**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility policy review, and observation of current practice, the facility failed to ensure one resident's medications were obtained and administered as ordered by the physician. The deficient practice led to one resident not receiving prescribed antibiotics for eight days, delaying treatment of infection. Findings include: Resident #33 was admitted to the facility on [DATE], following a hospital stay, with diagnoses including persistent vegetative state, quadriplegia, and respiratory failure with hypoxia. Review of the hospital records revealed that Resident #33 had admitted to the hospital on [DATE] for a malfunctioning G-tube. While at the hospital, the physician noted that the resident had been previously hospitalized for multilobar pneumonia and septic shock. The physician noted on February 11, 2025 that the resident's sepsis was originally severe, but had been improving with an antibiotic regimen of cefiderocol and newly added gentamicin. The physician also noted that the plan was to continue cefiderocol and gentamicin upon discharge, and the prescriptions had been ordered. Review of the hospital discharge orders revealed an order to administer cefiderocol 2 grams IV Piggyback, three times a day for 8 days. Further review of the discharge orders revealed an order to administer gentamicin 240 milligrams IV Piggyback every 24 hours for 10 days. These orders also gave instructions on what pharmacy to pick up the medication at. Review of the facility's physician orders revealed the following orders: Cefiderocol Sulfate Tosylate Intravenous Solution. Reconstituted 1 GM (Cefiderocol Sulfate Tosylate) Use 1 gram intravenously three times a day for Infection for 8 Days Discontinued. Start date: 02/13/2025. End date: 2/21/2025 Cefiderocol Sulfate Tosylate Intravenous Solution. Reconstituted 1 GM (Cefiderocol Sulfate Tosylate) Use 1 gram intravenously three times a day for UTI until 02/21/2025 15:59 Discontinued. Start date: 2/17/2025. End date: 02/21/2025 Gentamicin in Saline Intravenous Solution 2 MG/ML (Gentamicin in Saline). Use 240 mg intravenously one time a day for Infection for 10 Days. Gentamicin (gentamicin 100 mg/ 50 mL-NaCl 0.9% intravenous solution) Discontinued. Order date: 02/13/2025. Start date: 02/14/2025. End date: 02/24/2025 Gentamicin in Saline Intravenous Solution 2 MG/ML (Gentamicin in Saline). Use 240 mg intravenously one time a day for UTI for 10 Days gentamicin (gentamicin 100 mg/ 50 mL-NaCl 0.9% intravenous solution) Discontinued. Order date:02/17/2025. Start date: 02/18/2025. End date: 02/28/2025 Gentamicin in Saline Intravenous Solution 2 MG/ML. (Gentamicin in Saline) Use 240 mg intravenously one time a day for UTI until 02/24/2025 23:59 gentamicin (gentamicin 100 mg/ 50 mL-NaCl 0.9% intravenous solution) Active. Order date: 02/17/2025. Start Date: 02/18/2025. End date: 02/24/2025 Review of the Medication Administration Record for February 2025 revealed that no doses of Gentamicin or Cefiderocol were administered to Resident #33 between February 13, 2025 and February 18, 2025. Both orders were set originally to start on February 13, 2025. One dose of Cefiderocol was administered on February 19, 2025 at 6:00PM, and no doses of Gentamicin were administered on this date. Review of the nursing Medication Administration Notes revealed several notes stating that Gentamicin and Cefiderocol were on order and that the medications were unavailable. The nursing notes on February 14, 2025 revealed that Cefiderocol and Gentamicin IV medications were on order, and the NP was aware. The nursing note on February 15, 2025 revealed that these two medications were still not available, and that the provider and family were aware. A nursing note entered on February 18, 2025 revealed that the medications were still unavailable. The note revealed that the attending physician was notified, and a prescription order was sent to a different pharmacy. Nursing notes entered on February 19, 2025 revealed that the medications were still not obtained, and the nurse was attempting to order the medications. The nurse wrote that the provider, Director of Nursing (DON), and the resident's family were aware. Interview was conducted on February 20, 2025 at 10:34AM with Resident #33's Power of Attorney (POA) who confirmed that the resident had recently re-admitted to the facility from the hospital. She stated that she was unaware of any issues obtaining the antibiotics needed to treat the resident. She also stated that the hospital had told her that they would not discharge the resident to the facility unless the facility was able to provide the needed antibiotics to the resident. The POA explained that she had some concerns about the resident's care and medications, but she was unable to reach the DON when she called, and no calls had been returned to her. Interview was conducted on February 20, 2025 at 11:08AM with a Pharmacist (Staff #291) from the pharmacy that was initially sent the order for the two antibiotics. The pharmacist stated that the timing of antibiotics is absolutely important, and that the pharmacy prioritizes filling antibiotics for this reason. The pharmacist stated that they received the orders for Resident #33's antibiotics on February 13, 2025. She then stated that their pharmacy does not fill those medications for Resident #33's insurance, and that several staff members from the facility, including the DON, were notified on February 14, 2025 via email that they would have to fill the order with the facility's other pharmacy service. Interview was conducted on February 20, 2025 at 11:31AM with a Licensed Practical Nurse (LPN/Staff #18), who explained that once an order is put in and activated, it is sent directly to the pharmacy. She stated that if the medications are not in the facility, it is expected to call and ask the pharmacy why the medication had not arrived. The LPN stated that if there is an issue getting the medication, the DON and provider are informed and the DON handles it from that point on. Interview was conducted on February 20, 2025 at 12:59PM with the [NAME] President of Quality and Operational Excellence (VP / Staff #304) from the second pharmacy to receive Resident #33's antibiotic orders. She confirmed that they had received an order from the facility for Resident #33's antibiotics on February 14, 2025. The pharmacy had then called the facility and spoke with an LPN (Staff #18), notifying them that they could not fill the orders, as the medications were outside of the formula of what their pharmacy provides. The VP then explained that the pharmacy received orders for both of the medications again on February 18, 2025, so the pharmacy had attempted to call the facility to speak with them. The pharmacy left a message with the receptionist detailing that these orders could not be filled on February 18, 2025. Interview was conducted on February 20, 2025 at 1:48PM with the Director of Nursing (DON/ Staff #27), who explained the process the nurses should take upon noticing a medication had not arrived from pharmacy is to call the pharmacy and notify the management. From there, the DON explained he would take over and contact pharmacy to see if there are issues with the fulfilment. When asked about Resident #33, the DON explained that the orders for the two antibiotics, Gentamicin and Cefiderocol, were originally sent to the first pharmacy on Thursday, February 13, 2025. On Friday, February 14, 2025, the DON stated that he talked to the pharmacy and referred the orders to the second pharmacy for fulfillment. The DON stated that both pharmacies were going back and forth with insurance authorizations. He explained that he next contacted the second pharmacy on Tuesday, February 18, 2025. He also spoke with the Nurse Practitoner (NP) on this date. He stated that he notified the NP that the facility was having difficulty obtaining antibiotics for Resident #33. The DON stated that the NP wanted the facility to wait for the antibiotics to be filled, and if they cannot be filled, the resident would be sent out. The DON could not provide a timeframe on how long the facility would wait for the medications, instead stating that the staff were monitoring the resident. The DON stated he had also inquired about using other antibiotics, but was told it was vital to use Gentamicin and Cefiderocol, due to the specific microbes needing to be treated. The DON explained that he had just received the cost of the medications from the pharmacy and had obtained approval for the facility to pay the cost of the medications through the first pharmacy this date, February 20, 2025. At this time, the facility was awaiting delivery of the medications. The DON elaborated that he educated the admission team to ensure that pre-authorizations are done prior to the resident arriving to the facility. The DON confirmed that the resident had been receiving both medications at the hospital, and identified that a delay in receiving these antibiotics could result in increased infection. Review of the facility policy titled, Administering Medications, indicated that medications shall be administered in a safe and timely manner, and as prescribed. The policy indicated that medications must be administered in accordance with the orders, including any required time frame. Review of the facility policy titled, Pharmacy Services- Role of the Provider Pharmacy, indicated that the provider pharmacy shall supply the facility with approved medications, biologicals, and supplies, as well as any compounded medications or investigational drugs that are needed. Review of the facility policy titled, Documentation of Medication Administration, revealed that if a medication is not administered, the Medical Doctor (MD) is to be notified as to why, including if the medication is not available. The policy indicated that in the event that medications that are prioritized to be critical of care are not given, including IV antibiotics, an immediate call to the MD should be made for further orders. This policy also indicated that documentation is to include the medication, dose and time scheduled, the reason for not administering, and the action plan for medication regimen.

Based on review of clinical records and policy, observations, and staff interviews the facility failed to ensure enhanced barrier precaution (EBP) policies, notably use of personal protective equipment (PPE) during wound care, were up-to-date with professional standards of practice. The deficient practice may result in development or transmission of infections within the facility. Findings include: An observation of wound care was conducted on June 13, 2024 at 08:40 AM with Certified Wound Nurse/Licensed Practical Nurse (LPN/Staff # 65) after verbal consent of approval by Resident # 89. Staff # 65 entered the room, drew curtain for privacy, and donned gloves. Staff # 65 did not wear a protective gown at this time. Staff # 65 stated the pressure ulcer right hip wound care was classified as a clean procedure; and that, was setting up supplies on medical stand. Staff # 65 utilized cleaning technique with sterile water, applied silver alginate onto the wound bed with clean dressing, and appropriately assessed pain before and after care. An interview was conducted on June 13, 2024 at 08:58 AM with Staff # 65 regarding enhanced barrier precautions (EBP). Staff # 65 stated that whenever a resident is on (EBP), staff are expected to wear gown and gloves when providing high contact care; and that, wound care was considered high contact care. Staff # 65 stated per facility policy, this only applies to wounds (stage III or greater), therefore it was unnecessary to wear a gown for wound care that was performed on Resident # 89. Staff # 65 confirmed that this is the current facility practice; and that, unless wound was staged III or greater, no gown was used during wound care of any resident in the facility at this time. An interview was conducted on June 12, 2024 at 09:50 AM with Director of Nursing (DON/Staff # 78) who stated was the designated Infection Preventionist (IP) after previous certified IP left the facility. Staff # 78 stated that EBP practice was based on the facility's policies; and that, only wounds stage III or greater require use of gowns. Staff # 78 stated that as of June 12, 2024, he did not hold any qualifying infection prevention certification or training in infection control. Staff # 78 reassured a qualified IP was presently in the hiring process; and that, a tentative start date of June 20, 2024 was planned for the prospective IP. An interview was conducted on June 14, 2024 at 01:16 PM with DON who stated after thorough review of CDC recommendations, was informed of the updated requirements for enhanced based precautions and the use of gowns during any wound care. Review of the facility's policy titled, Infection Control and Modified Enhanced Barrier Policy/Procedures (revised June 2018) revealed enhanced barrier precautions will be based on the Centers for Disease Prevention & Control (CDC) guidance. The CDC website on healthcare acquired infections revealed that the enhanced barrier precautions are an infection control intervention designed to reduce the transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. The CDC further stated that nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDRO's (multi-drug resistant organisms). The CDC website further revealed that use of gown and glove for high-contact resident care activities is indicated when contact precautions do not otherwise apply; and that, because Enhanced Barrier Precautions do not impose the same activity and room placement restrictions as Contact Precautions, they are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. Updated July 12, 2022.https://cdc.gov/hai/containment/ PPE-Nursing-Homes.html.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure one resident (#407) was not abused by staff (#33) and one resident (#54) was not neglected by staff (#13). The deficient practice could result in residents being physically and emotionally harmed and not receiving the services that are needed. Findings include: Resident #407 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, delusional disorders, and respiratory failure. Review of the self-care deficit care plan, revealed that resident #407 required extensive assistance with ADIS related to dementia and respiratory failure dated January 3, 2023. Interventions included to use mechanical lift for transfers, wheelchair for long distance mobility, extensive assistance with bed mobility, total assistance with toileting, but it did not include a plan for bathing. The minimum data set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 12 indicating the resident had a moderate cognitive disorder. It also included that the resident required a one-person extensive assist with bed mobility, transfers, dressing, personal hygiene, and physical help in part of the bathing activity. Review of staff #33's time card revealed that she worked on July 24, 2023 from 6:00 a.m. to 6:30 p.m. Review of the task sheets revealed that the resident received a shower on July 24, 2023. Review of a weekly skin check dated July 24, 2023 did not reveal bruising to resident #407's left arm. Review of a progress note dated July 25, 2023 revealed that during medication pass, the licensed practical nurse (LPN/staff #25), was called to the resident's room by the certified nursing assistant (CNA/staff #16). Staff #25 entered the room and staff #16 pointed to the resident's left arm and stated that the resident had a bruise on her arm. Staff #25 asked the resident what happened and the resident stated that the CNA gave me a shower and she was rough with me. The resident stated that this is how she got the bruise and she didn't want the CNA taking care of her anymore. Review of staff #33's employee file revealed a Corrective Action Memo dated July 25, 2023 for unsatisfactory customer service. Staff #33 received a verbal warning: education provided to staff on transfers by using a gait belt for 1-2 persons transfer and 2 person for mechanical lift. Staff #33 was educated on how to identify the process for a resident transfer by looking at the ICSP in the POC for each resident. Review of staff #33's time card revealed that she worked on July 25, 2023 through July 28, 2023. An interview was conducted on August 15, 2023 at 9:47 a.m. with the Director of Nursing (DON/staff #2), who stated that the resident was bruised on the forearm when (CNA/staff #33) was pulling the resident's sweater on. She stated that she spoke to the resident and the resident is fragile, so the allegation did not meet the definition of abuse. She stated that the resident did identify staff #33 as the alleged perpetrator. An interview conducted on August 15, 2023 at 11:01 a.m. with (LPN/staff #25), who stated that (CNA/staff #16) was with the resident and called her to look one larger bruise, the size of a quarter, and one smaller bruise next to it on the resident's arm. She stated that the resident told her that a staff grabbed her hand when she was in the shower and this was when the injury occurred. Staff #25 stated that the resident described staff #33. The resident was asked if it was staff #33 and the resident said, yes. Staff #25 stated that she reported the injury and allegation to the nurse coming on duty (LPN/staff #86) and staff #86 reported it to the DON. Staff #25 stated that she, the DON, and staff #86 went into the resident's room to interview the resident, while staff #33 remained in the hallway. During the interview, the resident stated that staff #33 was rough with her and grabbing her arm, while she was giving her a shower. She stated that after the resident was interviewed, she, staff #33, and staff #86 went to the DON's office. Staff #33 stated that when she was putting on the resident's sweater, the resident's arm got caught in the arm and reached in to pull the resident's arm through the sleeve. Staff #25 stated that staff #33 said the resident was making noises like ou, ou, ou. Staff #25 thought the sounds indicated the staff was being too rough. An interview was conducted on August 15, 2023 at 1:48 p.m. with (CNA/staff #35), who stated that she assisted (CNA/staff #33) with the resident, who was in the shower in July, but didn't remember the exact day. She stated that staff #33 opened the bathroom door and asked her to help with the resident. She stated that she felt uneasy because usually resident #407 is easy and doesn't need someone else to help. She stated that staff #33 held the resident by standing in front of her with hands under her armpits and she stood behind the resident and pulled the resident's brief up. Staff #35 stated that knows the resident wasn't happy because she was complaining and fighting. She doesn't remember what the resident said, but the resident was in pain for sure, she knows that because the resident was saying things like ouch. She stated that the resident usually has pain, so you need to gentle with her, but she is not a hard to work with. When staff #35 was done helping, staff #33 told her to get out. Staff #35 stated that she knew staff #33 was upset because of the tone in her voice. She stated that she felt like something wasn't quite right. An interview was conducted on August 15, 2023 at 2:20 p.m. with resident #407, who stated that staff #33 yanked her up in the shower, hurt her arm and knee, and she got a bruise on her arm. She stated that she yelled in pain and the staff told her to shut-up. The resident identified staff #33. An interview was conducted on August 16, 2023 at 11:18 a.m. with (CNA/staff #33), who stated that she showered the resident and when she was dressing the resident, the resident's knitted sweater got caught on her left hand and she couldn't push it through, so she stuck her hand inside the opening of the arm of the sweater to pull the resident's arm through. Staff #33 stated that (CNA/staff #35) came into the bathroom to help her transfer the resident to her wheelchair. Staff #33 stated that staff #35 was standing on the resident's right side and she was standing on the resident's left side. She stated that both staff were facing the opposite direction of the resident and each put their arms under the armpit area to lift the resident. Staff #33 pulled the shower chair out, while staff #35 rolled the wheelchair behind the resident. She stated that they held the resident shoulder to shoulder and they were provided training after this happened on the correct way to transition a resident. She stated that they tried to do what she thought was safe, but the resident is fragile and they could have popped the resident's arm out of the socket. Staff #33 stated that the resident didn't yell when she was showering her, but she was being mouthy, and told staff #33 that she was stupid. Staff #33 stated that she is slowing down now because she does work fast and accidents can happen and sometimes she has too much strength and it could be too much for the resident. She stated that the day after the shower occurred, she came to work, and a CNA stated that the resident didn't want her in her room anymore and the resident had a bruise. The DON asked her what happened and then did the investigation right away. Staff #33 stated that it was substantiated that she had too much force when she grabbed the resident because the bruise was like a thumb print mark. -Resident #54 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included morbid obesity, chronic kidney disease, and an anxiety disorder. Review of the care plan dated October 1, 2021 revealed an alteration in elimination due to a colostomy. Interventions included to empty the colostomy bag as needed, ensure that supplies are available, house bowel care protocol, monitor and document bowel movements and to respond to call-light promptly. Review of the care plan dated October 12, 2018 revealed a self-care deficit, which requires extensive assistance with activities of daily living (ADLs) related to weakness, debility, infection, pain, obesity, and refusal of care at times. Interventions included to gather and provide necessary materials and equipment for (ADLs) and to provide verbal cues, prompts, redirection and hand-over-hand assistance as needed. Review of the order summary revealed an order dated October 31, 2022 for colostomy care: wafer - change every 7 days and as needed. Date and initial wafer using correct bag size, cut wafer to around the stoma. Cleanse area around the stoma, pat dry and apply skin prep. Secure appliance every night shift every Sunday for colostomy care use size 4 in. Review of the Treatment Administration Record (TAR) dated May 2023 revealed that colostomy care: wafer - change every 7 days and as needed. Date and initial wafer using correct bag size, cut wafer to around the stoma. Cleanse area around the stoma, pat dry and apply skin prep. Secure appliance every night shift every Sunday for colostomy care use size 4 in. treatment was provided on May 7, 2023 by staff #13. The (MDS) dated [DATE] included a brief interview for mental status score of 15 indicating the resident was cognitively intact. It also included that the resident had an ostomy and required a one-person extensive assist with toileting. Review of the task sheets dated May 2023 revealed that resident #54 had two bowel movements on May 7, 2023. It also revealed that care was to be provided to the resident in pairs. Review of the clinical record did not reveal an assessment for colostomy self-care. During an interview was conducted on August 16, 2023 at 10:00 a.m. with the MDS Coordinator (staff #17), she reviewed resident (#54's) MDS dated [DATE] and stated that in June 2023, the resident required a one-person extensive assist with toileting, which included ostomy care. Then she reviewed the colostomy care plan and stated that the resident required a one-person extensive assist with colostomy care. She explained that the amount of extensive assistance needed can change daily because the resident may want to participate some days, but not on other days. She also stated that it is the resident's right to choose not to participate in colostomy care. Staff #17 did not know to what extent the resident was able to participate in colostomy care and stated that she would have to ask a nurse and she is not aware of any formal training regarding colostomy care that is provided to the resident. On August 16, 2023 at 12:50 an interview was conducted with resident #54, who stated that she knows how to do the colostomy care. She is able to cut out the pattern and the holes in the wafer, but is not able to see if she is applying the wafer correctly and if the holes are not aligned, it will leak. She stated that staff #13 tried to make her put the wafer on by herself without washing her hands or giving her gloves. The resident stated that she told staff #13 that she couldn't see what she was doing and explained that the nurse is able to look directly down and line up the holes, but she can't see what she is doing. During the interview, the resident provided a video and a black woman with long hair could be heard saying she was here to train the resident and was not going to do the treatment, she told the resident that she could do it, they know she can. The staff said, do it. The staff was heard saying you need to do it. The resident was heard saying that she didn't have gloves and the staff didn't respond. The resident stated that staff #13 was trying to force her to remove the bag. The staff's tone was not encouraging or friendly and the resident stated that she felt staff was acting in a threatening manner. An interview was conducted on August 16, 2023 at 1:38 p.m. with the Assistant Director of Nursing (ADON/staff #13), who stated that the resident is supposed to be learning colostomy care and the resident did tell her that she couldn't see exactly where to place it. She stated that the resident is supposed to wear gloves and that she told the resident she would get her gloves. She stated that she never told the resident to do it. She stated that she told the resident she would help her to do it because the resident needed to be changed because it was messy. She stated that the resident has the right to request assistance. She also stated that there was supposed to be a second staff present during care and she was by herself. She stated that she listened to the video and there was nothing wrong with the tone of her voice. An interview was conducted on August 16, 2023 at 2:30 p.m. with the (DON/staff #2), who stated that they don't have an assessment for colostomy self-care for this resident. They don't do assessments. They teach and assist with care; this goes way back and the resident is able to do colostomy care, but just doesn't want to do it. She stated that she would look for documentation that the resident received training and is able to do colostomy care by herself. An interview was conducted on August 17, 2023 at 8:45 a.m. with the (DON/staff #2), who stated that neglect occurs when essential care is not provided for the resident. She stated that the resident has an order for ostomy care, and the resident is allowed to provide her own treatment if it is included in the physician's order. She also stated that if the resident is provided with education and training and says that he or she can't do it, or need help, it is her expectation that the staff complete the care/treatment. She stated that she reviewed the video the resident took and posted on YouTube when the incident occurred, but couldn't remember if the resident stated that she needed help, couldn't perform the task, didn't want to do it, or the resident asked for gloves. She stated that if gloves were not provided, it created a risk of infection. During the interview, she reviewed the investigation and stated that it didn't look like a second staff was present during the incident, which is required at all times. The facility's policy Abuse and Neglect Policy, revised October 2022 states that residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes, but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, neglect, deprivation of goods or services, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The facility's policy, Quality of Care, states that it is the policy of the facility to ensure it identifies and provides needed care and services that are resident centered, in accordance with the resident's preferences including colostomy care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to implement their abuse policy, by failing to report an allegation of abuse, submit a 5-day written investigation involving resident (#407) to the state agency, and failed to suspend staff #33 from providing care to the resident involved or any other residents during the investigation. Findings include: Resident #407 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, delusional disorders, and respiratory failure. Review ot the self-care deficit care plan, revealed that resident #407 required extensive assistance with ADIS related to dementia and respiratory failure dated January 3, 2023. Interventions included to use mechanical lift for transfers, wheelchair for long distance mobility, extensive assistance with bed mobility, total assistance with toileting, but it did not include a plan for bathing. The minimum data set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 12 indicating the resident had a moderate cognitive disorder. It also included that the resident required a one-person extensive assist with bed mobility, transfers, dressing, personal hygiene, and physical help in part of the bathing activity. Review of staff #33's time card revealed that she worked: -July 24, 2023 from 6:00 a.m. to 6:30 p.m. -July 25, 2023 from 6:00 a.m. to 6:30 p.m. -July 26, 2023 from 6:00 a.m. to 6:30 p.m. -July 27, 2023 from 6:00 a.m. to 6:00 p.m. -July 28, 2023 from 6:00 a.m. to 6:30 p.m. Review of the task sheets revealed that the resident received a shower on July 24, 2023. Review of a progress note dated July 25, 2023 revealed that during medication pass, the licensed practical nurse (LPN/staff #25), was called to the resident's room by the certified nursing assistant (CNA/staff #16). Staff #25 entered the room and staff #16 pointed to the resident's left arm and stated that the resident had a bruise on her arm. Staff #25 asked the resident what happened and the resident stated that the CNA gave me a shower and she was rough with me. The resident stated that this is how she got the bruise and she didn't want the CNA taking care of her anymore. Review of staff #33's employee file revealed a Corrective Action Memo dated July 25, 2023 for unsatisfactory customer service. Staff #33 received a verbal warning: education provided to staff on transfers by using a gait belt for 1-2 persons transfer and 2 person for mechanical lift. Staff #33 was educated on how to identify the process for a resident transfer by looking at the ICSP in the POC for each resident. An interview was conducted on August 15, 2023 at 9:47 a.m. with the Director of Nursing, who stated that the resident was bruised on the forearm when (CNA/staff #33) was pulling the resident's sweater on. She stated that she spoke to the resident and the resident is fragile, so the allegation did not meet the definition of abuse. She stated that the resident did identify staff #33 as the alleged perpetrator. An interview conducted on August 15, 2023 at 11:01 a.m. with (LPN/staff #25), who stated that (CNA/staff #16) was with the resident and called her to look one larger bruise, the size of a quarter, and one smaller bruise next to it on the resident's arm. She stated that the resident told her that a staff grabbed her hand when she was in the shower and this was when the injury occurred. Staff #25 stated that the resident described staff #33. The resident was asked if it was staff #33 and the resident said, yes. Staff #25 stated that she reported the injury and allegation to the nurse coming on duty (LPN/staff #86) and staff #86 reported it to the DON. Staff #25 stated that she, the DON, and staff #86 went into the resident's room to interview the resident, while staff #33 remained in the hallway. During the interview, the resident stated that staff #33 was rough with her and grabbing her arm, while she was giving her a shower. She stated that after the resident was interviewed, she, staff #33, and staff #86 went to the DON's office. Staff #33 stated that when she was putting on the resident's sweater, the resident's arm got caught in the arm and reached in to pull the resident's arm through the sleeve. Staff #25 stated that staff #33 said the resident was making noises like ou, ou, ou. Staff #25 thought the sounds indicated the staff was being too rough. The facility's policy, Abuse and Neglect Policy, revised on October 2022 states that allegations that alleged violations involving neglect, exploitation, mistreatment, or misappropriation of resident property, and does not result in serious bodily injury must be reported within 24 hours, results of all investigations of alleged violations are to be complete within 5 working days of the incident, and to suspend staff from providing care to the resident involved or any other residents during the investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to failed to report and allegation of abuse involving resident (#407) and failed to submit a 5-day written investigation to the state agency, and failed to complete a thorough investigation regarding an allegation of neglect involving resident #54. Findings include: Resident #407 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, delusional disorders, and respiratory failure. Review of the self-care deficit care plan, revealed that resident #407 required extensive assistance with ADIS related to dementia and respiratory failure dated January 3, 2023. Interventions included to use mechanical lift for transfers, wheelchair for long distance mobility, extensive assistance with bed mobility, total assistance with toileting, but it did not include a plan for bathing. The minimum data set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 12 indicating the resident had a moderate cognitive disorder. It also included that the resident required a one-person extensive assist with bed mobility, transfers, dressing, personal hygiene, and physical help in part of the bathing activity. Review of staff #33's time card revealed that she worked on July 24, 2023 from 6:00 a.m. to 6:30 p.m. Review of the task sheets revealed that the resident received a shower on July 24, 2023. Review of a weekly skin check dated July 24, 2023 did not reveal brusing to resident #407's left arm. Review of a progress note dated July 25, 2023 revealed that during medication pass, the licensed practical nurse (LPN/staff #25), was called to the resident's room by the certified nursing assistant (CNA/staff #16). Staff #25 entered the room and staff #16 pointed to the resident's left arm and stated that the resident had a bruise on her arm. Staff #25 asked the resident what happened and the resident stated that the CNA gave me a shower and she was rough with me. The resident stated that this is how she got the bruise and she didn't want the CNA taking care of her anymore. Review of staff #33's employee file revealed a Corrective Action Memo dated July 25, 2023 for unsatisfactory customer service. Staff #33 received a verbal warning: education provided to staff on transfers by using a gait belt for 1-2 persons transfer and 2 person for mechanical lift. Staff #33 was educated on how to identify the process for a resident transfer by looking at the ICSP in the POC for each resident. An interview was conducted on August 15, 2023 at 9:47 a.m. with the Director of Nursing, who stated that the resident was bruised on the forearm when (CNA/staff #33) was pulling the resident's sweater on. She stated that she spoke to the resident and the resident is fragile, so the allegation did not meet the definition of abuse. She stated that the resident did identify staff #33 as the alleged perpetrator. She did not report the incident or submit a 5-day written investigation to the state agency. An interview conducted on August 15, 2023 at 11:01 a.m. with (LPN/staff #25), who stated that (CNA/staff #16) was with the resident and called her to look one larger bruise, the size of a quarter, and one smaller bruise next to it on the resident's arm. She stated that the resident told her that a staff grabbed her hand when she was in the shower and this was when the injury occurred. Staff #25 stated that the resident described staff #33. The resident was asked if it was staff #33 and the resident said, yes. Staff #25 stated that she reported the injury and allegation to the nurse coming on duty (LPN/staff #86) and staff #86 reported it to the DON. Staff #25 stated that she, the DON, and staff #86 went into the resident's room to interview the resident, while staff #33 remained in the hallway. During the interview, the resident stated that staff #33 was rough with her and grabbing her arm, while she was giving her a shower. She stated that after the resident was interviewed, she, staff #33, and staff #86 went to the DON's office. Staff #33 stated that when she was putting on the resident's sweater, the resident's arm got caught in the arm and reached in to pull the resident's arm through the sleeve. Staff #25 stated that staff #33 said the resident was making noises like ou, ou, ou. Staff #25 thought the sounds indicated the staff was being too rough. -Resident #54 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included morbid obesity, chronic kidney disease, and an anxiety disorder. Review of the care plan dated October 1, 2021 revealed an alteration in elimination due to a colostomy. Interventions included to empty the colostomy bag as needed, ensure that supplies are available, house bowel care protocol, monitor and document bowel movements and to respond to call-light promptly. Review of the care plan dated October 12, 2018 revealed a self-care deficit, which requires extensive assistance with activities of daily living (ADLs) related to weakness, debility, infection, pain, obesity, and refusal of care at times. Interventions included to gather and provide necessary materials and equipment for (ADLs) and to provide verbal cues, prompts, redirection and hand-over-hand assistance as needed. Review of the order summary revealed an order dated October 31, 2022 for colostomy care: wafer - change every 7 days and as needed. Date and initial wafer using correct bag size, cut wafer to around the stoma. Cleanse area around the stoma, pat dry and apply skin prep. Secure appliance every night shift every Sunday for colostomy care use size 4 in. Review of the facility investigation revealed that the (DON/staff #2) did not include information regarding the video taken by the resident during the incident, even though she was aware of the video and stated that she saw the video. On August 16, 2023 at 12:50 an interview was conducted with resident #54, who stated that she knows how to do the colostomy care. She is able to cut out the pattern and the holes in the wafer, but is not able to see if she is applying the wafer correctly and if the holes are not aligned, it will leak. She stated that staff #13 tried to make her put the wafer on by herself without washing her hands or giving her gloves. The resident stated that she told staff #13 that she couldn't see what she was doing and explained that the nurse is able to look directly down and line up the holes, but she can't see what she is doing. During the interview, the resident provided a video and a black woman with long hair could be heard saying she was here to train the resident and was not going to do the treatment, she told the resident that she could do it, they know she can. The staff said, do it. The staff was heard saying you need to do it. The resident was heard saying that she didn't have gloves and the staff didn't respond. The resident stated that staff #13 was trying to force her to remove the bag. The staff's tone was not encouraging or friendly and the resident stated that she felt staff was acting in a threatening manner. An interview was conducted on August 17, 2023 at 8:45 a.m. with the (DON/staff #2), who stated that neglect occurs when essential care is not provided for the resident. She stated that the resident has an order for ostomy care, and the resident is allowed to provide her own treatment if it is included in the physician's order. She also stated that if the resident is provided with education and training and says that he or she can't do it, or need help, it is her expectation that the staff complete the care/treatment. She stated that she reviewed the video the resident took and posted on YouTube when the incident occurred, but couldn't remember if the resident stated that she needed help, couldn't perform the task, didn't want to do it, or the resident asked for gloves. She stated that if gloves were not provided, it created a risk of infection. During the interview, she reviewed the investigation and stated that it didn't look like a second staff was present during the incident, which is required at all times. The facility's policy, Abuse and Neglect Policy, revised on October 2022 states that allegations that alleged violations involving neglect, exploitation, mistreatment, or misappropriation of resident property, and does not result in serious bodily injury must be reported within 24 hours and results of all investigations of alleged violations are to be complete within 5 working days of the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure four residents (#88, #66, #44, #99 and #22) were free of staff verbal abuse. The deficient practice could result in an unsafe resident environment. Findings include: -Resident #88 was admitted on [DATE] with a diagnosis of Quadriplegia. The quarterly MDS (Minimum Data Set) assessment dated [DATE] included a BIMS (Brief Interview for Mental Status) score of 15 indicating the resident had intact cognition. -Resident #66 was readmitted on [DATE] with diagnosis of hemiplegia and hemiparesis. The annual MDS assessment dated [DATE] revealed the resident had a long-term and short-term memory problem and had av moderately impaired decision-making skills. -Resident #44 was admitted on [DATE] with diagnosis of spinal stenosis. The quarter MDS assessment dated [DATE] revealed the resident had a BIMS score of 11 indicating the resident had moderately impaired cognition. -Resident 99 was admitted on with diagnoses of stenosis of the larynx and type II diabetes. The quarterly MDS assessment dated [DATE] included a BIMS score of 15 indicating the resident had intact cognition. -Resident #22 admitted on [DATE] with diagnoses of acute and chronic respiratory along with anxiety disorder. The annual MDS assessment dated [DATE] revealed the resident had a BIMS score of 15 indicating the resident had intact cognition. The facility initial report dated March 9, 2023 included that activities staff was hosting an activity in the dining room on March 8, 2023 at 2:30 p.m. when CNA #48 came into the dining room and told multiple residents that if they wanted to be put back to bed and get changed before dinner, the residents had to come now. Per the report, CNA #48 stated that the residents can either eat dinner in shit and piss or come with CNA #48 to get changed. The facility follow-up report dated March 13, 2023 included the following reports from the residents: -Resident #44 reported that CNA #48 came into the dining room and told 4 residents that they had to go to their rooms now to be laid down or would have to wait until the second shift to be laid down.; -Resident #88 reported that the CNA wanted the resident to go back to their rooms from the activity to be put to bed and if they did not go, the residents would have to stay up until 6:30 p.m. Per the documentation, resident #88 chose to go because she cannot stay up that long. Resident #88 also reported that she wanted to stay in the activity but did not feel that she had a choice.; -Resident #22 reported that the CNA came into the dining room where the residents were having activities and told three other residents that they needed to go with him now to be changed or sit in the shit and piss until 6:30 when the next shift gets here and can change them; and to pick your (referring to the residents) poison. Resident #22 reported that she wished the CNA would have talked to the residents differently and pulled the residents on the side to discuss with them individually. Further, resident #22 reported that this made her nervous and upset; -Resident #99 reported that they were playing UNO in the dining room when CNA #48 came in and made an announcement that the residents either play UNO or go to be or the residents will have to wait until the next shift. Per the documentation, resident #88 reported that CNA #48 said you are my priority; and that, the CNAs attitude was like he was in charge. The report also included that at a later time, resident #99 shared that CNA #48 said that they would be left in their piss and shit while they eat dinner if they did not go with him now. Further, resident #99 said that she did not like the way CNA #48 talked to the other residents; but, since it was not directed at her, she was okay.; -Per the documentation, resident #66 was present during the incident but was non-interviewable. Continued review of the report included an interview conducted by the facility with CNA #48 who stated he did not tell the residents that they needed to go with him now or wait to be changed until the next shift. The report included that CNA #48 admitted to telling the residents to pick your poison; but denied telling the residents that they would be left in their shit and piss until the next shift. Further, the documentation included that CNA #48 reported that he was trying to make sure everyone was changed and ready for dinner before the trays came out and the next shift arrived. The facility concluded that the allegation of abuse had been substantiated by the facility Review of the personnel file of CNA #48 revealed that the CNA received in-service training on Elder Justice Act, abuse and neglect on May 10, 2022. Per the documentation, the termination date for CNA #48 was March 10, 2023 due the verbal abuse incident on March 8, 2023. Multiple attempts to interview resident #22 was conducted on March 22, 2023 but was unsuccessful because resident #33 was out of facility at an appointment. An interview with resident #44 was conducted on March 22, 2023 at 12:05 p.m. Resident #44 stated he was told by CNA #48 to leave now or be up until night shift arrives. An interview was conducted on March 22, 2023 at 12:45 p.m. with the activity staff (#24) who stated that on Wednesday on march 8, 2023 close to 3:30 p.m., there were 6 residents playing an Uno game in the dining room when CNA #48 walked in and told the residents sorry to interrupt. Staff #24 said that CNA #48 pressured the residents to leave now or they will put to bed by night shift. He stated that on his way out of the activity room CNA #48 told the residents they would either have to leave now or eat dinner sitting in their shit and piss. In an interview with another activity staff (#60) conducted on March 22, 2023 at 1:00 p.m., staff #60 stated there were 10 residents playing Uno in the dining room on March 8, 2023 at 2:30 p.m. Staff # 60 stated that CNA #48 came in at 3:30 p.m. and told the residents that they need to come with him if they need to be changed or they can stay and play the game and have to wait until 6:30 p.m. to be changed for dinner. Staff #60 further stated that CNA #48 told the resident that they can either eat dinner in shit or come with him. During an interview with vice president of clinical services (VP/Staff #36) conducted on March 22, 2023 at 11:30 a.m., staff #36 stated that they were going over the grievances form the day before when she noticed a couple of complaints regarding CNA #48 from the residents. She stated that she then went to inquire if CNA #48 was working and was told yes. Staff #36 stated that she immediately suspended CNA #48 on March 9, 2023 until the investigation was completed. Further, staff stated that CNA #48 had been terminated and was reported to the nursing board on March 13, 2023. A review of the facility's abuse policy revealed that residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes, but not limited to freedom from corporal punishment, involuntary seclusion, verbal, sexual, psychosocial neglect, deprivation of goods or services, financial, physical abuse, and physical or chemical restraint not requires to treat residents' symptoms. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, observations, review of the clinical record, and policy and procedure, the facility failed to honor preference to use an adult brief and to provide a low air loss (LAL) mattress as requested for one resident (#94). The deficient practice may result in preferences and needs essential to the resident not being accommodated. Findings include: Resident #94 was admitted on [DATE] with diagnoses of nontraumatic intracerebral hemorrhage, muscle weakness, difficulty in walking and diabetes mellitus. A care plan initiated on January 22, 2022 revealed the resident was at risk for impaired skin integrity. Goal was that the resident and family would be educated on prevention. Interventions included to apply barrier cream, peri-care after each incontinent episode and to turn & reposition PRN (as needed). The ADL (activities of daily living) dated February 9, 2022 included resident required extensive assistance with ADLs. Goal was that the resident would regain the prior level of independence and mobility. Interventions included assisting the resident with transfers promptly as needed to bedside commode or toilet to ensure continence, encourage independence within capabilities and assist with bathing/dressing body parts that resident cannot do. A health Status note dated March 28, 2022 revealed the resident reported he did not have a brief on at night. The note also included that the issue had been reported to DON (Director of Nursing) who stated that the facility don't put brief on patients at night to prevent breakdown due to moisture. Another health status note dated March 29, 2022 included that staff spoke with the resident regarding his concerns related to not able to wear a brief at night; and that, the staff explained the reasons for not wearing a brief at night to promote good skin health. According to the documentation, the resident stated understanding and requested to be able to wear a brief if he chooses. It also included staff told the resident that it was his right to request a brief at night. A progress note dated August 24, 2022 included the resident was complaining of the bed hurting his back and bottom. Per the documentation, the resident was assessed and revealed no open areas on back but had a tiny open spot on bottom; and that, the wound nurse instructed to cover the area with barrier cream. The note included the resident stated he wanted a LAL (low air loss mattress); but, the wound nurse explained why he did not qualify for LAL mattress. It also included the resident requested a foam pad to put on bed; and that, therapy would be asked for a foam pad. However, review of the clinical record revealed no evidence the resident was provided with a LAL mattress or foam pad on the bed as requested. Further, there was no evidence found that the resident was allowed to wear an adult brief at night. A discharge MDS dated [DATE] included that the resident had a stage two pressure injury. During an interview conducted with a Certified Nursing Assistant (CNA/staff #23) on February 9, 2023 at 9:59 a.m., staff #23 stated the residents have a right to request to use briefs. Regarding resident #94, the CNA stated that resident #94 started wearing briefs, progressed to use of pull ups and before his discharge, the resident was able to get up independently and go to the bathroom by himself. An interview was conducted on February 9, 2023 at 11:26 a.m. with a Wound Nurse (staff #138) who stated that resident #94 did not have a pressure reducing device because he was able to walk around. Staff #138 stated that she and the DON discussed the resident using briefs and the use of a LAL. Staff #138 stated that because the resident was able to move in the bed unassisted and was able to get up in his wheelchair for meals he did not have any kind of pressure relieving device added to the bed. Further, staff #138 stated she did not remember the resident having any wounds on his hip. During an interview conducted with the DON (staff #149) on February 9, 2023 at 12:12 p.m., the DON stated that residents have a right to make requests as long as the request does not affect their care. Regarding resident #94, the DON stated that the resident did not have a LAL because he did not have a wound that would qualify him for its use. The DON also said she did not know that the resident could not have a brief; however, she stated that she would not support placing a brief on a resident that could get up to keep the resident safe from moisture skin breakdown. Further, the DON stated she could not recall telling the resident that he could not have a brief. A policy titled Quality of Life - Homelike Environment (revised 12/2021) included that residents are provided with a safe, clean, comfortable homelike environment and encouraged to use their personal belongings to the extent possible. The staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, staff interviews, facility investigations, and facility policy and procedures, the facility failed to ensure one resident (#44) was free from neglect. The deficient practice could result in other residents being neglected. Findings include: Resident #44 was readmitted on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction, hypertensive heart disease without heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris, paroxysmal atrial fibrillation and type 2 diabetes mellitus with diabetic neuropathy. A care plan revised on revised June 12, 2019 included the resident had self-care deficit, requires extensive assistance with ADLS (activities of daily living) related to weakness and debility. The goal was that the resident would maintain and regain prior level of independence and mobility. Interventions included use of mechanical lift for transfers and mobility bars for increased bed mobility. The fall care plan with revision date of September 30, 2019, included the resident had a potential for falls secondary to debility, incontinence and weakness. Goal was that the facility would reduce the likelihood of the resident experiencing and injury. Interventions included to keep the bed low with a mat, use a Hoyer lift for transfer with the assistance of two staff and to keep the call light within reach. The NP (nurse practitioner) progress note dated January 4, 2023 included the resident had left hemiplegia. Assessment included CVA (cerebrovascular accident) with residual left sided weakness and seizures. Plan included fall precautions. Another care plan dated January 5, 2023 included the resident was at risk for injury related to decrease in range of motion. The monthly summary dated January 13, 2023 included the resident was alert, oriented to place and person, bed/chair bound, incontinent with bladder and had limited vision requiring additional assistance or support. A narrative note dated January 13, 2023 revealed that the resident had a fall on January 13, 2023 at 11:45 a.m.; and that, the resident was found on floor laying on his right side. According to the documentation, the resident was up in bed laying on the right side and was being assisted with peri care when staff stepped away from the room to get more supplies. The documentation also included that the resident was found lying on the right side next to the bed facing the door. Further, the documentation included the resident was not experiencing any new onset pain, denied hitting his head on the floor and sent out for CT (computed tomography) scan. An incident note dated January 13, 2023 included the CNA (certified nursing assistant) found the resident on the floor laying on his back. The note included the resident had small abrasion below left knee noted. Review of the Medication Administration Record (MAR) for January 2023 revealed the resident was medicated for a pain level of 10 out of 10 on January 13. The fall risk screen dated January 13, 2023 included a fall risk score of 14 indicating resident was at moderate risk. It also included that the reason for assessment was a recent fall. It also included the resident had total incontinence with bowel and bladder, was confined to a chair and was unable to independently come to a standing position. The fall investigation dated January 13, 2023 included the resident was observed on the floor laying on the right side next to the bed facing the door on January 13, 2023 at 11:45 a.m. Physical status prior to the fall included weakness and impaired mobility. Environmental status at the time of the fall included that the bed was locked. Interventions included every 15-minute checks during acute episode and the resident was sent out for a CT scan. The IDT (interdisciplinary team) post fall investigations dated January 15, 2023 included the resident was found lying on his back on the right side next to the bed facing the door. According to the documentation, the resident was being given peri care, the CNA left the room to get more supplies and the resident rolled out of the bed. New recommendations included ensuring the bed was at appropriate height and the resident was in proper safe positioning when walking from the resident's bedside. The IDT (interdisciplinary team) post fall investigations dated January 20, 2023 included the resident was found lying on his back on the right side next to the bed facing the door. According to the documentation, the resident was being given peri care, the CNA left the room to get more supplies and the resident rolled out of the bed. The CT scan result dated February 2, 2021 included the resident had a hematoma in the lower central forehead associated with a laceration and soft tissue gas. The quarterly MDS (Minimum Data Set) assessment dated [DATE] included a BIMS (Brief Interview for Mental Status) score of 13 indicating the resident was cognitively intact. The assessment also included that the resident required extensive assistance with bed mobility, dressing and personal hygiene and required total dependence for toilet use. During an interview with a CNA (staff #93) conducted on February 9, 2023 at 10:46 a.m., staff #93 stated resident #44 was sleepy that day and she woke him to get him changed. Staff #93 stated that she raised his bed rolled him on his side to clean him and she realized she needed to get some more supplies. Staff #93 stated she placed the resident on his back but left the bed elevated; and that, the resident had left sided weakness and did not move much. Staff #93 stated she left the room to get the supplies and when she was returning to the room, another CNA was walking past the room and saw the resident on the floor. An interview was conducted on February 9, 2023 at 12:12 p.m. with the Director of Nursing (DON/staff #149) who stated that staff are expected not to leave residents in an elevated bed when they leave the room; and that, in-service training were provided for all staff about providing care in pairs for residents that require assistance with turning. Review of the facility policy on Abuse and Neglect Policy revised on December 2016 included that residents have the right to be free from neglect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, resident and staff interviews, and review of facility policy/procedure, the facility failed to ensure one resident (#245) was free from misappropriation of personal funds. The deficient practice could result in residents having personal funds misappropriated by staff members. Findings include: Resident #245 was admitted on [DATE] with diagnoses of type 2 diabetes mellitus without complications, legal blindness and hypertensive urgency. A care plan initiated on October 3, 2018 revealed the resident had a self-care deficit and required limited/extensive assistance with ADLs (activities of daily living) related to being legally blind. Goal was that the resident would maintain a level of independence with ADLs. Interventions included to encourage independence within capabilities, explain purpose and expected task to the resident, and provide verbal cues, prompts, redirection and hand-over-hand assistance as needed. Review of the facility investigation dated December 22, 2020 included that on December 18, 2020, it was reported that a resident's credit card was being used by an employee for personal purchases and without resident knowledge. Continued review of the investigation revealed a resident statement that included the resident was blind and was having a CNA (certified nursing assistant) read his mail to him; and that, there was a bank statement that had charges the resident did not know about. Per the documentation, the resident gave the dietary aide his bank card information to order food delivery for the resident; and had approved the dietary aide to use his bank card to pay for the dietary aide's car payment, one time for gas, once to buy her new shoes, once for a lingerie purchase. The statement also included that the resident had authorized a $500 transfer to the dietary aide as a gift. However, the resident reported that he did not approve additional cash transfers of $150 on two occasions and $200. Further, the statement included that the resident felt the dietary aide took advantage of him and used him for his money. The investigation included the dietary aide reported that she had an approval for resident to purchase personal items. It also included a written statement dated December 21, 2020 from a certified nursing assistant (CNA/staff #204) who wrote that on December 18, 2020 resident #245 stated that he fired the dietary aide (staff #203) because the dietary aide had been using his debit card for purchases beyond ordering food. The CNA also wrote that the resident did not tell anyone because he did not want the dietary aide to lose her job; however, the resident told the dietary aide to return everything before he calls the police. The investigation concluded that the dietary aide committed financial exploitation of resident #245; and that, the dietary aide will not be allowed to work at the facility. During an interview conducted on February 9, 2023 at 9:59 a.m. with a CNA (staff #23) who stated she had heard that resident #245 had missing funds; and that, kitchen staff member used the resident's funds for personal gains. An interview was conducted on February 9, 2023 at 11:55 a.m. with a Social Services Director (staff #108) who stated the facility completed an investigation when they were notified of staff #203 using the resident's money for personal use. Staff #108 stated that resident #245 was legally blind, was vulnerable and wanted to help the dietary aide (staff #203) with car insurance and some personal items. During an interview conducted with the Director of Nursing (DON/staff #149) on February 9, 2023 at 12:12 p.m., the DON stated that the expectation was for staff to politely decline when residents offer them money. The DON said that if the resident still insists on providing the staff with money, the expectation was for staff to report it to their supervisor. A facility policy titled Abuse and Neglect Policy, revised on December 2016 included that residents have the right to be free from misappropriation of resident property and exploitation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, and policy and procedures, the facility failed to ensure a comprehensive care plan related to fall was developed with interventions for one resident (#95). The deficient practice could result in care needs not being met. Finding include: Resident #95 was admitted on [DATE] with diagnoses of hemiplegia, convulsions, atrial fibrillation and hypertension. A fall risk screen dated September 14, 2021 included a score of 12 indicating the resident was a moderate risk for fall. It also includes that the resident had 1-2 falls within the last six months. A skilled Progress note dated November 2, 2021 at 8:28 pm included that the Resident is alert, is oriented to person, is oriented to place, oriented to situation, responds verbally, pupils are equal, round, and reactive to light, and accommodation. An incident note date November 28, 2021 included the resident was on the floor beside his bed which was in the lowest position. The documentation included the resident was laying on the right side and had a bump on the left side of the forehead. A narrative note dated November 28, 2021 included the resident had a fall at 5:58 pm. and was found lying on the right side on the ground next to the bed which was in the lowest position. A fall investigation dated November 28, 2021 included the resident was found on the floor at 5:58 p.m. and had a bump on the left side of the forehead. Per the documentation, the resident was changed approximately 10 minutes before the incident. A physician order dated November 28, 2021 included to send the resident to the hospital for fall. The physician order dated December 2, 2021 included an order for a CT scan post fall. A narrative note dated December 6, 2021 revealed the resident was barefoot and was found lying on the dry floor on December 2, 2021 at 12:00 a.m. A health status note dated December 9, 2021 at 4:10 pm revealed that the CNA reported that resident was on the floor. The narrative note dated December 9, 2021 at 4:14 included the resident was found lying on right side on floor mat and was unable to respond on December 9, 2021 3:40 pm. The note included the resident did not use the call light and the resident was barefoot at time of fall. Despite documentation of risk and actual fall, there was no evidence found in the clinical record that a care plan was developed interventions in place to prevent fall from September 14 through December 9, 2021. The fall care plan initiated on December 10, 2021 revealed the resident had actual falls. Goal was that the facility would reduce the likelihood of the resident experiencing an injury related to fall. Interventions included to initiate neuro checks per fall protocol, report any abnormal findings to the physician, to monitor vital signs every shift per fall protocol and to place the call light within reach and encourage resident to use it prior to attempting to transfer or ambulate. A quarterly MDS assessment dated [DATE] included the resident had two or more no injury falls and 1 injury (except major) fall since admission. During an interview conducted with a certified nursing assistant (CNA/staff #23) on February 9, 2023 at 9:59 a.m., staff #23 stated that resident #95 told her that after his falls he started to decline. Staff #23 stated that the staff used a lot of preventive measure for the resident including a concave mattress and keeping the bed in the lowest position; however, the resident would still end up on the floor and in bed his feet would be where his head should be. An interview was conducted on February 9, 2023 at 10:25 a.m. with another CNA (staff #83) who stated that resident #95 had a decline in function and cognitive function after his fall; and that, the resident slowly lost his desire to eat. During an interview conducted with the Director of Nursing (DON/staff #149) on February 9, 2023 at 12:12 p.m., the DON stated that care plans are developed to meet resident care needs; and that, the care plans are based on hospital records, assessments, observations, provider orders, and changes in conditions. The DON stated that residents with falls would have a care plan initiated. A facility protocol titled Falls Protocol included that all residents are to be evaluated for risk of falls at the time of admission. The care plan needs to be updated with each fall and a new intervention must be done with each fall. A facility policy titled Care plans, Comprehensive Person-Centered (revised December 2016) included that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical needs. The care plan will describe the services that are furnished to maintain the the highest practicable physical well-being. The care plan will included risk factors associated with identified problems. The care plan will be revised as information about the residents' conditions change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, review of clinical records and facility policies and procedure, the facility failed to ensure one resident (#98) was served and provided with food that the resident was not allergic to. The deficient practice could result in residents at risk for allergic reaction. Findings include: Resident #98 was admitted on [DATE] with diagnoses of type 1 diabetes mellitus, Di [NAME] syndrome and adrenocortical insufficiency. The clinical record revealed documentation of allergies to multiple drugs, iodine, latex and strawberries A dietary note dated November 10, 2021 included that the resident was allergic to strawberries. A skilled note dated November 11, 2021 revealed the resident was given Benadryl (antihistamine)during the shift due to complaint of her tongue itching after the resident was provided a berry flavored yogurt. Per the documentation, the resident was advised to not consume any products with berries due to the allergy to strawberries; and that, the Benadryl was effective. During an interview with the Dietary Manager (staff #92) dated February 9, 2023 at 11:36 a.m., staff #92 stated that on admission a resident's likes, dislikes and allergies are reviewed with the resident or resident representative. Staff #92 stated food trays are reviewed to ensure that residents are not given foods they are allergic to; and that, the nursing staff should be checking the trays prior to giving it to the resident. Staff #92 stated there are several times during the meal tray process when multiple staff can intervene with what the resident was receiving. An interview conducted with the Director of Nursing (DON/staff #149) on February 9, 2023 at 12:12 p.m., the DON stated that the expectation was for staff to look at food trays to ensure residents are not receiving food or snacks they are allergic to. The DON stated the staff need to check tray cards and compare it to allergies on the face sheet. A facility polity titled Initial Resident Visitation/Nutritional Screening (revised 9/22/2021) included a procedure to obtain food allergies and note on Dietary Interview/Pre-Screen or other designated form and tray card.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #393 was admitted on [DATE] with diagnoses of acute respiratory failure, pulmonary disease, and anemia. Review of the clinical record revealed no evidence that a baseline care plan was developed with interventions until February 8, 2023. During an interview with social services director (staff #108) conducted on February 8, 2023 at 1:10 p.m., staff #108 stated that she complete care conferences within 5 days of resident admission. Regarding resident #393, the social services director stated that she had noticed the resident did not have a care plan. She stated that she put a section on social services is because she noticed that baseline care plan had not been done since resident admission. An interview with Director of Nursing (DON/staff #149) was conducted on February 8, 2023 at 3:32 p.m. The DON stated that care plans are completed upon admission; and that, baseline care plan will be printed, signed, and scanned back into their chart. In an interview with medical records director (staff #106) conducted on February 9, 2023 at 2:12 p.m., staff #106 stated that the ADON (assistant DON) gave her the baseline care plan on February 8, 2023 and was instructed to scan it in the electronic record. Staff #106 said that typically her process involves picking the baseline care plan from the baskets in the nursing unit, and scan them into the chart immediately daily. During an interview with the ADON (staff #28) conducted on February 9, 2023 at 2:20 p.m., the ADON stated the baseline care plan is usually completed by the interdisciplinary team (IDT) after resident admission. Regarding resident #393, the ADON stated that the resident was admitted on a weekend and because of the survey, the resident's baseline care plan was missed. The ADON stated that the standard practice if for base line care plan to be initiated and signed in the first 48 hours of resident admission. A facility care plan titled Care Plans - Baseline (revised December 2016) included that a baseline plan of care to meet the resident's immediate needs shall be developed for each resident with forty-eight (48) hours of admission. The policy is to assure that the resident's immediate care needs are met and maintained a baseline care plan will be developed with forty-eight (48) hours of resident's admission. Based on clinical record reviews, staff interviews, and facility policies and procedures, the facility failed to ensure a baseline care plan was developed for two residents (#98 and #393). The deficient practice could result in resident's not receiving basic care and services to meet their needs. Findings include: -Resident #98 was admitted on [DATE] with diagnoses of type 1 diabetes mellitus without complications and adrenocortical insufficiency. Review of the clinical record revealed the resident was prescribed with insulin sliding scale. However, there was no evidence found in the clinical record that a baseline care plan for diabetes or blood glucose monitoring was developed with interventions. During an interview conducted with the Director of Nursing (DON/staff #149) on February 9, 2023 at 12:12 p.m., the DON stated that care plans are developed to meet resident care needs; and that, the care plans are based on hospital records, assessments, observations, provider orders, and changes in conditions. Further, the DON stated that residents with diabetic monitoring and falls would have a care plan initiated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #33 was readmitted on [DATE] with diagnoses that included cellulitis of chest wall, hypotension, and chronic kidney disease. A physician order dated October 26, 2022 revealed an order for midodrine hydrochloride (vasoconstrictor) 10 milligrams (mg) one tablet by mouth three times a day for hypotension; and, to hold for systolic blood pressure (SBP) greater than 105. The MDS (minimum data set) dated December 20, 2022 revealed resident had a BIMS (brief interview for mental status) score of 15. indicating intact cognition. Active diagnosis included orthostatic hypotension. The care plan dated December 28, 2022 revealed resident had a diagnosis of hypotension. Intervention included to give medications as ordered. Another care plan dated December 28, 2022 revealed resident was alert, makes own decisions and was non-compliant with medication management. Intervention included encourage compliance and educate resident regarding non-compliance. The physician order for midodrine was transcribed on the medication administration record (MAR) October 2022 through February 2023. Review of the MAR from October 2022- February 2023 revealed that midodrine was documented as administered as ordered on multiple dates when the resident's systolic blood pressure reading of greater than 105. There was no evidence found in the clinical record why the medication was administered outside the ordered parameter and that the physician was notified. An interview was conducted on February 6, 2023 at 1:07 p.m. Resident #33 stated that staff attempted to give her midodrine when her blood pressure was high and that staff do not check her blood pressure before administering the medication. The resident identified the director of nursing (DON, staff #149) as one of the nurses that attempted or had given the medication when her blood pressure was high. An interview was conducted with a licensed practical nurse (LPN/staff #133) on February 9, 2023 at 10:59 a.m. The LPN (staff #133) stated that when a medication has ordered parameters, it must be given within, less or above the parameter, depending on the parameter. The LPN said that if the vital sign was outside the ordered parameter, he would contact the physician and would wait for orders whether or not the medication can be given. According to the LPN, midodrine is used for hypotension and it is a medication ordered with parameters. He stated that when the parameter was to hold for SBP greater than 105, then medication is held for a blood pressure of 117/80 because it is outside of the parameter; and, he would notify the physician. Further, LPN #133 stated that giving a medication outside of the parameter violates one of the laws of the medication rights and it can lead to issues with the resident; for example, resident can crash, become hypertensive and cause distress. An interview was conducted on February 10, 2023 at 2:00 p.m. with the DON (staff #149) with the administrator (staff #27), and a corporate executive (staff #60) present. The DON stated that midodrine is given to someone with low blood pressures and it is a medication that usually has ordered parameter that is by the physician. Regarding resident #33, the DON stated that the resident had a physician order to give midodrine 10 mg and to hold for SBP greater than 105. Review of the clinical record was conducted during the interview and the DON stated that midodrine was administered to the resident outside of parameter and this did not meet her expectations. Review of the facility's policy titled, Administering Medications revised on April 2019 revealed medications are administered in a safe and timely manner, and as prescribed. The following information is checked/verified for each resident prior to administering medications: vital signs, if necessary. Based on observations, clinical record review, interviews, policy and manufacturer guidelines, the facility failed to ensure physician was notified as ordered of the status of one resident (#98); and failed to ensure medication was administered as ordered by the physician for one resident (#33). The deficient practice could result in resident not receiving the medication to meet and treat their needs. Findings include: -Resident #98 was admitted on [DATE] with diagnoses of type 1 diabetes mellitus without complications and DiGeorge's syndrome. Review of the physician order recap revealed the orders to call the physician if BS (blood sugar) is 0-70 mg (milligrams)/dl (deciliter) and if BS is 351 mg/dl or higher. Review of the clinical record from November through December 2021revealed BS readings >351 mg/dl on the following dates: -November 5 = 393 mg/dL; -November 7 = 398 mg/dL; -November 17 = 363 mg/dL; -November 18 = 405 mg/dL and 389 mg/dL; -November 19 = 369 mg/dL; -November 20 = 392 mg/dL; -November 23 = 358 mg/dL; -November 24 = 516 mg/dL; -November 25 = 387 mg/dL and 500 mg/dL; -November 26 = 390 mg/dL and 451 mg/dL; -November 30 = 550 mg/dL; -December 4 = 373.0 mg/dL; and, -Decmber 5 = 351.0 mg/dL. Despite documentation of BS >351 mg/dl, there was no evidence found in the clinical record that the physician was notified of these BS readings as ordered. An interview was conducted on February 9, 2023 at 11:07 a.m. with a licensed practical nurse (LPN/staff #202) who stated that if the blood sugar level was high, she would notify the provider as ordered. Staff #202 stated that notifications to the provider are documented in the clinical record. Staff #202 also stated that when the blood sugar is high enough to call the provider, the provider usually gives another dose of insulin and the staff would recheck the blood sugar in 30 minutes. During an interview conducted with the Director of Nursing (DON/staff #149)bon February 9, 2023 at 12:12 p.m., the DON stated the expectation was that staff would to follow physician orders. The DON stated that blood sugars are checked as ordered and if the result was elevated the staff should recheck the blood sugar and report it to the provider. The DON stated that the notification to the provider should be documented in the clinical record; and that, if it was not documented, it was not done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to ensure on resident (#143) received necessary care and services in a timely manner after a fall. The deficient practice could result in negative resident outcomes. Findings include: -Resident #143 admitted to the facility on [DATE] with diagnoses that included osteomyelitis, type 2 Diabetes Mellitus (DM), and muscle weakness. The physician order dated [DATE] included for heparin sodium (anticoagulant) solution 5000 units/milliliter (ml) inject 1 ml subcutaneously every 8 hours for deep vein thrombosis (DVT) prophylaxis. A fall risk screen dated [DATE] included the resident had a history of falls. Review of the baseline care plan dated [DATE] included the resident's needs for activities of daily living (ADL), devices used, and a history of falls. The admission Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident's cognition was intact. The assessment included resident was frequently incontinent of bowel and bladder, received extensive assist for bed mobility, transfers, and toileting; had an impairment on one side of the lower extremities/functional limitation in range of motion (ROM) that interfered with daily functions or placed the resident at risk of injury. It also included that the resident did not ambulate, used a walker and a wheelchair. The assessment also coded a fall during the month prior to entry and no falls since admission to the facility. The associated Care Area Assessment (CAA) for falls included the resident was at risk for falls due to balance, medications, history of falls, incontinence, behaviors, occasional confusion and predisposing diagnoses. The care plan dated [DATE] revealed resident had the potential for fall secondary to debility, history of falls, incontinence, medication, and poor balance; and, was on anticoagulant therapy. The goals were that the facility would reduce the likelihood of the resident experiencing a fall and resident would have no ill effects from use of anticoagulant medication. Interventions included to assist with ADLs; call light and personal items within reach; monitor for adverse effects of medications, notify physician if present; and if resident sustains fall to assess the for injuries, obtain vital signs, notify physician and responsible party of incident and any injuries; monitor frequently for signs and symptoms of neurological impairment; and, to take precautions to avoid falls and signs and symptoms of bleeding. The [DATE] Medication Administration Record (MAR) revealed the resident was receiving the ordered heparin (anticoagulant). A nursing progress note dated [DATE] at 5:00 a.m. included the resident had a fall on [DATE] at 4:00 a.m.; and that, the resident was found lying on the floor in supine position. Per the documentation, the resident was alert and oriented at time of fall and sustained a raised area to the back of the head and to the left side of scalp. The note also included neurological checks were initiated, the provider was notified and was pending further instructions. Review of a nursing progress note dated [DATE] at 6:05 a.m. included that the neurological checks were within normal limits (WNL). The neurological flow sheet revealed that on [DATE] revealed the following documented change in resident at a given time: -Between 5:00 a.m. and 5:30 a.m. - pupil reactions changed from brisk to sluggish; -Between 5:30 a.m. and 6:00 a.m. - level of consciousness changed from fully conscious to lethargic; -Between 6:00 a.m. and 7:00 a.m. - change on Level of Consciousness (LOC) to obtund- very drowsy, responded to touch stimuli, movement of the left arm, hand grasps with left weakness, and pupil reaction, fixed. A nursing progress note dated [DATE] revealed that at 8:01 a.m., the resident was sent to the emergency room (ER) via 911. Another nursing progress note dated [DATE] at 11:00 a.m. revealed that at approximately 4:00 a.m. the resident was placed on fall protocol and neuro checks were initiated per facility protocol. The note documented that hands grips were weak but equal, pupils reactive, bilateral lower extremity (BLE) Range of Motion (ROM) within normal limits (WNL); and that, the physician was notified and was waiting for further instructions. In another nursing note dated [DATE] at 11:40 a.m. included that at approximately 7:30 a.m., the resident was verbally unresponsive and unresponsive to sternal stimuli, pupils were not reacting to light, and that the rapid responsive code was activated and 911 was called. Per the documentation, the staff continued to assess and monitor the resident until 911 arrived at approximately 7:15 a.m. and took over care. The note also included that the resident was taken to the ER (emergency room) for evaluation and the physician was notified. Review of another nursing note dated [DATE] at 4:47 p.m., revealed documentation of correction of time even happened from 7:30 a.m. to approximately 7:15 a.m. Despite documentation that physician was notified, there was no evidence found in the clinical record that the facility took additional action when the physician has not called back to give orders to assess the resident's change in condition. A care plan initiated on [DATE] revealed the resident had a fall with injury hematoma and skin tear. The goal was that the resident's injury would be resolved. Interventions included to assess the resident for injury such as pain, decreased ROM, skin injury, etc.; initiate neurological checks per fall protocol, report any abnormal findings to the physician; monitor for any new increased pain, discomfort or signs or symptoms of injury over 72 hours after fall; and, document any new problems and report to physician. Review of the Emergency Medical Services (EMS) records for [DATE] revealed the resident had altered level of consciousness (LOC), a ground level fall (GLF) with hematoma to the head and was on aspirin and heparin. Glasgow Coma Score (GCS-used to describe the level of consciousness in an individual) was 8 which indicated severe alteration in LOC. Per the report, the resident was dispatched for altered LOC; and that, the resident was only responsive to painful stimuli. The assessment included that resident made an audible groan in response to a sternal rub, but was not able to speak; had eyes shut and pupils unreactive to light. A physician order dated [DATE] revealed to send the resident to the hospital for evaluation and treatment related to a fall. The hospital records from [DATE] through [DATE] revealed resident presented to the emergency department (ED) at a trauma red on [DATE] status post ground level fall with head strike, was intubated on arrival due to low GCS and ED workup was notable for a large left sided Subdural Hematoma (SDH). The computed tomography revealed a large, acute left-sided subdural hematoma measuring up to 3.2 centimeters (cm); and, there was significant local mass effect with 1.8 cm of subfalcine herniation, left uncal herniation, and at least partial entrapment of the left lateral ventricle. Per the documentation, resident was given one unit of platelets and was taken to the OR with neurosurgery for craniotomy. The documentation also included that the resident was placed on comfort care on [DATE] and pronounced deceased at 4:51 p.m. Discharge Summary included diagnoses of acute encephalopathy, brain herniation, fall, and SDH. Review of the facility investigation dated [DATE] revealed the resident fell from the bed to the floor with hematoma to the back of the head. Per the documentation, neurological check within normal limits, the physician was notified and staff was waiting for a call back from the physician for orders at 4:00 a.m. During neurological checks, noted neurological difference resulting in resident being sent to the hospital. This incident was reported as an injury of unknown source of fall with major injury. The investigation also included that per hospital representative verbal report of Computed Tomography (CT) of head revealed resident had a brain bleed and was taken to the operating room (OR) to evacuate bleed. Further, the documentation included the resident expired on [DATE] in the hospital. It also included that an in-service was initiated with nursing staff to identify the process related around falls and neurological conditions and steps to be taken if call back from provider has not occurred. A corrective action memo for staff #46 dated [DATE] revealed that staff #46 had a violation of the facility policy or procedure. Per the documentation, resident had a change in condition with neurological checks and was not sent out of the facility to the hospital for the change. A phone interview was conducted on February 7, 2023 at 12:42 p.m. with the resident's provider (staff #200) who stated falls were common in the nursing home related to the population and resident's with dementia. He stated he recommended a resident be sent to the ER to rule out a brain bleed if the resident sustained a head trauma (i.e. any obvious signs and symptoms of bumps, lacerations, the resident fell and bumped their head); and, if the resident was on anticoagulation. He stated the resident would be sent to the ER if there were changes in their neurological checks. He stated if nursing staff was concerned they should send the resident out even if they were unable to speak to the provider or had not received a call back from the provider. He stated if the resident experienced a change, had a lump on the head, and was receiving anticoagulation; he would not expect the nurse to wait for a call back from the doctor before sending the resident to the ER; and that, the nurse had a license and could make that decision. He stated due to review of treatment times in the ER he did not know if it would have changed the outcome for the resident, even if the facility had called EMS at 5:45 or 6:00 a.m. when the resident was exhibiting changes in her neurological status. A phone interview was conducted with a Licensed Practical Nurse (LPN/staff #133) on February 7, 2023 at 1:12 p.m. The LPN stated he remembered he was told about the fall incident for resident #143 and he took her vital signs and did her neurological check. He stated he noticed a loss of consciousness and sent the resident out through 911. The LPN said that if a resident fell and the staff started neurological checks and the nurse saw changes in the checks it should be reported to the doctor and the resident should be sent out through 911. Further, he stated that as a nurse, if the doctor did not respond it was his responsibility to act in the best interest of the resident. He stated if he was on shift when the changes occurred he would send the patient out to the hospital. A phone interview was conducted on February 8, 2023 at 6:53 a.m., with the LPN (staff #46) who stated that if a resident had a change in neurological status/neurological checks it would be an altered LOC; and, the resident would need to be sent out to the hospital as they had potentially experienced trauma was on shift at the of the resident's fall. Regarding the fall incident of resident #143, she stated she remembered the resident; and that, during the shift the certified nursing assistant (CNA) was yelling that the resident was on the floor. She stated that she went to the room and found the resident on the floor with the bed controls in her hand. She stated she took the vitals, did a neurological check that had results that were normal at that time. She stated staff got the resident back into bed and she found the resident had skin tears and a bump on the back of her head/left side. Staff #46 said she left a message for the doctor by phone and texted him and was waiting for orders; and, continued with the fall protocol including neurological checks. She stated she never spoke to the doctor during her shift. She further stated she did not recall that the resident was exhibiting neurological changes. She stated the resident was sleeping and had to be woken up for neurological checks. However, staff #46 said that she did not know if it was a change in LOC or if the resident was less alert related to being woken up. She stated she could not recall if she had made any further call to the doctor or to administrative staff. She stated she should have sent the resident out if the resident was showing neurological changes as per protocol and would not need to wait to hear back from the provider. Staff #46 stated she received education/in-service and was written up for this incident. She stated she was told if a resident fell and had a suspected head injury, especially if they were on a blood thinner, she was supposed to send the resident to the hospital regardless of provider response. An interview was conducted on February 8, 2023 at 10:15 a.m. with the DON (staff #149) who stated if the fall was unwitnessed, staff would start neurological checks, even if the resident could tell staff what happened. She stated if the neurological checks begin to change, the nurse should notify the doctor to let them know what had changed; and, if staff cannot get hold of the doctor, the nurse should send the resident out for higher level of care and notify the DON. She stated the protocol was changed, as a result of this resident's incident. She stated that a resident on anticoagulation who had a fall, with or without evidence of head trauma, need to be sent out for a CT scan. She stated the nurse (staff #46) taking care of the resident left a message for the doctor and was waiting for orders. She stated when staff #46 noted a pupil reaction change for resident #143, she (DON) would have expected staff #46 to update the doctor, notify the DON, and send the resident out regardless of provider response. She stated it was important because a neurological change showed an obvious neurological deficit. The DON stated she always would have expected this resident to go out at the time of the fall, and because of the situation, she made the protocol more specific. Review of the 2021 [NAME] Nursing Drug handbook revealed that the adverse effects for Heparin included bleeding complications, ranging from local ecchymosis to major hemorrhage (cutaneous, gastrointestinal, genitourinary, intracranial, nasal, oral, pharyngeal, urethral, and vaginal). The facility policy on Falls and Fall Risk included that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident conditions that may contribute to risk of falls include medication side effects. In conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling. The facility's fall protocol dated [DATE] included that when a fall occurs, a call was to be placed to the ADON or DON after a fall; and, neuro checks were to be initiated on all residents unless it is witnessed with no head injury. Any change in Neuro examination, call to be place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #76 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, muscle weakness and hypertension. A care plan initiated on May 9, 2022 revealed the resident was at risk for falls related to history of falls, injury from falls, and poor safety awareness and impulsiveness. Interventions included resident chooses at times to roll off the bed to the floor, mattress placed on the floor related to resident rolling off bed to the floor. The Minimum Data Set, dated [DATE] coded that resident had one fall with no injury since admission. A care plan initiated on May 17, 2022 revealed the resident had potential disturbance in behavior as evidenced by yelling out, places self on floor frequently. Intervention included to anticipate resident's needs. The Minimum Data Set, dated [DATE] revealed resident had 2 falls with no injury since admission or re-entry. A care plan initiated on August 17, 2022 revealed the resident had Parkinson's. Interventions include to monitor for risk of falls. A fall investigation dated August 20, 2022 revealed the resident had an unwitnessed fall; and that, the resident was found on the floor. A care plan initiated on August 22, 2022 revealed the resident had a potential for falls and resident was at risk for injury from falls. A fall investigation dated September 12, 2022 revealed the resident had a witnessed fall. The care plan initiated on September 13, 2022 revealed the resident had a fall with injury. Interventions included to assess the resident for injury such as pain, decreased range of motion, skin injury, etc., initiate neurological checks per fall protocol, report any abnormal findings to the physician, monitor for any new increased pain, discomfort or sign and symptoms of injury over 72 hours after fall, and monitor vital signs every shift per fall protocol. An incident note dated October 30, 2022 at 7:30 a.m. revealed that a certified nursing assistant (CNA) reported to the LPN (staff # 57) that the resident has a reddened area to the right forehead/eyebrow; and that, the resident was sitting in a geriatric chair in the day room at that time. A nursing note dated October 30, 2022 at 4:31 p.m. revealed that a CNA reported that at 2:30 a.m. she found resident #76 on the floor. The nursing note by LPN #114 quoted the CNA who found the resident on the floor, Well you didn't fall, you just want to be on the floor. The note stated that LPN (staff #114) then assessed the resident who was sitting on geriatric chair at the nurses' station and found a reddened area to his right forehead. The note also included that the night shift nurse reported that nothing happened over night; and that, staff was not aware that the resident had fallen. Per the documentation, during breakfast resident's family identified a swelling to his hand; and family was informed by staff that the resident had a fall at 2:30 a.m. Despite documentation that resident had a fall on October 30, 2022 at 2:30 a.m., there was no evidence found in the clinical record that resident #76 was assessed. A neurological flow sheet dated October 30, 2022 revealed a neurological assessment was initiated at 6:45 a.m. A nursing note dated October 31, 2022 revealed resident #76 was sent to a hospital on October 30, 2022. A hospital visit summary dated November 8, 2022 revealed the resident was sent to the hospital on October 30, 2022. The chief complaint was that the resident was found on the ground by staff for unknown amount of time and the resident sustained a left wrist bruising and deformity. A facility investigative report dated November 4, 2022 revealed that two CNAs found the resident on a floor mattress at 2:30 a.m. on October 30, 2022, and helped the resident up and put him back into the bed. Per the documentation, the resident did not complain of any pain during the transfer. In an interview conducted with an LPN (staff #133) on February 9, 2023 at 10:59 a.m., the LPN stated that when a resident is found on the floor by a CNA the expectation is to notify the nurse immediately. The LPN (staff #133) stated that CNAs are not allowed to assess the resident and pick them up off the ground because they are not trained to; and that, the resident might have a fracture, so the CNAs can cause more harm to the patient. Further, the LPN stated the nurse must assess the resident while they're on the floor and then will assist the resident back up. The LPN said any delay in the assessment can endanger and put the resident at risk for internal bleeding especially if they are on a blood thinner medication. An interview was conducted on February 9, 2023 at 11:19 a.m. with a CNA (staff #96) who stated that if a resident had an unwitnessed fall she would call for a nurse; and that, if a nurse is not notified the resident's condition can worsen. An interview was conducted on February 9, 2023 at 2:00 p.m. with the Director of Nursing (DON/staff #149) with the administrator (staff #27) and a corporate executive (staff #60) present. The DON stated that resident #76 fell once on October 30, 2022; and that, a CNA found the resident on the floor at 2:30 a.m. The DON stated that the CNA notified the night shift nurse; however, there was no documentation from the night shift nurse that an assessment was completed at that time. The DON stated that when a resident falls the expectation is that a CNA reports the incident to a nurse immediately so the nurse can initiate an assessment. Review of the facility's policy titled, Change of Condition - Clinical Protocol, with a revision date of March 2018 revealed, Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident and how to communicate these changes to the nurse. Nursing assistants are encouraged to use the 'Stop and Watch Early Warning Tool' to communicate subtle changes in the resident to the nurse. The assigned nurse is to monitor their assigned residents for any changes of condition. In addition, the nurse shall assess and document/report the following baseline information: vital signs, neurological status, current level of pain, and any recent changes in pain level; level of consciousness; cognitive and emotional status; and onset, duration, and severity of change of condition. Review of the facility's policy titled, Fall Protocol on February 2023 revealed, Post fall steps for nurse that discovered/notified of fall include 1) all unwitnessed falls - begin neuro protocol. -Resident #11 was admitted on [DATE] with diagnoses that included dementia, type II diabetes, and schizophrenia. The MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview for mental status) score of 2 indicating the resident had severe cognitive impairment. It also included the resident was not steady when walking but was able to stabilize without staff assistance; and, required setup help only with regards to walking between locations in his room and one-person physical assist with personal hygiene. The care plan initiated on January 9, 2023 revealed the resident had a disturbance in behavior as evidenced by yelling, wandering in and out of others rooms and pacing. An observation conducted on February 6, 2023 at approximately 1:20 p.m. revealed the tap water temperature in resident #11's room as 120.8 degrees Fahrenheit. An observation was conducted with director of environmental services (staff #104) on February 9, 2023 at 8:18 a.m. Resident #11 was sitting in his bed inside his room. Staff #104 used his thermometer to measure the temperature of the tap water in resident #11's room; and, the thermometer reading was 120.2 degrees Fahrenheit. Staff #104 stated the temperature was supposed to be 120 degrees. An interview was conducted on February 9, 2023 at 11:31 a.m. with licensed practical nurse (LPN, staff #145) who stated that resident #11 was able to walk to the bathroom, had an intact sensory function to know to pull away if water is too hot. The LPN also stated he had not noticed any burns in the behavioral unit; or, no one had made any complaints about the tap water being too hot. -Resident #31 was admitted on [DATE] with diagnoses of legal blindness, type II diabetes, and schizoaffective disorder. The MDS assessment dated [DATE] included a BIMS score of 13 indicating the resident was cognitively intact. It also included the resident was not steady when walking but was able to stabilize without staff assistance; required setup help only with regards to walking between locations in his room and one-person physical assist with personal hygiene. In an observation conducted on February 6, 2023 at approximately 1:20 p.m., it revealed the tap water temperature in resident #31's room was 118 degrees Fahrenheit. An observation was conducted with director of environmental services (staff #104) on February 9, 2023 at approximately 8:18 a.m. Resident #31 was in the restroom without assistance. Staff #104 used his thermometer to measure the temperature of the tap water in resident #31's room; and revealed a reading of 123.6 degrees Fahrenheit. Staff #104 stated there was a potential risk for a burn with this temperature. An interview was conducted on February 9, 2023 at 11:31 a.m. with licensed practical nurse (LPN, staff #145) who stated resident #31 was able to walk to the bathroom, and his sensory is intact to know to pull away if water was too hot; and that, the resident was very sensitive to painful stimuli such as Accu-Chek for blood glucose monitoring. During an interview with the Director of Nursing (DON/staff #149), administrator (staff #27) and a corporate executive (staff #60) conducted on February 10, 2023 at 2:00 p.m., the DON stated the water temperature should not exceed 120 degrees Fahrenheit because of the risk of scalding. Review of the facility's policy on Safety of Water Temperatures and revised on February 2023 revealed that the tap water in the facility shall be kept within a temperature range to prevent scalding of residents. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 degrees F. Based on observations, clinical record review, staff interviews and review of facility documentation, policy and procedure, the facility failed to provide adequate supervision for two residents (#8 and #243) related to falls; failed to ensure one resident (#76) was assessed after a fall; and, failed to ensure a safe environment was provided for two residents (#11 and # 31). The deficient practice could result in increased resident injuries. Findings include: -Resident #8 was readmitted on [DATE] with diagnoses of chronic respiratory failure, morbid (severe) obesity, primary osteoarthritis, cerebral infarction without residual deficits, chronic pain syndrome and tracheostomy status. A care plan for self-care deficit, initiated on a previous admission dated September 7, 2013, included a goal that the resident would maintain a current level of care with ADLs (activities of daily living). Interventions included to assist the resident with transfers promptly as needed to toilet to promote continence, provide extensive assistance with bathing and bed mobility. Review of the clinical record revealed the resident was not assessed with interventions in place to use of a mechanical lift for transfers. An incident note dated February 2, 2021 at 10:20 p.m. included that the resident was in the shower room with 3 CNA's (certified nursing assistants) who were trying to transfer the resident from the shower bed to the wheelchair. The note included that the nurse saw the CNAs struggling and came to help with the chair. Per the documentation, the nurse was holding the wheelchair and the sling on the mechanical lift to ensure that chair did not tilt back while the CNA was controlling the mechanical lift. According to the note, the mechanical lift tilted forward and hit the resident in the forehead resulting in a laceration to the forehead. A physician order dated February 2, 2021 included that the resident was sent to the ER (emergency room) for CT (computerized tomography) scan of the head, evaluation and treatment. A physician order dated February 3, 2021 included daily wound treatment to the forehead and right supraorbital area and to refer resident to eye doctor for evaluation and treatment related to eye pain and trauma. The CT of the Head/Brain/Maxillofacial report dated February 13, 2021 revealed the resident had a laceration in the lower central forehead associated with a soft tissue mass measuring 3.5 cm x 1.4 cm x 3.4 cm compatible with a hematoma. The report included the resident had a fracture deformity of the right nasal bone and medial wall of the right orbit, both of which are thought to be chronic. The facility documentation survey report for February 2021 revealed the resident was transferred 37 times; and that, the resident was transferred by one-person physical assistance 4 of 37 times. A psychiatric note dated April 14, 2021 included the resident reported that showers can be particularly anxiety provoking due to recent mechanical lift accident. Another Psychiatric note dated June 9, 2021 included that resident reported increased anxiety occurring a few weeks ago, but stated those feelings have now passed. According to the note, the resident's main anxiety trigger appeared to be using the mechanical lift. An interview conducted on February 9, 2023 at 9:59 am with a certified nursing assistant (CNA/staff #23). Regarding the incident with resident #8, the CNA stated that the night shift was giving resident #8 a shower; and, when they lifted the resident in the mechanical lift, the legs of the lift were not open fully which allowed the mechanical lift to fall forward and landed the lift on top of the resident on the ground. Staff #23 stated that since then staff had been in-serviced on the correct way to use the mechanical lift. -Resident #243 was admitted on [DATE] with diagnoses of that muscle weakness, difficulty in walking, acute respiratory failure with hypoxia, anemia, coagulation defect, and acute pulmonary edema. A fall risk screen dated November 9, 2021 revealed the resident had a score of 16 indicating high risk for falls. It also included the resident had a history of 1-2 falls within the last six months. A skilled progress note dated November 11, 2021 included that the plan of care included fall precautions. A health status note dated November 16, 2021 at 9:44 am included that the resident was found on the floor lying on stomach in middle of room and noted to be soiled. Per the documentation, the resident was not able to provide an answer when asked what she was trying to do prior to the fall. The documentation also included the resident was assessed for injuries and ROM (range of motion), neuro checks implemented, the provider was notified and orders to send to ER for evaluation was received. The neurological flow sheet for November 16, 2021 from 6:30 a.m. through 12:45 p.m. revealed that neuro checks were to be completed every 15 minutes times 4 and then every 30 minutes times 4 and then every hour times 4. However, the documentation revealed no assessment for level of consciousness, movement, hand grasps, pupil size, pupil reaction and speech. A physician order dated November 16, 2021 included to send the resident to the hospital for CT scan related to unwitnessed fall and low platelet count. The health status note dated November 16, 2021 at 11:26 am included that the resident was taken to the ER; and that, once on the gurney, the resident began to become unresponsive but pulse was noted. Review of the clinical record revealed the resident was not care planned with interventions for fall. An interview was conducted on February 9, 2023 at 11:07 am with a Licensed Practical Nurse (LPN/staff #202) who stated that when the room for resident #243 at the start of her shift, the resident was found on the floor. She stated that resident had a noticeable decline after the fall on November 16, 2021 that necessitated a transfer to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, facility assessment, and policy review, the facility failed to ensure there was sufficient nursing staff to meet the needs of residents. The deficient practice resulted in residents' needs not being met. The census was 92. Findings include: Review of the facility assessment dated [DATE] revealed the purpose of the facility assessment was to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. The Facility Assessment allows the facility to make decisions about direct care staff needs, as well as well as their capabilities to provide services to residents. In the facility each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being. The assessment included a ratio of 1:9-10(residents) or less on the day shift and a ratio of 1:8-9 or less on the night shift for Certified Nursing Assistants (CNAs). The assessment also included the average census range is 85 residents. An interview was conducted on February 8, 2023 at 12:30 p.m. with a certified nursing assistant (CNA/staff #127) who stated that there are usually 3-4 CNA's on the floor, but has run the floor with only two CNA's. She stated that this would give her a total of 28-30 residents to care for with many of these residents required two- person assist. The CNA stated she has on the average 7-10 residents who require a Hoyer lift; and when they have to work short it was the residents who suffer because staff are late getting them up and residents do not get their showers for the day. The CNA stated the weekends are even worse with call offs and many of the nurses would not help answer the call lights and would just sit at the desk. The CNA stated there are times when they are unable to help a resident eat earlier because the facility does not have the time to sit in the room to feed the residents if all of the call lights are going off. The CNA stated residents' meals are cold or the residents would no longer eat them because it was too late for them. Further, the CNA stated they do not get their breaks because so many call lights are on. -Resident #33 was admitted on [DATE] with diagnoses of cellulitis of chest wall, type 2 diabetes mellitus and fistula of intestine The MDS (minimum data set) dated December 20, 2022 revealed a BIMS (brief interview for mental status) score of 15 indicating resident was cognitively intact. Review of the Care Plan revealed that resident #33 requires extensive assistance with ADL's (activities of daily living) due to weakness, debility, infection, pain and obesity. An Interview was conducted on February 9, 2023 at 8:52 a.m. with resident #33 who stated there have been many times she had to call the front desk to have someone come to her room. Resident stated there are a lot of new staff, but all the staff knew she would need to have her colostomy bag emptied before her meals. The resident stated her colostomy bag needed to be emptied approximately every two hours because it fills up quickly. The resident stated if they took care of her bag like they were supposed to it could last up to seven days. However, the resident said that when staff do not, it causes her colostomy bag to explode and causes her skin to become irritated from needing to change the seal from the leakage. The resident stated since the SA entered the building this week, staff have been answering her call light. However, at night there are only two CNA's on the floor: one for her hall and one for the other. The resident stated she does not sleep well at night because staff will not come and check on her colostomy bag unless she set a timer for staff to come help. The resident stated this causes her to stay awake and make her very tired; and, the day shift will not check her until they are done passing the breakfast trays. Further, the resident stated that day shift will not change her colostomy bag until sometime after 8:00 a.m. or 9:00 a.m. and by then it has already burst. The resident stated she becomes anxious and will text CNA's at night to see if they are working, to come and help her; however, staff do not answer the phone at night or they will transfer her to another station, and no one will come to help her. The resident stated it makes her feel desperate, makes her cry and sad because, she feels that the staff do not care about her at all. The resident stated it is bad enough having to ask someone to change her colostomy bag, but to have it explode when it did not have to happen was embarrassing to her; and that, her life was not appreciated and she was not treated with respect. -Resident #15 was admitted on [DATE] with diagnoses of multiple sclerosis, neuromuscular dysfunction and chronic pain syndrome. The care plan dated December 23, 2022 revealed resident required extensive assistance with activities of daily living, applying and/or maintenance of appliances and emptying of suprapubic catheter bag. An interview was conducted with resident #15 on February 9, 2023 at 9:29 a.m. The resident stated call lights take longer when there are only two people on the floor from 6:00 p.m. - 6:00 a.m.; and that, and when there are only two people at night she cannot take her shower. The resident stated it was taking the night shift an hour or more to answer her call light; and that, the week prior she turned on her call light at 6:40 p.m. and staff did not respond until 9:15 p.m. The resident stated the CNA told her it was because there were only two of them on the floor. The resident stated on the average it takes 45-60 minutes to answer my call light on day shift and on the night shift it takes hours. The resident stated she had not had a shower in two weeks; and, a CNA told her she could not have one because she required a Hoyer lift and it takes two people to shower her and there would be no one to answer the call lights. The resident stated she needed to be fed due to her contractures; but there have been times when she did not get assistance with her dinner. The resident stated staff would drop off her tray at 5:00 p.m. and would not tell the incoming shift that she had not been feed. The resident stated the staff does not do their rounds anymore so she had sat with a cold tray with no one to feed her. The resident stated she will call for help, but no one will answer or she can't reach her call light for help; and that, it was scary being stuck in a room with no way to call for any one and hungry. -Resident #7 was admitted on [DATE] with diagnoses of dementia, chronic respiratory failure, chronic obstructive pulmonary disease, heart failure and dysphagia. The MDS assessment dated [DATE] revealed BIMS score of 15 indicating resident #7 cognitively intact. The care plan dated December 2, 2022 revealed resident #7 was at risk for choking and required assistance with eating, extensive to total assistance with ADLs and applying and/or maintenance/care of bilateral hand splints per the physician's order and the residents care plan. During an interview conducted with resident #7 on February 9, 2023 at 10:34 a.m., the resident stated it normally takes staff 30-40 minutes to answer her call light because the staff were busy; and that, this happens mostly at night time. The resident stated she had to wait for two hours or more multiple times; and, the facility does not have enough staff to help all the residents. -Resident #30 was admitted on [DATE] with diagnoses of quadriplegia, neuromuscular dysfunction, polyneuropathy and anxiety. The MDS assessment dated [DATE] revealed BIMS score of 15 indicating resident #30 cognitively intact. Review of the care plan dated December 5, 2022 revealed resident #30 required extensive assistance with ADLs Living and applying and/or maintenance/care of splints per the physician's order and the residents care plan. An interview was conducted on February 9, 2023 at 10:57 AM with resident #30 who stated it takes 20 minutes for staff to answer her call light and that there have been times when they never did answer her call light. The resident stated the staff act like they were doing her a favor by helping her. The resident stated there have been multiple times she had to wait until 10:00 p.m. to get her medications when she should have had them no later than 9:00 p.m. as they are scheduled at 8:00 p.m. The resident stated there had been numerous times when she was provided with a shower because there were only two CNA's on the floor. The resident stated she has gone without a shower for a week multiple times because there was only one CNA's on the floor. The resident stated her roommate had fallen and it took them 10 minutes to respond. The resident also stated that the CNA's had told her that she had to be patient and to wait because there was only have two CNA's and one nurse in the unit. An interview was conducted on February 10, 2023 at 8:45 a.m. with staffing coordinator (staff #14) who said that the average census for the facility was in the low 90's and in the case of a call off she would reach out to her PRN (as needed) staff and the therapy department would add their restorative nursing assistant (RNA). Staff #14 stated weekends are staffed the same as during the week; and, weekends are when the facility has the most call off's and she would add more staff to the weekend schedule with on-call staff. She stated there had been no staffing concerns brought to her attention and that staff understand that they all work as a team. Staff #14 stated if she was unable to find coverage she or some of the administrative staff would go out on the floor to assist with call lights until she was able to find coverage. Staff #14 stated there had been times when there had been two CNA's on the Long-Term Care floor when there should be 3-4. She stated if she was unable to find coverage for the night shift, the day shift will help by putting most of the residents to bed. She stated that this was not the ideal situation, but there was a shortage of both licensed staff and CNA's. Staff #14 stated the current census, residents' acuity, needs, and diagnoses are considered when she determines staffing requirements and assignments. In an interview conducted with the DON (staff #12) with the administrator (staff #27) present on February 9, 2023 at 11:26 a.m., the DON stated that she determines the number of staffs needed to provide care to the residents and shares this information with the Staffing Coordinator. The DON stated that she was aware that there were times when there were only 1-2 CNA's providing care during a shift and agreed that they were short staffed and was in the process of hiring. However, she stated that the applications are limited. The DON stated that she would like to have three to four CNAs for each shift. Review of the facility's policy regarding staffing revised December 2022, revealed sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment.

Based on observations, staff interviews, facility documentation, policies and procedures, the facility failed to ensure expired medications were appropriately disposed and available for resident use; and, failed to ensure medications were stored in accordance with professional standards. The deficient practice could result in residents receiving expired medications and that medications are stored safely. Findings include: During an observation conducted on February 10, 2023 from approximately 8:00 a.m. through 9:00 a.m. of three medication carts and three medication storage rooms, there were expired medications found. An observation of cart 2 was conducted with Licensed Practical Nurse (LPN/staff #39) on February 10, 2023 and revealed a Humalog insulin for one resident had an opened date of January 9, 2023. Review of the box revealed that the manufacturer recommended disposal of the medication 28 days after opening. In an interview conducted staff #39 on February 10, 2023 at 8:04 a.m., staff #39 stated that the date on the Humalog insulin indicated the date that it was opened on January 9, 2023; and that, it was more than 28 days ago. During an observation of cart 3 located in unit 2b conducted with another LPN (staff #70) revealed a Lantus insulin for one resident that had an opened date of January 10, 2023. Review of the box revealed that the manufacturer recommended disposal of the medication 28 days after opening. An interview was conducted on February 10, 2023 at approximately 8:15 am with the LPN (staff #70) who stated the Lantus insulin should be disposed or discarded after 28 days of being opened. Staff #70 stated that the Lantus was opened on January 10, 2023. An observation of cart 1 conducted with another LPN (staff #133) revealed a bottle of sodium bicarbonate (which was indicated as a medication from home) with an expiration date of December 17, 2022. During an interview with the LPN (staff #133 conducted on February 10, 2023 at 8:04 a.m. staff #133 stated the facility uses house stock sodium bicarbonate and do not administer the home medication. A continued observation of the medication storage room located in Unit 2 revealed that inside the medication refrigerator, under the condenser, there were boxes of insulin that were wet, water logged, or soggy. In an interview conducted with the Maintenance Director (staff #104) on February 10, 2023 at 8:50 a.m., staff #104 stated that they were aware of the problem related to the medication refrigerator. An interview was conducted on February 10, 2023 at 9:50 am with the Director of Nursing (staff #149). The DON stated the expectation was that staff was to check expiration dates prior to administering medications and ensure medications are stored per the manufacturer's guidelines. The DON stated that insulin should be discarded 28 days after opening. A facility policy titled Storage of Medications (revised 12/22) included the facility stores all drugs and biologicals in a safe, secure and orderly manner. The policy included that the nursing staff are responsible for maintaining medication storage and outdated drugs or biologicals are destroyed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interview, clinical record review, and review of policy and procedures, the facility failed to ensure that one sampled resident (#20) was assessed to safely self-administer medications. The deficient practice could result in resident self-administering medications without being assessed. Findings include: Resident #20 was admitted to the facility on [DATE] with diagnoses that included heart failure, primary hypertension, and major depressive disorder. A Self-Administration of Medication assessment dated [DATE] revealed the resident wanted to self-administer some medications. The medication listed was calcium carbonate (antacid). The assessment included that the resident was independent with decision-making ability, was able to name the dosage, frequency, and reason for use, was able to tell time and able to state the time that the medication was due, and had a history of non-compliance with medication or other treatments. Based upon these answers, the resident was assessed to safely self-administer calcium carbonate. The documentation indicated that the resident's care plan would be updated to reflect the decision. A personal choices and daily preferences care plan dated 06/07/21 related to the resident's verbalization that the resident wanted medications to be left at the bedside had a goal for staff to incorporate the resident personal choices. Interventions included for preference choices to be upheld within the facility setting to the resident's physical and cognitive ability. Further review of the resident's clinical record did not reveal for an additional assessment of the resident to include for medications other than calcium carbonate. The quarterly Minimum Data Set assessment dated [DATE] revealed the resident scored 15 on the Brief Interview for Mental Status, indicating the resident had intact cognition. The assessment included the resident required extensive-total 1-person physical assistance for most activities of daily living. The assessment also included the resident received antidepressant, anticoagulant, antibiotic, diuretic, and opioid medications during the lookback period. Review of the physician summary order report revealed orders active as of 11/16/21 that included for the following medications: -amlodipine besylate 10 milligrams (mg) by mouth one time a day for hypertension -duloxetine HCl (antidepressant) 20 mg by mouth one time a day for depression -apixaban (anticoagulant) 2.5 mg by mouth every 12 hours -furosemide (diuretic) 40 mg by mouth in the evening for fluid retention -gabapentin (painkiller) 800 mg by mouth two times a day for neuropathy -levothyroxine 25 micrograms by mouth at bedtime for hypothyroidism -losartan potassium 50 mg by mouth one time a day for hypertension -metoprolol tartrate 25 mg by mouth two times a day for hypertension -oxycodone HCl (opioid) 5 mg by mouth every 8 hours as needed for pain 6-10 Review of the Medication Administration Records for September 2021, October 2021, and November 2021 revealed the resident received medications in accordance with physician's orders. On 11/16/21 at 8:35 a.m., an observation of the resident was conducted. The resident was observed to be asleep in a semi-reclining position with a partially eaten tray of food resting on an over-the-bed table in front of the resident. An empty medication cup was noted on the table next to the tray of food. An interview was conducted on 11/16/21 at 12:13 p.m. with a Licensed Practical Nurse (LPN/staff #26). She stated that the Nurse Practitioner had ordered resident #20's medications so that the resident could administer them herself. She stated that she will leave the medications with the resident so she does not have to wake her up, because the resident is unpleasant in the mornings. She stated that she leaves the lunchtime medications with the resident because the resident prefers to take them with food. On 11/16/21 at 12:16 p.m., an interview was conducted with a Registered Nurse (RN/staff #2). She stated that a resident would be assessed in order for them to self-administer medications. She stated that the resident would have to be able to understand what the medications were for, what times they should be taken, and that they had been assessed to swallow them safely. An interview was conducted with the resident on 11/16/21 at 1:10 p.m. She stated that the nurse had left her medications with her to take while she was eating her lunch. Two empty medication cups were observed laying on top of the uneaten meal on her plate. On 11/16/21 at 1:16 p.m., an interview was conducted with the Director of Nursing (DON/staff #103) and the [NAME] President of Clinicals (staff #300). Staff #300 stated that the process for self-administration of medications included an assessment of the resident to ensure that they could do so safely. She stated that is the expectation. She stated that it would not meet her expectation for a resident to self-administer medication without an assessment. She stated that risks associated with residents self-administering medication without an assessment would include that the medications might not be taken, medications might be hoarded, and/or delay of time-sensitive medications. The facility policy titled Self-Administration of Medications included that residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the resident's comprehension of the purpose and proper dosage and administration time for his or her medications, and the ability to recognize risks and major adverse consequences of his or her medications. The staff and practitioner will document their findings and the choices of residents who are able to self-administer medications, and the staff and practitioner will periodically reevaluate the resident's ability to self-administer medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to ensure that the Office of the State Long Term Care Ombudsman was notified of one resident's (#108) discharge to the hospital. The sample size was 2. The deficient practice could result in the ombudsman not being informed of resident transfers and discharges. Findings include: Resident #108 was admitted to the facility on [DATE], with the diagnosis of Alzheimer's disease. An admission nursing note dated 8/20/2021 revealed the resident arrived to the facility at approximately 4:51 PM via transport on a stretcher. Review of a nursing note dated 8/22/2021 stated the new resident had a physical altercation with another resident last evening. Behavioral Health spoke with the unit nurse, Director of Nursing (DON), and physician regarding the incident and the decision was made to send the resident out. The resident's family was notified. A discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had an unscheduled discharge to the hospital. A physician's order dated 8/23/2021 included to discharge the resident to the emergency department due to danger to others, assaulting several peers and stating that he plans to harm and kill peers; guest is not appropriate to return to facility. However, review of the clinical record revealed no evidence the State Long Term Care ombudsman was notified of the transfer/discharge. During an interview conducted on 11/18/21 at 11:44 AM with the Director of Social Services (staff #105), she stated that their discharge procedure changed recently and that now the case manager plays the part of the discharge planner. Staff #105 stated the resident's family is notified by the nurse for hospitalizations. Regarding notifying the ombudsman, staff #105 stated in 2019 she was told to stop doing the notifications and that she has not done it since. Staff #105 stated she was told to stop sending the notices, that it was no longer necessary. She also stated that she used to send the notices to the ombudsman at the end of the month. During an interview conducted on 11/18/21 at 12:01 PM with the Administrator (staff #28), she stated that family, physician, DON and clinical resources would be notified of a discharge to the hospital. When asked if the Office of the State Long Term Care Ombudsman is notified, staff #28 stated she believed they should be but cannot say it is being done. She stated she works closely with the Ombudsman and the Ombudsman has never notified her that notifications were not being sent. Review of the facility policy titled Discharge/Transfer revised on 11/2021 revealed when the facility transfers or discharges a resident who meets any of the criteria for discharge, the facility must ensure that the transfer or discharge is documented in the resident's medical record. The policy also included the local Ombudsman for each facility will be notified of a resident's discharge, date, and location within 30 days. The notification to the Ombudsman should include: name of resident, name of person notified, relationship to resident, date of notification, effective date, transfer date, and reason for discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was fully completed for one sampled resident (#47). The deficient practice can result in PASRRs not being completed. Findings include: Resident #47 was readmitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, depressive type, personal history of traumatic brain injury, and anxiety disorder. Review of the Level I PASRR screening completed on 02/12/21 revealed that the resident did not have any serious mental illness, including schizoaffective disorder, and did not have any mental disorders, including anxiety disorder. In addition, no response was given to identify whether or not the resident had exhibited symptoms related to adaptation to change, whether or not the resident had currently or within the past 2 years received mental health services, and whether or not the resident had experienced significant life disruption because of mental health symptoms. The screening concluded that no referral was necessary for any Level II. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] included that the resident had not been evaluated by Level II PASRR and determined to have a serious mental illness and/or mental retardation or a related condition. The resident scored 7 on the Brief Interview for Mental Status, indicating the resident had severe cognitive impairment. The assessment included the resident required extensive to total 1 to 2 person physical assistance for most activities of daily living, and active diagnoses included anxiety disorder, psychotic disorder (other than schizophrenia), and schizophrenia (e.g., schizoaffective and schizophreniform disorders). A physician's order dated 03/31/21 included for aripiprazole (antipsychotic) 5 milligrams (mg) 1 tablet at bedtime to reduce agitation and psychosis related to schizoaffective disorder, depressive type. Review of the Medication Administration Records for March 2021, April 2021, May 2021 and June 25, 2021 revealed the antipsychotic medication was administered in accordance with physician's orders. On 11/17/21 at 12:24 p.m., an interview was conducted with the Director of Social Services (staff #105). She stated that it was her responsibility to ensure that a PASRR was completed and in the resident's clinical record. She stated the PASRR is completed either at the hospital or on the same day the resident is admitted to the facility. Staff #105 stated that when she completes the PASRR, she will review the resident's admission paperwork and obtain the information pertinent to the PASRR. She stated that the correct diagnoses should be marked on the PASRR, and her expectation would be that the PASRR would reflect accurate diagnoses. Staff #105 stated that consequences of inaccurate diagnostic information include that the resident may not receive the interventions needed based upon the State's requirements, and that the MDS assessment may not accurately reflect the resident's diagnoses. Staff #105 reviewed resident #47's PASRR and stated that unfortunately, she had missed the errors. An interview was conducted on 11/17/21 at 1:48 p.m. with the Director of Nursing (DON/staff #103) and the [NAME] President of Clinicals (staff #300). Staff #103 stated that his expectation was that the PASRR should be completed at the time of admission. Staff #300 stated that if the hospital completed the PASRR, she would expect that the document would be reviewed for accuracy upon the resident's admission. She stated that if the PASRR was not accurate, residents may not receive the services they need. The facility policy titled admission Criteria included that the facility admits only residents whose medical and nursing care needs can be met. The objective of the policy is to provide uniform criteria for admitting residents to the facility. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID), or related disorders (RD) per the Medicaid PASRR process. The facility conducts a Level I PASRR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for MD, ID, or RD. If the Level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the State PASRR representative for the Level II evaluation and determination screening process. The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID, or RD. The social worker is responsible for making referrals to the appropriate State-designated authority. Upon completion of the Level II evaluation, the State PASRR representative determines what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, and policy and procedure review, the facility failed to ensure that one resident (#308) and/or their representatives were provided a written summary of the baseline care plan. The risk would be that the resident/representative might not be aware of the plan of care. The sample was 22. Findings include: Resident #308 was admitted to the facility on [DATE], with diagnoses that included pneumonia, dysphagia, muscle weakness, Bipolar disorder, and depressive episodes. Review of the clinical record revealed that the resident's Baseline Care Plan initiated on November 2, 2021, identified multiple problem areas which included the following: oxygen therapy, diabetes, required staff assistance with toileting, bathing, dressing, and transfers physical/occupational therapy, and psychotropic and antibiotic medications. Review of the medical record revealed that a comprehensive Care Plan was initiated on November 8, 2021. An admission Minimum Data Set (MDS) assessment dated [DATE], included a Brief Interview for Mental Status (BIMS) score of 15, which indicated that the resident was cognitively intact. However, further review of the clinical record revealed no evidence that the resident was provided with a written summary of the baseline care plan. An interview was conducted on November 15, 2021 at 11:40 AM with the resident who stated that she did not receive a baseline care plan summary. An interview was conducted on November 16, 2021 at 02:14 PM with a Licensed Practical Nurse (staff #67), who stated that the facility had just started the baseline care planning process with the new administration. She stated that the admission nurse would complete the baseline care plan, including the initial assessment, and would then review it with the resident. The LPN further stated that at that time the resident would then acknowledge, by signing the care plan form. She also stated that the signed baseline care plan would be scanned into the EMR (electronic medical record) and then placed in the paper chart. The LPN stated that the baseline care plan should be completed as soon as possible after admission. An interview was conducted on November 17, 2021 at 09:42 AM with the Director of Social Services (staff #105), who stated that the nurse is responsible for developing the baseline care plan, reviewing it with the resident and then obtaining the resident's signature on a copy of the baseline care plan. She stated that the original copy is placed in the resident's hard chart, and is also scanned into the EMR. Staff #105 reviewed the resident's record and stated that a signed copy of the baseline care plan was not in the EMR. She then reviewed the paper chart for the signed baseline care plan and stated that it was not in the chart. An interview was conducted on November 17, 2021 at 09:55 AM with the MDS Director (staff #56), who stated that baseline care plans are reviewed by the admission nurse with the resident, who would then obtain the resident's signature on a printed copy, then the resident would be given a copy along with a copy of the medication list. She stated the signed copy should be filed in the paper chart or scanned into the EMR. She reviewed the resident's medical record and stated that she did not see the signed baseline care plan in the EMR. She also reviewed the paper chart and stated that the summary was not in the hard chart. She stated that this did not meet the facility policy and the risk would be that the resident might not be aware of the plan of care. An interview was conducted on November 17, 2021 at 10:02 AM with a unit secretary (staff #89), who stated that she scans records into the EMR for the unit. She reviewed the medical record and stated that the baseline care plan was not scanned into the EMR. She then looked through the basket she keeps with records that are awaiting to be scanned, and stated that the baseline care plan was not in the basket. She then reviewed the resident's hard chart and stated that the summary was not in the chart. An interview was conducted on November 17, 2021 at 11:09 AM with the Director of Nursing (staff #103), who stated that it is the facility policy that baseline care plans should be completed, printed, reviewed by the resident or Power of Attorney (POA), then signed, and scanned into the EMR. He reviewed the resident's medical record and stated that the baseline care plan was completed by the admission nurse on November 3, 2021, but that the signed summary was not scanned into the medical record. He further stated that this does not meet the facility policy regarding baseline care plans. An interview was conducted on November 17, 2021 at 11:14 AM with the [NAME] President of Clinical Services (staff #300), who reviewed the progress notes and stated that she did not see any documentation that the baseline care plan summary had been signed by the resident or POA. She stated that there was no documentation in the progress notes that the resident had refused to sign the baseline care plan. She further stated that this does not meet the facility policy. The facility policy titled, Care Plans-Baseline, revealed that a baseline care plan will be developed within forty-eight hours of the resident's admission. The Interdisciplinary Team will review the healthcare practitioner's orders, medications, routine treatments, and implement a baseline care plan to meet the resident's immediate care needs. The resident and their representative will be provided a summary of the baseline care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interviews, and facility policy and procedures, the facility failed to ensure that a care plan was implemented for one resident (#72) regarding behavior interventions. The risk could be that the resident would not be receiving care as ordered. The sample size was 22. Findings include: Resident #72 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included mood disorder, anxiety disorder, depressive episodes, acute and chronic respiratory failure with hypoxia or hypercapnia, acute diastolic heart failure, type 2 diabetes mellitus, age related physical debility, and chronic pain syndrome. Review of the care plan initiated on June 17, 2021 revealed a care plan for a behavior problem related to potential for false allegations or accusatory toward staff. Interventions included that two staff members were to provide cares due to potential for making false allegations. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], included a Brief Interview for Mental Status with a score of 15, which indicated the resident had intact cognition. The MDS assessment also included the resident had a PHQ-9 (patient health questionnaire-9) severity score of 13 which indicated moderate depression and that no behaviors had been exhibited. Observations were conducted of the resident receiving care in the resident's room with one staff in attendance on November 15 at 1:10 PM, November 16 at 2:14 PM, November 17, 2021 at 9:00 AM, 9:30 AM, 10:20 AM, and at 2:10 PM. An interview was conducted on November 17, 2021 at 09:33 AM with a Certified Nursing Assistant (CNA/staff #42), who stated that the resident requires one-person assistance with most care. The CNA also stated that she was not aware of anything in the resident's care plan regarding the need for two staff to be present for care. An interview was conducted on November 17, 2021 at 10:12 AM with the MDS Director (staff #56), who stated that when a resident has behaviors that require two staff at all times, a green tag is placed outside the resident's room. She stated that this is how staff would know that they need two staff in the room at all times. The MDS Director then reviewed the resident's care plan and stated that the resident has a care plan regarding behavior problems, with interventions of two staff to provide cares due to the potential for making false allegations. She further stated that the resident's door should have a green tag, and that staff should deliver care with two staff on all shifts. She looked at the resident door and stated there was no green tag on the door. An interview was conducted on November 17, 2021 at 11:50 AM with the Director of Nursing (DON/staff #103), who stated that the facility expectation is to follow care plans as written. He stated that resident #72 had graduated off cares in pairs. He reviewed the resident's care plans and stated that cares in pairs had not been removed from the care plan. The DON further stated that the care plan should have been updated before November 17, 2021 to reflect the change. The DON stated that this was not following facility policy and the risk could be the resident may not receive ordered care An interview was conducted on November 18, 2021 at 08:41 AM with the MDS Coordinator (staff #56), who stated that she did not know when the cares in pairs was discontinued. She reviewed the medical record and did not see documentation of the resident exhibiting any behaviors. She also stated that when the resident returned to the facility in August 2021 that the cares in pairs had not been removed from the care plan at that time. She stated that through November 17, 2021, staff should have been providing care in pairs for the resident, as written in the care plan interventions. She also stated that she felt that this was a care plan issue, that the care plan was not updated. She stated that this did not meet the facility expectation regarding updates to the care plan. An interview was conducted on November 18, 2021 at 09:46 AM with a CNA (registry staff #302), who stated that she has worked at the facility for 9 months and has worked with resident #72. She stated that the resident was in cares in pairs a while ago, but not recently. She further stated that she did not know when it changed. She also stated that the only way staff would know that the resident required cares in pairs would be if the nurse told them. The CNA stated that she has cared for the resident for the last couple of weeks and did not provide the care with another staff member. Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. The Interdisciplinary Team must review and update the care plan when there is a significant change in the resident's condition, when the resident has been readmitted to the facility from a hospital stay, and at least quarterly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure the physician was notified regarding blood glucose results as ordered for one resident (#308). The sample size was 5. The deficient practice could result in the physician not being notified as ordered about abnormal blood glucose results. Findings include: Resident #308 was admitted to the facility on [DATE] with diagnoses that included pneumonia, type 1 diabetes mellitus, dysphagia, and muscle weakness. A physician's order dated November 3, 2021 included for Humalog Solution 100 UNIT/ML (milliliters) Insulin Inject as per sliding scale: if blood sugar (BS) 0 - 70 call physician and initiate hypoglycemia protocol; BS 71 - 200 = 0 units; BS 201 - 250 = 2 units; BS 251 - 300 = 4 units; BS 301 - 350 = 8 units; BS 351+ = 10 units; BS 351 and > give 10 units and call physician, subcutaneously four times a day for diabetes mellitus. This order was discontinued on November 10, 2021. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The assessment included the resident had received insulin injections during the lookback period. Review of the Medication Administration Record (MAR) for November 2021 revealed that Humalog 10 units had been administered to the resident on November 5 for BS 393 at 08:00 PM and on November 7 for BS 398 at 12:00 PM. However, review of the clinical record did not reveal the physician had been notified as ordered. The care plan initiated on November 10, 2021 revealed the resident had a nutritional problem related to diabetes mellitus type 1. The goal was that the resident would maintain adequate nutritional status. Interventions included monitor weight, skin, and labs. A physician's order dated November 10, 2021 included for Humalog Solution 100 UNIT/ML Insulin Inject as per sliding scale: if BS 0 - 70 call physician and initiate hypoglycemia protocol; BS 71 - 150 = 0 units; BS 151 - 200 = 3 units; BS 201 - 250 = 5 units; BS 251 - 300 = 7 units; BS 301 - 350 = 10 units; BS 351+ = 12 units, BS 351 and > give 12 units and call physician, subcutaneously four times a day for diabetes mellitus. Review of the MAR for November 2021 revealed that Humalog 12 units had been administered to the resident on November 17 for BS 363 at 0800 AM. Further review of the clinical record did not reveal the physician had been notified as ordered. An interview was conducted on November 18, 2021 at 10:02 AM with the Unit Manager (staff #131), who stated that the process for sliding scales would be to notify the physician if the blood glucose is above a certain level. She also stated that the call to the physician should be documented in the progress notes or in the MAR notes. The Unit Manager stated that it is the facility policy to follow physician orders as written and to document the blood glucose level and units administered in the MAR. She reviewed the physician's orders for Humalog and stated that November 3 - 9, 2021 the sliding scale was written to notify the physician for blood glucose level of 351 and over. She further stated that a new order for Humalog was received dated November 10, 2021, that the physician should be notified for a blood glucose of 351 and over. She then reviewed the November 2021 MAR and stated that she saw no documentation that the physician had been contacted for blood glucose levels over 351 on November 5, 7 and 17, 2021. The Unit Manager stated that this were not following the facility policy or physician orders for administration of insulin. She also stated that this did not meet the facility expectations and the outcome could be a risk of not following protocol, physician's orders not being followed, and blood glucose being out of parameters. An interview was conducted on November 18, 2021 at 11:50 AM with the Director of Nursing (DON/staff #103), who stated that the facility policy is to follow physician's orders as written, including insulin with sliding scale and parameters. The DON reviewed the physician orders for Humalog for November 3 and November 10 and stated that the physician should be notified for a blood glucose of 351 or over. The DON reviewed the November 2021 MAR and stated that the blood glucose level is documented above 351 on November 5, 7, and 17, 2021 and the physician should have been notified according to the parameters. The DON reviewed the November progress notes and stated that there was no documentation that the physician had been notified regarding blood glucose levels on November 5, 7, and 17. He also stated that these did not meet the facility policy or expectations, and did not follow physician's orders. He stated that the risk for not following physician's orders as written could be that blood sugars would not be managed correctly. Review of the facility policy titled, Administering Medications, revealed medications are administered in accordance with prescriber orders, including any required time frame. If a dosage is believed to be inappropriate or excessive for a resident, or a mediation has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interview, and facility policy, the facility failed to ensure that ordered therapy exercises and services were consistently provided as ordered for one resident (#71). The sample size was 3. The deficient practice could result in the development of or worsening of physical mobility and contractures. Findings include: Resident #71 was admitted to the facility on [DATE] with diagnoses that included Quadriplegia, Cerebral Infarction and Chronic Respiratory Failure. Review of the quarterly Minimum Date Set (MDS) assessment dated [DATE], revealed that the Brief Interview for Mental Status (BIMS) score was 15, indicating the resident had no cognitive impairment. The MDS included the resident was an extensive 2 person assist for dressing, bed mobility and transfer, and required total assist with eating. Review of orders dated 10/13/21 included for bilateral upper and lower extremity Passive Range of Motion (PROM) exercises to be performed to resident tolerance up to 3 times weekly. Review of the plan of care revealed a self-care deficit with interventions that included monitoring for decreased joint movement and contractures, and Restorative Nursing Assistant (RNA) services as ordered. A review of the Restorative Nursing Assistant (RNA) task log indicated that the first PROM exercise was not performed until 10/26/21. Other PROM exercises were documented on 10/30/21, 11/2/21, 11/4/21, and 11/9/21. There was no evidence that PROM exercises were performed after 11/9/21. An interview was conducted with the Director of Nursing (DON/staff #103) on 11/18/21 at 09:45 AM. The DON stated that physical therapy develops RNA and exercise programs for the resident's needs. Staff #103 stated therapy then obtains orders from a physician and then the RNAs performs the tasks as ordered. The DON added that the facility had several RNAs, however they have left. The DON stated the RNA tasks are now being performed by the therapists. An interview was conducted with the Director of Therapy (staff #64) on 11/18/21 at 10:01 AM. The director stated that the therapists are performing the RNA tasks since the RNAs have left. He stated that when the task is completed, it is documented in the task log. Staff #64 further stated that the order for this resident is written for exercises up to 3 times weekly, however this is only ideal because they are short of staff. He included that the resident has not been seen by the therapists for PROM exercises. The therapist added that an order is written with the expectation that the exercises are to be performed as the resident is able to tolerate up to 3 time weekly. Staff #64 stated that there is no documentation that the exercises have been performed after 11/9/21 or that the resident cannot tolerate the exercises. A second Interview was conducted with the DON (staff #103) on 11/18/21 at 10:39 AM. The DON stated that it is his expectation that PROM exercises be performed as ordered. He added that this is not always possible because of staffing issues. An interview was conducted with resident #71 on 11/18/21 at 12:12 PM. The resident stated that she was tolerating the passive range of motion exercises well until the RNA left. The resident stated that afterwards, no one has been performing the exercises. The resident stated that she gets very stiff when the exercises are not done and wants to continue with the PROM exercises. Review of the facility policy titled Restorative Nursing Program revised November 2017 included that the facility provides restorative nursing services to help residents to maintain or regain their highest practical and functional levels of mobility as possible. The physicians restorative order will include specific restorative activities to be performed as well as the frequency of services provided. The policy also included that the RNA will document the resident's participation progress and participation within the electronic medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure the medication error rate was not 5% or greater by failing to administer medications as ordered for one resident (#11). The error rate was 7.41%. The deficient practice could result in further medication errors. Findings include: Resident #11 was admitted to the facility on [DATE] with diagnoses that included other seizures, other chronic pain, and age-related osteoporosis without current pathological fracture. Review of a physician order dated 10/26/20 included for guaifenesin (expectorant) 400 milligrams (mg); give one tablet twice daily for cough. A physician order dated 5/11/21 revealed for gabapentin (anticonvulsant/painkiller) 100 mg; give 200 mg every 12 hours for neuropathy. During a medication administration observation conducted on 11/16/21 at 10:27 a.m. with a Licensed Practical Nurse (LPN/staff #26), the LPN was observed to administer gabapentin 100 mg and guaifenesin 600 mg to resident #11. An interview was conducted on 11/16/21 at 12:08 p.m. with staff #26. She stated that she had administered 1 tablet of gabapentin 100 mg, and not two. She reviewed the physician orders and confirmed that the order for gabapentin indicated to give two 100 mg tablets, for a total of 200 mg. In addition, she reviewed the bottle of guaifenesin and stated that it contained 600 mg tablets, not 400 mg as the physician order directed. She stated that guaifenesin is usually dosed at 600 mg and that she would have to walk down to Central Supply to see if they had any 400 mg tablets. The LPN stated that administration of the wrong dose of medication would be considered a medication error. On 11/16/21 at 1:16 p.m., an interview was conducted with the Director of Nursing (DON/staff #103). He stated that his expectation for medication administration would include a review of the orders, review of the medication card, verifying again the medication once the medication is in the cup, administer the medications, and watch the resident take them. The DON stated that he would anticipate that the nurse would check the dose on the bottle to ensure they are administering the correct dose. The facility policy titled Administering Medications included that medications are to be administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with the prescriber orders, including any required time frame. The individual administering medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure medications were administered in accordance with physician orders for one resident (#20). The sample size was 5. The deficient practice increased the risk for adverse side-effects. Findings include: Resident #20 was admitted to the facility on [DATE] with diagnoses that included heart failure, primary hypertension, and major depressive disorder. -Regarding antihypertensives: A review of the care plan initiated on 11/26/18 revealed the resident is receiving medications for hypertension. The goal was that the resident's blood pressure would remain within normal limits. Interventions included to administer prescribed medications per physician orders. Review of physician orders dated 1/07/2020 revealed for metoprolol tartrate 25 mg (milligrams) two times daily for hypertension. Hold for SBP (systolic blood pressure) less than 100 and/or HR (heart rate) less than 55. Another physician order dated 8/27/20 included for losartan potassium 50 mg one time a day for hypertension. Hold if SBP is less than 100 or if HR is less than 60. Review of the September 2021 Medication Administration Record (MAR) revealed the resident received metoprolol tartrate on 2 occasions when the SBP was less than 100: at 8:00 p.m. on 9/22 for a BP of 95/50, and at 8:00 p.m. on 9/28 for a BP of 98/60. The following was noted on the October 2021 MAR: -The resident received losartan potassium on one occasion when the SBP was less than 100: at 12:00 p.m. on 10/23 for a BP of 91/54. -The resident received metoprolol tartrate on 3 occasions when the SBP was less than 100: at 8:00 p.m. on 10/10 for a BP of 93/52, at 8:00 p.m. on 10/20 for a BP of 93/50, and at 12:00 p.m. on 10/23 for a BP of 91/54. Per the November 2021 MAR: -The resident received losartan potassium on one occasion when the SBP was less than 100: at 12:00 p.m. on 11/11 for a BP of 96/46. -The resident received metoprolol tartrate at 12:00 p.m. on 11/11 for a BP of 96/46. -Regarding opioid analgesics: Review of the care plan initiated on 11/20/18 revealed the resident is prescribed PRN (as needed) opioid medication for pain relief. The goal was the resident would be free of any discomfort or adverse side effects from pain medication. Interventions included administer medication as ordered. A physician order dated 08/05/20 included for acetaminophen (non-opioid analgesic) 325 mg; Give 2 tablets every 6 hours PRN (as needed) for pain of 1-5/10 on a pain scale. Not to exceed 3 grams within 24 hours. Another physician order dated 06/07/21 revealed for oxycodone HCl (opioid analgesic) 5 mg; Give 1 tablet every 8 hours PRN for pain of 6-10 on a pain scale. Review of the September 2021 MAR revealed the resident received oxycodone HCl on 7 occasions when the pain level was below 6/10: 9/5 for a pain level of 5, 9/13 for a pain level of 0, 9/18 and 9/23 for pain levels of 5, 9/24 for a pain level of 4, and 9/26 and 9/27 for pain levels of 5. Additional review revealed the resident did not receive acetaminophen at all during the month. The October 2021 MAR included that the resident received oxycodone HCl on more than 15 occasions for pain levels less than 6/10, including: 10/7, 10/8, 10/9, 10/11, 10/12, 10/14, 10/15, 10/16, 10/17, 10/18, 10/22, 10/23, 10/25, 10/28, and 10/31. However, further review did not reveal that the resident had received acetaminophen on any occasion during the month. Per the November 2021 MAR, the resident received oxycodone HCL on 7 occasions for a pain level of less than 6/10, including: 11/2, 11/4, 11/5, 11/10, 11/11, 11/12, and 11/13. However, review of the MAR did not include for administration of acetaminophen on any occasion. On 11/16/21 at 10:20 a.m., an interview was conducted with a Licensed Practical Nurse (LPN/staff #26). She stated that usually when administering a pain medication PRN, she will ask the resident to rate their pain on a pain scale. She stated that she knows the residents pretty well, so she knows where their pain is located and what they rate it at. She stated that they do not have a lot of PRN pain medications anymore, so it is kind of nice. Staff #26 stated that she always checks the resident's blood pressure and pulse before administering an antihypertensive medication. The LPN stated that if she accidentally gave an antihypertensive she would call the provider to report it, check the resident's vitals every 15 minutes, and document in the resident's clinical record. She stated that she could think of only one instance of when she had administered a medication below the ordered parameter. She stated that the risk for administration of an antihypertensive to a resident whose SBP was less than 100 might include dropping the resident's BP even further. Staff #26 reviewed the resident's MARs and stated that she did not think she had administered the medication. She stated that she thinks she forgot to document holding the medication. The LPN stated that when there are only 2 nurses on a hall with 52 residents, it is scary sometimes because they make mistakes. An interview was conducted on 11/16/21 at 1:16 p.m. with the Director of Nursing (DON/staff #103) and the [NAME] President of Clinicals (staff #300). Staff #300 stated that the expectation is that nursing will follow the physician ordered parameters when administering medications. She stated that if the resident's BP consistently fell below parameters, she would expect that nursing would contact the physician, and document that in the clinical record. She stated that administration of medications outside of parameters did not meet her expectations. The facility policy titled Administering Medications included that medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required timeframe. Allergies to medications and vital signs, if necessary are checked/verified for each resident prior to administering medications. If a resident uses PRN medications frequently, the attending physician and Interdisciplinary Care Team, with support from the consultant pharmacist as needed, shall reevaluate the situation, examine the individual as needed, determine if there is a clinical reason for the frequent PRN use, and consider whether a standing dose of medication is clinically indicated.