Based on observation and staff interview the facility failed to to ensure the activities program was directed by a qualified professional. The census was 39. The findings were: 1. Random observations from 4/10/23 to 4/13/23 in the solarium and activities room showed residents participating in various activities. 2. Interview on 4/10/23 at 3:39 PM with the activities director revealed she had not completed the special training needed to coordinate the program. 3. Interview on 4/12/23 at 10:16 AM with the human resources director confirmed the activities director had not completed the training required to coordinate the activities program.

Based on staff interview, review of staff schedules, and review of the Staffing Data Submission Payroll Based Journal (PBJ) report, the facility failed to ensure an RN worked at least 8 consecutive hours within each 24 hour period, 7 days a week. The census was 39. The findings were: 1. Review of the PBJ report showed no RN coverage for 8 consecutive hours in a 24 hour period for the following 12 days: 5/14/22 and 5/15/22, 6/5/22, 6/11/22 and 6/16/22, 8/6/22 and 8/7/22, 10/1/22 and 10/2/22, 11/13/22, 12/10/22 and 12/11/22. Further review of the facility staff schedules showed no RN coverage for the following 8 days: 10/30/22, 11/11/22, 11/27/22, 1/8/23, 2/4/23, 2/5/23, 2/17/23 and 2/18/23. 2. Interview with the DON on 4/13/23 at 2:34 PM revealed s/he could not recall the facility having a day without an RN present in the building; however, due to a new scheduling program she was unable to provide evidence RN staffing requirements were met.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident representative and staff interview, and review of the facility newsletter, the facility failed to facilitate the inclusion of the residents' representative in the care planning process for 3 of 4 sample residents (#7, #20, #27) reviewed for the care planning process. The findings were: 1. Review of the 12/14/21 annual MDS assessment showed resident #7 was admitted to the facility on [DATE] and was coded as having severe cognitive impairment. Review of the medical record showed the resident had a family member named as his/her representative. The following concerns were identified: a. Review of the Interdisciplinary Team Care Plan Review document showed care conferences were held on 4/21/21, 7/7/21, 9/29/21, and 12/21/21 with only staff members in attendance. There was no evidence the resident's representative had been contacted prior to the care conference. b. Interview with the resident's representative on 3/7/22 at 8:05 PM revealed the facility called to notify her of any changes, however she did not recall having a sit-down meeting. 2. Review of the 1/18/22 annual MDS assessment showed resident #20 was admitted to the facility on [DATE] and had a BIMS score of 3 out of 15 (severe cognitive impairment). Review of the medical record showed the resident had a family member named as his/her representative. The following concerns were identified: a. Review of the Interdisciplinary Team Care Plan Review document showed care conferences were held on 5/26/21, 8/18/21, 10/27/21, and 1/26/22 with only staff members in attendance. There was no evidence the resident's representative had been contacted prior to the care conference. 3. Review of the 2/8/22 annual MDS assessment showed resident #27 was admitted to the facility on [DATE] and had a BIMS score of 9 out of 15 (moderate cognitive impairment). Review of the medical record showed the resident had a family member named as his/her representative. The following concerns were identified: a. Review of the Interdisciplinary Team Care Plan Review document showed care conferences were held on 6/16/21, 8/25/21, 11/17/21, and 2/16/22 with only staff members in attendance. There was no evidence the resident's representative had been contacted prior to the care conference. 4. Interview with the social services director on 3/9/22 at 4:32 PM revealed the facility sent out a monthly newsletter which contained the names of the residents and the date the resident's care conference was scheduled. 5. Review of the facility's March newsletter showed each Wednesday of the month had 1 to 4 residents scheduled for a care conference. In addition, the newsletter stated Please take note of your family member's Care Conference. If you would like to attend in person or via phone, please contact [the social service director and phone number]. 6. Interview with the social services director on 3/10/22 at 10:20 AM revealed the residents' representatives were expected to call the facility if they wanted to be included in the care conference. Further, the facility did not have a process in place to contact the family members that had not responded to the notice in the newsletter. The social service director confirmed the process could be better to ensure residents' representatives were notified of a pending care conference.