Every finding on record at Stonegate Nursing and Rehabilitation

Based on observation, interview and record review the facility failed to ensure the interdisciplinary team determined if a resident was able to self-administer medications for 1 of 15 residents (Resident #20) reviewed for resident rights.The facility failed to ensure Resident #20, was clinically appropriate to self-administer nasal spray that were at the resident's bedside. The failure had the potential to place residents at risk for unsafe drug administration.Findings included:Record review of Resident #20's admission MDS, dated [DATE], reflected Resident #20 was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #20's BIMS score was 12 which indicated moderate cognitive impairment. Resident #20's active diagnoses included Hypertension (high blood pressure), Renal insufficiency (kidney failure), anxiety disorder (mental health conditions that cause excessive fear and worry).Record review of Resident #20's undated Care Plan did not address Resident #20's need or use of medications at her bedside. Record review on 02/10/26 of Resident #20's clinical records reflected no assessment was completed to indicate if Resident #20 was able to self-administer medication. Record review on 02/10/26 of Resident #20's order summary revealed Resident #20 did not have a physician's order for nasal spray. Record review on 02/10/26 of Resident #20's MAR reflected Resident #20 did not have an order for nasal spray. Observation and interview on 02/10/26 at 11:38 AM, revealed Resident #20 had a bottle of Nasal Spray at her bedside. Resident #20 stated she had the medication for a while, she administered it herself with no help from staff. Resident #20 stated she kept the medication at her bedside because sometimes her nose got dry, and she used it as needed to keep her breathing comfortably. Resident #20 stated staff had never questioned her use of the nasal spray or having it on her bedside table. Interview and observation on 02/11/26 at 1:49 PM with LVN G revealed there were no residents in the facility that were able to self-administer medication. LVN G stated he was not aware of Resident #20 having any medications at her bedside table. He revealed if there were any medications, then perhaps the resident's family brought the medications in. LVN G stepped inside Resident #20's room and removed the medication at bedside which included an over-the-counter nasal spray. LVN G educated Resident #20 that medication was not allowed at bedside, and that he would contact the physician for an order, she could ask the medication to be administered by staff anytime she needed it. LVN G stated residents were not allowed to have nasal spray at the bedside. He stated he would contact the doctor to get an order and provide the nasal spray for the resident as needed. LVN G stated residents having medications at their bedside placed other residents at risk of gaining access to the medication and misusing it. LVN G stated everyone was responsible for observing and removing medications from bedside. Interview on 02/12/2026 10:44 AM with ADON H revealed residents were not allowed to self-administer medications on their own while in the facility. ADON H stated she was notified that Resident #20 had over the counter medication at her bedside. ADON H stated it was all staff's responsibility to remove any medications found in the resident room. ADON H further stated, Angel Rounds were done to observe for oxygen, medication, call lights within reach and clear and free floors, this is the time medications should be removed and given to the nurse on the floor so she could notify the physician. ADON H stated residents having any type of medication at their bedside placed them at risk of over medicating or having a change of condition.Interview on 02/12/2026 at 3:35 PM with the DON revealed ambassadors were responsible for identifying and educating residents about having medications in their room. Staff were to remove the medication and notify the nurse, the nurse would then call doctor and get an order for it if resident wanted to continue taking the medication. DON stated residents were not allowed to administer their own medications. DON stated residents having medications in their room placed themselves at risk of getting duplicate treatment, overdosing and residents having medication without the nursing staff or physician knowing.Interview on 02/12/26 at 5:00 PM with the DON and Regional Leadership revealed they did not have a policy regarding residents self-administering medications, however provided their Storage of Medication listed below.Record review of the facility's Storage of Medication policy, revised April 2007, reflected the following: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Based on observation, interview, and record review the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary and comfortable interior for 1 of 33 residents (Resident #64) reviewed for sanitary and comfortable environment.The facility failed to maintain Resident #64's wheelchair in a sanitary condition leaving food, liquid spills, dirt, and debris to collect down both sides of the wheelchair when observed on 02/10/26. This failure could place residents at risk of contamination and infections. Findings included: Record review of Resident #64's Quarterly MDS, dated [DATE], reflected Resident #64 was an [AGE] year-old male originally admitted to the facility on [DATE], and readmitted on [DATE]. Resident #64's diagnoses included muscle weakness (lack of strength to move limbs or joints) and diabetes (a chronic condition causing high blood sugar due to insufficient insulin production). He had a BIMS score of 09 indicating cognitive was moderately impaired. Resident #64 required use of a manual wheelchair. Record review of Resident #64's Care Plan dated 01/29/26 revealed Resident #64 has an ADL self-care performance deficit, which requires assistance: cognitive deficit secondary to dementia disease progression, impaired decision making, limited mobility Goal: Resident #64 Will be cleaned, well-groomed, appropriately dressed and maintained through next review date. Interventions: -Resident#64 will be cleaned, well-groomed, appropriately dressed and weight maintained through next review date. Interventions: -Transfer: requires assist x2 staff participation assist mechanical lift. Bed Mobility: res requires assist x1 staff participation. Observation and interview on 02/10/26 at 10:40 AM with Resident #64 revealed he was in his wheelchair. Resident #64's wheelchair had food particles, liquid spills, dirt, and debris on both sides of the wheelchair. Resident #64 indicated he used a wheelchair for mobility throughout the facility. Resident #64 stated he was not aware his wheelchair looked dirty, and he could not recall his wheelchair being cleaned. Observation on 02/11/26 at 7:15 AM revealed Resident #64 was in his wheelchair. Resident #64's wheelchair had food particles, liquid spills, dirt, and debris on both sides of the wheelchair.Observation and interview on 02/11/26 at 10:48 AM with CNA A revealed today was her first day working with Resident #64. She said she had not observed Resident #64's wheelchair to have dried food, spills, and debris on the sides. CNA A stated aides on the overnight shift were responsible for cleaning resident wheelchairs. CNA A stated if she observed residents with dirty wheelchairs, she would just clean it herself. CNA A further stated she would not want to sit in a dirty chair, so she could imagine residents did not want to sit in a dirty chair as well. CNA A stated that when residents were in a dirty environment it placed them at risk of infection.Interview/observation on 02/11/26 at 11:20AM with LVN B revealed Resident #64's Wheelchairs was observed dirty on the sides with debris, dried food, and liquid spills. She stated she works with Resident #64 regularly on 6-2 shift. She said she had not observed Resident #64's wheelchair to have dried food on the sides, and if she would have reported to the ADON. LVN B stated aides on the overnight shift were responsible for cleaning resident wheelchairs. LVN B stated that when residents were in a dirty environment it placed them at risk of infection.Attempts to contact CNA C on the overnight (10:00 PM - 6:00AM) shift on 02/12/26 at 12:30PM was unsuccessful. Interview on 02/12/26 at 03:47PM with the DON revealed her expectation was for the night shift CNAs to clean the chair routinely and when dirty. The DON stated the overnight shift had a wheelchair cleaning schedule they were supposed to go by. The schedule was reviewed and there was no evidence the wheelchair was cleaned. The DON stated aides do not document when the task was completed so there was no indication resident chair was cleaned. She stated she was responsible of auditing that the chairs were being cleaned, and she could not recall the last time she audited. The DON stated not ensuring residents' wheelchairs were cleaned placed residents at risk of a buildup of debris and could lead to infection and dignity issue.Interview on 02/12/26 at 04:15PM with the Administrator revealed CNAs on the overnight shift were responsible for ensuring all wheelchairs were cleaned according to the schedule. The Administrator stated the facility was working on making another schedule and getting somebody who will be responsible of cleaning the wheelchairs. Record review of the facility's Equipment-General use for all residents policy, dated August 2006, reflected: Wheelchairs, walkers, crutches, canes are maintained by our facility for the general use of as all residents.

Based on interview and record review, the facility failed to assess each resident quarterly (every 3 months) using the MDS form specified by the state and approved by CMS for 1 of 5 residents (Resident #56) reviewed for assessments. The facility failed to ensure Residents #56's quarterly MDS assessment was completed within three months from the previous assessment. This failure could place residents at risk of not receiving necessary care or receiving inappropriate care for their conditions. Findings included: Record review of Resident #56's electronic health record reflected she had an entry MDS assessment completed on 10/02/25 and a significant change MDS completed on 10/09/25. There was a quarterly MDS assessment that was still in progress and had not been completed, dated 01/09/26. Her original admission date was 05/07/24 and most recent readmission date was 10/02/25. Interview on 02/12/26 at 10:45 AM with the Regional MDS Coordinator revealed she knew Resident #56's quarterly MDS was still in progress. The Regional MDS Coordinator said the facility had personnel changes recently and went a few months without having an MDS Coordinator full-time at the facility. The Regional MDS Coordinator said usually a quarterly MDS assessment was completed every 92 days. The Regional MDS Coordinator said Resident #56's was past the 92 days and was overdue. The Regional MDS Coordinator said the purpose of the quarterly MDS assessment was to collect data about the resident's care needs. The Regional MDS Coordinator said she was trained to submit quarterly MDS assessments timely but no one monitored to ensure they were completed timely. Interview on 02/12/26 at 3:34 PM with the DON revealed she knew the Regional MDS Coordinator had been working on getting caught up on MDS assessments. The DON said she had nothing to do with monitoring or completing MDS assessments. The DON said she expected all resident's MDS assessments to be completed timely. Record review of the facility's policy, revised September 2010, and titled Resident Assessment Instrument reflected: 1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and review according to the following schedule:.c. At least quarterly.

Based on observations, interviews, and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 of 5 residents (Resident #21) reviewed for nutritional status. The facility failed to recognize, evaluate, and address timely interventions and prevent weight loss when Resident #21 experienced severe weight loss of 6.48% (8 pounds) from 01/12/26 to 02/12/26. This failure could place residents at risk for improper care, weight loss, malnutrition, and overall health decline. Findings included: Record review of Resident #21's significant change in status assessment, dated 01/16/26, reflected he was a [AGE] year-old male who was originally admitted to the facility on [DATE] and had recently readmitted to the facility on [DATE]. The MDS reflected no BIMS score was calculated. The MDS reflected he had short-term and long-term memory problems and was severely impaired in daily decision making. His active diagnoses included diabetes (chronic condition that occurs when body cannot properly use blood sugar leading to high blood sugar levels), seizure disorder or epilepsy (a medical condition characterized by recurrent, unprovoked seizures caused by abnormal electrical activity in the brain), and down syndrome (a genetic condition caused by the presence of an extra copy of chromosome 21, leading to developmental delays and distinct physical features). His MDS did not indicate he had any weight loss. Record review of Resident #21's Order Summary Report, dated 02/12/26, reflected the following: HS snack at bedtime, order date 01/12/26 Record review of Resident #21's Care Plan, revised 02/06/26, reflected the following: Focus: Mr./Mrs. is at risk for weight fluctuations d/t____ Changes [sic] in appetite, difficulty adjusting to new environment, recent hospitalization, mechanically altered diet, therapeutic diet 2/10/26 [sic] -5% wight [sic] loss1/13/26 [sic] -3% weight lossInterventions: Monitor weights as per facility protocol.RD to evaluate and treat. Record review of Resident #21's meal eaten percentage from 01/12/26 to 02/12/26 reflected he ate over 50% of each meal each day. Record review of Resident #21's Weights, dated 02/12/26, reflected the following:11/10/25 120 lbs.01/13/26 108 lbs.02/12/26 100.6 lbs. Record review of Resident #21's Nutrition Assessment, dated 01/20/26, reflected the following: Current Weight- 108# [sic], Usual Body Weight- 108# [sic], DBW Range?- 125# +/- 10% .There was also a check noted in the box titled Undesirable Weight Loss? Notes: No new weight in [electronic health record] noted, used recent body weight of 108# to estimate calorie/protein needs.Will continue to monitor nutritional status. Goal: gradual weight gain to IBW Recs: 1) Suggest starting protein supplement, 30 ml BID to promote wound healing 2) Recommend vitamin C & zinc for wound healing 3) weekly weights x4 to monitor weight trends. Record review of an undated and untitled piece of paper provided by CNA D reflected the following: 1-13-26.Re Admits [sic].[Resident #21's Room Number] 108.0 LB [sic] [Resident #21]. Record review of an undated and untitled piece of paper provided by CNA D reflected the following: 1-20-26.Weekly.[Resident #21's Room Number] 105.7 [Resident #21]. Record review of an undated and untitled piece of paper provided by CNA D reflected the following: 1-28-26.Weekly.[Resident #21's Room Number] 103.2 [Resident #21] Mon [sic]. Record review of the facility's monthly weights list, which was undated, reflected Resident #21 weighed 94.6 pounds. Record review of CNA D's folder where she kept all the resident's weights listed out showed on one side of the folder the following: [Resident #21] 99.4 LB, 100.1 LB Observation on 02/11/26 at 9:51 AM of Resident #21 revealed he was sitting in his wheelchair in the common area but was not interviewable. He was dressed and groomed and did not appear to be in any distress. Observation on 02/11/26 at 11:19 AM of Resident #21 revealed he was asleep in bed, his bed was low to the ground, and he had a fall mat at his bedside. Observation on 02/11/26 at 1:15 PM of Resident #21 revealed he was in the dining room sitting at a table being helped to eat his lunch. Later observation of his meal revealed he had eaten all of his meal. Interview on 02/12/26 at 10:01 AM with LVN G revealed Resident #21 had been eating very well lately after he was re-admitted from the hospital about a month or so ago. LVN G said he noted Resident #21 had weight loss when he first re-admitted but since then has been eating every meal and mostly 100% of each meal that he was aware of. LVN G said Resident #21 needed assistance to eat his meals so he ate mostly in the dining room being assisted to eat by someone. LVN G said Resident #21 was currently not receiving any nutritional supplements that he was aware of because he had not been triggered for weight loss. LVN G said during Resident #21's hospital stay, they changed his seizure medications and that seemed to have made the biggest difference in his appetite once he re-admitted . Observation and interview on 02/12/26 at 10:05 AM with CNA D and CNA E revealed they weighed Resident #21's wheelchair which was 87.8 pounds. CNA D and CNA E then brought Resident #21 to the scale in the wheelchair and they both weighed 188.8 lbs. CNA D and CNA E said that meant Resident #21 weighed 101 pounds. Interview on 02/12/26 at 10:07 AM with CNA D revealed she was responsible for obtaining resident's weights and writing them down on the pieces of paper she provided the surveyor. CNA D said she weighed Resident #21 this morning and got the weights 99.4 and 100.1 pounds. CNA D said she was only responsible for obtaining the weights and confirmed Resident #21 weighed 108 pounds upon readmission on [DATE], 105.7 pounds on 01/20/26, 103.2 pounds on 01/28/26, 99.4 pounds one day last week, and 99.4 pounds this morning. CNA D confirmed after Resident #21 ate breakfast and was weighed with the surveyor he weighed 101 pounds. CNA D said she provided her paperwork with resident weights to ADON F and DON. CNA D said she always made a copy of that days' weights and gave it to ADON F. CNA D said she was only responsible for obtaining weights for re-admitted residents, newly admitted residents, daily weighed residents, weekly weighed residents, and monthly weighed residents. CNA D said if she noticed a weight loss from one month to the next she would let ADON F and the DON know but since she did not have that information from week to week she would not know if a resident had lost weight or not. CNA D said she was not sure what ADON F did with the weight measurements she gave her after she was given a copy of them. Interview on 02/12/26 at 10:19 AM with ADON H revealed she was told about Resident #21's weight loss last month when he was re-admitted to the facility but he had also just come back from the hospital. ADON H said the other ADON (ADON F) was responsible for tracking and trending resident's weights. ADON H said ADON F and the DON went to the weight meetings together to discuss any resident's weight loss. ADON H said Resident #21 losing 7 pounds in one month was a lot of weight loss. ADON H said the RD sent her recommendations to the DON and she would follow-up on them. ADON H said she had no further information about Resident #21's weight loss. Interview on the phone on 02/12/26 at 11:14 AM with Resident #21's RP revealed he had just received a phone call from the facility letting him know about Resident #21's weight loss. Resident #21's RP said he was at the facility a few days ago and did not notice any weight loss on Resident #21. Resident #21's RP said he knew Resident #21 was not eating well while he was at the hospital about a month ago but they changed his seizure medications and that seemed to help his appetite to come back. Resident #21's RP said he was told Resident #21 lost about 7-8 pounds over the last month since being back at the facility. Interview on the phone on 02/12/26 at 11:59 AM with the RD revealed she just started consulting at the facility at the beginning of January. The RD said she recalled sending an email to the DON on 01/20/26 after completing Resident #21's assessment and noting his weight loss after his hospital stay and making recommendations. The RD said she noted there was not a new weight in the system for her to review since 11/10/25 so she looked at his hospital records which showed the 108 pounds upon re-admission. The RD said she was concerned about Resident #21's weight loss from November to January and now from January to February. The RD said normally the DON and nursing staff were good at communicating resident's weight loss to her so she could check on it. The RD said she was not sure why the facility never mentioned Resident #21 to her. The RD said her original recommendation on 01/20/26 was to add a protein supplement and weigh him weekly. The RD said she had not been back to the facility yet so she was not able to follow up to see if the facility followed her recommendations or not for Resident #21. The RD said she noted Resident #21's meal intake was high and he was receiving assistance to eat and she did not have any other weights to go by besides the 108 pounds from the hospital, she would assume the added protein supplement would have Resident #21 losing a smaller amount of weight over the last month rather than the 7 pounds he did lose. The RD said once she makes the recommendation for a resident, she sent an email to the DON directly so she can review and discuss with the doctor. The RD said she had extreme concerns about Resident #21's weight loss because that was a large amount of weight lost and the facility was not documenting his weekly weights to trend it or providing him with the recommended protein supplement either. The RD said she expected the facility to take and follow the recommendations she made after consulting the doctor about them. Interview on 02/12/26 at 12:26 PM with ADON F revealed she was responsible for entering in resident's weights after CNA D provided her the copies of the information. ADON F said she just started in December and was not sure why Resident #21's weights were not put in the system over the last few months. ADON F said she was only supposed to enter the weights into the electronic health record and then attend the monthly weight meetings. ADON F said she attended a weight meeting recently but could not remember when it was or if Resident #21 was discussed or not. ADON F said the recommendations made by the RD were the DON's responsibility. ADON F said she just took over the ADON role recently and was still in training so she did not have any further information regarding Resident #21's weight loss. Observation and interview on 02/12/26 at 12:50 PM with CNA E of Resident #21's plate revealed he ate everything on his plate except half his piece of cornbread. CNA E said he normally had a good appetite and ate all of his breakfast and lunch meals. Interview on the phone on 02/12/26 at 1:35 PM with the MD revealed she was aware of Resident #21's weight loss as she spoke with the DON this morning about it. The MD said she had been following Resident #21's weight closely because he was diagnosed with protein calorie malnutrition a while back. The MD said she noted in October, November, and December that he had weight loss and needed assistance to eat his meals. The MD said she was at the facility 3 times a week and whenever the RD made recommendations, they were placed in her box and she signed off on them as soon as she saw them. The MD said she could not recall if she reviewed Resident #21's RD recommendations made on 01/20/26 but she rarely disagreed since they were the expert in that case so she would have approved them if she saw them. The MD said the only information she had in the system regarding Resident #21's weight was that he weighed 120 pounds in November and 108 pounds in January. The MD said normally she would be contacted about such a severe amount of weight loss in that short time and would discuss nutritional interventions but she was not made aware of that prior to today (02/12/26). The MD said she was told Resident #21 lost 8 pounds since January now and thought being assisted to eat was helping him. The MD said Resident #21 seemed to have a good appetite but his disease progression was taking a natural course with his dementia and down syndrome. The MD said Resident #21 should still have nutritional interventions to prevent weight loss, however. The MD said she knew Resident #21 had been in and out of the hospital recently with a lot of problems and weight loss can happen with that, but she expected his weight to improve with interventions. The MD said she would have added nutritional interventions to Resident #21's orders earlier if she had known about his weight loss. Interview on 02/12/26 at 3:34 PM with the DON revealed she did see the RD's recommendations from 01/20/26 regarding Resident #21's weight loss during an audit recently. The DON said she saw it today and notified the doctor, RD, and Resident #21's RP. The DON said ADON F was supposed to be tracking and trending resident's weights, including Resident #21 each week prior to this. The DON said she was not sure how Resident #21 losing 7 or 8 pounds in the last 30 days could affect him. The DON said once she received the RD's recommendations, she printed them out and provided them to the doctor to sign off on. The DON said she thinks the email from the RD on 01/20/26 which included Resident #21's recommendations got lost in the shuffle so they were not implemented or followed. The DON said the doctor recently ordered pro-stat liquid protein and health shakes to his orders to help him gain or stabilize his weight. The DON said as far as she knew, Resident #21 needed assistance to eat and was eating 100% of all 3 of his meals. The DON said she did not want a significant weight loss like what Resident #21 has had over the last month and nutritional supplements would have made it more gradual or stabilized if they had been implemented earlier. The DON said since they did not have the weekly weight information they were not aware Resident #21 was losing so much weight so fast. The DON said the purpose of residents not losing weight was to maintain nutritional balance. The DON said if residents were losing weight they could become nutritionally compromised. The DON said she expected ADON F to be monitoring resident weights and reporting to her any concerns or trends of weight loss. Record review of the facility's Nutrition (Impaired)/Unplanned Weight Loss- Clinical Protocol, revised December 2008, reflected the following: 1. The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits readily available comparisons over time.3. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weigh- actual weight) / (usual weigh) x 100]:1 month- 5% weight loss is significant; greater than 5% is severe.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 2 medication carts (200 Hall) and 2 of 2 residents (Residents #1 and #2) reviewed for pharmacy services. The facility failed to ensure the 200 Hall nurses' medication cart had accurate narcotic counts for Residents #1 and #2. This failure could place residents at risk for medication errors, drug diversion, and delay in medication administration. Findings included: 1. Record review of Resident #1's Quarterly MDS Assessment, dated 02/16/25, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included fracture of other parts of the pelvis, subsequent encounter for fracture with routine healing. The resident BIMS score was not indicated. Record review of Resident #1's physician's orders, dated 2/16/25, reflected an order for the resident to receive Hydrocodone-Acetaminophen Oral Tablet 5-325 mg (narcotic pain medication), 1 tablet by mouth every 4 hours as needed for pain. Record review of Resident #1's medication February 2025 MAR reflected Hydrocodone-Acetaminophen Oral Tablet 5-325 mg was last administered on 02/19/25 at 9:02 AM. 2. Record review of Resident #2's Entry MDS Assessment, dated 02/03/25, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included medically complex conditions (health issues that involve multiple body systems, often chronic). The resident cognition was intact with a BIMS score of 13. Record review of Resident #2's physician's orders, dated 02/10/25, reflected an order for the resident to receive Hydrocodone-Acetaminophen Oral Tablet 10-325 mg, 1 tablet by mouth every 6 hours as needed for pain. Record review of Resident #2's February MAR reflected Hydrocodone-Acetaminophen Oral Tablet 10-325 mg was last administered on 02/19/25 at 2:30 PM. Observation and record review on 02/19/25 at 2:43 PM of the 200 Hall nurses' medication cart and the Narcotic Administration Record with RN A revealed Resident #1's Narcotic Administration Record for Hydrocodone-Acetaminophen Oral Tablet 5-325 mg reflected a total of 54 pills remaining, while the blister pack count was 53 pills. It had last been administered on 02/18/25. Review of Resident #2's Narcotic Administration Record revealed the Hydrocodone-Acetaminophen Oral Tablet 10-325 mg had a total of 49 pills remaining, while the blister pack count was 48 pills. It had last been administered on 02/19/25 at 8:00 AM. Interview with RN A on 02/20/25 at 10:57 AM revealed he administered Resident #1's Hydrocodone-Acetaminophen Oral Tablet 5-325 mg 1 tablet every 4 hours as needed and Hydrocodone-Acetaminophen Oral Tablet 10-325 mg 1 tablet to Resident #2 as needed every 6 hours, and he had not signed off on the Narcotic Administration Record log. He said he gave the residents the medication, but he forgot to sign off on the Narcotic Administration Record. He stated he knew he was supposed to sign-out on the narcotic count sheet log after administration and on the Medication Administration Record, but he did not. RN A stated failure to sign off narcotics could lead to overdose since the person who came after him would not be able to tell when the narcotic was administered. He said he did an in-service on medication administration and narcotic signing out, and he knew better because he had been a nurse for a long time. Interview on 02/20/25 at 1:36 PM with the ADON revealed his expectation was for staff administering narcotic medications to document the medications when they were given to the resident on the MAR and to sign on the narcotic log. The ADON stated failure to document could lead to incorrect counting and forgetting when administered. He said it was his responsibility to audit the medication carts, but he did not indicate how often this was done. Interview on 02/20/25 at 2:58 PM with the DON revealed her expectation was for staff administering narcotic medications to document the medications when they were given to the resident on the MAR and to sign on the narcotic log. The DON said failure to document could lead the nurse to forgetting when medication was administered. She said it was the responsibility of the DON and the ADONs to audit the medication carts. She said the facility had completed inservices on medication administration and marcotic sign out. Record review of the training records dated 01/31/25 and 01/20/25 reflected RN A was in attendance. Record review of the facility's Controlled Substances policy, dated December 2012, reflected the following: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule 11 and other controlled substances.

Based on observation, interview, and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 1 residents (Resident #3) reviewed for accommodation of needs. The facility failed to ensure Resident #3 had access to his call light. This failure could place residents at risk of not being able to call for help when needed. Findings included: Record review of Resident# 3's Quarterly MDS Assessment, dated 01/13/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and a readmission on 01/07/25. Resident #3 had diagnoses which included fractures, anemia (low blood levels) and hypertension (high blood pressure) . The resident's cognition was severely impaired with a BIMS score of 3. His Functional Status assessment reflected he needed substantial assistance with all his activities of daily living. Record review of Resident #3's care plan, dated 01/08/25, reflected Focus: [Resident #3] has hip fracture due to fall. Goal: The Surgical incision will heal without signs and symptoms of infection or breakdown by review date. Interventions: Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. Observation on 02/19/25 at 1:00 PM revealed Resident #3 lying on his bed, and his call light cord was clipped on the ceiling suspended curtain away from the resident. Observation and interview on 02/19/25 at 2:25 PM revealed Resident #3 was lying on his bed, and his call light was clipped on the curtain. Resident #3 said he did not realize the call light was not within reach. He said he knew how to use the call light and had not called for help. Observation and interview on 02/19/25 at 2:34 PM with CNA B revealed she was assigned to Resident #3. She stated the last time she was in the room was when she was dressing him, and he did not want to get up in his chair. She stated she preferred to remain in bed, but she could not tell at what time. She said when she left him, the call light was within reach. CNA B stated she could not tell how it got clipped to the curtain. She put the call light within reach. She stated she was supposed to be checking whether the call light was within reach while doing her rounds. CNA B stated Resident #3 knew how to use the call light though he hardly called because he used a urinal. CNA B stated failure to have the call light within reach was a resident would not be able to call in case he needed help, and this could lead to a fall. Interview on 02/20/25 at 2:58 PM with the DON revealed her expectation was for the call light to be within reach at all times. The DON said some residents were able to move the call light, and she expected staff to check during rounds and place it within reach. She said the risk of the call light not being within reach was residents could not call for help. She said she did training on call lights, and the training record dated 01/02/25 was provided which showed CNA B was in attendance. Record review of the facility's Call Lights Answering policy, dated October 2010, reflected: . When the resident is in bed or confined to chair be sure the call light is within easy reach of the resident.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: The facility failed to ensure food temperatures were checked on 01/03/25 while on the steam table before serving residents between 7:00 AM to 8:30 AM. These failures could place residents, who receive food from the kitchen, at risk for food contamination and foodborne illness. Findings included: Observation on 01/03/25 in the kitchen revealed the following: 7:00 AM - a pan of oatmeal, scrambled eggs, pureed, mechanical soft meat were on the steam table uncovered; 7:23 AM - [NAME] A put omelets on the steam table; 7:25 AM - toast was taken out of the oven and place in a different pan and then put on the steam table; 7:40 AM - bacon was put on top of the steam table. [NAME] A plated food without checking the temperatures; 7:56 AM - trays for 100 Hall were completed and sent out; 7:57 AM - [NAME] A added bread to the steam table; 8:16 AM - trays for 200 Hall were completed and sent out; and 8:30 AM - trays for 300 Hall were completed and sent out. Interview on 01/03/25 at 8:35 AM with [NAME] A revealed she was running behind and did not check temperatures for the breakfast food before serving. [NAME] A stated by not checking the temperatures the residents could get food that were too cold or too hot. Interview on 01/03/25 at 8:45 AM with the Dietary Manager revealed the [NAME] was supposed to check temperatures on the steam table before food was served to the residents. She stated food could be contaminated, and the residents could be served cold food. She stated the temperatures were checked on the days that were blank on the temperature log for December and January. The Dietary Manager stated [NAME] A wrote the temperature logs and a different place. She stated the temperatures should be written down in the log book as the tempertures are checked. She stated she checked the temperature book, and she updated the temperature log to reflect those temperatures. Interview attempted to with the facility's Dietitian on 01/03/25 at 9:00 AM via telephone; however, the Dietitian did not call back prior to exit. Interview attempted with [NAME] N on 01/03/25 at 9:00 AM via telephone; however, [NAME] N did not call back prior to exit. Interview on 01/03/25 at 1:30 PM with the Administrator revealed dietary staff should be bringing trays out like 10 at a time to make sure the resident's food was hot, not setting up all the trays, and then serving the residents. Record review of the facility's Food Preparation and Service policy reflected: Cooking and holding temperatures and times: The danger zone for food temperatures is between 41 degrees and 135 degrees Fahrenheit. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. Potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt, and cottage cheese. The following internal cooking temperatures/times for specific foods must be reached to kill or sufficiently inactivate pathogenic microorganisms: 5.Poultry and stuffed foods - 165 F. Ground meat, ground fish and eggs held for service - at least 115 F Fish and other meats - 145 F for 15 seconds .Food Distribution and service .3. The temperature of foods held in steam tables will be monitored by food service staff .

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments for two (Medication Cart #1 and Medication Cart #2) of four medication carts and nurses' station counter (Hall 200- East Station) reviewed for medication storage. 1. The facility failed to lock Medication Cart #1 and Medication Cart #2 on 01/02/25, leaving all medications on the cart accessible on Hall 100 (West Station). 2. The facility failed to secure medications on the nurses' station counter on Hall 200 (East Station) on 01/03/25 at 5:30 AM. These failures could place residents at risk for drug diversions. Findings included: Observation on 01/02/25 at 3:30 PM revealed Medication Cart #1 was unlocked, and the top and second drawers were open completely facing a resident room. Observation of Medication Cart #2 revealed the medication cart was unlocked, and the drawers were facing the open entry way. Observation on 01/03/25 at 5:30 AM of the 200 Hall (East Station) revealed medications were left out unattended, in reach of residents, and visible at the nurses' station counter: *Theophylline ER 300 mg tab, quantity: 30 *Potassium CL Micro ER 10 meq tab, quantity: 30 *Aripiprazole 2 mg tab, quantity: 30 *Jardiance 10 mg tab, quantity: 14 *Escitalopram 10 mg tab, quantity: 30 *Atorvastatin 10 mg tab, quantity: 30 *Ezetimibe 10 mg tab, quantity: 30 *Levetiracetam 500 mg tab, quantity: 60 *Ranolazine ER 500 mg tab, quantity: 60 *Tamsulosin 0.4 mg cap, quantity: 60 *Eliquis 5 mg tab, quantity: 28 *Furosemide 20 mg tab, quantity: 30 *Isosorbide Dinitrate 20 mg tab, quantity: 90 *Metformin 1000 mg tab, quantity: 120 *Metoprolol Tartrate 75 mg tab, quantity: 60 Interview on 01/02/25 at 3:02 PM with MA H revealed medication carts were supposed to be locked when not in use. Interview on 01/03/25 at 5:35 AM with LVN G revealed the medications came in last night, and she was in the process of sorting out the medications and was putting the medications in the medication cart. Interview on 01/03/25 at 5:40 AM with LVN I, a PRN nurse, revealed medications were supposed to be put up in the medication cart or medication room when delivered. LVN I stated the medications were sorted out by name and put in the medication cart. LVN I stated residents could take the medications when left out or medication cart unlocked. Interview on 01/03/25 at 6:16 AM with LVN J revealed medication carts not being used were supposed to be locked at all times when not in use. LVN J stated residents could take medications that were left out. Interview on 01/03/25 at 6:35 AM with LVN K revealed medications could not be left out because residents could take the medications. LVN K stated medication carts could not be left unlocked when they were not being used. Interview on 01/03/25 at 11:50 AM with ADON A and ADON L revealed medications were supposed to be put up as soon as they came in. Medication carts were supposed to be locked when not being used. Interview on 01/03/25 at 1:10 PM with the DON revealed when medications were delivered the nurse should sign for the medications and put the medications away in the medication carts. DON C stated residents could take medications. Record review of the pharmacy delivery manifest dated 01/02/25 reflected the medications were delivered at 10:26 PM on 01/02/25. Record review of the facility's Security of Medication Cart, revised April 2007 reflected: The nurse must secure the medication cart during the medication pass to prevent unauthorized entry .3. The cart must be locked before nurse enters the resident's room .4. Medication carts must be securely locked at all times when out of the nurse's view.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 2 of 6 residents (Residents #34 and #3) reviewed for abuse. 1. The facility failed to ensure Resident #34 had the right to be free from abuse when she was verbally and mentally abused by the Weekend Activities Assistant on 07/14/24. 2. The facility failed to ensure Resident #3 had the right to be free from abuse when he was verbally and mentally abused by CNA U on 07/08/24. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 07/08/24 and ended on 07/14/24. The facility had corrected the noncompliance before the investigation began. These failures placed residents at risk of abuse, trauma, and psychosocial harm. Findings included: 1. Record review of Resident #34's Admission Record, dated 10/22/24, reflected the resident was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #34's Quarterly MDS Assessment, dated 09/13/24, reflected she had a BIMS score of 15, indicating no cognitive impairment. Her diagnoses included anxiety disorder (characterized by intense, excessive, and persistent worry and fear about everyday situations), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), and psychotic disorder (a group of serious mental illnesses that all have signs of psychosis, which is characterized by an impaired relationship with reality, often including confusion, hallucinations, and delusions). Record review of Resident #34's care plan, revised on 08/22/24, reflected the following: Focus: [Resident #34] is at risk for adverse psychosocial effects related to verbal allegation .Goal: Will have no indications of psychosocial well being problems by/through review date .Interventions: Consult with: Pastoral care, Social services, Psych services .When conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. Record review of Resident #34's Psychiatric Follow Up, dated 07/17/24, reflected: Staff reports: more tearful/withdrawn since an incident with staff member .Presents: in activity room with peers agreed to leave for interview .Subjective: 'not so good' said another resident came in her room and they kissed one night next day he changed details of the event to others, [the Weekend Activities Assistant] confronted her publicly about it. It made her uncomfortable, now feels others do not like her. Wants to isolate in her room to avoid perceived shame/judgement. [arrow up] dep/stress/anx denies- SI/HI, irritability, mania psychosis, insomnia, [arrow down] appetite no other concerns reported [sic]. Record review of Resident #34's Psychological Services Progress Note, dated 07/24/24, reflected: Patient's Response to Intervention: Pt is stressed and angry today - has had some conflicts with peers and is still upset and reactive to those - she is responsive to some de escalation and redirection to coping vs over focus on recent past incidents. Followed up with staff Record review of witness statement written by the Housekeeping Supervisor for Resident #34 dated 07/14/24 reflected: Today July 14, 2024, witnessed by the [WCN] and [MA D] & Nurse, The Weekend Activities Assistant said to resident 'You told [Resident #45] to come in the room, when he is not allowed in the room, and yall are going to be seperated to different facilitys.' Resident states she was yelling at her 'for kissing [Resident #45] and asking him to come in her room, and should have told him to leave the room.', Resident called her [family member] and told her about situation. Resident states she did not hit her but did not apreciate how she yelled at her, also that The Weekend Activities Assistant came to her room after word went to The Weekend Activities Assistant about situation and states- 'The Weekend Activities Assistant told me she was going to get fired because of her lying about it and you don't even feel bad about it.' Resident states- -[Resident #22] lied to [the Weekend Activities Assistant] and thats why she was trying to tell her to not allow him in her room but yelled at her. -Resident was Asked- Do you feel like you were abused?- -Residents Answer- 'No, just yelling and did not understand why [the Weekend Activities Assistant] came in here to tell her she is going to get her fired.' witness 1) X [signed by the WCN] 2) X __[blank]_______ X Resident [signed by Resident #34] X [signed by the Housekeeping Supervisor] [sic]. Observation and interview on 10/23/24 at 9:47 AM revealed Resident #34 lying in her bed in her room. Resident #34 said she was doing okay now but was very upset about what happened between her and the Weekend Activities Assistant. Resident #34 said the Weekend Activities Assistant had yelled at her because she thought something that was not true. Resident #34 said the Weekend Activities Assistant only wanted to believe the male resident, so she got mad at her and hurt her feelings by yelling at her. Resident #34 said it also embarrassed her because the Weekend Activities Assistant yelled at her in front of people and put her hand on her thigh. Resident #34 said she told someone about what happened and got the Weekend Activities Assistant fired for yelling at her. Resident #34 said it made her feel really bad about herself because it was in front of people who then took the Weekend Activities Assistant's side of things. Resident #34 said the situation made her cry and not want to leave her room. Resident #34 said lots of residents loved the Weekend Activities Assistant, including herself, until she yelled at her and things changed. Telephone interview on 10/24/24 at 8:28 AM with Resident #34's family member revealed the family member was called one day and was told the Weekend Activities Assistant was very rude to Resident #34 and touched her leg. Resident #34's family member said then the Weekend Activities Assistant came to Resident #34's room and told her it was all her fault, they let me go. Resident #34's family member said Resident #34 was very upset and crying over the situation. Resident #34's family member said the Weekend Activities Assistant was rude on many occasions to the residents at the facility. Telephone interview on 10/23/24 at 9:20 AM with the Weekend Activities Assistant revealed Resident #34 accused her of hitting and kicking her three times. The Weekend Activities Assistant said she never laid a hand on Resident #34. The Weekend Activities Assistant said she was terminated from the facility because she went to Resident #34's room and told the resident she should not have said those things. The Weekend Activities Assistant said she never retaliated against Resident #34. The Weekend Activities Assistant said when she talked to Resident #34 at the nurse's station, there were 3 nurses standing nearby and 5 other residents. The Weekend Activities Assistant said she never got loud while talking with Resident #34 but her voice was loud to begin with. The Weekend Activities Assistant said she told Resident #34 that the resident needed to decide who she wanted to be with and what she wanted to be. The Weekend Activities Assistant said she had this conversation with Resident #34 at the nurse's station with others nearby and they could hear the conversation. The Weekend Activities Assistant said she did not think the conversation would have been embarrassing to Resident #34. The Weekend Activities Assistant said she was originally suspended based on the allegation Resident #34 made. The Weekend Activities Assistant said she did not think talking to Resident #34 was abusive or went against her rights in any way. The Weekend Activities Assistant said she had called and still talked to residents at the facility but never discussed the situation regarding her being terminated. Record review of a witness statement written by the Housekeeping Supervisor dated 07/14/24 reflected: To whom it may concern, I [Housekeeping Supervisor], I was on the west hall when I overheard Resident #34 call her [family member] to tell her the activities person [the Weekend Activities Assistant] was cussing and yelling and kicking her legs. I informed the [WCN and the Administrator] of the situation after witnessing [CNA V] tell [the Weekend Activities Assistant] that [Resident #34] is claiming abuse by her and I saw [the Weekend Activities Assistant] storm off- from investigation- it was told to me by [Resident #34] & [the Weekend Activities Assistant] 'that [the Weekend Activities Assistant] went into room to confront resident about situation because you know I did not abuse you, you will get me fired'- the [WCN] and I [the Housekeeping Supervisor] conducted investigation and sent [the Weekend Activities Assistant] home for the day per request of Admin, until investigation is completed. [sic]. Interview on 10/23/24 at 10:16 AM with the Housekeeping Supervisor revealed she did not witness anything that happened between Resident #34 and the Weekend Activities Assistant on 07/14/24. The Housekeeping Supervisor said she was cleaning and coming down the hallway when Resident #34 was on the phone at the nurse's station with her family member and said that the Weekend Activities Assistant had yelled at her, was being very rude to her, and came into her room and touched her leg. The Housekeeping Supervisor said Resident #34 told her family member that she was being neglected and abused. The Housekeeping Supervisor said she went to tell the WCN who had given Resident #34 the telephone to begin with. The Housekeeping Supervisor said she called the Previous Administrator to tell her about the allegation that Resident #34 made. The Housekeeping Supervisor said she was told to go and talk to Resident #34 to get her story which was that the Weekend Activities Assistant had yelled at her at the nurse's station and in her room. The Housekeeping Supervisor said she went to talk to the Weekend Activities Assistant who said she had gone back to Resident #34's room to confront her. The Housekeeping Supervisor said she was told to send the Weekend Activities Assistant home that day on 07/14/24. The Housekeeping Supervisor said she knew to report any abuse or allegation immediately to the Administrator and would do so now, and that yelling at a resident was considered abuse. Interview on 10/23/24 at 10:43 AM with the Social Worker revealed Resident #34 and another resident in the facility were in a relationship until the male resident ended it. The Social Worker said Resident #34 was severely affected by it emotionally until the male resident tried to start up the relationship again. She said Resident #34 was not sure what to do and asked others to help her make the decision. She said the intention the Weekend Activities Assistant had in talking with Resident #34 about the situation was that either she wanted to be with the male resident or she did not, but the Weekend Activities Assistant did not want Resident #34 presenting one way to them and then another way to the male resident regarding their relationship. The Social Worker said on the day of the incident (07/14/24), the male resident went to Resident #34's room and there was some confusion as to whether Resident #34 invited him to see her or he went in on his own. She stated Resident #34 was already in an emotional state and misconstrued what the Weekend Activities Assistant said which was probably a training issue. The Social Worker said the problem with what the Weekend Activities Assistant did was when she went back to confront Resident #34 when she said to her look what you did, you got me fired. She stated this was not true, the Weekend Activities Assistant was only suspended pending the investigation at the time. The Social Worker said the real issue was that the Weekend Activities Assistant had talked to Resident #34 about the situation in front of everyone which made the resident feel embarrassed. The Social Worker said the Weekend Activities Assistant continued to be inappropriate when she was campaigning for herself to the other residents because the lines were blurred between employee and residents. The Social Workre said while the Weekend Activities Assistant was suspended pending the investigation, she had called residents on their personal cell phones which was viewed as retaliatory. The Social Worker said she spoke with Resident #34 who blamed herself for getting the Weekend Activities Assistant fired, so she explained to the resident that the Weekend Activities Assistant was terminated based upon her own actions. The Social Worker stated she followed-up with Resident #34 to ensure she was okay. She said she knew to report any abuse or allegation immediately to the Administrator and would do so now and that yelling at a resident was considered abuse. Record review of a witness statement written by MA D, dated 07/14/24, reflected: I [MA D], on the above date, 07/14/24, and approximate time of 0900 [9:00 AM], I did witness [the Weekend Activities Assistant], Activity Director approch down the hallway towards [Resident #34], she had mentioned to me [Resident #22] had left a grievance on her desk regarding [Resident #45] and [Resident #34]. She continued down the hallway to [Resident #34] at the nursing station, she was a little loud and showing concern towards [Resident #34]. I did witness what seemed to be [the Weekend Activities Assistant] a bit angry at the situation. I did not witness additional conversation as I was busy. End of report. [sic]. Interview on 10/23/24 at 2:05 PM with MA D revealed the Weekend Activities Assistant had verbally abused Resident #34 very loudly in the hallway where everyone could hear it and she wrote a witness statement about it. MA D said the Weekend Activities Assistant was very angry with Resident #34 because there was a grievance written about her. MA D said she saw the Weekend Activities Assistant in the hallway upset and in passing said she was so mad about the grievance. MA D said the Weekend Activities Assistant was upset because it was like a soap opera in the facility and said the Weekend Activities Assistant said she was sick of [Resident #34] crying for days about her male friend in the facility. MA D said the Weekend Activities Assistant was saying she was sick of [Resident #34] going back and forth with her male friend because he upset Resident #34 so much. MA D said she was down the hallway passing medications when she saw Resident #34 at the nurse's station in front of everyone and the charge nurse intervened to take Resident #34 to her room away from the Weekend Activities Assistant who had just yelled at her. MA D said Resident #34 was bawling, crying, and extremely visibly upset at what had just happened. MA D said Resident #34 was very emotional about the situation for a long time because the other residents were giving her a hard time because they loved the Weekend Activities Assistant. MA D said Resident #34 for a while and would not come out of her room after the situation had occurred. MA D said now Resident #34 has reintegrated again and people have stopped talking about what happened, but Resident #34 was blamed for the Weekend Activities Assistant being terminated by other residents. MA D said she knew to report any abuse or allegation immediately to the Administrator and would do so now, and that yelling at a resident was considered abuse. Record review of a witness statement written by the WCN and dated 07/14/24 reflected: In the morning at the nursing station west while [Resident #34] is at the nursing station awaiting for nurse to give pain pill, [Resident #45] passed by her and where talking and I saw [the Weekend Activities Assistant] start separating them because they kissed on Thursday and she was telling them not to be in the room together, and resident was refusing, I did not let him in my room, [the Weekend Activities Assistant] replies yes he said that you called him to come. [The Weekend Activities Assistant] voice tone was really loud, and ended having resident cry- stating that she should not yell at her in the presence of many people. No touching or hitting observed. After patient talking to [family member] state she's been abused by [the Weekend Activities Assistant], who yelled at her in public and Administrator was notified. [sic]. Interview on 10/24/24 at 8:15 AM with the WCN revealed she was standing at the nurse's station when the Weekend Activities Assistant came towards Resident #34. The WCN said apparently there was something that happened and she did not have the background information nor remembered the words that were said during the conversation between Resident #34 and the Weekend Activities Assistant. The WCN said the main thing she took away from it was that the Weekend Activities Assistant was yelling at Resident #34. The WCN said Resident #34 did not take it well trying and tried to tell the Weekend Activities Assistant that she did not do whatever she was accusing her of. The WCN said Resident #34 told the Weekend Activities Assistant you don't have to yell at me like that. The WCN said someone called the Previous Administrator and the Weekend Activities Assistant was to be sent home. The WCN said after the Weekend Activities Assistant was told to go home, the Weekend Activities Assistant went to Resident #34's room and said you got me fired. The WCN said Resident #34 told the Weekend Activities Assistant No, I didn't want to fire you. The WCN said the Weekend Activities Assistant should not have yelled at Resident #34, nor should she have had that conversation in public which made Resident #34 feel humiliated in front of people. The WCN said the situation happened at the nurse's station where other residents and staff were around. The WCN said when the Weekend Activities Assistant yelled at Resident #34, it was abuse even if that was how she talked that was not an excuse to treat a resident that way. The WCN said Resident #34 was crying a lot after the situation happened. The WCN said Resident #34 was at the nurse's station looking for her pain pill when she called her family member and told them that the Weekend Activities Assistant had humiliated and abused her. The WCN said staff should change the way they talk to a resident to remain respectful. The WCN said the Weekend Activities Assistant had yelled at Resident #34 twice at the nurse's station and then also went to her room on the way out of the building. The WCN said she did not consider the situation to be abuse at the time she witnessed it because she was new at the facility and other staff who witnessed it had said that was how the Weekend Activities Assistant normally talked but after the second time it happened that day, Resident #34 had called her family member to report it to them. The WCN said she did not like what was said to Resident #34 so she reported it to the Previous Administrator. The WCN said she knew to report any abuse or allegation immediately to the Administrator and would do so now, and that yelling at a resident was considered abuse. Record review of an undated witness statement written by CNA V reflected: In the morning on [blank space] [Resident #34] was @ the Desk crying I asked her what was going on she told me [the Weekend Activities Assistant] yelled @ her. And it wasn't right and who to talk to. I told the Nurse on duty that she wanted to report [the Weekend Activities Assistant] for yelling @ her. [sic]. Interview on 10/24/24 at 8:37 AM with CNA V revealed Resident #34 came up to her and said the Weekend Activities Assistant had yelled at her. CNA V said she told the nurse and Resident #34 was going to write a grievance about it. CNA V said Resident #34 was very upset and was crying about the situation. CNA V said she was not sure what happened or why the Weekend Activities Assistant had yelled at Resident #34. CNA V said Resident #34 had made an allegation of abuse. CNA V said she was not sure who the nurse was that told Resident #34 to file a grievance about the Weekend Activities Assistant yelling at her. CNA V said she knew to report any abuse or allegation immediately to the Administrator and would do so now, and that yelling at a resident was considered abuse. Interview on 10/24/24 at 9:00 AM with Resident #34's Psychiatric NP revealed he had cared for Resident #34 before and after the incident of abuse from 07/14/24. He stated Resident #34 was very sensitive and staff had to be aware of how they said things to her and where they said them. He stated the situation made Resident #34 feel very uncomfortable at the facility. He stated the situation with the Weekend Activities Assistant easily upset Resident #34 and made her self-isolate for a few weeks but that was just his guess on the timeline. The Psychiatric NP said Resident #34 was a very anxious resident who marinated/ruminated on things easily. He stated Resident #34 self-isolated because she felt as if others did not like her due to the Weekend Activities Assistant being fired. The Psychiatric NP said Resident #34 seemed back to normal now and was out of her room enjoying activities with others. During a confidential interview with a resident, the resident revealed she talked to the Weekend Activities Assistant often on the phone. The resident stated she was not supposed to say anything but was willing to tell the surveyor what they talked about sometimes. The resident said the Weekend Activities Assistant had yelled at her before, but she never reported it to anyone. The resident said she was cleaning up the activity room one day when the Weekend Activities Assistant walked up to her face and said, Why did you do that? Now I'm not going to be able to find anything in here! The resident said she wheeled out of the room away from the Weekend Activities Assistant. The resident said she and everyone else knew that the Weekend Activities Assistant had a temper, but that did not mean she could talk to people any kind of way. The resident said it made her feel bad that the Weekend Activities Assistant yelled at her, but she figured it was related to something with the Weekend Activities Assistant's home life because she knew things were not good. The resident said she knew the Weekend Activities Assistant had yelled at a few people, but no one ever reported her. She stated she was not sure why the Weekend Activities Assistant was always yelling. The resident said she was not afraid of the Weekend Activities Assistant but did not like that she yelled at people. The resident said she overheard the Weekend Activities Assistant yelling at Resident #34 because the Weekend Activities Assistant believed the male resident over Resident #34. The resident said the Weekend Activities Assistant got upset with Resident #34 and went to talk to her at the nurses' station. The resident said she was not sure why the Weekend Activities Assistant yelled at Resident #34 in front of everyone, but it made Resident #34 very upset, made her cry, and made her not want to leave her room for a while. The resident said the Weekend Activities Assistant should not have embarrassed Resident #34 that way by yelling at her in front of everyone or yelling at her in general but the Weekend Activities Assistant let her temper get the best of her. The resident said after the Weekend Activities Assistant had to leave the facility, she said it was because she broke a rule but the Resident was not allowed to tell anyone that was what the Weekend Activities Assistant had told her. Telephone interview on 10/24/24 at 3:00 PM with the Former Administrator revealed staff called her and told her Resident #34 made an allegation to them about the Weekend Activities Assistant, saying she cussed and yelled at her at the nurse's station. The Former Administrator told them what steps to take, including letting the Weekend Activities Assistant know she had to leave the building. The Former Administrator said the Weekend Activities Assistant did talk loud, so someone could perceive things as yelling or screaming. She stated as the Weekend Activities Assistant was leaving the facilitiy she was retaliatory towards Resident #34. She stated the Weekend Activities Assistant put her hands on her hips and told Resident #34, Why did you say all those lies about me? You got me fired., as she was leaving the building. The Former Administrator said Resident #34 had psychological issues that could be perpetuated by the Weekend Activities Assistant's behavior towards her. She stated she had to ask the Weekend Activities Assistant not to call the residents anymore because it was putting fuel on the fire regarding her behavior because she made the residents worried about her after she got fired. She stated the Weekend Activities Assistant could not separate the residents as customers of hers and honor them with respect instead of treating them like they were her family members. The Former Administrator said a resident had reported to her that the Weekend Activities Assistant had talked loud and hateful to some people especially if they gossiped, and the residents talked about her like she was another resident and not like an employee. She stated a resident had reported that the Weekend Activities Assistant did get mad and raised her voice but she still loved the residents. She said she had to tell the resident that she still had a duty to fulfill as the Administrator to keep the residents safe. Record review of a witness statement from the Weekend Activities Assistant, dated 07/14/24 reflected: Upon arrival, I saw the grievance on the floor from [Resident #22], stating that [Resident #45] keeps coming into thier private living area uninvited, after being told to stay away- I went to [Resident #45], asked him why he can't follow our wishes to stay away from [Resident #34]. He again said 'ok, I wont go in there anymore, but tell her to quit telling me to come in.' After that, I went to [Resident #34] and asked her what happened- her story was that she doesn't want anything to do with him and he is the one that keeps pursuing her- I asked her if she knew how much this affected her Roommate- And that [Resident #22] was told by [Resident #34] that [Resident #45] had kissed her, but her story changed 3X, [Resident #34], says that I hit her leg- This is simply a bald-face lie- I did not put my hand on her, in anyway shape or form This statement is true- [signed by the Weekend Activities Assistant] [sic]. Record review of an undated and unsigned witness statement that was included in the facility's provider investigation report evidence reflected: .Even tho, [the Weekend Activities Assistant] has a temper. She was upset with us before, but we know, she loves us .If [the Weekend Activities Assistant] needs to control that more have her talk with someone .[sic]. Record review of the facility's Provider Investigation Report, dated 07/22/24, reflected an incident date of 07/14/24 involving Resident #34 and the Weekend Activities Assistant. For the Description of the Allegation section was: Resident alleged the activity director hit her leg and yelled at her at the nurses station for kissing another resident who is no longer her friend. The Provider Response section reflected: Activity director was sent home on suspension as a precaution on Sunday following the communication. She then alleged it was abuse on Monday and no longer inappropriate comments. Resident did say that [the Weekend Activities Assistant] never hit her. She tapped her on the leg bending down to speak to her while she was sitting in her wc at the ns. Interviews with staff and other residents was completed to determine any other witnesses possible or other information related to the investigation. Education continues for MANE. Additional training added regarding separation of employees and residents and a healthy, professional boundary. Psych services were called. MD called. Medical director informed. Planned call with [Resident #34's family member] on 7/23/2024 to review final findings of the investigation [sic]. The Investigation Summary reflected: [The Weekend Activities Assistant's] communication was witnessed at the station to be loud and with her usual deep, loud voice .The problem is that the employee was informed later about the resident's comments by another CNA. She became upset and went back to resident in her room with hands on hip saying, 'Why did you lie about me.' 'You got me fired. You don't even care.' The activity director then started calling around to other residents on their personal cell phones to discuss her being upset she got fired perpetuating the theatrics of the matter further placing [Resident #34] at risk for feeling the act director has retaliated against her for reporting the matter. The resident says she frequently pits one resident against another with comments or actions .She had been counseled on multiple occasions about toning down her voice, and remaining focused on her personal feelings or beliefs with regard to residents and their needs. We feel she struggles to separate her being the residents 'friends' and being their paid employee and understanding her responses are required to be above reproach. We found through interviews, she is still calling the residents as of this evening of this report. She told another resident via text that '[Resident #34] ruined her life.' .It is unclear why she intentionally went down to the residents' room to 'confront her'. Regardless, it was inappropriate and with disregard for or lack of true understanding of the consequences of her actions. [sic]. The Provider Action Taken Post-Investigation section reflected: We recommend termination of employee for violating our policy for abuse, neglect, and retaliation/fear of reprisal for any resident. We will Continue training and add the communications and inappropriate texts and messaging to the training. Separation is required for employees. We treat our residents like family but there is a professional line. Ongoing monitoring for resident continues to ensure there are no lasting adverse outcomes related to this incident. Counseling as necessary for support services for resident. SW and Administrator will continue checking ins. [sic]. The facility investigation findings confirmed abuse had occurred. Record review of the grievances binder and log for the last three months revealed there was no grievance on file regarding the Weekend Activities Assistant yelling at Resident #34. Record review of an undated and untitled paper provided by the facility reflected personnel information for the Weekend Activities Assistant including a position start date of 11/18/20, a termination date of 07/30/24 with a termination reason of Gross Misconduct; a last work date of 07/14/24 and comments of Discourtesy to residents .please refer to separation notice. Record review of an in-service, dated 07/14/24, reflected staff were trained on the facility's policy regarding abuse and neglect, including when, what, and to whom abuse should be reported to; the WCN and CNA V had both signed the in-service. 2. Record review of Resident #3's Admission Record, dated 10/22/24, reflected the resident was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #3's Annual MDS Assessment, dated 10/04/24, reflected he had a BIMS score of 13, indicating no cognitive impairment. Further review revealed he had a diagnosis of cerebral palsy (a group of conditions that affect movement and posture. It's caused by damage that occurs to the developing brain, most often before birth). Observation and interview on 10/23/24 at 9:30 AM of Resident #3 revealed he was in his wheelchair in the dining room alone. Resident #3 was able to remember when the CNA yelled at him. Resident #3 said the CNA was very mean to him and he felt it was abusive. Resident #3 said it made him feel bad when it happened. Resident #3 said the CNA got fired and now staff treat him very well. Record review of the facility's Provider Investigation Report dated 07/15/24 reflected the facility reported an incident involved Resident #3 on 07/08/24. The description of the allegation reflected: .The maintenance director

Based on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse and neglect of residents for 2 of 6 residents (Residents #34 and #3) reviewed for abuse. 1. The facility failed to protect Resident #34 from retaliation after the Weekend Activities Assistant was suspended based on an allegation of abuse on 07/14/24. 2. The facility failed to protect Resident #3 from verbal and mental abuse by CNA U on 07/08/24. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 07/08/24 and ended on 07/14/24. The facility had corrected the noncompliance before the investigation began. These failures placed residents at risk of ongoing abuse, trauma, and psychosocial harm. Findings included: 1. Record review of the facility's policy, revised December 2016, and titled Abuse Investigation and Reporting reflected: .5. The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. [sic]. Record review of Resident #34's Admission Record, dated 10/22/24, reflected the resident was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #34's Quarterly MDS Assessment, dated 09/13/24, reflected she had a BIMS score of 15, indicating no cognitive impairment. Her diagnoses included anxiety disorder (characterized by intense, excessive, and persistent worry and fear about everyday situations), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), and psychotic disorder (a group of serious mental illnesses that all have signs of psychosis, which is characterized by an impaired relationship with reality, often including confusion, hallucinations, and delusions). Record review of Resident #34's care plan, revised on 08/22/24, reflected the following: Focus: [Resident #34] is at risk for adverse psychosocial effects related to verbal allegation .Goal: Will have no indications of psychosocial well being problems by/through review date .Interventions: Consult with: Pastoral care, Social services, Psych services .When conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. Record review of Resident #34's Psychiatric Follow Up, dated 07/17/24, reflected: Staff reports: more tearful/withdrawn since an incident with staff member .Presents: in activity room with peers agreed to leave for interview .Subjective: 'not so good' said another resident came in her room and they kissed one night next day he changed details of the event to others, [the Weekend Activities Assistant] confronted her publicly about it. It made her uncomfortable, now feels others do not like her. Wants to isolate in her room to avoid perceived shame/judgement. [arrow up] dep/stress/anx denies- SI/HI, irritability, mania psychosis, insomnia, [arrow down] appetite no other concerns reported [sic]. Record review of Resident #34's Psychological Services Progress Note, dated 07/24/24, reflected: Patient's Response to Intervention: Pt is stressed and angry today - has had some conflicts with peers and is still upset and reactive to those - she is responsive to some de escalation and redirection to coping vs over focus on recent past incidents. Followed up with staff Record review of witness statement written by the Housekeeping Supervisor for Resident #34 dated 07/14/24 reflected: Today July 14, 2024, witnessed by the [WCN] and [MA D] & Nurse, The Weekend Activities Assistant said to resident 'You told [Resident #45] to come in the room, when he is not allowed in the room, and yall are going to be seperated to different facilitys.' Resident states she was yelling at her 'for kissing [Resident #45] and asking him to come in her room, and should have told him to leave the room.', Resident called her [family member] and told her about situation. Resident states she did not hit her but did not apreciate how she yelled at her, also that The Weekend Activities Assistant came to her room after word went to The Weekend Activities Assistant about situation and states- 'The Weekend Activities Assistant told me she was going to get fired because of her lying about it and you don't even feel bad about it.' Resident states- -[Resident #22] lied to [the Weekend Activities Assistant] and thats why she was trying to tell her to not allow him in her room but yelled at her. -Resident was Asked- Do you feel like you were abused?- -Residents Answer- 'No, just yelling and did not understand why [the Weekend Activities Assistant] came in here to tell her she is going to get her fired.' witness 1) X [signed by the WCN] 2) X __[blank]_______ X Resident [signed by Resident #34] X [signed by the Housekeeping Supervisor] [sic]. Observation and interview on 10/23/24 at 9:47 AM revealed Resident #34 lying in her bed in her room. Resident #34 said she was doing okay now but was very upset about what happened between her and the Weekend Activities Assistant. Resident #34 said the Weekend Activities Assistant had yelled at her because she thought something that was not true. Resident #34 said the Weekend Activities Assistant only wanted to believe the male resident, so she got mad at her and hurt her feelings by yelling at her. Resident #34 said it also embarrassed her because the Weekend Activities Assistant yelled at her in front of people and put her hand on her thigh. Resident #34 said she told someone about what happened and got the Weekend Activities Assistant fired for yelling at her. Resident #34 said it made her feel really bad about herself because it was in front of people who then took the Weekend Activities Assistant's side of things. Resident #34 said the situation made her cry and not want to leave her room. Resident #34 said lots of residents loved the Weekend Activities Assistant, including herself, until she yelled at her and things changed. Telephone nterview on 10/24/24 at 8:28 AM with Resident #34's family member revealed she was called one day and was told that the Weekend Activities Assistant was very rude to Resident #34 and touched her leg. Resident #34's family member said then the Weekend Activities Assistant came to Resident #34's room and told her it was all her fault, they let me go. Resident #34's family member said Resident #34 was very upset and crying over the situation. Resident #34's family member said the Weekend Activities Assistant was rude on many occasions to the residents at the facility. Telephone interview on 10/23/24 at 9:20 AM with the Weekend Activities Assistant revealed Resident #34 accused her of hitting and kicking her three times. She stated she never laid a hand on Resident #34. She said she was terminated from the facility because she went to Resident #34's room and told the resident she should not have said those things. The Weekend Activities Assistant said she never retaliated against Resident #34. She said when she talked to Resident #34 at the nurses' station, there were 3 nurses standing nearby and 5 other residents. The Weekend Activities Assistant said she never got loud while talking with Resident #34, but her voice was loud to begin with. She said she told Resident #34 that the resident needed to decide who she wanted to be with and what she wanted to be. She said she had this conversation with Resident #34 at the nurse's station with others nearby and they could hear the conversation. The Weekend Activities Assistant said she did not think the conversation would have been embarrassing to Resident #34. She said she was originally suspended based on the allegation Resident #34 made. She said she did not think talking to Resident #34 was abusive or went against her rights in any way. The Weekend Activities Assistant said she had called and still talked to residents at the facility but never discussed the situation regarding her being terminated. Record review of a witness statement written by the Housekeeping Supervisor dated 07/14/24 reflected: To whom it may concern, I [Housekeeping Supervisor], I was on the west hall when I overheard Resident #34 call her [family member] to tell her the activities person [the Weekend Activities Assistant] was cussing and yelling and kicking her legs. I informed the [WCN and the Administrator] of the situation after witnessing [CNA V] tell [the Weekend Activities Assistant] that [Resident #34] is claiming abuse by her and I saw [the Weekend Activities Assistant] storm off- from investigation- it was told to me by [Resident #34] & [the Weekend Activities Assistant] 'that [the Weekend Activities Assistant] went into room to confront resident about situation because you know I did not abuse you, you will get me fired'- the [WCN] and I [the Housekeeping Supervisor] conducted investigation and sent [the Weekend Activities Assistant] home for the day per request of Admin, until investigation is completed [sic]. Interview on 10/23/24 at 10:16 AM with the Housekeeping Supervisor revealed she did not witness anything that happened between Resident #34 and the Weekend Activities Assistant on 07/14/24. She said she was cleaning and coming down the hallway when Resident #34 was on the phone at the nurse's station with her family member and said that the Weekend Activities Assistant had yelled at her, was being very rude to her, and came into her room and touched her leg. She said Resident #34 told her family member that she was being neglected and abused. The Housekeeping Supervisor said she went to tell the WCN who had given Resident #34 the telephone to begin with. She said she called the Former Administrator to tell her about the allegation that Resident #34 made. The Housekeeping Supervisor said she was told to go and talk to Resident #34 to get her story which was that the Weekend Activities Assistant had yelled at her at the nurse's station and in her room. She said she went to talk to the Weekend Activities Assistant who said she had gone back to Resident #34's room to confront her. She said she was told to send the Weekend Activities Assistant home that day on 07/14/24. The Housekeeping Supervisor said she knew to report any abuse or allegation immediately to the Administrator and would do so now, and that yelling at a resident was considered abuse. Interview on 10/23/24 at 10:43 AM with the Social Worker revealed Resident #34 and another resident in the facility were in a relationship until the male resident ended it. She said Resident #34 was severely affected by it emotionally until the male resident tried to start up the relationship again. The Social Worker said Resident #34 was not sure what to do and asked others to help her make the decision. She said the intention the Weekend Activities Assistant had in talking with Resident #34 about the situation was that either she wanted to be with the male resident or she did not, but the Weekend Activities Assistant did not want Resident #34 presenting one way to them and then another way to the male resident regarding their relationship. She said on the day of the incident (07/14/24), the male resident went to Resident #34's room and there was some confusion as to whether Resident #34 invited him to see her or he went in on his own. The Social Worker said Resident #34 was already in an emotional state and misconstrued what the Weekend Activities Assistant said which was probably a training issue. She stated the problem with what the Weekend Activities Assistant did was when she went back to confront Resident #34 and she said to her, look what you did, you got me fired. The Social Worker said this was not true, the Weekend Activities Assistant was only suspended pending the investigation at the time. She said the real issue was that the Weekend Activities Assistant had talked Resident #34 about the situation in front of everyone which made the resident feel embarrassed. She said the Weekend Activities Assistant continued to be inappropriate when she was campaigning for herself to the other residents because the lines were blurred between employee and residents. The Social Worker said while the Weekend Activities Assistant was suspended pending the investigation, she had called residents on their personal cell phones which was viewed as retaliatory. She said she spoke with Resident #34 who blamed herself for getting the Weekend Activities Assistant fired, so she explained that she was terminated based on her own actions. The Social Worker said she followed up with Resident #34 to ensure she was okay. She said she knew to report any abuse or allegation immediately to the Administrator and would do so now, and that yelling at a resident was considered abuse. Record review of a witness statement written by MA D, dated 07/14/24, reflected: I [MA D], on the above date, 07/14/24, and approximate time of 0900 [9:00 AM], I did witness [the Weekend Activities Assistant], Activity Director approch down the hallway towards [Resident #34], she had mentioned to me [Resident #22] had left a grievance on her desk regarding [Resident #45] and [Resident #34]. She continued down the hallway to [Resident #34] at the nursing station, she was a little loud and showing concern towards [Resident #34]. I did witness what seemed to be [the Weekend Activities Assistant] a bit angry at the situation. I did not witness additional conversation as I was busy. End of report. [sic]. Interview on 10/23/24 at 2:05 PM with MA D revealed the Weekend Activities Assistant had verbally abused Resident #34 very loudly in the hallway where everyone could hear it and she wrote a witness statement about it. MA D said the Weekend Activities Assistant was very angry with Resident #34 because there was a grievance written about her. MA D said she saw the Weekend Activities Assistant in the hallway upset and in passing said she was so mad about the grievance. MA D said the Weekend Activities Assistant was upset because it was like a soap opera in the facility and said the Weekend Activities Assistant said she was sick of [Resident #34] crying for days about her male friend in the facility. MA D said the Weekend Activities Assistant was saying she was sick of [Resident #34] going back and forth with her male friend because he upset Resident #34 so much. MA D said she was down the hallway passing medications when she saw Resident #34 at the nurse's station in front of everyone and the charge nurse intervened to take Resident #34 to her room away from the Weekend Activities Assistant who had just yelled at her. MA D said Resident #34 was bawling, crying, and extremely visibly upset at what had just happened. MA D said Resident #34 was very emotional about the situation for a long time because the other residents were giving her a hard time because they loved the Weekend Activities Assistant. MA D said Resident #34 for a while and would not come out of her room after the situation had occurred. MA D said now Resident #34 has reintegrated again and people have stopped talking about what happened, but Resident #34 was blamed for the Weekend Activities Assistant being terminated by other residents. MA D said she knew to report any abuse or allegation immediately to the Administrator and would do so now, and that yelling at a resident was considered abuse. Record review of a witness statement written by the WCN and dated 07/14/24 reflected: In the morning at the nursing station west while [Resident #34] is at the nursing station awaiting for nurse to give pain pill, [Resident #45] passed by her and where talking and I saw [the Weekend Activities Assistant] start separating them because they kissed on Thursday and she was telling them not to be in the room together, and resident was refusing, I did not let him in my room, [the Weekend Activities Assistant] replies yes he said that you called him to come. [The Weekend Activities Assistant] voice tone was really loud, and ended having resident cry- stating that she should not yell at her in the presence of many people. No touching or hitting observed. After patient talking to [family member] state she's been abused by [the Weekend Activities Assistant], who yelled at her in public and Administrator was notified. [sic]. Interview on 10/24/24 at 8:15 AM with the WCN revealed she was standing at the nurse's station when the Weekend Activities Assistant came towards Resident #34. The WCN said apparently there was something that happened and she did not have the background information nor remembered the words that were said during the conversation between Resident #34 and the Weekend Activities Assistant. The WCN said the main thing she took away from it was that the Weekend Activities Assistant was yelling at Resident #34. The WCN said Resident #34 did not take it well trying and tried to tell the Weekend Activities Assistant that she did not do whatever she was accusing her of. The WCN said Resident #34 told the Weekend Activities Assistant you don't have to yell at me like that. The WCN said someone called the Former Administrator and the Weekend Activities Assistant was to be sent home. The WCN said after the Weekend Activities Assistant was told to go home, the Weekend Activities Assistant went to Resident #34's room and said you got me fired. The WCN said Resident #34 told the Weekend Activities Assistant No, I didn't want to fire you. The WCN said the Weekend Activities Assistant should not have yelled at Resident #34, nor should she have had that conversation in public which made Resident #34 feel humiliated in front of people. The WCN said the situation happened at the nurse's station where other residents and staff were around. The WCN said when the Weekend Activities Assistant yelled at Resident #34, it was abuse even if that was how she talked that was not an excuse to treat a resident that way. The WCN said Resident #34 was crying a lot after the situation happened. The WCN said Resident #34 was at the nurse's station looking for her pain pill when she called her family member and told them that the Weekend Activities Assistant had humiliated and abused her. The WCN said staff should change the way they talk to a resident to remain respectful. The WCN said the Weekend Activities Assistant had yelled at Resident #34 twice at the nurse's station and then also went to her room on the way out of the building. The WCN said she did not consider the situation to be abuse at the time she witnessed it because she was new at the facility and other staff who witnessed it had said that was how the Weekend Activities Assistant normally talked but after the second time it happened that day, Resident #34 had called her family member to report it to them. The WCN said she did not like what was said to Resident #34 so she reported it to the Former Administrator. The WCN said she knew to report any abuse or allegation immediately to the Administrator and would do so now, and that yelling at a resident was considered abuse. Record review of an undated witness statement written by CNA V reflected: In the morning on [blank space] [Resident #34] was [at] the Desk crying I asked her what was going on she told me [the Weekend Activities Assistant] yelled [at] her. And it wasn't right and who to talk to. I told the Nurse on duty that she wanted to report [the Weekend Activities Assistant] for yelling [at] her [sic]. Interview on 10/24/24 at 8:37 AM with CNA V revealed Resident #34 came up to her and said the Weekend Activities Assistant had yelled at her. CNA V said she told the nurse and Resident #34 was going to write a grievance about it. CNA V said Resident #34 was very upset and was crying about the situation. CNA V said she was not sure what happened or why the Weekend Activities Assistant had yelled at Resident #34. CNA V said Resident #34 had made an allegation of abuse. CNA V said she was not sure who the nurse was that told Resident #34 to file a grievance about the Weekend Activities Assistant yelling at her. CNA V said she knew to report any abuse or allegation immediately to the Administrator and would do so now, and that yelling at a resident was considered abuse. Interview on 10/24/24 at 9:00 AM with Resident #34's Psychiatric NP revealed he had cared for Resident #34 before and after the incident of abuse from 07/14/24. He stated Resident #34 was very sensitive and staff had to be aware of how they said things to her and where they said it. He stated the situation made Resident #34 feel very uncomfortable at the facility. He said the situation with the Weekend Activities Assistant easily upset Resident #34 and made her self-isolate for a few weeks but that was just his guess on the timeline. Resident #34's Psychiatric NP said Resident #34 was a very anxious resident who marinated/ruminated on things easily. He said Resident #34 self-isolated because she felt as if others did not like her due to the Weekend Activities Assistant being fired. He stated Resident #34 seemed back to normal now and was out of her room enjoying activities with others. During a confidential interview with a resident, the resident revealed she talked to the Weekend Activities Assistant often on the phone and she was not supposed to say anything but was willing to tell the surveyor what they talked about sometimes. The resident said the Weekend Activities Assistant had yelled at her before, but she never reported it to anyone. The resident said she was cleaning up the activity room one day when the Weekend Activities Assistant walked up to her face and said, Why did you do that? Now I'm not going to be able to find anything in here! The resident said she wheeled out of the room away from the Weekend Activities Assistant. The resident said she and everyone else knew that the Weekend Activities Assistant had a temper but that did not mean she could talk to people any kind of way. The resident said it made her feel bad that the Weekend Activities Assistant yelled at her but she figured it was related to something with the Weekend Activities Assistant's home life because she knew things were not good. The resident said that she knew the Weekend Activities Assistant had yelled at a few people but no one ever reported her and she was not sure why the Weekend Activities Assistant was always yelling. The resident said she was not afraid of the Weekend Activities Assistant but did not like that she yelled at people. The resident said she overheard the Weekend Activities Assistant yelling at Resident #34 because the Weekend Activities Assistant believed the male resident over Resident #34. The resident said the Weekend Activities Assistant got upset with Resident #34 and went to talk to her at the nurse's station. The resident said she was not sure why the Weekend Activities Assistant yelled at Resident #34 in front of everyone but it made Resident #34 very upset, made her cry, and made her not want to leave her room for a while. The resident said the Weekend Activities Assistant should not have embarrassed Resident #34 that way by yelling at her in front of everyone or yelling at her in general but the Weekend Activities Assistant let her temper get the best of her. The resident said after the Weekend Activities Assistant had to leave the facility, she said it was because she broke a rule but the Resident was not allowed to tell anyone that was what the Weekend Activities Assistant had told her. Telephone interview on 10/24/24 at 3:00 PM with the Former Administrator revealed staff called her and told her that Resident #34 made an allegation to them about the Weekend Activities Assistant, saying she cussed and yelled at her at the nurse's station. She stated she told them what steps to take, including letting the Weekend Activities Assistant know she has to leave out of the building. She said the Weekend Activities Assistant did talk loud and so someone could perceive things as yelling or screaming. The Former Administrator said on the Weekend Activities Assistant's way out of the facility she was retaliatory towards Resident #34 when she put her hands on her hips and told Resident #34 Why did you say all those lies about me? You got me fired. while she was leaving the building. She stated Resident #34 had psychological issues that could be perpetuated by the Weekend Activities Assistant's behavior towards her. The Former Administrator said she had to ask the Weekend Activities Assistant not to call the residents anymore because it was putting fuel on the fire regarding her behavior because she made the residents worried about her after she got fired. She said the Weekend Activities Assistant could not separate the residents as customers of hers and honor them with respect instead of treating them like they were her family members. The Former Administrator said a resident had reported to her that the Weekend Activities Assistant had talked loud and hateful to some people especially if they gossiped and the residents talked about her like she was another resident and not like an employee. She said a resident had reported that the Weekend Activities Assistant did get mad and raised her voice but she still loved the residents. The Former Administrator said she had to tell the resident that she still had a duty to fulfill as the Administrator to keep the residents safe. Record review of a witness statement from the Weekend Activities Assistant, dated 07/14/24 reflected: Upon arrival, I saw the grievance on the floor from [Resident #22], stating that [Resident #45] keeps coming into thier private living area uninvited, after being told to stay away- I went to [Resident #45], asked him why he can't follow our wishes to stay away from [Resident #34]. He again said 'ok, I wont go in there anymore, but tell her to quit telling me to come in.' After that, I went to [Resident #34] and asked her what happened- her story was that she doesn't want anything to do with him and he is the one that keeps pursuing her- I asked her if she knew how much this affected her Roommate- And that [Resident #22] was told by [Resident #34] that [Resident #45] had kissed her, but her story changed 3X, [Resident #34], says that I hit her leg- This is simply a bald-face lie- I did not put my hand on her, in anyway shape or form This statement is true- [signed by the Weekend Activities Assistant] [sic]. Record review of an undated and unsigned witness statement that was included in the facility's provider investigation report evidence reflected: .Even tho, [the Weekend Activities Assistant] has a temper. She was upset with us before, but we know, she loves us .If [the Weekend Activities Assistant] needs to control that more have her talk with someone [sic] Record review of the facility's Provider Investigation Report, dated 07/22/24, reflected an incident date of 07/14/24 involving Resident #34 and the Weekend Activities Assistant. The Description of the Allegation section reflected: Resident alleged the activity director hit her leg and yelled at her at the nurses station for kissing another resident who is no longer her friend. The Provider Response section reflected: Activity director was sent home on suspension as a precaution on Sunday following the communication. She then alleged it was abuse on Monday and no longer inappropriate comments. Resident did say that [the Weekend Activities Assistant] never hit her. She tapped her on the leg bending down to speak to her while she was sitting in her wc at the ns. Interviews with staff and other residents was completed to determine any other witnesses possible or other information related to the investigation. Education continues for MANE. Additional training added regarding separation of employees and residents and a healthy, professional boundary. Psych services were called. MD called. Medical director informed. Planned call with [Resident #34's family member] on 7/23/2024 to review final findings of the investigation [sic]. The Investigation Summary reflected: [The Weekend Activities Assistant's] communication was witnessed at the station to be loud and with her usual deep, loud voice .The problem is that the employee was informed later about the resident's comments by another Cna. She became upset and went back to resident in her room with hands on hip saying, 'Why did you lie about me.' 'You got me fired. You don't even care.' The activity director then started calling around to other residents on their personal cell phones to discuss her being upset she got fired perpetuating the theatrics of the matter further placing [Resident #34] at risk for feeling the act director has retaliated against her for reporting the matter. The resident says she frequently pits one resident against another with comments or actions .She had been counseled on multiple occasions about toning down her voice, and remaining focused on her personal feelings or beliefs with regard to residents and their needs. We feel she struggles to separate her being the residents 'friends' and being their paid employee and understanding her responses are required to be above reproach. We found through interviews, she is still calling the residents as of this evening of this report. She told another resident via text that '[Resident #34] ruined her life.' .It is unclear why she intentionally went down to the residents' room to 'confront her'. Regardless, it was inappropriate and with disregard for or lack of true understanding of the consequences of her actions. [sic]. The Provider Action Taken Post-Investigation section reflected: We recommend termination of employee for violating our policy for abuse, neglect, and retaliation/fear of reprisal for any resident. We will Continue training and add the communications and inappropriate texts and messaging to the training. Separation is required for employees. We treat our residents like family but there is a professional line. Ongoing monitoring for resident continues to ensure there are no lasting adverse outcomes related to this incident. Counseling as necessary for support services for resident. SW and Administrator will continue checking ins. [sic]. The Facility Investigation Findings confirmed abuse had occurred. Record review of the grievances binder and log for the last 3 months revealed there was no grievance on file regarding the Weekend Activities Assistant yelling at Resident #34. Record review of an undated and untitled paper provided by the facility reflected personnel information for the Weekend Activities Assistant including a position start date of 11/18/20, a termination date of 07/30/24 with a termination reason of Gross Misconduct; a last work date of 07/14/24 and comments of Discourtesy to residents .please refer to separation notice. Record review of an in-service, dated 07/14/24, reflected staff were trained on the facility's policy regarding abuse and neglect, including when, what, and to whom abuse should be reported to; the WCN and CNA V had both signed the in-service. 2. Record review of Resident #3's Admission Record, dated 10/22/24, reflected the resident was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #3's Annual MDS Assessment, dated 10/04/24, reflected he had a BIMS score of 13, indicating no cognitive impairment. Further review revealed he had a diagnosis of cerebral palsy (a group of conditions that affect movement and posture. It's caused by damage that occurs to the developing brain, most often before birth). Observation and interview on 10/23/24 at 9:30 AM revealed Resident #3 in his wheelchair in the dining room alone. Resident #3 was able to remember when the CNA yelled at him. Resident #3 said the CNA was very mean to him, and he felt it was abusive. Resident #3 said it made him feel bad when it happened. Resident #3 said the CNA got fired and now staff treat him very well. Record review of the facility's Provider Investigation Report dated 07/15/24 reflected the facility reported an incident involved Resident #3 on 07/08/24. The description of the allegation section reflected: .The maintenance director then saw and heard the employee yell at [Resident #3] to get in his room . The Description of the assessment section reflected: [Resident #3] feels she was rude yelling at him to go to his roo[TRUNCATED]

Based on interview and record review, the facility failed to ensure all alleged violations involving abuse or neglect were reported to the facility Administrator immediately but no later than 2 hours for 1 of 6 residents (Resident #34) reviewed for abuse and neglect. The facility failed to immediately notify their Abuse Coordinator (the Former Administrator) when the Weekend Activities Assistant had yelled at Resident #34 at the nurse's station in front of other residents and staff on 07/14/24. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 07/14/24 and ended on 07/14/24. The facility had corrected the noncompliance before the investigation began. This failure placed residents at risk of continued abuse, trauma, and psychosocial harm. Findings included: Record review of the facility's Reporting Abuse to Facility Management policy, revised December 2009 reflected the following: It is the responsibility of our employees, facility consultants, Attending Physicians, family members, visitors etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management .3. All personnel, residents, family members, visitors, etc., are encouraged to report incidents of resident abuse or suspected incidents of abuse .9. When an incident of resident abuse is suspected or confirmed, the incident must be immediately reported to facility management regardless of the time lapse since the incident occurred. Reporting procedures should be followed as outlined in this policy. Record review of Resident #34's Admission Record, dated 10/22/24, reflected the was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #34's Quarterly MDS Assessment, dated 09/13/24, reflected she had a BIMS score of 15, indicating no cognitive impairment. Her diagnoses included anxiety disorder (characterized by intense, excessive, and persistent worry and fear about everyday situations), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), and psychotic disorder (a group of serious mental illnesses that all have signs of psychosis, which is characterized by an impaired relationship with reality, often including confusion, hallucinations, and delusions). Record review of Resident #34's care plan, revised on 08/22/24, reflected the following: Focus: [Resident #34 is at risk for adverse psychosocial effects related to verbal allegation .Goal: Will have no indications of psychosocial well being problems by/through review date .Interventions: Consult with: Pastoral care, Social services, Psych services .When conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. Observation and interview on 10/23/24 at 9:47 AM revealed Resident #34 lying in her bed in her room. Resident #34 said she was doing okay now but was very upset about what happened between her and the Weekend Activities Assistant. Resident #34 said the Weekend Activities Assistant had yelled at her because she thought the resident said something to her friend by telling him to come to her room but she never told him to do that. Resident #34 said the Weekend Activities Assistant only wanted to believe the male resident, so she got mad at Resident #34 and hurt her feelings by yelling at her. Resident #34 said it also embarrassed her because the Weekend Activities Assistant yelled at her in front of people and put her hand on her thigh. Resident #34 said she told someone about what happened and got the Weekend Activities Assistant fired for yelling at her. Resident #34 said it made her feel really bad about herself because it was in front of people who then took the Weekend Activities Assistant's side of things. Resident #34 said the situation made her cry and not want to leave her room. Resident #34 said lots of residents loved the Weekend Activities Assistant, including herself, until she yelled at her and things changed. Telephone interview on 10/24/24 at 8:28 AM with Resident #34's family member revealed she was called one day and was told that the Weekend Activities Assistant was very rude to Resident #34 and touched her leg. Resident #34's family member said then the Weekend Activities Assistant came to Resident #34's room and told her it was all her fault, they let me go. Resident #34's family member said Resident #34 was very upset and crying over the situation. Resident #34's family member said the Weekend Activities Assistant was rude on many occasions to the residents at the facility. Record review of the facility's Provider Investigation Report, dated 07/22/24, reflected an incident date of 07/14/24 involving Resident #34 and The Weekend Activities Assistant. The Description of the Allegation section reflected: Resident alleged the activity director hit her leg and yelled at her at the nurses station for kissing another resident who is no longer her friend. The Provider Response section reflected: .Education continues for MANE . The Provider Action Taken Post-Investigation section reflected: We recommend termination of employee for violating our policy for abuse, neglect, and retaliation/fear of reprisal for any resident. We will Continue training and add the communications and inappropriate texts and messaging to the training [sic] . The facility investigation findings reflected the facility confirmed abuse had occurred. Record review of a witness statement from the Weekend Activities Assistant, dated 07/14/24 reflected: Upon arrival, I saw the grievance on the floor from [Resident #22], stating that [Resident #45] keeps coming into thier private living area uninvited, after being told to stay away- I went to [Resident #45], asked him why he can't follow our wishes to stay away from [Resident #34]. He again said 'ok, I wont go in there anymore, but tell her to quit telling me to come in.' After that, I went to [Resident #34] and asked her what happened- her story was that she doesn't want anything to do with him and he is the one that keeps pursuing her- I asked her if she knew how much this affected her Roommate- And that [Resident #22] was told by [Resident #34] that [Resident #45] had kissed her, but her story changed 3X, [Resident #34], says that I hit her leg- This is simply a bald-face lie- I did not put my hand on her, in anyway shape or form This statement is true- [signed by the Weekend Activities Assistant] [sic]. Telephone interview on 10/23/24 at 9:20 AM with the Weekend Activities Assistant revealed Resident #34 accused her of hitting and kicking her three times. The Weekend Activities Assistant said she never laid a hand on Resident #34. The Weekend Activities Assistant said she was terminated from the facility because she went to Resident #34's room and told the resident she should not have said those things. The Weekend Activities Assistant said she never retaliated against Resident #34. The Weekend Activities Assistant said when she talked to Resident #34 at the nurse's station, there were 3 nurses standing nearby and 5 other residents. The Weekend Activities Assistant said she never got loud while talking with Resident #34 but her voice was loud to begin with. The Weekend Activities Assistant said she told Resident #34 that the resident needed to decide who she wanted to be with and what she wanted to be. The Weekend Activities Assistant said she had this conversation with Resident #34 at the nurse's station with others nearby and they could hear the conversation. The Weekend Activities Assistant said she did not think the conversation would have been embarrassing to Resident #34. The Weekend Activities Assistant said she was originally suspended based on the allegation Resident #34 made. The Weekend Activities Assistant said she did not think talking to Resident #34 was abusive or went against her rights in any way. The Weekend Activities Assistant said she had called and still talked to residents at the facility but never discussed the situation regarding her being terminated. Interview on 10/23/24 at 2:05 PM with MA D revealed she knew to report any abuse or allegation immediately to the Administrator and would do so now, and that yelling at a resident was considered abuse. Interview on 10/24/24 at 8:15 AM with the WCN revealed she was standing at the nurse's station when the Weekend Activities Assistant came towards Resident #34. The WCN said apparently there was something that happened and she did not have the background information nor remembered the words that were said during the conversation between Resident #34 and the Weekend Activities Assistant. The WCN said the main thing she took away from it was that the Weekend Activities Assistant was yelling at Resident #34. The WCN said Resident #34 did not take it well trying and tried to tell the Weekend Activities Assistant that she did not do whatever she was accusing her of. The WCN said Resident #34 told the Weekend Activities Assistant you don't have to yell at me like that. The WCN said someone called the Former Administrator and the Weekend Activities Assistant was to be sent home. The WCN said after the told the Weekend Activities Assistant to go home, the Weekend Activities Assistant went to Resident #34's room and said, you got me fired. The WCN said Resident #34 told the Weekend Activities Assistant No, I didn't want to fire you. The WCN said the Weekend Activities Assistant should not have yelled at Resident #34, nor should she have had that conversation in public which made Resident #34 feel humiliated in front of people. The WCN said the situation happened at the nurse's station where other residents and staff were around. The WCN said when the Weekend Activities Assistant yelled at Resident #34, it was abuse even if that was how she talked that was not an excuse to treat a resident that way. The WCN said Resident #34 was crying a lot after the situation happened. The WCN said Resident #34 was at the nurse's station looking for her pain pill when she called her family member and told them that the Weekend Activities Assistant had humiliated and abused her. The WCN said staff should change the way they talk to a resident to remain respectful. The WCN said the Weekend Activities Assistant had yelled at Resident #34 twice at the nurse's station and then also went to her room on the way out of the building. The WCN said she did not consider the situation to be abuse at the time she witnessed it because she was new at the facility and other staff who witnessed it had said that was how the Weekend Activities Assistant normally talked but after the second time it happened that day, Resident #34 had called her family member to report it to them. The WCN said she did not like what was said to Resident #34 so she reported it to the Former Administrator. The WCN said she knew to report any abuse or allegation immediately to the Administrator and would do so now, and that yelling at a resident was considered abuse. Interview on 10/24/24 at 8:37 AM with CNA V revealed Resident #34 came up to her and said the Weekend Activities Assistant had yelled at her. CNA V said she told the nurse and Resident #34 was going to write a grievance about it. CNA V said Resident #34 was very upset and was crying about the situation. CNA V said she was not sure what happened or why the Weekend Activities Assistant had yelled at Resident #34. CNA V said Resident #34 had made an allegation of abuse but she did not report it to the Former Administrator. CNA V said she had been told to report any allegation of abuse to the Former Administrator but did not think about it at the time. CNA V said she realized that she should have immediately reported the allegation of abuse to the Former Administrator and would immediately report an allegation to the current Administrator. CNA V said she was not sure who the nurse was that told Resident #34 to file a grievance about the Weekend Activities Assistant yelling at her. CNA V said she knew to report any abuse or allegation immediately to the Administrator and would do so now, and that yelling at a resident was considered abuse. Telephone interview on 10/24/24 at 3:00 PM with the Former Administrator revealed staff called her and told her that Resident #34 made an allegation to them about the Weekend Activities Assistant, saying she cussed and yelled at her at the nurse's station. The Former Administrator told them what steps to make, including letting the Weekend Activities Assistant know she has to leave out of the building. Interview on 10/24/24 at 3:22 PM with the Administrator revealed he started at the facility on 10/03/24 and was not fully aware of the self-reports from July. The Administrator said he expected staff to treat residents with dignity and respect. The Administrator said staff were not allowed to yell at residents and that would be considered abuse. The Administrator said all staff were trained on the facility's abuse policy and were expected to follow it. The Administrator said all staff were responsible for ensuring residents were free from abuse. The Administrator said all staff knew to report abuse immediately to him, as the Abuse Coordinator. The Administrator said if a resident was abused it could destroy their emotional state, cause them to feel disrespected or belittled, or could cause them to become depressed. Record review of an in-service, dated 07/14/24, reflected staff were trained on the facility's policy regarding abuse and neglect, including when, what, and to whom abuse should be reported to; the WCN and CNA V had both signed the in-service. The Administrator was notified on 10/24/24 at 4:58 PM, that a past non-compliance IJ situation had been identified due to the above failures.

Based on observation, interview, and record review, the facility failed to ensure each resident was provided with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of 2 of 23 residents (Residents #41 and #239) observed. The facility failed to have an adequate supply of milk for all residents. This failure had the potential to affect all facility residents who consumed food from the facility kitchen. Findings included: Observation on 10/22/24 at 7:15 AM revealed the facility milk box contained only 12 individual servings of milk. Observation and interview on 10/22/24 at 11:53 AM with Resident #41 revealed that the resident does not receive requested milk with her breakfast approximately one time per month. Resident #41 stated she was told that they were out of milk. Resident #41 stated that in the past five weeks at the facility, she had not received milk twice. Observation and interview on 10/22/24 at 11:14 AM with Resident #239 revealed that the resident did not receive milk that morning for breakfast. The resident was eating her breakfast, and there was no milk on her tray. Resident stated that she wanted milk, but she had not received it. Interview on 10/22/24 at 7:15 AM with the Dietary Aide revealed that was not enough milk for the residents who wanted milk in the mornings with their breakfast. The Dietary Aide stated approximately once a month there was not enough milk to meet the needs of the residents. The Dietary Aide said that was everyone's responsibility to report to the Dietary Manager if they observed that the facility was running low on milk so that an emergency milk order could be placed. The Dietary Aide concluded by stating that if there was not enough milk for the residents who preferred milk with their meal, the residents would become angry and upset. The Dietary Aide revealed the department was last in-serviced on reporting when dietary items were low to the Dietary Manager the previous Friday. Interview on 10/22/24 at 7:21 AM with the Dietary Manager revealed there was not enough milk for the morning's breakfast. The Dietary Manager stated there was not enough milk because she was only allowed to order milk based on census, and sometimes more milk was needed than she was allowed to order. The Dietary Manager stated this has been the company's policy since she has worked at the facility as the Dietary Manager since January 2024. The Dietary Manager stated that in emergencies she could call for an emergency delivery of milk to be delivered to the facility. The Dietary Manager also said that the regular milk delivery was scheduled for the following day. The Dietary Manager stated that in an emergency, she could use powdered milk if necessary that she kept in her emergency food supply. The Dietary Manager revealed there was not enough milk in the building for the residents who wanted milk with their breakfast. The Dietary Manager revealed it was her responsibility to ensure there was enough milk in the facility to meet the needs of the residents. The Dietary Manager stated the cooks and the dietary aides were responsible for reporting to her if the milk supply ran low. The Dietary Manager stated she had a storage of seven days of food as an emergency supply, and she received a food delivery twice a week. The storage room was observed as well. The Dietary Manager concluded by stating that she in-serviced her staff every Monday and Friday. Interview on 10/23/24 at 12:18 PM with the Dietary District Manager revealed the Dietary Manager should have called in for an emergency delivery of milk prior to the breakfast meal. The Dietary District Manager stated it was the Dietary Manager's responsibility to keep milk in-house. The Dietary District Manager also said that if residents were not given milk, it would be a dignity issue as well as a nutritional risk. The Dietary District Manager stated staff were in-serviced two times per week. Record review of the facility's current Menus policy, dated December 2008, reflected: Policy Interpretation and Implementation .8. If a food group is missing from a resident's daily diet (e.g., dairy products), the resident will be provided an alternate means of meeting the resident's nutritional needs (e.g., calcium supplement or fortified non-dairy alternatives) 11. Menu planning will consider the cultural backgrounds and food habits of residents.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good grooming, and personal hygiene for 1 of 22 residents (Resident #74) reviewed for ADL care. The facility failed to ensure Resident #74's fingernails were cleaned and cut. This failure could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings included: Record review of Resident #74's Face Sheet, dated 10/24/24, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. Record review of Resident #74's MDS assessment, dated 10/03/24, reflected a BIMS score of 5 indicating severe cognitive impairment. The MDS also reflected diagnoses of stroke, hemiplegia of the right dominant side, and renal insufficiency. The MDS also reflected in Section GG that Resident #74 required substantial/maximal assistance with Activities of Daily Living. Record review of Resident #74's Care Plan, dated 10/22/24, reflected a Focus: Resident exhibits ADL Self Care Performance Deficit, requires assistance: cognitive deficit secondary to dementia disease progression, hemiplegia, impaired decision making, vision impairment. Goal: Will be cleaned, well-groomed, appropriately dressed and weight maintained through next review date. Interventions: Bathing:Bathing requires assist x 1 staff participation. Eating: requires assist x 1 staff participation. Toileting: requires assist x 1 staff participation. Transfer: requires assist x 1 staff participation assist . Bed mobility: Resident requires assist x 1 assist staff participation. Observation and interview on 10/22/24 at 10:19 AM revealed Resident #74 sitting in his wheelchair in the common in front of the nurses' station on East Hall. Resident #74's fingernails were observed to be long on both hands. The resident stated he would like his fingernails trimmed. Interview on 10/24/24 at 11:30 AM with CNA A revealed nail care was supposed to be performed on residents as needed as well as on their shower days. CNA A stated she asked the Rresident #74 earlier that day if he wanted his nails trimmed, and he told her no. She said that the evening shift had completed it the day before. She also revealed that if nails were not kept trimmed and clean that residents could get an infection because they could scratch themselves resulting in a skin tear. CNA A also stated that if she did not have time to provide nail care, she should ask the next oncoming shift or her nurse to assist with nail care. She stated she had not been in-serviced on nail care since working here in the last two months. Interview on 10/24/24 at 11:42 AM with LVN B revealed CNAs were responsible for nail care. LVN B stated the CNAs were supposed to check the resident's nails every time they were showered and/or bathed. LVN B also said that if she observed a resident's nails too long, she would cut them herself. LVN B continued and stated that she had not noticed Resident #74's nails needed to be cut. LVN B also stated she could not recall a policy on ADLs and nail care, nor could she remember the last time she was in-serviced on nail care. Interview on 10/24/24 at 11:52 AM with ADON A revealed it was everyone's responsibility to examine the residents' nails. ADON A stated CNAs were to provide nail care when they showered the residents and as needed. ADON A also said if a resident refused nail care, then it should be care planned. ADON A revealed long nails could cause trauma. ADON A further revealed CNAs performed nail care on non-diabetics and if residents were diabetic, then nurses were supposed to perform nail care. ADON A revealed he could not remember the last in-service on nail care. In addition, ADON A stated he spoke with the Therapy Director who provided a soft splint for the resident's hand. Record review of the facility's current Care of Fingernails/Toenails policy, dated April 2007, reflected the following: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infection. General Guidelines: 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aide in the prevention of skin problems around the nail bed. 3. Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments. 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. 5. Watch for and report any changes in the color of the skin around the nail bed, blueness of the nail, any signs of poor circulation, cracking of the skin between the toes, any swelling, bleeding, etc. 6. Stop and report to the nurse supervisor if there is evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease.

Based on observation, interview, and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 3 residents (Resident #8) reviewed for respiratory therapy. LVN Y failed to ensure Resident #8's nasal cannula was changed and dated according to doctor's orders on 10/20/24. This failure could lead to respiratory infections, poor air quality, and not having their respiratory requirements met. Findings included: Record review of Resident #8's Admission Record, dated 10/24/24, reflected the resident was an [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #8's Quarterly MDS Assessment, dated 09/24/24, reflected she had a BIMS score of 15 indicating no cognitive impairment. Her diagnoses included Asthma, Chronic Obstructive Pulmonary Disease or Chronic Lung Disease. Resident #8's MDS did not address her use of oxygen therapy. Record review of Resident #8's Order Summary Report, dated 10/24/24, reflected the following: O2: Change and label water humidification and NC tubing weekly on _Sunday____and on___10-6___shift. One time a day every Sun with an order date of 10/16/23 and start dated of 10/22/23. Record review of Resident #8's care plan, revised 04/03/24, reflected the following: Focus: [Resident #8] has Oxygen Therapy as needed r/t Ineffective gas exchange .Goal: Will have no s/sx of poor oxygen absorption through the review date .Interventions: OXYGEN SETTINGS: O2 via nasal cannula/mask . Observation and interview on 10/23/24 at 9:10 AM with Resident #8 revealed she had her nasal cannula on her face being used and had a piece of tape with the date 10/14 [LVN Y's initials] on it. Resident #8 said she was doing good and was cared for by the staff. Observation and interview on 10/23/24 at 11:51 AM with Resident #8 revealed her nasal cannula was on her face being used and had a piece of tape with the date 10/14 [LVN Y's initials] on it. Resident #8 said she needed a new one because no one came to change it a few days ago like they were supposed to. Observation and interview on 10/23/24 at 11:50 AM with LVN X revealed she cared for Resident #8. LVN X said the night shift nurse on Sundays usually changed the nasal cannula for residents each week. LVN X said then on Mondays, ADON Z normally checks to make sure all the nasal cannulas were changed for each resident. LVN X said the purpose of the nasal cannula being changed was for sanitation and infection control reasons. LVN X said she had not noticed that Resident #8's nasal cannula was still dated 10/14/24 and was not changed this past Sunday (10/20/24). LVN X said usually the nurse who changed the nasal cannula would date and initial it to acknowledge when it was completed. LVN X saw Resident #8's nasal cannula dated 10/14 and said she would change it immediately. LVN X said she was not sure why it was not changed this past Sunday (10/20/24). Interview on 10/24/24 at 8:52 AM with ADON Z revealed he was told yesterday that Resident #8's nasal cannula was not changed. ADON Z said the night shift nurse on Sundays was responsible for changing a resident's nasal cannula. ADON Z said he usually came in on Mondays and checked to make sure all residents who used oxygen had their nasal cannula changed the day before. ADON Z said he worked on Sunday (10/20/24) and thought he had changed Resident #8's nasal cannula but thought he got distracted with something else and forgot. ADON Z said since he thought he had changed it himself, he did not need to check and ensure it was completed. ADON Z said the purpose of changing the nasal cannula every week was because of infection control. ADON Z said if a resident's nasal cannula was not changed it could become a breeding ground for something to colonize in the tubing. Attempted telepone interview on 10/25/24 at 9:21 AM with LVN Y was unsuccessful as there was not an answer. Interview on 10/25/24 at 3:09 PM with the Interim DON revealed a resident's nasal cannula was supposed to be changed weekly as ordered. Record review of the facility's Oxygen Administration policy, revised March 2004, reflected the following: .1. Verify that there is a physician's order for this procedure. Record review the physician's orders or facility protocol for oxygen administration

Based on observation and interview, the facility failed to ensure, in accordance with State and Federal laws, the facility stored all drugs and biologicals in locked compartments for 1 of 5 carts (100 Hall Nurse cart) reviewed for storage. LVN C failed to secure the nurse medication cart for 100 Hall. This failure could place residents at risk of obtaining medications not prescribed to them. Findings included: Observation on 10/22/24 at 7:10 AM medication cart paraked at the nurse's station, identified by MA D as the nurse medication cart for the 100 Hall, was noted to be unlocked. All drawers, with the exception of the controlled substances drawer, were able to be opened. Five residents were sitting around the nurse's station in the common area. Interview on 10/22/24 at 7:13 AM with MA D revealed the day shift nurse was late arriving so she counted with LVN C. MA D stated LVN C requested MA D leave the 100 Hall nurse cart open so she could get something out before she left. MA D stated she was not aware LVN C had not locked the cart when she was done. MA D stated the risk of leaving a medication cart open was a resident getting medications not prescribed to them and having an allergic reaction, or an adverse outcome. Interview on 10/24/24 at 2:40 PM with the DON revealed all medication carts were to be locked when the staff member walked away from the cart. She stated the risks of leaving a cart unlocked included residents having access to medications that were not theirs and having unintended consequences or reactions. Interview on 10/25/24 at 9:06 AM with LVN C revealed she did not recall asking MA D to leave the cart open, did not recall why she might have asked her to do so, and did not recall if she did go back into the cart after handing over the keys. LVN C stated, I've slept since then. Record review of the facility's Storage of Medications policy, dated April 2007, reflected: .7. Compartments (including but not limited to drawers, cabinets .) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others

Based on observation, interview, and record review, the facility failed to ensure that the menu was followed for the lunch meal for 1 of 5 residents (Resident #9) reviewed for food and nutrition services. The facility failed to ensure residents on a pureed diet were served pureed bread and pureed angel food cake during the lunch meal on 10/23/24. This failure could place residents at risk for unwanted weight loss, hunger, and metabolic imbalances. Findings included: Record review of Resident #9's MDS, dated [DATE], reflected the resident was a [AGE] year-old female with primary diagnoses of dementia, stroke, and hemiplegia. Resident also was unable to complete a BIMS test. Further review reflected Resident #9 required a mechanically altered therapeutic diet. Record review of Resident #9's consolidated physician's orders, dated 10/25/24, reflected the resident had an active order for a regular diet, dysphagia advanced level 1 texture, regular consistency starting on 09/18/24. Record review of Resident #9 care plan, dated 08/20/24, reflected: Focus: Resident #9 requires a therapeutic regular diet, Dys Adv (Dysphagia Level texture. Goal: Will comply with diet through the next review date. Interventions: Alert MD/NP and document residents' inability to consume correct diet and obtain recommendations to down-grade as indicated. Offer a supplement of the resident choice when/if consumption of meal is less than 50%. Offer an alternative when/if resident does not like the meal. Provide diet as per MD order. Nurse to ensure proper diet is served. RD to evaluate and make recommendations as indicated. Record review of Order Listing Report dated 10/25/24 reflected the facility had five total residents on a pureed diet. Record review of the facility's menu for the lunch meal on 10/23/24 revealed roast turkey, honey roasted carrots, green beans, cornbread dressing, dinner roll, and brown sugar glazed angel food cake. Observation on 10/23/24 at 12:52 PM revealed Resident #9's tray ticket stated that the resident was supposed to have a dinner roll and pureed brown sugar glazed angel food cake on the tray. However, Resident #9 did not receive pureed bread nor pureed angel food cake. Resident #9 instead received applesauce instead of the cake for dessert. Observation on 10/23/24 at 1:07 PM revealed the test tray provided to survey team did not have pureed bread or pureed angel food cake. Interview on 10/23/24 at 1:10 PM with the Dietary Manager revealed the dessert and pureed bread were not served, but they were prepared. The Dietary Manager stated the [NAME] forgot to put the pureed bread and pureed angel food on the trays of the residents who received pureed trays. The Dietary Manager revealed it was the server's responsibility to put the individual items on the residents' trays and the Cook's responsibility to prepare the purees. The Dietary Manager said the residents who did not receive the same pureed food items as everyone else could get upset and would not receive the full nutritional value as the residents that received the regular texture trays. Interview on 10/23/24 at 1:31 PM with the District Dietary Manager revealed the pureed bread and pureed angel food cake were missing from the test tray delivered to survey team. The District Dietary Manager stated the dietary team simply did not place all the pureed items on the puree trays. The District Dietary Manager stated the resident would not receive all the nutritive value of the meal if they do not receive all the items on the menu. Record review of the facility's Therapeutic Diets policy, dated November 2015, reflected the following: Therapeutic diets shall be prescribed by the Attending Physician. The facility will strive for the fewest possible dietary restrictions .Routine menus are planned by the Food Services Manager and approved by a Registered Dietician for nutritional adequacy. The Food Services Manager will establish and use a tray identification system to ensure that each resident receives his or her diet as ordered.

Based on observation, interview, and record review the facility failed to provide food prepared in a form designed to meet individual needs for 1 of 5 residents (Resident #9) reviewed for food consistency. The facility failed to ensure Resident #9's pureed carrots were free of whole slices of carrots. This failure placed all residents, especially those with swallowing issues, at risk of aspirating or choking. Findings included: Record review of Resident #9's MDS, dated [DATE], reflected the resident was a [AGE] year-old female with primary diagnoses of dementia, stroke, and hemiplegia. Resident also was unable to complete a BIMS. Further review reflected Resident #9 required a mechanically altered therapeutic diet. Record review of Resident #9's consolidated physician's orders, dated 10/25/24, reflected the resident had an active order for a regular diet, dysphagia advanced level 1 texture, regular consistency starting on 09/18/24. Record review of Resident #9 care plan, dated 08/20/24, reflected: Focus: Resident #9 requires a therapeutic regular diet, Dys Adv (Dysphagia Level texture. Goal: Will comply with diet through the next review date. Interventions: Alert MD/NP and document residents' inability to consume correct diet and obtain recommendations to down-grade as indicated. Offer a supplement of the resident choice when/if consumption of meal is less than 50%. Offer an alternative when/if resident does not like the meal. Provide diet as per MD order. Nurse to ensure proper diet is served. RD to evaluate and make recommendations as indicated. Record review of Order Listing Report dated 10/25/24 reflected the facility had five total residents on a pureed diet. Record review of the facility's menu for the lunch meal on 10/23/24 revealed roast turkey, honey roasted carrots, green beans, cornbread dressing, dinner roll, and brown sugar glazed angel food cake. Observation on 10/23/24 at 12:45 PM revealed there were chunks of carrots in the puree portion of the puree test tray. Interview on 10/23/24 at 1:10 PM with the Dietary Manager revealed she observed the chunks of carrot slices in the pureed carrots. The Dietary Manager stated pureed foods should be smooth, like a pudding texture. The Dietary Manager said if everything was not completed pureed, the resident could choke or aspirate. The Dietary Manager stated it was the responsibility of the dietary aides and nurses to ensure the resident did not receive a puree with chunks in it. The Dietary Manager revealed she in-serviced last week on how to prepare pureed foods. Interview on 10/23/24 at 1:31 PM with the Dietary District Manager revealed he observed the chunks of carrot slices in the pureed carrots. The Dietary District Manager stated pureed foods should not have chunks in it. He stated that it could be a choking hazard. The Dietary District Manager said the responsibility was the cook's and dietary aide's responsibility to ensure the trays do not go out with the purees incorrectly processed. Record review of the facility's undated corporate recipe for Carrots reflected: 1. For Pureed: Measure out desired # of servings into food processor. Blend until smooth. Follow directions on food thickener guidelines of specific product used in your facility for liquid and thickener measurements.

Based on observation, interview, and record review, the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were maintained on each resident that were accurately documented for 1 of 3 residents (Resident #8) reviewed for accuracy of clinical records. The facility failed to ensure LVN Y accurately documented on Resident #8's TAR that her nasal cannula was not changed on 10/20/24 as ordered. This failure could place residents at risk of inaccurate medical records that could affect monitoring and medical services provided. Findings included: Record review of Resident #8's Admission Record, dated 10/24/24, reflected the resident was an [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #8's Quarterly MDS Assessment, dated 09/24/24, reflected she had a BIMS of 15 indicating no cognitive impairment. Her diagnosis included Asthma, Chronic Obstructive Pulmonary Disease or Chronic Lung Disease. Record review of Resident #8's Order Summary Report, dated 10/24/24, reflected the following: O2: Change and label water humidification and NC tubing weekly on _Sunday____and on___10-6___shift. One time a day every Sun with an order date of 10/16/23 and start dated of 10/22/23. Record review of Resident #8's October 2024 TAR reflected the following: O2: Change and label water humidification and NC tubing weekly on _Sunday____and on___10-6___shift. One time a day every Sun- Start Date- 10/23/2023 0000 with a check mark and LVN Y's initials for 10/20/24. Record review of Resident #8's care plan, revised 04/03/24, reflected the following: Focus: [Resident #8] has Oxygen Therapy as needed r/t Ineffective gas exchange .Goal: Will have no s/sx of poor oxygen absorption through the review date .Interventions: OXYGEN SETTINGS: O2 via nasal cannula/mask . Observation and interview on 10/23/24 at 9:10 AM revealed Resident #8 had her nasal cannula on her face being used and had a piece of tape with the date 10/14 [LVN Y's initials] on it. Resident #8 said she was doing good and was cared for by the staff. Observation and interview on 10/23/24 at 11:51 AM revealed Resident #8's nasal cannula was on her face being used and had a piece of tape with the date 10/14 [LVN Y's initials] on it. Resident #8 said she needed a new one because no one came to change it a few days ago like they were supposed to. Interview on 10/24/24 at 8:52 AM with ADON Z revealed if staff did not provide a treatment they should make a note why it was not done. ADON Z said if there was a check mark on a resident's TAR, that meant it was completed. ADON Z said if LVN Y did not change Resident #8's nasal cannula she should not have checked on the resident's TAR that it was completed. ADON Z said the purpose of accurate documentation on a resident's TAR was to inform the oncoming staff of what was accomplished and what still needed to be accomplished. ADON Z said there could be a gap in a resident's care if the information on their TAR was inaccurate. ADON Z said he only checked resident's TARs for completion, not accuracy. ADON Z said he believed that each nurse was responsible for what they documented. ADON Z said LVN Y was responsible for ensuring she documented accurately on Resident #8's TAR regarding the nasal cannula not being changed on Sunday (10/20/24). Attempted telephone interview on 10/25/24 at 9:21 AM with LVN Y was unsuccessful as there was not an answer. Interview on 10/25/24 at 3:09 PM with the Interim DON revealed staff were not supposed to document that they provided a treatment if they did not provide it. The Interim DON said staff were responsible for documenting accurately on a resident's TAR. Record review of the facility's Oxygen Administration policy, revised March 2004, reflected the following: After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 1. The date and time that the procedure was performed. 2. The name and title of the individual who performed the procedure.

Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored securely for 2 (Resident #30 and Resident #73) of 18 residents observed for medication storage. 1. Resident #30 had 1 bottle of Tums pills stored at the resident's bedside table not locked in a lock box or secured in the medication cart or medication room. 2. Resident #73 had unidentified cream at her bedside table and unidentified pills in a plastic cup on her bed not locked in a lock box or secured in the mediation cart or mediation room. This failure could place residents at risk of overmedication or adverse drug reactions. Findings included: 1. Record review of Resident #30's Face Sheet, dated 08/31/23, revealed the resident was a [AGE] year-old female who was admitted on [DATE], readmitted on [DATE]. Resident #30 had diagnoses that included hyperlipidemia (cholesterol and fats in blood), atherosclerotic heart disease of native coronary artery (build-up of fats, cholesterol, and other fats), hypertension (high blood pressure), and muscle weakness. Review of Resident #30's MDS dated [DATE] revealed the resident's cognitive was intact with a BIMS score of 14. Review of Resident #30's care plan, dated 03/21/23, revealed the resident had altered cardiovascular status related to hyperlipidemia. The care plan reflected: Goal: Will be free from signs and symptoms of complications of cardiac problems through the review date. Intervention: Observe/document/report to MD PRN any signs and symptoms of Coronary Artery Disease: chest pain or pressure especially with activity, heartburn, nausea and vomiting, shortness of breath, excessive sweating, dependent edema, changes in cap refill, color/warmth of extremities. Record review of Resident #30's order summary report dated 08/31/23 did not reveal physician's order for Tums (over-the-counter medication used to treat symptoms caused by too much stomach acid such as heartburn, upset stomach, or indigestion). Observation on interview on 08/29/23 at 11:23 AM revealed Resident #30 with a bottle of Tums on the nightstand table. According to Resident #30, her family member brought them in for her to use when she had an upset stomach or heartburn. Resident #30 stated she just had them there in case she needed them; she was not able to say when she last used them. 2. Record review of Resident #73's face Sheet, dated 08/31/23, revealed the resident was a [AGE] year-old female who was admitted on [DATE]. Resident #73 had diagnoses that included: cellulitis of the right and left lower limb (A serious bacterial infection of the skin. Usually affects the leg and the skin appears as swollen, red, and painful), psoriasis (a chronic skin condition), urticaria (skin rash), sepsis, and candidiasis. Review of Resident #73's MDS dated [DATE] revealed the resident's cognitiion was intact with a BIMS score of 15. Review of Resident #73's care plan, dated 03/21/23, revealed the resident had limited physical mobility related to compression fracture of thoracic vertebrae and cellulitis of lower extremities. The care plan reflected: Goal: Will remain free of complications related to immobility, including skin-breakdown. Intervention: Observe/document/report to physician as needed signs and symptoms of immobility: skin-breakdown. Record review of Resident #73's order summary report dated 08/31/23 revealed she had an order for: - Acidophilus Probiotic Oral Tablet (Lactobacillus) Give1 capsule by mouth one time a day for supplement; - Magnesium Oxide Oral Tablet 400 MG (Magnesium Oxide) Give 1 tablet by mouth one time a day for supplement-Multivitamin-Minerals Oral Tablet (Multiple Vitamins w/ Minerals) Give 1 tablet by mouth one time a day for wound healing; and - Ammonium Lactate External Cream 12 % (Lactic Acid (Ammonium Lactate)) Apply to bilateral lower extremity topically every day shift for dry skin. Interview with LVN D on 08/29/23 at 12:22 PM, who was the charge nurse for Hall 100, revealed the facility did not have residents who self-administered medications. She stated residents were not allowed to have medications in their rooms, and residents' families were educated not to leave over-the-counter medications with the residents. LVN D was observed going to Resident #30's room, and she asked the resident about the Tums located on nightstand. LVN D was observed removing the Tums from the nightstand. Observation and interview on 08/30/23 at 9:00 AM of Resident #73 revealed there was a medication cup of cream on her table in her room. She revealed she had been having this prescription medication in her room for a while. Resident #73 then pointed out at the bottom of both legs and ankles dry patches of skin. Resident #73 stated she compiled a collection of this leftover medication to save to apply the cream to her legs on her own. Resident #73 was observed with a small container of pills on her bed, when asked what they were, Resident #73 stated they were supplements that she puts in a cup to administer on her own daily. Resident #73 stated the prescription cream that she applied to her legs were given to her by staff after they administered cream to her legs. Resident #73 stated the pills in the cup were supplements she removed from bottles that her sister brought to her. During observation of the room, surveyor did not observe any bottles of supplements in the room. Interview with LVN D on 08/30/23 at 2:22 PM, LVN D stated she completed a room sweep and was able to observe unidentified pills in a covered cup on Resident #73's bed and a cup of cream later identified as a prescription cream that Resident# 73 gets applied to both legs. LVN D stated Resident #73 said she placed the pills in the cup herself and like to have them in the cup so that she could administer them. LVN D stated nursing staff are responsible for administering any type of medication whether it was pills, supplements, or prescription cream to residents and ensure there are no medications left in resident rooms. If resident are able to have medications in their rooms it puts them at risk of overmedicating, possible choking, or other residents could get ahold of them. LVN D stated she had not seen Resident #73 with any pills or cream in a cup when she entered the room prior to today. Interview on 08/30/23 at 9:19 AM with the ADON revealed residents should not have any medications in the room with them. The ADON stated residents would have to pass an assessment which would indicate they are capable of administrating medications on their own and none of our residents are capable of passing the assessment. The ADON stated nursing staff are responsible for ensuring resident do not have any type of medications whether over the counter or prescribed in their rooms. The ADON stated Resident #30 should not have Tums in her room because it could be a risk of Tums interacting with her medications and we need to know what she was taking at all times. The ADON stated Resident #73 should not have any loose pills or prescription medication in her room. The ADON stated Resident #73 had a prescription for her legs that nursing staff administered but was not aware of any supplements that she would take on her own. The ADON stated if she did have supplements, nursing staff should be aware so the staff could administer them to her. The nursing staff were responsible for applying any topical prescription for residents. The ADON stated she asked nursing staff to complete a sweep to ensure residents did not have any over-the-counter medications. Interview on 08/31/23 at 3:49 PM with the DON revealed residents are not supposed to have medication of any kind in their rooms. The DON stated there were no residents who were able to self-administer medications on their own. The DON stated the ADON addressed this issue with her, and the facility did a room sweep to ensure residents were without any over-the-counter or prescription medications in their rooms. The DON stated it was the responsibility of the nursing staff to remove any pills, prescriptions, or over-the-counter medications from resident rooms. The DON stated residents having medications in their rooms put them at risk of double medicating, staff not knowing what they are taking, or other residents could get ahold of them. Review of the facility's current, undated Storage of Medications policy reflected: . The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner

Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 2 (Resident #65 and Resident #37) of 6 residents reviewed for enteral nutrition, in that: 1. The facility failed to appropriately label formula bag for Resident #65. 2. The facility failed to follow Resident #37's physician orders for enteral feeding. These failures could affect residents receiving enteral nutrition/hydration and place them at risk of health complications and decline in health. Findings included: 1. Record review of Resident #65's face sheet dated 08/31/23, revealed the resident was [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with a diagnoses that including type 2 diabetes mellitus, moderate protein-calorie malnutrition, and gastrostomy status (g-tube). Record review of Resident #65's quarterly MDS dated [DATE], revealed the resident had moderate cognitive impairment with a BIMS score of 11. The assessment reflected Resident #65 required extensive assistance with eating, one-person physical assist, and the resident received nutrition via feeding tube and a mechanically altered diet. Record review of Resident #65's care plan revised dated 03/15/23 revealed requires tube feeding r/t dysphagia, inability to consume enough caloric intake with diagnosis of CVA and Protein Calorie Malnutrition. Goal: Will maintain adequate nutritional and hydration status aeb weight stable, no s/sx of malnutrition or dehydration through review date. Will remain free of side effects or complications related to tube feeding through review date. Record review of Resident #65's physician order dated 08/25/23 revealed GT: diabetic source or equivalent @ 70 cc /hr per GT X 12Hrs Start feeding at 6pm and remove at 6am every 12 hours: Start diabetic source or equivalent @ 70 cc/hr per GT X 12Hrs Start feeding at 6pm and remove at 6am. Observation and interview 08/29/23 at 3:48 PM revealed Resident #65 lying in bed. A feeding pump was next to Resident #65's bed, and it was not infusing. A bag of enteral feeding was hanging from the pole of the feeding pump with no time, date and without initials to indicate who administered the feeding. The formula bag had about 3/4 of formula left inside. Resident #65 stated he was unsure when the bag was placed in his room. The resident refused to answer any further questions. Interview on 09/29/23 at 4:23 PM with LVN A, an agency nurse, revealed she was the nurse for Resident #65. LVN A stated she had not been to Resident #65's room today (08/29/23). LVN A stated Resident #65's feeding started at 6:00 PM and ended at 6:00 AM. LVN A stated formula bags should be dated with the time, date and the nurse's initials. LVN A stated she was unaware Resident #65 had a formula bag in his room, she stated she worked the previous night, and she was the one who provided Resident #65 with his feeding. LVN A was informed the formula bag had no time, date and initials. She stated she placed it on a sticker. LVN A stated the bag should had been removed this morning. LVN A was asked if she could show where she placed the sticker, LVN A stated, If you did not see a label or sticker, it might not have it. LVN A stated formula bags needed to have a time and date, so other nurses knew when it needed to be thrown out. Observation and interview on 08/29/23 at 4:30 PM with the ADON in Resident #65's room revealed the ADON observed the formula bag. The ADON stated formula bag did not have a time, date, and nurse initials. There was no observation of a sticker on the tubing. The ADON stated the formula bag should be labeled with the time and date. The ADON stated LVN A was the one, who hung it up last time (08/28/23), and it should have been discarded when the feeding was turned off. The ADON stated she would be removing the formula bag. She stated it was important to label the formula bag, so that staff knew when it needed to be discarded. 2. Record review of Resident #37's face sheet dated 08/31/23 revealed the resident was [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with a diagnoses that included dementia without behavioral disturbance, adult failure to thrive, and gastrostomy status. Record review of Resident #37's quarterly MDS dated [DATE] revealed the resident had moderate cognitive impairment with a BIMS score of 11. The assessment reflected Resident #37 required extensive assistance with eating, one-person physical assist, and the resident received nutrition via a feeding tube. Record review of Resident #37's care plan revised dated 07/29/23 revealed: Resident requires tube feeding r/t dysphagia. Resident also receives diet for pleasure feedings, regular dysphagia puree level 1. Goal: Will maintain adequate nutritional and hydration status aeb weight stable, no s/sx of malnutrition or dehydration through review date. Will remain free of side effects or complications related to tube feeding through review date. Interventions: The resident is able to tolerate tube feeding: Formula: Jevity 1.5 Rate: 65cc/hour x 20 hours down time of 4 hours (9am - 1pm). The resident is depended on staff for tube feeding and water flushes. Record review of Resident #37's physician order dated 06/12/23 revealed pump give Jevity 1.5 at 65 cc/hr per g-tube for 20 hours every shift. The orders reflected the g-tube feeding down time was from 9:00 AM-1:00 PM. The order start date was 06/12/23. Record review of Resident #37's physician order dated 06/12/23 revealed an order for the nutrition stop feeding one time a day at 9:00 AM. The order reflected a nurtition start feeding in the afternoon 1:00 PM. Record review on 08/30/23 at 1:15 PM of Resident #37's August 2023 MAR revealed Resident #37 had been connected at 1:00 PM. Observation on 08/30/23 at 2:00 PM of Resident #37 to be in her wheelchair. Resident #37 was not connected to her g-tube. An attempt was made to interview Resident #37; however Resident #37 would not respond to questions. Observation on 08/30/23 at 2:37 PM of Resident #37 to be in her wheelchair. Resident #37 was not connected to her g-tube. Observation on 08/30/23 at 2:42 PM revealed LVN B entering Resident #37 room and was observed to hang Resident #37 formula bottle, dated 8/30 at 3:00 PM. Observed Resident #37 to be in her wheelchair, and LVN C was observed to check Resident #37 g-tube placement, aspirated and flushed g-tube with 30 cc of water. LVN C then proceed to connect Resident #37 to her g-tube feeding. Interview on 08/30/23 at 2:52 PM with LVN B revealed she was the nurse for Resident #37. LVN B reviewed Resident #37's physician orders and stated Resident #37 had an order to connect resident at 1:00 PM. LVN B stated when she started her shift today (08/30/23) she was informed Resident #37 was not connected and was informed something about her breakfast. During the interview with LVN B, the ADON intervened by stating Resident #37 could eat by mouth as well; however, the resident refused to eat breakfast. The ADON stated they did not disconnect Resident #37 until 11:00 AM. The ADON stated she notified the physician, and the physician agreed to connect Resident #37 at 3:00 PM. The ADON stated she had documented the conversation. When LVN B was asked if she had documented in the Resident #37 MAR prior to providing Resident #37's formula feeding, the ADON intervened by stating it was a mistake by LVN B. Record review of Resident #37's Progress notes dated 08/30/23 at 14:54 [2:54 PM] by ADON revealed: Resident did not feel like eating any of her breakfast so instead of taking her feeding down at 9am to 1pm. The feeding will be taken down from 11am to 3pm today. Dr is aware. Follow-up interview on 08/30/23 at 3:26 PM with LVN B revealed she started her shift at 12:30 PM. LVN B stated the ADON was the nurse for Resident #37 this morning (08/30/23). LVN B stated the ADON had told her that she had done everything, so she assumed Resident #37 was already connected to her feeding. LVN B stated she documented on Resident #37's MAR that the feeding was already provided; however, later the ADON informed her she had not connected Resident #37 yet. LVN B stated the ADON informed her that Resident #37 did not have breakfast this morning (08/30/23), and they did not disconnect Resident #37 until 11:00 AM and would need to be connected at 3:00 PM. LVN B stated the ADON informed her Resident #37 ate 100% of her lunch. LVN B stated the ADON was the one, who contacted the doctor. She stated she was not sure of the time. LVN B stated prior to documenting she should have ensured Resident #37 was connected. LVN B stated it was not the proper thing to do. LVN B stated the risk of not following physician orders was that it could cause digestive problems. Interview via phone call on 08/30/23 at 3:46 PM with Resident #37's Physician revealed she received a text from the facility regarding Resident #37. The Physician stated the text informed her Resident #37 was disconnected at 11:00 AM because she was tired, and she had eaten all her lunch. The Physician stated she agreed to start the feeding at 3:00 PM and signed the order. When asked at what time she received the text message the Physician stated, for some reason it does not show the time. The Physician then stated she might have received a call stating resident was tired. Record review of Resident #37's physician order date 08/30/23 revealed Enteral Feed Order one time only for Enteral Feeding until 08/30/2023 23:59 [11:59 PM] May Stop the enteral feeding at 11:00 a.m. Start Date 08/30/2023 1907 [7:07PM]. Record review of Resident #37's physician order date 08/30/23 revealed Enteral Feed Order one time only for Enteral Feeding until 08/30/2023 23:59 [11:59 PM] May re-start the enteral feeding at 3:00 p.m. Start Date 08/30/2023 1907 [7:11PM]. Interview on 08/31/23 at 3:23 PM with the ADON revealed Resident #37 was not disconnected from her g-tube feeding until 11:00 AM due to refusing to eat breakfast on 08/30/23. She stated Resident ate 100% of her lunch and she notified the doctor in which the doctor agreed to connect Resident #37 until 3:00 PM. She stated she called the Physician at around 9:00 AM. The ADON stated LVN B documented by mistake on Resident #37's MAR, because it was rare that situations like this happened. The ADON stated it was the responsibility of the nurses, herself, and the DON to update resident's physician orders. She stated it was the responsibility of herself and the DON to monitor the documentation that was being recorded by staff. She stated the risk of not following physician orders was that it could cause a change in condition. Interview on 08/31/23 at 3:41 PM with the DON revealed her expectation was for her staff to follow physician orders. If there were any modifications, they must notify the physician. She stated she was made aware of Resident #37 refusing her breakfast; however, the resident ate all her lunch. She stated at times Resident #37 did eat and at times she did not. She stated her expectations were for the times Resident #37 refused to eat staff should continue the feedings and notify the physician. The DON was notified Resident #37's MAR indicated Resident #37 was provided with her feeding at 1:00 PM; however, the resident was not connected until 3:00 PM. The DON stated the best practice was for staff to follow physician orders and then document after the procedure was completed. The DON stated each formula bag should be labeled with the time, date and nurses initials. She stated the formula was good for 24 hours. The DON stated the risk of not following physician order would depend on the situation. Record review of the facility policy on medication orders, revised November 2014, reflected: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. Recording Orders: .4. Enteral Orders - When recording orders for enteral tube feedings, specify the type of feeding, amount, frequency of feeding and rationale if prn. The order should always specify the amount of flush following the feeding. Example: Isocal 250cc followed by H20 50 cc every 4hours via NG tube .

Based on interview and record review, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for one of six residents (Resident #1) reviewed for pain management. The facility failed to ensure Resident #1 received medications according to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure could place residents at risk of unrelieved pain and discomfort. Findings included: Record review of Resident #1's Admission Record, print date 10/18/22, in the EHR revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was discharged to the hospital on 09/16/22 and did not return to the facility. Record review of Resident #1's Admission MDS, dated [DATE], revealed the resident admitted to the facility on [DATE] from an acute hospital. The resident was cognitively intact with a BIMS score of 15. The resident required extensive assistance of two people for bed mobility and was totally dependent upon two people for transfers. The Pain Assessment Interview reflected the resident had pain or hurting in the last five days, had almost constant pain, and the resident reported she had pain at a level 4 on a 00-10 pain scale. Record review of Resident #1's care plan, dated 09/15/22, revealed it was her baseline care plan, which only addressed droplet precautions and skin integrity. Record review of Resident #1's physician orders, dated 09/14/22, reflected Resident #1 had the following orders for pain medication: - [MEDICATION(S)] Sodium Gel 1% (used to treat arthritis pain) apply to affected areas topically every 8 hours as needed for pain, start date 09/14/22; and - [MEDICATION(S)] Tablet 15 mg (used to treat severe chronic pain) take 1 tablet by mouth every 4 hours as needed for pain, start date 09/14/22. These two pain medications were both ordered as PRN medications and were the only two pain medications that had been ordered. Record review of Resident #1's September 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] Sodium Gel 1% apply to affected areas topically every 8 hours as needed for pain, start date 09/14/22; and - [MEDICATION(S)] Tablet 15 mg take 1 tablet by mouth every 4 hours as needed for pain, start date 09/14/22. Further review of the September 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no other pain medications on the MAR for Resident #1, which meant Resident #1 received no pain medications. Record review of Resident #1's progress note, dated 09/16/22, in the resident's EHR revealed Resident #1 was transferred to the hospital on 09/16/22. Further review reflected the resident did not return to the facility. Record review of the [Ambulance Service] Mobile Healthcare Patient Care Report, dated 09/16/22 7:58 PM, reflected: Dispatched to listed location .Upon arrival, states relates that pt is being sent out due to being in pain. Per pt records, the pt has significant medical history and has chronic pain. Facility relates they do not have her medications yet to be able to give her, so they are sending her to the hospital Interview on 10/17/22 at 11:48 AM, the EMT stated she was called to transport Resident #1 to the hospital for pain control. Upon arrival there were two nurses at the resident's bedside who could not relate anything about the resident's medical history other than she was complaining of pain and her pain medications had not been delivered by the pharmacy, so they had nothing to give her for pain. During transport Resident #1 relayed to her, she had been at the facility for two days and had not received anything for her pain. Resident #1 rated her pain at a 7 on a 1-10 scale. Interview on 10/18/22 at 10:25 AM, MA A stated the pharmacy delivered to the facility twice a day, once around 3:00 AM and again around 3:00 PM. She stated all PRN pain medications were administered by the nurses. Interview on 10/18/22 at 10:30 AM, RN B stated the facility had an E-Kit that was stocked with common medications that the nurses could pull out if the resident's medications had not been delivered to the facility. She stated the kit did not contain [MEDICATION(S)] but did have other pain medications such as [MEDICATION(S)] and Tylenol #3. RN B stated when a new admission arrived it was the nurse's responsibility to input all the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 10/18/22 at 10:40 AM, the DON stated the pharmacy had a cut-off time of 6:00 AM and 6:00 PM for new orders. Meaning orders placed before 6:00 PM would be delivered on the 3:00 AM delivery, and before 6:00 AM for the afternoon delivery. She stated it was the nurse's responsibility to ensure all medications were entered and that the pharmacy received the orders. The DON stated [MEDICATION(S)] was a Schedule II medication that required a special form in order to fill it. The physician had to either write a physical prescription on a triplicate form, or an electronic prescription could be sent to the pharmacy. Nurses could not call in prescriptions for Schedule II medications. The DON stated they discovered Resident #1's prescription for [MEDICATION(S)] had not been sent to the pharmacy when they investigated her complaint of not receiving her pain medication on 09/16/22. She stated she did not know why the nurses had not called the physician for an intermediate order for [MEDICATION(S)], which was stocked in the E-Kit, to hold the resident over until her [MEDICATION(S)] could be delivered. She stated it was an agency nurse that admitted the resident and agency nurses had been assigned to her hall the two days she was at the facility. The DON stated they had initiated a new process of the Charge Nurse reviewing all orders for new admissions, and the DON or the ADON checking the pharmacy system for all medications. Interview on 10/18/22 at 11:15 AM, the Pharmacist stated there was no prescription or order for [MEDICATION(S)] in their system. She stated they accepted either the triplicate form, or an electronic order directly from the physician for Schedule II medications. She did not know the specifics for Resident #1 but stated most likely the nurse at the facility entered the order for [MEDICATION(S)] based off the hospital discharge orders but did not follow up and have the attending physician write a prescription for it. Without the prescription they could not fill it and send it to the facility. Interview on 10/18/22 at 11:50 AM, Resident #1 stated she had been at the facility for two days and the nurse would not give her pain medications. She stated they kept telling her they had not been delivered from the pharmacy yet. She stated her pain finally got too severe for her to handle, and she asked to go to the hospital. She stated she was in the hospital for two days to get her pain to a manageable level again, and she opted to go to another facility instead of returning to this facility. She stated she had no medication issues at her new facility.

Based on interview and record review the facility failed to provide pharmaceutical services, which included procedures that assured accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs of each resident, for one of six residents (Residents #1) reviewed for pharmacy services. The facility failed to ensure Resident #1's orders for [MEDICATION(S)] and [MEDICATION(S)] Sodium Gel were received by the pharmacy in order for it to be delivered to the facility, which resulted in the resident having to be sent to the hospital when her pain became too severe due to her not receiving her pain medications. This failure could place residents at risk for not receiving the therapeutic benefits of the prescribed medications. Findings included: Record review of Resident #1's Admission Record, print date 10/18/22, in the EHR revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included [CONDITION(S)], lupus, peripheral autonomic [CONDITION(S)], and Stage 3 pressure ulcer. She was discharged to the hospital on 09/16/22 and did not return to the facility. Record review of Resident #1's Admission MDS, dated [DATE], revealed the resident admitted to the facility on [DATE] from an acute hospital. The resident was cognitively intact with a BIMS score of 15. The resident required extensive assistance of two people for bed mobility and was totally dependent upon two people for transfers. The Pain Assessment Interview reflected the resident had pain or hurting in the last five days, had almost constant pain, and the resident reported she had pain at a level 4 on a 00-10 pain scale. Record review of Resident #1's care plan, dated 09/15/22, revealed it was her baseline care plan, which only addressed droplet precautions and skin integrity. Record review of Resident #1's physician orders, dated 09/14/22, reflected Resident #1 had the following orders for pain medication: - [MEDICATION(S)] Sodium Gel 1% (used to treat arthritis pain) apply to affected areas topically every 8 hours as needed for pain, start date 09/14/22; and - [MEDICATION(S)] [MEDICATION(S)] Tablet 15 mg (used to treat severe chronic pain) take 1 tablet by mouth every 4 hours as needed for pain, start date 09/14/22. These two pain medications were both ordered as PRN medications and were the only two pain medications that had been ordered. Record review of Resident #1's September 2022 MAR revealed all of Resident #1's medications had been entered into the MAR on 09/14/22 by 4:00 PM to meet the 6:00 PM deadline for 3:00 AM pharmacy delivery on 09/15/22. The MAR reflected the following orders for pain medications: - [MEDICATION(S)] Sodium Gel 1% apply to affected areas topically every 8 hours as needed for pain, start date 09/14/22; and - [MEDICATION(S)] [MEDICATION(S)] Tablet 15 mg take 1 tablet by mouth every 4 hours as needed for pain, start date 09/14/22. Further review of the September 2022 MAR revealed the [MEDICATION(S)] [MEDICATION(S)] or [MEDICATION(S)] Sodium Gel had not been administered from 09/14/22-09/16/22. There were no other pain medications on the MAR for Resident #1, which meant Resident #1 received no pain medications. Record review of Resident #1's progress note, dated 09/16/22, in the resident's EHR revealed Resident #1 was transferred to the hospital on 09/16/22. Further review reflected the resident did not return to the facility. Record review of the [Ambulance Service] Mobile Healthcare Patient Care Report, dated 09/16/22 7:58 PM, reflected: Dispatched to listed location .Upon arrival, states relates that pt is being sent out due to being in pain. Per pt records, the pt has significant medical history and has chronic pain. Facility relates they do not have her medications yet to be able to give her, so they are sending her to the hospital Interview on 10/17/22 at 11:48 AM, the EMT stated she was called to transport Resident #1 to the hospital for pain control. Upon arrival there were two nurses at the resident's bedside who could not relate anything about the resident's medical history other than she was complaining of pain and her pain medications had not been delivered by the pharmacy, so they had nothing to give her for pain. During transport Resident #1 relayed to her, she had been at the facility for two days and had not received anything for her pain. Resident #1 rated her pain at a 7 on a 1-10 scale. Interview on 10/18/22 at 10:25 AM, MA A stated the pharmacy delivered to the facility twice a day, once around 3:00 AM and again around 3:00 PM. She stated all PRN pain medications were administered by the nurses. Interview on 10/18/22 at 10:30 AM, RN B stated the facility had an E-Kit that was stocked with common medications that the nurses could pull out if the resident's medications had not been delivered to the facility. She stated the kit did not contain [MEDICATION(S)] but did have other pain medications such as [MEDICATION(S)] and Tylenol #3. RN B stated when a new admission arrived it was the nurse's responsibility to input all the admission orders into the EHR, and all medications in the EHR automatically transferred over to the system the pharmacy used to deliver to the facility. Interview on 10/18/22 at 10:40 AM, the DON stated the pharmacy had a cut-off time of 6:00 AM and 6:00 PM for new orders. Meaning orders placed before 6:00 PM would be delivered on the 3:00 AM delivery, and before 6:00 AM for the afternoon delivery. She stated it was the nurse's responsibility to ensure all medications were entered and that the pharmacy received the orders. The DON stated [MEDICATION(S)] was a Schedule II medication that required a special form in order to fill it. The physician had to either write a physical prescription on a triplicate form, or an electronic prescription could be sent to the pharmacy. Nurses could not call in prescriptions for Schedule II medications. The DON stated they discovered Resident #1's prescription for [MEDICATION(S)] had not been sent to the pharmacy when they investigated her complaint of not receiving her pain medication on 09/16/22. She stated she did not know why the nurses had not called the physician for an intermediate order for [MEDICATION(S)], which was stocked in the E-Kit, to hold the resident over until her [MEDICATION(S)] could be delivered. She stated it was an agency nurse that admitted the resident and agency nurses had been assigned to her hall the two days she was at the facility. The DON stated they had initiated a new process of the Charge Nurse reviewing all orders for new admissions, and the DON or the ADON checking the pharmacy system for all medications. Interview on 10/18/22 at 11:15 AM, the Pharmacist stated there was no prescription or order for [MEDICATION(S)] in their system. She stated they accepted either the triplicate form, or an electronic order directly from the physician for Schedule II medications. She did not know the specifics for Resident #1 but stated most likely the nurse at the facility entered the order for [MEDICATION(S)] based off the hospital discharge orders but did not follow up and have the attending physician write a prescription for it. Without the prescription they could not fill it and send it to the facility. Interview on 10/18/22 at 11:50 AM, Resident #1 stated she had been at the facility for two days and the nurse would not give her pain medications. She stated they kept telling her they had not been delivered from the pharmacy yet. She stated her pain finally got too severe for her to handle, and she asked to go to the hospital. She stated she was in the hospital for two days to get her pain to a manageable level again, and she opted to go to another facility instead of returning to this facility. She stated she had no medication issues at her new facility.

Based on observation, interview, and record review, the facility failed to maintain an Infection Control Program designed to help prevent the transmission of disease and infection for eight (Residents #3, #4, #5, #6, #7, #8, #9, and #10) of 18 residents reviewed for infection control. CNA B failed accurately report signs and symptoms of COVID-19 she was displaying when screened at the beginning of her shift on 01/10/21 and 01/12/21 and continued work with residents while displaying signs and symptoms of COVID-19. CNA B tested positive for COVID-19 on 01/12/21. The facility failed to determine which residents CNA B interacted with, place those residents in quarantine due to an unknown COVID-19 status, and use appropriate PPE during interactions with those residents. An Immediate Threat was identified on 01/15/21. While the Immediate Threat was removed on 01/17/21, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not Immediate Threat, due to facility continuing to monitor the effectiveness of their plan of removal. The facility was provided the Immediate Threat template on 01/15/21. This failure placed residents at risk of exposure to COVID-19, which could result in serious illness, hospitalization , or even death. Findings included: Interview on 01/15/21 at 3:20 PM with CNA B revealed she worked on Sunday, 01/10/21, while experiencing body aches, pressure in her head, and a runny nose stating she thought it was just a head cold. CNA B stated before working her temperature had been taken and she had answered NO to the questions that asked if she was having any type of COVID-19 symptoms. She further stated she had called in to work the following day (Monday 01/11/21) due to not feeling well and took medication to treat her symptoms., She stated she returned to work on Tuesday 01/12/20, thinking she was doing better. She stated on Wednesday she woke up with worsened symptoms, including intense headache, runny nose, and sore throat, but did not work that day. CNA B stated her assignment was the residents in rooms 200 - 210 (Residents #3, #4, #5, #6, #7, #8, #9, and #10). CNA B stated she had circled NO to the COVID-19 questions because she thought it was just a head cold. She stated they were being tested for COVID-19 twice a week and she had not had a positive test. She agreed she probably should have answered the questions truthfully. Review of CNA B's COVID-19 screening questionnaire dated 01/10/21 and 01/12/21, revealed she circled NO to question #4 with reflected the following: Do you have signs or symptoms of a respiratory infection such as fever, cough, shortness of breath, difficulty breathing, fatigue, sore throat, chills, repeated shaking with chills, muscle pain, body aches, congestion, or runny nose, nausea, vomiting, diarrhea, headache, or new loss of taste and smell. Review of the facility line listing (document designed to be used as a line list template for investigations of outbreaks of unexplained respiratory illness), reflected CNA B tested positive for COVID-19 on 01/12/21. Multiple observations on 01/13/21, 01/14/21, and 01/15/21 revealed Hall 200 was part of the facility's cold zone where COIVD-19 negative residents resided Residents #3, #4, #5, #6, #7, #8, #9 and #10. During those observations, staff working with residents on the 200 hall were only wearing surgical masks when entering the rooms to provide care. There were no signs indicating the residents in those rooms should have been quarantined, after being exposed to a COVID-19 staff member. Further observation revealed there was no additional PPE such as gowns, N95, and face shields set outside of the rooms for staff to use prior to entering. Interview on 01/15/21 at 2:31 PM with the Administrator and DON revealed CNA B tested positive during their routine weekly testing. They stated they did not do any contact tracing or quarantine any residents that had direct exposure to the staff members and they were only wearing surgical masks when providing care. The Administrator also said they thought they were following the correct protocols and procedures and the residents did not need to be quarantined because they were being tested weekly for COVID-19. Interview on 01/15/21 at 5:10 PM with the Administrator and the DON revealed all staff were screened prior to working and they were to fill out the COVID-19 questions truthfully. They also stated they had never been contacted by CNA B to let them know she was feeling sick or that she had worked with any type of symptom. Review of the record of in-service titled PPE and New CDC Guidelines dated 07/11/20 revealed that one of the topics included, Employees showing symptoms must stop working, get tested , self-quarantine for 10 days. The in-service was signed by CNA B as being in attendance. Review of the facility's policy titled Coronvirus updated 12/09/20 reflected the following: .Staffing Staff to report to the facility via phone prior to reporting for work if they have known exposure or symptoms Review of the CDC's Responding to Coronavirus (COVID-19) in Nursing Homes, updated 04/30/20, reflected the following: Determine which residents received direct care from and which HCP had unprotected exposure to HCP who worked with symptoms consistent with COVID-19 or in the 48 hours prior to symptom onset. Residents who were cared for by these HCP should be restricted to their room and be cared for using all recommended COVID-19 PPE until results of HCP COVID-19 testing are known. If the HCP is diagnosed with [REDACTED].g., there is an outbreak in the facility) Residents who are known close contacts should be considered for testing initially, and, if negative, again about 5-7 days after exposure. If testing is negative, residents should remain in quarantine for 14 days. (accessed on 01/28/21 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html) The Administrator and DON were notified of the Immediate Threat on 01/15/21 at 5:10 PM. The facility was asked to provide a Plan of Removal to address the Immediate Threat. The Facility's Plan of Removal for Immediate Threat was accepted on 01/16/21 at 12:56 PM and reflected the following: Monitoring of the plan of removal reflected: IN-SERVICE CONDUCTED: On 1/15/2021 the facility created a donning and doffing station on at the East Nurses Station to supply all appropriate PPE for the staff working with quarantined residents. The appropriate PPE for staff working with quarantine patients is N-95 masks, face shield or goggles, gowns and gloves. The facility provided instruction on proper donning and doffing of PPE. Germicide wipes and hand sanitizer were also provided. Education and in-service were begun with staff on 1/15/21. The in-service training was started and will continue with all shifts until all staff members have completed required in-services. The staff member will not be allowed to return to work on the floor as required in our Plan of Removal until they are in-serviced and complete a post test. All in-servicing and training will be performed by the Director of Clinical Operations. All clinical and housekeeping staff will be educated. Education will be completed by 1/16/2021. 1. All residents with unknown status will be quarantined in their rooms until status is determined or 14 days from known exposure. 2. Use of proper PPE for staff working with quarantined residents. The proper PPE is N95 mask, face shield or goggles, gown and gloves at all times. 3. Quarantine Hall will have donning and doffing stations established and maintained with proper PPE. 4. All staff will answer COVID-19 screening forms accurately and honestly upon entering the facility. All staff exhibiting symptoms will not enter the building. If staff is feeling sick, they should not come to work. IMPLEMENTAION OF CHANGES: The Director of Nursing and Administrator implemented required quarantine rooms status for residents effective 1/15/2021 @ 3 pm. Donning and doffing station established on the East hall. Appropriate signage, in regard to proper donning and doffing as well entering a quarantined space, were placed outside the doors and at donning and doffing station. These stations were stocked with N95 masks, face shields, gowns, gloves, germicidal wipes and hand sanitizer. Stations were completed 1/15/21. Quarantine precautions were setup so that hooks were placed inside each resident door for storage of individual gowns for patient care. This was completed 1/16/21. Identified staff will be educated on the process of placing residents in quarantine for 14 days when they have had contact with a COVID-19 positive staff members. All education will be complete 1/16/21. Monitoring: The Director of Clinical Operations, Director of Nursing and Administrator will be responsible for monitoring educational requirements. This process began on 1/15/21, education will continue each shift until 100% of the staff is educated on the above criteria. All staff identified above will educated by 1/16/21. Walking rounds will be made each shift to ensure compliance and documentation will be reviewed daily. All new hired staff will receive the same in-service education noted above. The schedule and designee for each shift and day will be as follows- Monday through Friday, morning and evening shifts will be conducted by the Director of Nursing, Administrator and or Assistant Director of Nursing. The night shift round will be conducted by the Director of Nursing, Administrator, Assistant Director of Nursing. Saturday and Sunday, morning and evening shift, will be conducted by Director of Nursing, Administrator, Assistant Director of Nursing, and or Weekend Supervisor, RN. Walking rounds will be completed daily for 30 days until 2/16/21. If 100% compliance is achieved monitoring rounds will be reduced to weekly for 30 days until 3/16/21. Walking rounds and results will be produced and discussed monthly at QAPI with the Interdisciplinary Team. At any time, education acknowledgment of not understanding of what is required to maintain compliance, clarification will be provided immediately by one on one in-servicing by the Director of Clinical Operations, Director of Nursing, Administrator, and or Assistant Director of Nursing. Interviews and observations were conducted on 01/17/21 starting at 11:12 AM and completed at 3:16 PM with 23 staff members (CNA B, C, D, G, H, M, N, P, Q, R, S, T, U, V, LVN F, I, J, K, L, Weekend Supervisor, Laundry Aide, Social Worker, RN O) from various shifts regarding in-services which included correct use of PPE, staff assignments on the hot, warm, and cold unit, identification of residents who were supposed to be in isolation/quarantine, room moves, contact tracing, and the line listing. The staff members were able to: Explain proper PPE for staff working with quarantined residents and All staff will answer COVID-19 screening forms accurately and honestly upon entering the facility. All staff exhibiting symptoms will not enter the building. If staff is feeling sick, they should not come to work. Observations revealed residents in rooms 200 - 210 were quarantined and there were signs posted at each door letting staff know full PPE was to be worn before entering each room. Staff was observed donning and doffing the PPE appropriately before entering each room. The Administrator and DON were made aware that all residents with direct exposure to a positive staff member were to be quarantined and staff acknowledged they understood they needed to answer the COVID-19 questionnaire truthfully and not go in to work if they were sick or exhibiting any type of symptoms. An Immediate Threat was identified on 01/15/21. While the Immediate Threat was removed on 01/17/21, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not Immediate Threat, due to the facility monitoring their plan of removal.