**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure that an allegation of abuse for one resident (#34) was reported to the State Agency. Findings include: Resident #34 was admitted to the facility on [DATE] with diagnoses that included dementia, epilepsy, and major depressive disorder. Review of the Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Review of the facility's grievances revealed a grievance filed which indicated that Resident #34 had reported to a nurse on May 14, 2025 that a Certified Nursing Assistant (CNA) had pulled her hair while caring for her. The grievance indicated that Resident #34 did not know why it had happened. This grievance form indicated that an investigation was initiated and that the allegation was reported to the appropriate parties, including the State Agency. This grievance was marked as resolved on May 19, 2025. A nursing progress note dated May 15, 2025 revealed that the resident was provided care with two staff members on this date. The note detailed that no behaviors were noted and no concerns were voiced by the resident. Further review of the progress notes revealed a progress note, dated May 16, 2025, which indicated that an Adult Protective Services (APS) worker was at the facility due to Resident #34's report. There was no evidence found in the progress notes to indicate that any allegations or reports were made on behalf of Resident #34, nor any details about the situation. On May 19, 2025 at approximately 2:15PM, a list of the facility's self-reported incidents within the last ninety days was requested. The Director of Nursing (DON/Staff #11) provided a statement, dated May 19, 2025, which revealed that the facility did not have any self-reports within the last three months. Later, on May 19, 2025 at 4:26PM, the [NAME] President of Health Services (VP/Staff #23) provided a statement which also indicated that the facility did not have any self-reports in the last ninety days. Review of complaints and facility self-reports submitted to the state agency revealed no evidence that the facility had submitted a self-report for Resident #34's allegation of staff-to-resident abuse on or about May 14, 2025. Interview was conducted on May 20, 2025 at 10:18AM with a Social Worker (Staff #7), who stated that if she received a grievance relating to abuse, she would report it to the VP and DON to report and investigate. The Social Worker explained that since the VP was the abuse coordinator, she would take charge but would also delegate to the DON or to the Social Worker to investigate any allegations of abuse. The Social worker stated that typically, an abuse investigation would consist of interviewing the resident who made the allegation, other residents, and staff. When asked about the grievance filed by Resident #34, the social worker explained that the DON had obtained the initial report and filed the grievance for the resident. She further explained that the DON and Social Worker had jointly conducted the interviews to investigate the allegation. She stated that no residents that she interviewed had any concerns with their care or with staff. When asked where the investigation and results were documented, the Social Worker was unsure where the investigation was documented, but suggested that the VP would typically maintain a folder for investigations. Interview was conducted on May 20, 2025 at 10:27AM with the Director of Nursing (DON/Staff #11), who explained that she had submitted a self-report online to the state agency regarding Resident #34. She explained that she had submitted the report online on May 14, 2025 and followed the steps to verify her email, but had not heard back. The DON provided an email from the state agency, dated May 14, 2025 at 2:38PM, which instructed the user to click a link to verify the email address after a request of complaint submission by the facility tto show that the complaint had been received by the state agency. The email stated that once the email address was verified, the complaint would be submitted to the state agency for review. The DON stated that she had clicked the link as instructed. The DON did not provide any further documentation to show that the complaint had been finalized and submitted. Follow-up interview was conducted on May 20, 2025 at 10:38AM with the Director of Nursing (DON/Staff #11), who stated that she would expect any allegations of abuse, which included sexual, physical, emotional, and mental abuse, to be reported to the abuse coordinator right away. She explained that the allegation should then be reported to the state agency, APS, police, the ombudsman, family, and the provider. The DON stated that the morning of May 14, 2025, Resident #34 stated that a CNA had pulled her hair and she did not know why. The DON again explained that she had reported Resident #34's allegation of abuse to the state agency and other required parties on May 14, 2025 at approximately 07:40AM. The DON also stated that an investigation was completed of the allegation. Interview was conducted on May 20, 2025 at 11:05AM with the [NAME] President of Health Services (VP/Staff #23), who stated that all allegations of physical abuse should be reported within two hours to the appropriate agencies. The VP stated that Resident #34's allegation of abuse was reported immediately on May 14, 2025, and the five-day facility investigation was completed on May 19, 2025. The VP stated that the facility was unable to substantiate the allegation of abuse due to lack of evidence. The VP explained that if any hair pulling occurred when staff was changing the resident's clothing, that it would have been accidental. When asked why this investigation was not included when requesting the last ninety days of self-report investigations, the VP stated that it must have been an oversight, as the facility just completed the five-day report on the day that this was requested. Review of the facility policy titled, Abuse, Neglect and Exploitation, revealed that all alleged violations should be reported to the administrator, state agency, adult protective services and to all other required agencies within specified timeframes, which include: immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews, facility documentation and a policy review, the facility failed to ensure that one sampled resident (#37) was notified prior to the room change. The deficient practice could result in residents and their representatives, not provided with the opportunity to exercise autonomy regarding their interests, preferences and desires, in regards to a room change. Findings include: Resident #37 was admitted on [DATE] with diagnoses of vascular dementia, moderate, with other behavioral disturbance; major depressive disorder, recurrent, moderate; and unspecified dementia, severe, with other behavioral disturbance. Review of a quarterly Medicare Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 00 indicating resident had severe cognitive impairment. A social service note dated July, 15, 2024, revealed that Power of Attorney (POA) had called the Social Worker (SW/staff #38); and that, the SW re-iterated information regarding the cancelled room change, that had been previously discussed during a scheduled quarterly care plan meeting. The note also revealed the resident enjoyed the 4th floor and the connections made on the 4th floor. Review of the electronic health records (EHR) revealed no evidence that the resident or responsible party were provided a written notice prior to the re-initiation of the room change that occurred approximately between the dates of July 22, 2024 and August 3, 2024. Further review of the EHR revealed that the resident or responsible party did not complete a consent form for a room of change that occurred approximately between July 22, 2024 and August 3, 2024. An interview was conducted on August 26, 2024 at 11:29AM with the resident's POA, who stated that they had a concern with the resident moving rooms. The POA reported that to their knowledge, a room change took place while the social services coordinator was out of office. The POA stated that there had been a discussion previously to complete a room change, however, it was then discussed that the room change was cancelled. The POA reported that they were unaware of the room change, until they made a visit to the facility; and, was advised that the resident was no longer on the 4th floor, but now on the 3rd floor. An interview was conducted on August 29, 2024 at 11:20AM with the SW (staff # 38), who stated the room change process start with reaching out to the POA, and/or representative for the update in treatment; and then, a 30-day notice letter are to be sent out to the resident and/or representative. Regarding resident #37, the SW stated that a room change letter had been sent out in June; and that, the POA should have received it. The SW also said that following the letter, they had reached out to the POA and relayed to the POA that the room change had been cancelled. However, the SW admitted that the room change decision and implementation happened while she was out of town. Staff #38 stated that there was miscommunication regarding that room change for resident #37; and that, the room change happened without the proper room change notification expectations. Review of a facility policy titled, Notification of Room or Roommate Change, revealed that notification of room changes will be documented according to the facility's established practices, and to include completion of a Notification of Room or Roommate Changes form signed by the resident and/or resident's legal representative. The policy included that the resident has the right to notification of room or roommate changes and to agree prior to the change taking place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews, and facility policy review the facility failed to ensure one resident (#44) was assessed and care planned for the use of a power wheelchair seatbelt and bed rails/mobility bars. The deficient practice could lead to a resident experiencing decreased mobility, possible entrapment, and psychosocial and/or physical harm. Findings include: Resident #44 was admitted into the facility on October 12, 2022 with diagnoses that included acute transverse myelitis, hemiplegia following cerebral infarction, major depressive disorder, and myocardial infarction. The care plan dated October 13, 2022 indicated that the resident required assist with completion of activities of daily living and with mobility due to transverse myelitis and hemiplegia. Another care plan dated October 13, 2022 revealed the resident had a functional decline related to CVa (cerebrovascular disease). Interventions included assistance with ADLs (activities of daily living) as needed) and use cushion in wheelchair. Further review of the care plan revealed no evidence that use of the power wheelchair seatbelt or bedrails/mobility bars on her bed were addressed with interventions implemented. Review of the physician orders revealed no evidence of any orders regarding use or assessment of seatbelt on her power wheelchair or bedrails/mobility bars on her bed. Further, there was no evidence in the clinical record that the resident was assessed for seatbelt use on her power wheelchair or bedrails/mobility bars on her bed. Review of the Treatment Administration Record (TAR) for July 2024 revealed no assessment, intervention, or monitoring, for Resident #44's seatbelt on her power wheelchair or bedrails/mobility bars on her bed. The quarterly Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident had intact cognition. The MDS also included that restraints and alarms, bed rail in bed and trunk restraint used in chair were coded as not used. An observation conducted on August 26, 2024 at 11:57 AM revealed Resident #44 in bed with mobility bars present on the sides of her bed and a power wheelchair with a seatbelt present positioned in front of the bed against the wall. Resident #44 confirmed that this was her personal wheelchair. In an interview conducted on August 29, 2024 at 08:06 AM, Resident #44 stated that the mobility bars sometimes get in her way, but that they were there for a reason. In an interview conducted on August 29, 2024 at approximately 8:10 AM, a licensed practical nurse (LPN/staff #76) stated that he was not aware of any process that the facility had for assessing and monitoring possible restraints. Staff #76 stated that a restraint was considered to be a full side rail on a bed; and, anything that keeps a resident from getting out of bed, chair alarms or straps that restrain a patient. He further stated there were no residents at the facility that had been assessed for possible restraints because the facility does not use restraints. In an interview on August 29, 2024 at 10:07 AM, the Director of Nursing (staff #12) stated that the facility does not restrain anybody; and that, restraints were anything that keeps the resident from getting up from the bed or chair. The DON said that a seatbelt was a restraint if the resident could not self-release; or, siderails were restraints if they cover the whole end of the bed. The DON said that if a resident had a seatbelt on their chair, then the facility conducts an assessment if the resident can self-release the seatbelt and this is documented in the electronic record. During the interview, a review of the clinical record was conducted with the DON who stated that resident #44 did not have any assessment for seatbelt use and bed rail/mobility bars and she could not find any documentation that the resident was assessed for ability to self-release seatbelt and/or use of bedrails/mobility bars. The DON said that if a resident was not assessed for a possible restraint, there was a risk of possible harm such as choking, if resident slide down in the chair, or contractures if they are restrained. Further, the DON said that the expectation was that staff would complete restraint assessment for residents who had a potential restraint and to document it on the TAR as per the facility policy. Review of the facility's policy on Restraint Free Environment revealed that restraints was defined as any physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints may include but are not limited to: using bed rails that keep the resident from voluntarily getting out of bed and using devices in conjunction with a chair such as trays, bars, or belts, that the resident cannot remove and prevents the resident from rising. Before a resident is restrained, the facility will determine the specific medical symptom that warrants the use of the restraint, the type of direct monitoring and supervision that will be provided during the use of the restraint, how the resident will request staff assistance while the restraint is in place, and how to assist the resident in attaining or maintaining his or her highest practicable level of physical well-being. Finally, the care plan should be updated accordingly to include the development and implementation of interventions, to address any risks related to the use of the restraint.

Based on observations and staff interviews, the facility failed to ensure daily staff posting was current and posted at the beginning of each shift. The deficient practice could result in the accurate daily staffing information not available to residents and visitors. Findings include: An observation in 4th floor was conducted on August 26, 2024 at 8:36 a.m. The daily staff posting was located on the wall by the elevators and across from the 4th floor nurse's station. The daily staff posting was dated January 3, 2024. On August 26, 2024, at 8:40 AM, an observation in the 3rd floor was conducted; and, the daily staff posting was found on the wall by the elevators and across from the 3rd floor nurse's station. The daily staff posting was dated August 6, 2024. An observation in the 4th floor was conducted on August 27, 2024 at 7:57 AM. There was no daily staff posting found on the 4th floor. An observation in the 4th floor was conducted on August 28, 2024 at 8:00 AM. There was no daily staff posting found on the 4th floor. In an interview with the director of nursing (DON/staff #12) conducted on August 29, 2024 at 12:25 PM, the DON stated that the daily staff posting was located on the 3rd floor by the nurse's station; and that, the residents on the 4th floor and their family can ask for the daily staffing information. The DON provided a copy of the daily staff posting dated August 26, 2024 and stated that this posting was previously posted on the 3rd floor on August 26, 2024. Review of the daily staff posting provided by the DON revealed that the date was altered from what appeared to be 8/06/24 and changed to 8/26/24. An interview with the administrator (staff #59) was conducted August 29, 2024 at approximately 12:27 PM. The Administrator stated that a lot of residents from the 4th floor frequently come to the 3rd floor for activities, resident council, or to meet with the Director of Nursing in her office, and would be able to see the daily staff posting. The administrator said that the residents from the 4th floor who do not participate in activities, resident council, or to meet with the Director of Nursing in her office can be brought to the 3rd floor any time or the resident can go to the 3rd floor themselves if they want. Further, the administrator said that staff had not educated residents and their families on the daily staff posting located on the 3rd floor. In an interview with a registered nurse (RN/staff #49) at the 4th floor conducted on August 30, 2024 at 6:56 AM. The RN stated that there usually was a daily staff posting on the 4th floor. The RN then pointed to the empty space on the wall by the elevator across from the nurse's station where there was a pushpin present in the wall. However, there was no daily staff posting posted on the wall; and, the RN stated that there was a daily staff posting found on the 3rd floor as well.

Based on observations, staff interview, and policy review, the facility failed to ensure that the third-floor resident nourishment refrigerator food was stored in accordance with professional standards for food service safety. The deficient practice could result in food growing harmful bacteria that is a risk factor to cause foodborne illness. Findings include: During an observation of the third-floor nourishment refrigerator conducted on August 27, 2024 at 12:50 PM, revealed upon the refrigerator shelves, two fruit plates that were undated and partially uncovered. On half of the two paper-plates were green grapes and banana slices, and on the other half of paper plate were red color (strawberry color) liquid puddles with red stain soaked into the paper plate. The section of the plates with red color puddled juices had the clear plastic wrap pulled back leaving both plates partially uncovered with the banana slices and grapes exposed. An interview was conducted on August 27, 2024 at 12:57 PM with the registered dietician (RD/staff #35) near the third-floor secured nourishment refrigerator. Registered Dietician (#35) stated that the two fruit plates located within the nourishment refrigerator were from the night-shift staff, and that staff should have placed a use-by dated sticker on each plate and recovered the plates with saran wrap. The registered dietician opened the third-floor nourishment refrigerator and removed the two un-dated fruit plates and disposed. Review of the facility policy titled, Production, Purchasing, Storage; Food and Supply Storage revealed that the procedures are to cover, label and date unused portions and open packages with a completed orange-color label system. Products are good through the close of business on the date noted on the orange label and to discard food past the use-by or expiration date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #44 was admitted on [DATE] with diagnoses of included acute transverse myelitis, hemiplegia following cerebral infarction, major depressive disorder, and myocardial infarction. The care plan dated October 13, 2022 indicated that the resident required assist with completion of activities of daily living and with mobility due to transverse myelitis and hemiplegia. Another care plan dated October 13, 2022 revealed the resident had a functional decline related to CVa (cerebrovascular disease). Interventions included assistance with ADLs (activities of daily living) as needed) and use cushion in wheelchair. Further review of the care plan revealed no evidence that use of the power wheelchair seatbelt or bedrails/mobility bars on her bed were addressed with interventions implemented. The quarterly Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident had intact cognition. The MDS also included that restraints and alarms, bed rail in bed and trunk restraint used in chair were coded as not used. An observation conducted on August 26, 2024 at 11:57 AM revealed Resident #44 in bed with bed rails/mobility bars present on the sides of her bed; and, a power wheelchair with a seatbelt present positioned in front of the bed against the wall. Resident #44 stated that this was her personal wheelchair. In an interview conducted on August 29, 2024 at 08:06 AM, Resident #44 stated that the mobility bars sometimes get in her way, but that they were there for a reason. Review of the facility's policy on Restraint Free Environment revealed that the care plan should be updated accordingly to include the development and implementation of interventions, to address any risks related to the use of the restraint. Based on clinical record review, staff interview, and policies and procedures, the facility failed to ensure that a comprehensive person-centered care plan with interventions related to use of oxygen was developed for one resident (#38) and related to the use of a power wheelchair seatbelt and bed rails/mobility bars for one resident (#44). The deficient practice could result in the resident not receiving the necessary care and services according to their assessed needs. Findings include: Resident #38 was readmitted to facility March 28, 2024 with diagnoses of chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure. The physician note dated March 29, 2024 revealed that resident had an oxygen saturation of 90% on room air, had an oxygen flow rate of 2 liters, and a respiratory rate of 18 breaths per minute. The documentation included that resident was oxygen dependent without any shortness of breath or wheezing while on 2 liters of oxygen. Diagnoses included emphysema and chronic hypoxemic respiratory failure. Plan was to continue oxygen at 2 liters for chronic hypoxemic respiratory failure. A physician order dated March 30, 2024 included to change oxygen tubing weekly and to initial and date when the change was done. Another physician order dated March 30, 2024 included for supplemental oxygen at 1-4 liters via nasal cannula in order to keep resident oxygen level above 90%. Review of the Significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated resident had cognitive impairment. The MDS also included that resident experienced shortness of breath while lying flat or with exertion and used oxygen. Review of hospice comprehensive assessment and plan of care dated July 15, 2024 revealed an order to initiate oxygen at 2-4 liters via nasal cannula continuously or as needed as indicated. The pain/palliative care consult notes dated July 24, 2024 revealed the resident was oxygen dependent. The physician visit note dated July 31, 2024 assessment statement stated resident was oxygen dependent due to COPD. Despite documentation that the resident was on oxygen therapy, the care plan related to oxygen use was not developed with interventions until August 28, 2024. The care plan with revision date of August 28, 2024 included the resident was expected to lose weight related to emphysema, angina at rest, paroxysmal atrial fibrillation and chronic hypoxemic respiratory failure. Intervention included to administer oxygen as ordered. An interview was conducted with a licensed practical nurse (LPN/staff #60) on August 26, 2024 at 1:09 p.m. The LPN stated that resident #38 should have the oxygen via nasal cannula on. An interview with Assistant Director of Nursing (ADON/staff #68) conducted on August 27, 2024 at approximately 1:00 p.m. The ADON stated that care plans were created on admission, and updated as needed to meet the needs of the resident. ADON located the administrate oxygen intervention in Beatitudes care plan version. ADON believes the oxygen care planning portion was handled by Hospice of the Valley, and will obtain a copy for the surveyor. An interview with the ADON and the restorative nurse assistant (RNA/staff#78) was conducted on August 29, 2024 at 1:28 p.m. Both the ADON and the RNA said that the resident should have the oxygen on her. In an interview with the ADON conducted on August 30, 2024 at approximately 9:00 a.m., the ADON stated that resident #38 was often encouraged to wear oxygen as ordered on a regular basis to prevent shortness of breath and discomfort. The facility policy on Oxygen Therapy included that care planning for oxygen should include oxygen delivery type, time to administer, equipment settings, monitoring of oxygen saturation levels, and monitoring for complications. Review of the facility policy on Comprehensive Care Plan revealed that the care plan will include measurable objectives and timeframes to meet the resident's needs. The objectives will be utilized to monitor the resident's progress.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, interviews, and policy review; the facility failed to ensure oxygen was administered as ordered for one resident (#38); and, failed to ensure there was a physician order for the use of oxygen for one resident (#50). The deficient practice could result in resident complication and respiratory distress and hospitalization. Findings include: -Resident #38 was readmitted to facility March 28, 2024 with diagnoses of chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure. The physician note dated March 29, 2024 revealed that resident had an oxygen saturation of 90% on room air, had an oxygen flow rate of 2 liters, and a respiratory rate of 18 breaths per minute. The documentation included that resident was oxygen dependent without any shortness of breath or wheezing while on 2 liters of oxygen. Diagnoses included emphysema and chronic hypoxemic respiratory failure. Plan was to continue oxygen at 2 liters for chronic hypoxemic respiratory failure. A physician order dated March 30, 2024 included to change oxygen tubing weekly and to initial and date when the change was done. Another physician order dated March 30, 2024 included for supplemental oxygen at 1-4 liters via nasal cannula in order to keep resident oxygen level above 90%. The pain/palliative care consult notes dated April 26, May 1 and May 16, 2024 revealed the resident was oxygen dependent. Review of the Significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated resident had cognitive impairment. The MDS also included that resident experienced shortness of breath while lying flat or with exertion and used oxygen. The pain/palliative care consult notes dated July 24, 2024 revealed the resident was oxygen dependent. The physician visit note dated July 31, 2024 assessment statement stated resident was oxygen dependent due to COPD. The care plan with revision date of August 28, 2024 included the resident was expected to lose weight related to emphysema, angina at rest, paroxysmal atrial fibrillation and chronic hypoxemic respiratory failure. Intervention included to administer oxygen as ordered. An interview was conducted with a licensed practical nurse (LPN/staff #60) on August 26, 2024 at 1:09 p.m. The LPN stated that the oxygen concentrator was turned on at 1.5 liters but was not on the resident because the resident's nasal cannula was on the floor. She stated that the resident should have the oxygen via nasal cannula on; and that, the LPN encouraged the resident compliance with oxygen use and the importance of keeping the nasal cannula on. Further, the LPN instructed the resident to notify staff if the nasal cannula falls off or causes discomfort. On August 27, 2024 from 8:00 p.m. through 10:00 p.m., the facility had a power outage and was using their emergency power system. An observation was conducted on August 29, 2024 at 1:28 p.m. The resident was lying supine in bed and was pushing the buttons on the bed controls which were not working. The resident laid flat with three pillows on head of bed and tried to reposition herself in bed and attempted to sit up; and, did not have the oxygen via nasal cannula on. The resident attempted to reach the call light but was unable to because it was on the side table by her bed. The resident's wheelchair was close to bottom right of bed, with an oxygen tank attached to back of chair; and, the arrow on the oxygen tank pressure gauge pointed to distal end of red area. There was no nasal cannula or tubing attached to the tank. The oxygen concentrator was uncovered and unplugged to the left of resident's dresser with the nasal cannula wrapped around concentrator handle. The nasal cannula was labeled with date August 26, 2024 only and was uncovered while on concentrator. There was no red wall outlet found in the resident's room. The resident complained of not being able to get comfortable, was having difficulty in breathing and requested to have her oxygen brought over and to help elevate her head. The assistant director of nursing (ADON/staff #68) and the restorative nurse assistant (RNA/staff#78) were called to join in the observation. The ADON elevated the resident head using a pillow, and placed pulse oximeter on the resident's finger. The resident's oxygen saturation reading was 87% at 1:45 p.m. and 86% at 1:59 p.m. Both the ADON and RNA stated that the resident's portable oxygen tank on the wheelchair had a pressure gauge in red zone. Both staffs stated that the resident should have the oxygen on her. The RNA immediately left the resident room and came back with an oxygen tank replacement; and, the resident was transferred from bed to chair and was brought to the medication cart area by dining room. At 2:02 p.m., the resident's oxygen saturation was 89 % at 2 liters via nasal cannula. At 2:07 p.m., oxygen was increased to 4 liters; and at 2:09 p.m., resident's oxygen saturation was 92%. In an interview with the ADON conducted on August 30, 2024 at approximately 9:00 a.m., the ADON stated that resident #38 was often encouraged to wear oxygen as ordered on a regular basis to prevent shortness of breath and discomfort. Review of the facility policy entitled Oxygen Concentrator states to keep the oxygen concentrator set up turned off when not actively in use. Facility policy further instructs to keep oxygen delivery devices covered in a plastic bag when not in use. Policy also includes that it is the nurse responsibility to change oxygen tubing and cannula weekly, and as needed if it becomes soiled or contaminated. Review of the policy entitled Oxygen Therapy states the reason for the administration of oxygen is to treat or prevent the symptoms and manifestations of hypoxia. Policy further dictates that staff shall notify the physician of any changes in the resident's condition, including changes in vital signs, oxygen concentrations, or evidence of complications associated with the use of oxygen. -Resident #50 was admitted on [DATE] with diagnoses that included metabolic encephalopathy, Type 2 diabetes mellitus, and congestive heart failure. A physician order dated June 11, 2024 revealed an order for oxygen (O2) saturations (sat) every shift for O2 use. Review of the Medical Record Administration (MAR) for June through August 2024 revealed no evidence that oxygen was administered to the resident. The care plan dated June 23, 2024 included that resident was on for oxygen therapy. Interventions included to administer oxygen as ordered by the medical doctor, and safety per protocol. Review of a comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate cognitive impairment. The assessment also included that the resident was receiving oxygen therapy. An amended provider progress note dated July 11, 2024, revealed no evidence on the medication review list that Resident #50 was receiving oxygen. Per the documentation, the staff increases the oxygen to 5 liters. However, the documentation did not include any oxygen orders such as oxygen liters required and whether or not oxygen was to be administered continuously. A provider progress note dated August 24, 2024 revealed the resident had continued hypoxia and need for oxygen. Assessment of chest and lungs revealed the resident was on 4 liters via nasal cannula, continuous oxygen and a plan to continue oxygen supplementation. The medication review list section did not include the resident was receiving oxygen. Despite documentation that the resident was on oxygen, the clinical record revealed no evidence of a physician orders for administration of oxygen from January 1 through August 29, 2024 revealed An observation conducted on August 27, 2024 at 8:20 a.m. revealed resident #50 was lying in bed with oxygen being administered via a nasal cannula. In another observation conducted on August 28, 2024 at 9:30 a.m., the resident was lying in bed, awake and able to converse, with oxygen administered via nasal cannula. Another observation was conducted on August 29, 2024 at 9:31 a.m. and revealed that the resident was lying in bed with a certified nursing assistant (CNA) assisting him with breakfast. The resident had oxygen on via nasal cannula. An interview was conducted on August 29, 2024 at 9:52 a.m. with a Licensed Practical Nurse (LPN/staff #29), who stated that resident #50 had been on the 4th floor for a couple of months, received oxygen continuously since then, and had been administered oxygen when he was on the other unit. The LPN stated that a physician order for oxygen would be required in order to administer oxygen to a a resident. A review of the clinical record was conducted by the LPN during the interview and the LPN stated that she found no physician order to administer oxygen to the resident; and that, there was also no documentation in the MAR and TAR that oxygen was administered to the resident. She further stated that the only physician order related to oxygen that in the clinical record was the order for oxygen saturations every shift for oxygen use; and this indicated that the resident was on oxygen. The LPN further stated that the clinical record revealed there was no evidence of discontinued or deleted orders for oxygen administration for resident #50. An observation of resident #50 in his room was conducted with the LPN who stated that the resident was receiving 4.5 liters of oxygen via nasal cannula. Further, the LPN said that there should have been a physician order for oxygen use for resident #50; however, there was none and this was an error. The LPN stated that resident #50 was administered oxygen without a physician order and this did not meet the facility policy. An interview with resident #50 was conducted on August 29, 2024 at 10:11 a.m. The resident stated that he had been receiving oxygen for about 3 months. During an interview with the Director of Nursing (DON/Staff #12) was conducted on August 29, 2024 at 10:20 a.m. The DON stated that the expectation was that there was physician order for oxygen use and monitoring of oxygen saturation for residents receiving oxygen. A review of the clinical record was conducted by the DON who stated that there was no evidence of a physician order for oxygen administration; and that, resident #50 was currently receiving oxygen. The DON further stated that this situation did not follow the facility policy, and the risk could result in residents receiving oxygen that they may not require. An interview was conducted with an LPN (staff #76) on August 29, 2024 at 10:31 a.m. The LPN stated that resident #50 was transferred to the unit about a month ago; and, the resident had been administered oxygen since June 2024. Further, the LPN stated that oxygen administration required a physician order. Review of a facility policy titled, Oxygen Administration, revealed that oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Oxygen is administered under orders of a physician, except in the case of an emergency. Review of a facility policy titled, Medication Orders, revealed that medications should be administered only upon the signed order of a person lawfully authorized to prescribe. Verbal orders should be received only by licensed nurses, or pharmacists, and confirmed in writing by the physician, on the next visit to the facility.

-Regarding Foley catheter bag An observation was conducted on August 28, 2024 at 7:51 AM. The resident (#19) was lying in bed with his indwelling catheter bag laying on the floor beside the resident's bed. Another observation was conducted on August 28, at 11:07 AM and revealed the resident (#19) was in bed with the indwelling catheter bag on the floor beside the resident's bed. In an interview on August 28, 2024, at 11:37 AM, a certified nursing assistant (CNA/staff #11) stated that the catheter bag should not be on the floor in order to stay clean. An interview with another CNA (staff #1) was conducted on August 28, 2024, at 11:42 AM. The CNA (staff #1) stated that the catheter bag should not be on the floor, and if it is on the floor, then there is a risk of infection. An observation of resident #19 was conducted with the CNA (staff #1) during the interview; and, the CNA stated that the resident's indwelling catheter bag was on the floor and it should not be. The CNA said that she would get a bag for it in order to hang it on the side of the bed. During an interview conducted on August 29, 2024, at 12:44 PM, the Director of Nursing (DON/staff #12) stated that a catheter bag should not be on the floor, and that there was risk of infection if it was on the floor. Review of the facility's policy titled Appropriate Use of Indwelling Catheters revealed that indwelling catheters (urethral or suprapubic) will be utilized with current standards of practice, with interventions to prevent complications to the extent possible. Possible complications include but are not limited to: urinary tract infection, blockage of catheter, pain, discomfort, and bleeding. -Regarding resident equipment During an observation in the dining area conducted on August 28, 2024 at approximately 7:45 a.m., the licensed practical nurse (LPN/Staff #29) attempt wrist BP (blood pressure) check on resident and the wrist cuff reading was unsuccessful. The LPN returned the wrist cuff to the medication cart, obtained a manual arm cuff from cart and used it to get a BP from the same resident. The LPN then returned both the wrist and the arm BP cuffs into the medication cart without disinfecting or wiping them down. An interview with the with LPN (staff #29) was conducted on August 28, 2024 at approximately 7:50 a.m. The LPN said that it was necessary to wipe down equipment before locking it inside the medication cart to avoid spreading any type of infection. However, the LPN stated that she forgot for wipe down or disinfect the wrist and arm cuff she used on one resident before putting it back in the medication cart. An interview with the assistant director of nursing (ADON/staff #68) was conducted on August 28, 2024 at approximately 9:15 a.m. The ADON stated that dirty items should never be placed in the medication cart; and, all resident equipment should be wiped down with approved disinfectant wipes to avoid spreading of infection before and after each resident use. The DON (staff #12) joined the interview and stated that resident equipment such as BP cuffs were usually wiped down with disinfectant wipes; and that, staff were to use the alcohol prep pads located in the medication cart when disinfectant wipes were not available. A review of facility policy entitled Medication Administration included that medication cart/storage should be kept clean, organized, and stocked with adequate supplies in order to break the chain of infection. The facility policy on Cleaning and Disinfection of Resident Care Equipment revealed that blood pressure cuffs were classified as reusable multiple resident non-critical item. Multiple-resident use equipment was to be cleaned and disinfected after each use. The staff should follow established infection control principles for non-critical equipment. Based on observations, staff interviews, and policy review the facility failed to ensure that infection control practices and standards were followed; failed to perform hand hygiene during provision of care; failed to ensure reusable resident equipment was cleaned and disinfected after its use. The deficient practice could result in the spread of disease and infections to residents. The facility census was 52 residents. Findings include: -Regarding wound care observation: During a wound care observation for Resident (#7) conducted on August 28, 2024 at 8:17 AM, the licensed practical nurse (LPN/staff #29) took a multiuse wound wash solution and betadine container from the treatment cart and into the resident's room. During the course of treatment application, the LPN (staff #29) touched the wound wash and betadine container with gloves used to removed soiled dressing; and, following the application of the wound treatment, staff #7 removed her gown and gloves, and returned the betadine and wound wash bottles directly to the wound treatment cart without sanitizing the bottles. An interview was conducted on August 28, 2024 at 8:17 AM with the LPN (staff #29) who stated that supplies used on residents during treatment down, staff would wipe them down with sanitizing/bleach wipes to ensure infection would not spread to other residents. Regarding the wound care observation, the LPN said that she should have sanitized or wiped down the wound wash solution and betadine containers that were brought into resident (#7)'s room before putting them back in the unit's treatment cart. An interview with the Director of Nursing (DON/Staff #12) was conducted on August 29, 2024 at 1:49 PM. The DON stated that any item used on a resident should be cleaned when it leaves the resident's room; and that, it would not meet the facility's protocol if the items were not cleaned prior to putting them back into the treatment cart. The facility policy titled, Wound Care revealed that after wound treatment is completed, reusable supplies are to be wiped with a sanitizing agent as indicated (outsides of containers that were touched by unclean hands, scissors, blades, etc.) prior to returning the supplies to the treatment cart. -Regarding Enhanced Barrier Precautions: During an observation on the 4th floor conducted on August 26, 2024 at approximately 8:45 a.m., there were residents on enhanced barrier precautions (EBP). However, there were no EBP signs posted in the walls of resident rooms in the hallway. On August 26, 2024 at 10:04 AM, the social services director (SSD/staff # 38) walked down the hallway on the 4th floor and placed the enhanced barrier precautions (EBP) signs next to resident's rooms. At 10:11 a.m., multiple staff were placing EBP signs in the hallway next to resident's rooms. An interview was conducted with the Director of Nursing (DON/Staff #12) on August 27, 2024 at 1:01 PM. The DON stated that staff were expected to use gown, gloves, and a face shield (for splashing) when providing care to residents on EBP. She then stated the EBP policy included that staff would use personal protective equipment (PPE) for any resident care. The DON further stated that staff would know that the resident/s was on EBP because there would be a sign on the resident's door and staff had worked on the unit all the time. The DON stated that she saw staff putting EBP signs by the resident's rooms that morning the survey team arrived on the unit. She further stated that not having EBP signage posted was considered an issue and the risk to the residents would include spread of infection. In an interview with a Certified Nursing Assistant (CNA/Staff #87) conducted on August 28, 2024 at 10:15 AM, the CNA stated that she would have to wear a gown and gloves anytime she goes into the room of residents on EBP for any task that needed to be done. The CNA further stated that she would know which residents were on EBP by the EBP signage outside the resident's room or the nurse would let her know. She also stated that the EBP signs were posted in the hallways by the resident's room on her last shift on Friday, August 23, 2024; however, she was not aware the signs had been taken down before the survey team arrived on the unit. The facility's policy titled, Enhanced Barrier Precautions, revealed that the facility would have discretion on how to communicate to staff which residents required the use of EBP, as long as staff were aware of which residents required the use of EBP during high-contact care activities. -Regarding hand hygiene: An observation conducted on the fourth-floor unit on August 26, 2024 at 8:30 AM, revealed that hand sanitizer was not accessible inside or immediately outside of resident's rooms. During a facility observation conducted on August 26, 2024 at 8:47 AM, the Certified Nursing Assistant (CNA/Staff #22) performed hand hygiene and put on gloves before transferring a resident into bed from a wheelchair using a gait belt. After the transfer, the CNA (Staff #22) removed her gloves but did not perform hand hygiene upon leaving resident's room. Hand sanitizer was not observed outside of resident's room. Further observation conducted on August 26, 2024 at 9:36 AM, a CNA (Staff #16) transported resident (#28) back to her room via wheelchair. The CNA (Staff #16) walked over to another resident (#38) and lifted up her blanket. The CNA (Staff #16) then walked back over to resident (#28) and took the resident back out of the room via wheelchair. The CNA (Staff #16) did not perform hand hygiene between resident interactions or when leaving the room. An interview was conducted on August 26, 2024 at 8:30 AM with a Certified Nursing Assistant (CNA/Staff #16), who stated that the hand sanitizer was located on the unit's medication cart and at the nurse's station. She further stated if the staff did not have time to go the nurse's station or medication cart that they would wash their hands going in and out of the resident's room. An interview was conducted on August 28, 2024 at 10:15 AM with a CNA (Staff #87), who stated that hand hygiene would be performed using either soap and water in the resident's room or hand sanitizer. She further stated that hand hygiene would be performed before and after touching residents and upon entering and leaving the resident's rooms. An interview was conducted on August 29, 2024 at 10:24 AM with the Assistant Director of Nursing (ADON/Staff #68), who stated the policy for hand hygiene included the expectation that staff was to wash or use hand sanitizer between resident contact. She further stated that hand sanitizer was located at the nurse's station and on the medication cart. The ADON (Staff #68) was informed of the observations of CNA (Staff #16) from August 29, 2024. The ADON stated that she would speak with CNA (Staff #16) to correct the behavior. An interview was conducted on August 27, 2024 at 1:01 PM with the Director of Nursing (DON/Staff #12), who stated that hand hygiene would be performed before and after contact with a resident, and at meal times. She also stated that the fourth floor was previously a dementia unit so there were no hand sanitizers installed in the hallways. The DON (Staff #12) stated that she expected staff to wash their hands when going in or out of resident rooms. The facility policy titled, Hand Hygiene, revealed that hand hygiene is a general term for cleaning hands by either handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub. The policy indicated that staff would perform hand hygiene when indicated, and that the use of gloves did not replace hand hygiene. If the task required gloves, the staff would perform hand hygiene prior to putting on gloves and immediately after removing gloves.

Based on observations, staff and resident interviews, and the facility's documentation and policies, the facility failed to ensure a safe and comfortable environment for residents. The deficient practice could result resident not having a homelike environment and risk for injury and harm. Findings include: Review of the open work order report generated on July 15, 2024 did not reveal any work order pertaining to any of the issues identified during the walk-through observations. During the initial tour of the 4th floor unit conducted on August 28, 2024 at 12:17 PM., multiple rooms were found to have the following: -Water stains on the ceiling tile; -Door frame had a splatter of a brown substance; and, -Temperature probe above the dining area on the 4th floor had built up substance and appeared to be leaking. An interview with a Licensed Practical Nurse (LPN/ #29) was conducted on August 29, 2024 at 12:58 PM. The LPN (staff #29) stated that there was a work order website to put an order in and that staff can always call into the maintenance department. An interview with the Senior Maintenance Engineer (staff #205) was conducted on August 30, 2024 at 8:04 a.m. Staff #205 stated that he conducts a walkthrough of the facility unit/s at least once a week; and that, the maintenance technician for the building does daily walkthroughs to check in and speak with nursing staff to see if anything needs to be done that was not currently in their work orders. Staff #205 stated that staining on the walls/ceilings would be suspicious and the facility would try to get them changed out to find the source of the problem. Staff #205 stated that the staining could occur due to moisture coming from something. Staff #205 further stated that it may be aesthetically unpleasing and anytime there was a high moisture situation there was the chance of mildew. An interview with the Administrator (staff #110) was conducted on July 17, 2024 at 1:09 p.m. The administrator stated that the expectation was that the living area for residents was clean, free of obstruction, without significant odors and safe from hazards. The administrator said that repairs such as paint and upkeep should be maintained to have a homelike environment; and, this was important since the facility was the home for people living here and they deserve a good quality of life. The administrator also said that it has to be safe so that residents were not put at risk for accidents or injuries. Further, the administrator stated that if the facility was not homelike and not safe, the residents might feel discomfort, might reduce the homelike environment feel until things were repaired and could result in a risk for some type of injury i.e. if legs extend beyond the wheelchair there could be a risk of injury. Review of the facility policy titled Preventive Maintenance Program revised January 11, 2023 and reviewed January 22, 2024 indicated that the facility must be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel and the public. The facility policy titled Work Request System revised May 14, 2019 and reviewed January 15, 2024 indicated that the work order request system was designed to provide an established and effective means of requesting, coordinating, and completing maintenance of a corrective nature. A facility policy titled Resident Rights issued June 8, 2020 and reviewed September 25, 2023 indicated that residents have a right to a safe, clean, comfortable, and homelike environment.

Based on personnel file review, staff interviews, and facility policy review, the facility failed to maintain an effective training program for two of 15 sampled staff (#70 and #19). The deficient practice could lead to a deficit in staff or volunteers' knowledge and/or skills which could affect resident care, leading to harm. Findings include: -Regarding the registered nurse (RN/staff #70) Review of personnel file for the RN (staff #70) revealed a hire date of November 07, 2022. The annual training transcript for the RN revealed that the most recent annually required training modules covering the topics of abuse, neglect, and exploitation, elder justice act, resident rights, dementia management, and infection control had been completed on November 08, 2022. There was no evidence found that the RN had taken any training modules after November 8, 2022. -Regarding the housekeeper (staff #19) The personnel file for the housekeeper (staff #19) included a hire date of August 21, 2023. Review of the housekeeper's annual training transcripts revealed that the most recent annually required training modules covering the topics of abuse, neglect, and exploitation, elder justice act, resident rights, dementia management, and infection control had been completed on August 21, 2023. There was no evidence found that the housekeeper had taken any training modules after August 21, 2023. An interview with the human resources assistant (HR assistant/staff #90) was conducted on August 28, 2024 at 9:57 AM. The HR assistant stated that she could not tell specifics regarding which annual training modules are required for all employees, contract staff, and volunteers. In an interview with the Administrator (Staff #59) conducted on August 29, 2024 at 11:15 AM, the administrator reviewed the provided annually required training module transcripts for Staff #70 and Staff #19. The administrator then stated that there were no annual training module transcripts on the topics of abuse, neglect, and exploitation, elder justice act, resident rights, dementia management, and infection control for the RN (staff #70) and the housekeeper (staff #19). The administrator also stated that annual training meant within the past 365 days. During an interview with the [NAME] President of Human Resources and Risk Management (VP of HR/staff #40) conducted on August 30, 2024 at 08:35 AM, she stated that when COVID hit, the facility did not update their training; and when the Administrator came on board, the administrator was not aware of that. The VP of HR also said that the facility was missing their old policy and was currently writing a new one. The VP of HR also said that their new written policy included what topics of training were required annually. Review of the facility's policy titled New Hire Training and Annual In-Service Policy revealed that orientation training for newly hired staff members and volunteers, as well as annual training for current staff and volunteers is to include training on the topics of nursing care institution policies and procedures, resident rights, infection control, hand washing, linen handling, prevention of communicable diseases, and disaster plans.

Based on personnel file review, staff interviews, and facility policy review, the facility failed to ensure two of 15 sampled staff (#70 and #19) received ongoing education on residents rights . The deficient practice could lead to a deficit in staff or volunteers' knowledge and/or skills which could affect resident care, leading to harm. Findings include: -Regarding the registered nurse (RN/staff #70) Review of personnel file for the RN (staff #70) revealed a hire date of November 07, 2022. The annual training transcript for the RN revealed that the most recent annually required training modules covering the topics of abuse, neglect, and exploitation, elder justice act, resident rights, dementia management, and infection control had been completed on November 08, 2022. There was no evidence found that the RN had taken any training on resident rights after November 8, 2022. -Regarding the housekeeper (staff #19) The personnel file for the housekeeper (staff #19) included a hire date of August 21, 2023. Review of the housekeeper's annual training transcripts revealed that the most recent annually required training modules covering the topics of abuse, neglect, and exploitation, elder justice act, resident rights, dementia management, and infection control had been completed on August 21, 2023. There was no evidence found that the housekeeper had taken any training on resident rights after August 21, 2023. An interview with the human resources assistant (HR assistant/staff #90) was conducted on August 28, 2024 at 9:57 AM. The HR assistant stated that she could not tell specifics regarding which annual training modules are required for all employees, contract staff, and volunteers. In an interview with the Administrator (Staff #59) conducted on August 29, 2024 at 11:15 AM, the administrator reviewed the provided annually required training module transcripts for Staff #70 and Staff #19. The administrator then stated that there were no annual training module transcripts on the topics of abuse, neglect, and exploitation, elder justice act, resident rights, dementia management, and infection control for the RN (staff #70) and the housekeeper (staff #19). The administrator also stated that annual training meant within the past 365 days. During an interview with the [NAME] President of Human Resources and Risk Management (VP of HR/staff #40) conducted on August 30, 2024 at 08:35 AM, she stated that when COVID hit, the facility did not update their training; and when the Administrator came on board, the administrator was not aware of that. The VP of HR also said that the facility was missing their old policy and was currently writing a new one. The VP of HR also said that their new written policy included what topics of training were required annually. Review of the facility's policy titled New Hire Training and Annual In-Service Policy revealed that orientation training for newly hired staff members and volunteers, as well as annual training for current staff and volunteers is to include training on the topics of nursing care institution policies and procedures, resident rights, infection control, hand washing, linen handling, prevention of communicable diseases, and disaster plans.

Based on personnel file review, staff interviews, and facility policy review, the facility failed to ensure two of 15 sampled staff (#70 and #19) received training on abuse, neglect and exploitation. The deficient practice could lead to a deficit in staff or volunteers' knowledge and/or skills which could affect resident care, leading to harm. Findings include: -Regarding the registered nurse (RN/staff #70) Review of personnel file for the RN (staff #70) revealed a hire date of November 07, 2022. The annual training transcript for the RN revealed that the most recent annually required training modules covering the topics of abuse, neglect, and exploitation, elder justice act, resident rights, dementia management, and infection control had been completed on November 08, 2022. There was no evidence found that the RN had taken any training on abuse, neglect and exploitation after November 8, 2022. -Regarding the housekeeper (staff #19) The personnel file for the housekeeper (staff #19) included a hire date of August 21, 2023. Review of the housekeeper's annual training transcripts revealed that the most recent annually required training modules covering the topics of abuse, neglect, and exploitation, elder justice act, resident rights, dementia management, and infection control had been completed on August 21, 2023. There was no evidence found that the housekeeper had taken any training on abuse, neglect and exploitation after August 21, 2023. An interview with the human resources assistant (HR assistant/staff #90) was conducted on August 28, 2024 at 9:57 AM. The HR assistant stated that she could not tell specifics regarding which annual training modules are required for all employees, contract staff, and volunteers. In an interview with the Administrator (Staff #59) conducted on August 29, 2024 at 11:15 AM, the administrator reviewed the provided annually required training module transcripts for Staff #70 and Staff #19. The administrator then stated that there were no annual training module transcripts on the topics of abuse, neglect, and exploitation, elder justice act, resident rights, dementia management, and infection control for the RN (staff #70) and the housekeeper (staff #19). The administrator also stated that annual training meant within the past 365 days. During an interview with the [NAME] President of Human Resources and Risk Management (VP of HR/staff #40) conducted on August 30, 2024 at 08:35 AM, she stated that when COVID hit, the facility did not update their training; and when the Administrator came on board, the administrator was not aware of that. The VP of HR also said that the facility was missing their old policy and was currently writing a new one. The VP of HR also said that their new written policy included what topics of training were required annually. Review of the facility's policy titled New Hire Training and Annual In-Service Policy revealed that orientation training for newly hired staff members and volunteers, as well as annual training for current staff and volunteers is to include training on the topics of nursing care institution policies and procedures, resident rights, infection control, hand washing, linen handling, prevention of communicable diseases, and disaster plans.

Based on personnel file review, staff interviews, and facility policy review, the facility failed to ensure two of 15 sampled staff (#70 and #19) received training on infection control. The deficient practice could lead to a deficit in staff or volunteers' knowledge and/or skills which could affect resident care, leading to harm. Findings include: -Regarding the registered nurse (RN/staff #70) Review of personnel file for the RN (staff #70) revealed a hire date of November 07, 2022. The annual training transcript for the RN revealed that the most recent annually required training modules covering the topics of abuse, neglect, and exploitation, elder justice act, resident rights, dementia management, and infection control had been completed on November 08, 2022. There was no evidence found that the RN had taken any training on infection control after November 8, 2022. -Regarding the housekeeper (staff #19) The personnel file for the housekeeper (staff #19) included a hire date of August 21, 2023. Review of the housekeeper's annual training transcripts revealed that the most recent annually required training modules covering the topics of abuse, neglect, and exploitation, elder justice act, resident rights, dementia management, and infection control had been completed on August 21, 2023. There was no evidence found that the housekeeper had taken any training on infection control after August 21, 2023. An interview with the human resources assistant (HR assistant/staff #90) was conducted on August 28, 2024 at 9:57 AM. The HR assistant stated that she could not tell specifics regarding which annual training modules are required for all employees, contract staff, and volunteers. In an interview with the Administrator (Staff #59) conducted on August 29, 2024 at 11:15 AM, the administrator reviewed the provided annually required training module transcripts for Staff #70 and Staff #19. The administrator then stated that there were no annual training module transcripts on the topics of abuse, neglect, and exploitation, elder justice act, resident rights, dementia management, and infection control for the RN (staff #70) and the housekeeper (staff #19). The administrator also stated that annual training meant within the past 365 days. During an interview with the [NAME] President of Human Resources and Risk Management (VP of HR/staff #40) conducted on August 30, 2024 at 08:35 AM, she stated that when COVID hit, the facility did not update their training; and when the Administrator came on board, the administrator was not aware of that. The VP of HR also said that the facility was missing their old policy and was currently writing a new one. The VP of HR also said that their new written policy included what topics of training were required annually. Review of the facility's policy titled New Hire Training and Annual In-Service Policy revealed that orientation training for newly hired staff members and volunteers, as well as annual training for current staff and volunteers is to include training on the topics of nursing care institution policies and procedures, resident rights, infection control, hand washing, linen handling, prevention of communicable diseases, and disaster plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation and policy, the facility failed to ensure an allegation of abuse for one resident (#39) was reported as required. The deficient practice could lead to continued abuse of the resident or other residents. Findings include: Resident #39 admitted on [DATE] with diagnoses of cerebral infarction, hemiplegia and hemiparesis and dysphagia. Review of the facility investigation revealed the incident occurred on January 3, 2023 at 4:00 p.m. The investigation included that on January 4, 2023, a certified nursing assistant (CNA/staff #27) reported that the resident told her that the big girl with the red hair had punched her in the head; and that, the date of the alleged abuse was January 3, 2023. Continued review of the investigation included that on interview with the resident the facility during a resident interview, the resident described the alleged perpetrator and identified a CNA (staff #19). The investigation also included a statement from the CNA (staff #27) that on January 4, 2023 resident #39 reported multiple times throughout the day at the nursing station that the big girl with the red hair punched her in the head. The statement also included that when the resident reported that the incident happened yesterday; and that, later that day the resident repeated the same statement. Further review of the facility investigation revealed that staff #35 was called to the room to assist with resident #39 on January 3, 2023 at approximately 4:30 p.m. she was asked by CNA (staff #19) for help in assisting resident #39. Staff #35 wrote in her statement that resident #39 told her to get her (referring to staff #19) away from me, she's (referring to staff #19) tossing me around and hitting me. Despite documentation of an allegation of abuse, there was no evidence the facility that the facility reported the allegation of abuse to the State agency until January 4, 2023 on the after-office hour message line. An interview was conducted on January 18, 2023 at 1:01 p.m. with CNA (staff #27) who stated resident #39 came to the nurse's station and reported that the lady with the red hair hit her in the back of her head. She stated the resident kept saying the same thing and she went and reported to the administrator right away. In an interview with another CNA (staff #35) conducted on January 18, 2023 at 1:07 p.m., staff #35 stated she received training on types of abuse and reporting abuse; and that, she supposed to report abuse right away to her nurse/supervisor, nurse manager and administrator. The CNA stated in her written statement, the resident #39 described that the alleged CNA (#19) was tossing me (referring to resident) around and hitting me (referring to resident) was an allegation of abuse. However, staff #35 said resident #39 had paranoia and she figured it was just one of those times. Staff #35 that at the time the resident made the allegation, she approached the resident and asked her if she was ok and the resident said yes. She stated after she got the resident up she went to nurses' station and told nurse (staff #55) about the report she received from resident #39. She stated she does not know whether or not the nurse had reported the allegation. An interview was conducted on January 18, 2023 at 1:26 p.m. with Licensed Practical Nurse (LPN/staff #55) who stated that no abuse allegation was reported to her on January 3, 2023. She stated if a resident stated a staff member was tossing and hitting a resident, that would be an allegation of abuse and she would have expected it to be reported. The LPN stated if it had been reported to her she would have contacted the nurse manager or nurse administrator immediately as the facility has two hours to file a report to the State Agency. Further, the LPN said they had to take every allegation seriously and act as if the allegation happened. During an interview with the Administrator/Director of Nursing (DON/staff #12) conducted on January 18, 2023 at 3:22 p.m., staff #12 stated she was the abuse coordinator; and that, if there was an allegation of staff abuse from a resident, it should be reported to the nurse on duty that day, preferably nurse assigned to resident. Staff #12 said staff was not expected to figure out if abuse happened, it was their job to report. She stated the nurse was expected to notify the Administrator or the nurse manager right away so they could do the required reporting. She stated it was important to report immediately to protect their residents from being harmed, and to make sure the resident was safe and secure. Regarding the incident with resident #39, she said the reporting CNA (staff #27) came to her office on January 4, 2023 at approximately 4:30 p.m. and told her the resident reported that the girl with the big red hair had hit the resident in the head. She stated an allegation from a resident that a staff member was tossing them around and hitting them was allegation of abuse; and, she expected that it would be reported immediately, she stated in reference to the statement from CNA (staff #35) the date of the alleged abuse was January 3, 2023; and, it should have been reported immediately and was not. However, she stated that staff did not follow facility protocol on abuse reporting. Review of the facility Policy on Abuse, Neglect and Exploitation revised on April 2022 revealed that it was their policy to maintain an environment where residents are free from abuse, neglect, exploitation and misappropriation of resident property and all residents, staff, families, visitors, volunteers and resident representatives are encouraged and supported in reporting any suspected acts of abuse, neglect, exploitation and misappropriation of resident property, or exploitation. It also included that the nursing home administrator or designee will report abuse to the State Agency per State and federal requirements. Further, it is their policy to ensure the reporting of crimes against resident or individual receiving care within prescribed timeframes to the appropriate entities; and that, the facility will report alleged violations related to mistreatment, exploitation, neglect or abuse, including injuries of unknown source and misappropriation of resident property and report the results of all investigation to the proper authorities within prescribed timeframes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation, staff interviews and review of facility policy, the facility failed to prevent further potential abuse by staff following an abuse allegation for one resident (#39). The deficient practice could lead to continued abuse of the resident or other residents. Findings include: Resident #39 admitted to the facility on [DATE] with diagnoses of cerebral infarction, hemiplegia and hemiparesis, and dysphagia. Review of the facility investigation revealed the incident occurred on January 3, 2023 at 4:00 p.m. The investigation included that on January 4, 2023, a certified nursing assistant (CNA/staff #27) reported that the resident told her that the big girl with the red hair had punched her in the head; and that, the date of the alleged abuse was January 3, 2023. Continued review of the investigation included that on interview with the resident the facility during a resident interview, the resident described the alleged perpetrator and identified a CNA (staff #19). The investigation also included a statement from the CNA (staff #27) that on January 4, 2023 resident #39 reported multiple times throughout the day at the nursing station that the big girl with the red hair punched her in the head. The statement also included that when the resident reported that the incident happened yesterday; and that, later that day the resident repeated the same statement. Further review of the facility investigation revealed that staff #35 was called to the room to assist with resident #39 on January 3, 2023 at approximately 4:30 p.m. she was asked by CNA (staff #19) for help in assisting resident #39. Staff #35 wrote in her statement that resident #39 told her to get her (referring to staff #19) away from me, she's (referring to staff #19) tossing me around and hitting me. There was no evidence found in the clinical record and facility documentation that resident #39 was protected from further abuse from the alleged CNA (staff #19). Review of the employee time card for the alleged CNA (staff #19) revealed that staff #19 worked on January 3, 2023 from 5:58 a.m. through 6:11 p.m. A review of facility documentation revealed that the alleged CNA (staff #19) was suspended only on January 4, 2023. The HR (human resources)/progressive discipline form dated January 4, 2023 revealed that on January 4, 2023, there was an allegation of abuse from a resident against CNA (staff #19) who was informed that she would be removed from schedule during the investigation and findings. In an interview with another CNA (staff #35) conducted on January 18, 2023 at 1:07 p.m., staff #35 stated she received training on types of abuse and reporting abuse; and that, she supposed to report abuse right away to her nurse/supervisor, nurse manager and administrator. The CNA stated in her written statement, the resident #39 described that the alleged CNA (#19) was tossing me (referring to resident) around and hitting me (referring to resident) was an allegation of abuse. However, staff #35 said resident #39 had paranoia and she figured it was just one of those times. Staff #35 that at the time the resident made the allegation, she approached the resident and asked her if she was ok and the resident said yes. She stated after she got the resident up she went to nurses' station and told nurse (staff #55) about the report she received from resident #39. She stated the alleged CNA (staff #19) continued to work with resident #39 and the rest of her assigned residents for the remainder of the shift. She further stated it was important to remove the alleged perpetrator/staff from patient care to prevent potential abuse to residents; and that, staff #19 should have not continued to give care based on facility protocol. An interview was conducted on January 18, 2023 at 1:26 p.m. with Licensed Practical Nurse (LPN/staff #55) who stated that no abuse allegation was reported to her on January 3, 2023. She stated if a resident stated a staff member was tossing and hitting a resident, that would be an allegation of abuse and she would have expected it to be reported. The LPN stated if it had been reported to her she would have contacted the nurse manager or nurse administrator immediately as the facility has two hours to file a report to the State Agency. Further, the LPN said they had to take every allegation seriously and act as if the allegation happened. She stated the alleged CNA (staff #19) would not have continued to work with resident #39; and, she would not have allowed the alleged CNA (staff #19) to give further resident care until direction was received from administration. The LPN said it was important to keep an alleged perpetrator from working to keep them from hurting other residents and to keep residents safe. During an interview with the Administrator/Director of Nursing (DON/staff #12) conducted on January 18, 2023 at 3:22 p.m., staff #12 stated she was the abuse coordinator; and that, in a case of an allegation of staff to resident abuse, the alleged perpetrator would be immediately removed from the floor and sent home. She stated the alleged perpetrator would not be able to return until the completion of investigation determined substantiation. Staff #12 said that it was important to report the allegation of abuse immediately to protect their residents from being harmed, and to make sure the resident was safe and secure. Regarding the incident with resident #39, she stated there was an allegation from a resident that a staff member was tossing around and hitting the resident. Staff #12 also said that the nurse working the shift at the time the alleged event was not interviewed and should have been interviewed. She stated in reference to the statement from CNA (staff #35) the date of the alleged abuse was January 3, 2023; and, there was a risk for further resident abuse since the alleged CNA (staff #19) continued to work with resident #39 and the rest of her assigned residents for the remainder of the shift. She stated the protocol was not followed to protect residents from further abuse. Review of the facility Policy on Abuse, Neglect and Exploitation revised on April 2022 revealed that it was their policy to maintain an environment where residents are free from abuse, neglect, exploitation and misappropriation of resident property. The facility will take actions in response to an alleged violation of abuse, neglect, exploitation or mistreatment to include preventing further abuse from occurring while the investigation is in progress. All staff will cooperate during the investigation to assure the resident is fully protected. During the investigation the alleged perpetrator will immediately be removed and resident protected. Employees accused of alleged abuse will be immediately removed from the resident's area and will remain removed pending the results of a thorough investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record, staff interview and facility policy and procedures, the facility failed to ensure that a PASARR (Preadmission Screening and Resident Review) Level 1 screening was completed as required for one resident (#25). The deficient practice could result in specialized services not provided to meet resident's needs. Findings include: Resident #25 was admitted on [DATE] with diagnosis of bipolar disorder. The admission MDS (Minimum Data Set) assessment dated [DATE] revealed the resident was not evaluated by level 2 PASARR and was not determined to have serious mental illness and/or mental retardation or a related condition. However, the assessment revealed the resident had an active diagnosis of manic depression/bipolar disease. Review of the clinical record revealed no evidence that a PASARR level 1 screening was completed for resident #25 until January 17, 2023. The PASARR Level 1 screening dated January 17, 2023 revealed the resident had serious mental illness and diagnosis of bipolar disorder. It also included that the resident was not on a 30-day convalescent care, not on respite admission and did not have terminal state or severe illness. Per the screening, there was no referral necessary for any level II. An interview was conducted with social services (staff #70) and the admissions coordinator (staff #13) conducted on January 17, 2023 at 3:17 p.m. The admission coordinator (staff #13) stated that he could not find a PASARR Level 1 screening for resident #25 in the clinical records. The social services (staff #70) stated that there was no PASARR Level 1 screening completed for resident #25 prior to January 17, 2023. Staff #70 stated they are required to complete a PASSAR Level 1 for a resident upon admission; and that, resident #25 recently transitioned long term care. Staff #70 said she reviewed the resident's records, did a status change and completed a PASARR level 1 screening for resident #25 only this morning. In an interview with the admissions coordinator (staff #13) conducted on January 19, 2023 at 10:05 a.m., staff #13 said he did not receive from previous facility the completed PASARR screening for resident #25. He stated he reached out to the previous facility yesterday and will do so again this morning. Staff #13 further stated that he normally does not miss a resident not having a PASARR level 1 screening on admission; however, this one has slipped by. During another interview with the social services (staff #70) conducted on January 19, 2023 at 10:44 a.m., staff #70 stated that PASARR Level 1 screening is an evaluation to determine the level of care the resident need; and, the type of facility appropriate for the resident. Staff #70 said not having PASSAR Level 1 may result in the resident with mental illness not receiving the level of care they need. Further, staff #70 stated that it was important to have the baseline for care purposes. A review of the facility policy, Resident Assessment-Coordination with PASSAR Program reviewed/revised on April 2021 revealed that all applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening; and, a record of the pre-screening shall be maintained in the resident's medical record.

Based on staff interviews and review of facility documentation and policy, the facility failed to use the services of a Registered Nurse (RN) for at least eight hours consecutive hours a day, seven days a week. The census was 57 and the sample was 15. The deficient practice could result in not enough staff to meet the resident's needs. Findings include: Review of facility punch detail for registered nurses revealed no evidence of RN coverage on February 13, 2022 The Facility Assessment revealed that nursing shifts are twelve hours with a goal of consistent assignments. On January 20, 2023 at 8:23 a.m., the Director of Nursing (DON/staff #12) stated that her expectation was to have an RN scheduled to work at least 8 hours per day, that included weekends. The DON stated that she and the Nurse Manager also cover; however, they do not have a punch detail of the time they are in the facility as they are salaried employees. In a later interview conducted with the DON/staff #12 on January 20, 2023 at 9:44 a.m., the DON stated that she reviewed the PBJ (Payroll Based Journal) staffing for February 13, 2022 and there was no evidence that an RN had been scheduled to work in the building on that day. She stated that this did not meet the facility policy or expectation; and, the risk could include no staff available to administer intravenous medications, and not having the higher critical thinking of an RN available. The facility policy on Abuse Prevention, revealed that the facility deploys trained, qualified and competent staff on each shift in sufficient numbers to meet the needs of the residents. Staff have knowledge of the individual resident's care needs, as identified by the Facility Assessment.

Based on staff interviews and review of facility documentation and policy, the facility failed to ensure he Daily Staff Postings for nursing staff were accurate for actual hours worked by licensed and unlicensed direct care nursing staff. The deficient practice could result in residents and visitors not being informed of accurate and current staffing information. Findings include: A review of five randomly chosen days of staff postings compared with the staff assignment sheets revealed that none of the staff postings matched the actual number of staffs that worked. Further review of the Daily Staff Postings revealed no evidence of the actual and total hours worked by licensed and unlicensed nursing staff on December 8, 9, 10, 11 and 12. The Daily Staff Postings from December 8 through 12, 2022 also revealed inaccurate staffing data posted on the following dates: -December 8 - there were 7 CNAs (Certified Nursing Assistants) who worked on the day shift, and 6 CNAs worked on the evening shift. However, a review of the punch detail revealed that 6 CNAs actually worked on the day shift, and five CNAs worked on the evening shift; -December 9 - there was one Registered Nurses (RN) and one Licensed Practical Nurse (LPN) who worked on the day shift. However, the punch detail for December 9, 2022 revealed that two RNs and 1 LPN worked on the day shift; -December 10 - there was one Registered Nurses (RN) and one Licensed Practical Nurse (LPN) worked on the day shift. Review of the punch detail revealed that there were two RNs and 1 LPN who worked on the day shift; -December 11 - there were 7 CNAs worked the day shift, and 6 CNAs worked the night shift. Review of the punch detail revealed that 8 CNA's actually worked on the day shift, and 5 CNAs actually worked on the night shift; and, -December 12 - there were 6 CNAs who worked on the evening shift, but the punch detail revealed there were only 5 CNAs who actually worked the evening shift. An interview was conducted on January 19, 2023 at 10:50 a.m. with the Staffing Coordinator (staff #71) who stated the Human Resources (HR) department tracks the nursing productivity; and the administrator was responsible for updating the staff posting form on a daily basis. The Staffing Coordinator stated the expectation was for staff postings to be accurate with the actual number of staffs that worked for the day. She further stated they currently do not document the total hours worked by licensed or unlicensed staff on the daily staff posting form. During the interview, the staffing coordinator reviewed the daily staff posting forms and compared them to the staff assignment forms from December 8 through December 12, 2022. The staffing coordinator stated the daily staffing forms were not accurate and this did not meet the facility expectation. During an interview with the Director of Nursing (DON/staff #12) conducted on January 19, 2023 at 1:08 p.m., the DON stated her expectation was that the daily staff posting accurately reflect the staff that worked each day. She also stated she expected the staff posting to be updated with any changes throughout the day. During the interview, the DON reviewed the daily staff postings for December 8 through December 12, 2022 and stated that they were not accurate. Further, the DON said that an inaccurate staff posting could result in residents/family not having accurate staffing information. The facility policy on Posting Direct Care Daily Staffing Numbers, revealed that the facility will post on a daily basis, the total number of hours worked by the nursing staff on each shift, who are responsible for providing direct care to residents. A daily posting of the number of hours for Nurses (RN, LPN) and the number of CNAs for each shift who are responsible for providing direct care will be posted in a prominent location, accessible to residents and visitors in a clear and readable format.

Based on observation, staff interview and review of facility policy, the facility failed to ensure food items were stored in accordance with professional standards for food service safety by failing to ensure temperatures for the refrigerators were consistently monitored, maintained and documented. The deficient practice could result in food served to residents not safe for consumption. Findings include: During an initial kitchen tour conducted on January 17, 2023 conducted with the executive chef (staff #91) revealed no recorded refrigerator temperature for the following dates and times: -January 06, 2023 for the p.m. shift; -January 08, 2023 for the a.m. shift; -January 09, 2023 for a.m. shift; -January 15, 2023 for a.m. shift; and, -January 16, 2023 for the a.m. shift. In an interview conducted immediately following the observation, the Executive Chef (staff # 91) stated that regular staff were not present and temporary staff was on shift on the days that temperatures were not recorded. Staff #91 stated that the expectations was that regardless of which staff are on shift, the refrigerator temperatures are recorded each morning and evening and should be recorded. A review of the facility policy on Production, Purchasing, Storage, and Cold Storage Temperatures revealed that at the beginning of each month a new log is to be started. It also included that each morning at opening and evening at closing, record temperatures of each storage unit; initial each entry; and to circle any deviant readings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure one resident (#18) or resident representative was informed in advance of the risks and benefits prior to administration of a psychotropic medication. The deficient practice could result in not having the right to choose the option the resident prefers. Findings include: Resident #18 admitted on [DATE] with diagnoses of dementia, depressive disorder, and Parkinson's disease. The care plan initiated on July 5, 2022 revealed the resident was receiving an antidepressant for depression and was at risk for adverse effects. A physician order dated September 23, 2022 included for Mirtazapine (antidepressant) for depression as evidenced by restlessness and low appetite. The MAR (medication administration record) from September 2022 through January 2023 revealed the resident received Mirtazapine as ordered. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated resident had severe cognitive impairment. The assessment also included the resident received daily antidepressant use in the assessment time period. However, further review of the clinical record revealed no evidence the resident/representative was informed of the risks and benefits of Mirtazapine prior to administering the medication. An interview was conducted on January 20, 2023 at 8:30 a.m. with the Administrator/Director of Nursing (DON/staff #12) who stated she was unable to find documentation that the risks/benefits of Mirtazapine was discussed and provided to resident #18 or resident representative. Staff #12 also said that the facility failed to obtain informed consent for use of Mirtazapine from the resident #18 or resident representative. In an interview conducted with a Licensed Practical Nurse (LPN/staff # 54) on January 20, 2023 at 9:43 a.m., the LPN stated when staff gets a new medication order for a psychotropic medication, a consent for its use is obtained from and explained to the resident or the resident's Power of Attorney (POA). She stated she would explain to the resident and/or POA what the psychotropic medication would be used for, the dose, the expected benefits, and adverse effects. She stated staff was not supposed to administer a psychotropic medication without obtaining the psychotropic consent. The LPN also stated it was important to make the resident or family aware of the risks because a psychotropic medication use had side effects and could snow people. Further, she stated staff did not follow policy if consent was not obtained prior to the use or administration of a psychotropic medication to the resident. The LPN also said that if there is no documentation found in the clinical record that a consent and risk/benefits for its use, there was no way to show that the consent was obtained. During a second interview with the Administrator/DON (staff #12) conducted on January 20, 2023 at 9:59 a.m., staff #12 stated the informed consent was the documentation for the risk and benefit for psychotropic medication use. She stated staff were expected to obtain the informed consent with the resident/responsible party; and that, the documentation or discussion of informed consent included providing the name and dose of the medication, possible contributing factors for use, diagnosis of why the resident was taking the medication, and adverse effects. Staff #12 also said the nurse and family member were supposed to sign the form and if obtained by phone staff would note it as verbal consent. She stated that if the resident or representative did not give informed consent, there should be a discussion with the resident or representative by the nursing, administrative team, and physician to alleviate concerns and answer questions; and that, if consent was still not obtained, the medication would not be given or will be discontinued. Regarding resident #18, she stated staff did not obtain informed consent for Mirtazapine prior to its administration to the resident. The facility policy on Psychotropic Medication revised on November 2021 revealed that based on each resident's comprehensive assessment, the facility will ensure to provide the resident/resident representative with information on the medication, indication, dose, side effects, adverse consequences and goal of treatment; and, obtain informed consent from the resident and/or resident representative and document education, information regarding the medication indication and directions for use, side effects and potential adverse consequences, risks and benefits of the medication and resident choice. The resident and/or responsible party will be notified regarding dose changes and this will be documented in the nurse notes. Consents and any psychotropic medications will be reviewed quarterly at resident care conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure care provided met professional standards of care by failing to follow physician orders regarding insulin for one resident (#14). The deficient practice could result in adverse outcomes and/or complications related to diabetes mellitus (DM). Findings include: Resident #14 admitted to the facility on [DATE] with diagnoses that included dysphagia, dementia, and type two diabetes mellitus (DM). The care plan dated January 17, 2019 revealed the resident had DM and was at risk for complications to this disease process, especially if blood sugars were not well controlled. The goal was that the resident's blood sugars would be controlled within normal limits. Intervention included insulin as ordered. The physician order dated March 31, 2021 revealed an order for Novolog Flex pen U-100 insulin Aspart 100 unit/milliliter (ml) subcutaneous 17 units plus sliding scale insulin (SSI) three times a day for DM type 2: -150-199 mg/dl (milligrams/deciliter), give 3 units; -200-249 mg/dl, give 6 units; -250-299 mg/dl give 9 units; -300-349 mg/dl give 12 units; -350-399 mg/dl give 15 units; -400-449 mg/dl give 18 units; -450-499 mg/dl give 21 units; and to notify physician if glucose was over 500 mg/dl. Review of the Medication Administration Record (MAR) for Novolog for November 2022 revealed that on the following dates for the 7:30 a.m. dose, Novolog insulin was not administered according to the physician's ordered parameter for insulin: -November 2 - blood sugar (BS) was 215 mg/dl and 6 units of insulin was administered. However, the resident should have received 23 units of insulin per the physician's order; -November 6 - BS was 211 mg/dl and 6 units of insulin was administered. However, the resident should have received 23 units of insulin per the physician's order; -November 13 - BS was 107 mg/dl and no insulin were administered; and that, medication was not administered with no noted reason. However, the resident should have received 17 units of insulin per the physician's order; and, -November 15 - BS was 216 mg/dl and 26 units of insulin was administered. However, the resident should have received 23 units of insulin per the physician's order. The MAR for December 2022 revealed that on the following dates for the 7:30 a.m. dose, Novolog insulin was not administered according to the physician's ordered parameter for insulin: -December 2 - BS was 221 mg/dl and 6 units of insulin was administered. However, the resident should have received 23 units of insulin per the physician's order. -December 4 - BS was 327 mg/dl and 32 units of insulin was administered. However, the resident should have received 29 units of insulin per the physician's order. -December 31 - BS was 228 mg/dl and 6 units of insulin was administered. However, the resident should have received 23 units of insulin per the physician's order. A review of the MAR for January 2023 revealed on the following dates for the 12:00 noon dose, Novolog insulin was not administered according to the physician's ordered parameter for insulin: -January 1 - BS was 109 mg/dl. Zero insulin was administered and the documentation included that the medication was not administered with no noted reason. However, the resident should have received 17 units of insulin per the physician's order; -January 6 - BS was 131 mg/dl and 20 units of insulin was administered. However, the resident should have received 17 units of insulin per the physician's order; -January 14 - BS was 162 mg/dl and 3 units of insulin was administered. However, the resident should have received 20 units of insulin per the physician's order; -January 18 - BS was 219 mg/dl and 13 units of insulin was administered. However, the resident should have received 23 units of insulin per the physician's order; and, -January 19 - BS was 266 mg/dl and 29 units of insulin was administered. However, the resident should have received 26 units of insulin per the physician's order. Review of the progress notes for November 2022 through January 2023 revealed no documentation why Novolog insulin was not administered according to the physician ordered parameters; and that, the physician was notified. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident's cognition was severely impaired. The assessment included a diagnosis of DM and daily insulin injections. An interview was conducted on January 20, 2023 at 9:04 a.m. with a Registered Nurse (RN/staff #81) who stated staff was expected to follow the physician orders as written, including insulin and sliding scales. He stated the risks for insulin not given as ordered included resident having hyperglycemia, insulin shock; altered mental status, and it could lead to ketoacidosis. The RN said that if the resident was given too much insulin they could become hypoglycemic, sweaty, clammy, drowsy, and could pass out. During the interview, a review of the clinical record was conducted with the RN who stated the insulin orders included that resident #14 was supposed to get 17 units of Novolog insulin plus additional sliding scale insulin whose was dependent on the resident's blood sugar. The RN said that if he thinks the blood sugar was low, he would give the resident food/drink, and hold the medication until he could call the doctor and get direction. The RN said that the January 2023 MAR in the three entries he reviewed, insulin was not administered according to the physician ordered parameter for the sliding scale. During an interview with the Administrator/Director of Nursing (DON/staff #12) conducted on January 20, 2023 at 9:52 a.m., staff #12 stated staff are expected to follow the physician's orders as written, including following the orders for insulin and SSI administration. Staff #12 said that if the resident refuse, staff was still expected to follow the physician's order until they had an updated order from physician. She stated the risk factor if the ordered amount of insulin was not given could be adverse health effects. During the interview, a review of the clinical record was conducted with staff #12 who stated that the January 2023 MAR revealed that staff had not administered the insulin as ordered by the physician. The facility policy on Timely Administration of Insulin reviewed/revised on April 2021 revealed that it was their policy to provide timely administration of insulin in order to meet the needs of each resident and to prevent adverse effects on a resident's condition. All insulin will be administered in accordance with physician's orders. Review the insulin order to include resident name, medication name, medication dosage, time to be administered, route of administration. Review of a facility policy on Medication Management policy revised on June 2021 revealed that medications will be administered to residents as prescribed and by persons lawfully authorized to do so in a manner consistent with good infection control and standards of practice. Prior to administration, the medication and dosage schedule on the Medication Administration Record (MAR) is compared with the medication label. Medications are administered in accordance with written orders of the attending physician or physician extender. A review of the facility policy on Physician's Orders updated on April 2021 included that to ensure accuracy, physician orders will be written, noted and carried out as ordered.

**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 one of two sampled residents (#17) was provided appropriate care and treatment related to bowel care. The deficient practice could result in the residents having discomfort and difficulty having a bowel movement. Findings include: Resident #17 was admitted on [DATE] with diagnoses that included End Stage Renal Disease, Heart Failure, and Constipation. Review of the clinical record revealed physician orders dated 11/18/21 for Amitiza 8 mcg (microgram) capsule once daily for constipation and to monitor the CNA (Certified Nursing Assistant) daily Bowel Movement (BM) report twice daily. Review of the care plan regarding choices dated November 21, 2021 included to respect the resident's rights to refuse medications. Review of the care plan regarding constipation dated November 21, 2021 included to encourage the resident to drink fluids, ambulate, eat high fiber diet, and take stool softeners as ordered. The admission Minimum Data Set assessment dated [DATE] revealed a score of 9 on the Brief Interview for Mental Status which indicated the resident had moderate impaired cognition. The assessment included the resident did not have constipation, was frequently incontinent of bowel, and required extensive assistance of one person for toilet use. Review of the Medication Administration Record dated January 2022 revealed the resident refused Amitiza on the following days: 1/02/22 1/03/22 1/04/22 1/05/22 1/10/22 A review of the documentation for BM revealed the resident did not have a BM on the following days/night shift: 1/4/22 1/5/22 1/6/22 1/7/22 1/9/22 1/10/22 1/11/22 1/12/21 No BM on day shift and small BM on night shift. Continued review of the clinical record, including nursing notes for January 2022, revealed no evidence the resident's lack of BM from January 4 - 7; 9-11, 2022 was addressed. An interview was conducted on January 12, 2022 at 08:30 AM with a CNA (staff #57), who stated they document residents' bowel movements on a scale of 0 to 4, 0 equals no BM. Staff #57 also stated that they monitor residents' fluid intake/meal percentage consumed. The CNA stated that if a resident does not have a BM for 3 days, the nurses receives a flag in the Electronic Medical record (EMR) and will follow up with treatment. On January 12, 2022 at 09:47 AM, an interview was conducted with an agency Registered Nurse (RN/staff #95). The RN stated that if a resident has constipation, the nurse caring for the resident receives notification from the daily task in the EMR. Staff #95 stated that she was aware that resident #17 had refused the medication for constipation the week prior. The RN stated the nurse should initiate the Bowel Care standing orders for a resident experiencing constipation. The RN also stated that if the standing orders were not effective, the nurse would notify the physician and mention the issue in the care team meeting. During another interview conducted with staff #95 on January 12, 2022 at 11:14 AM, staff #95 reviewed the clinical record and stated resident #17 had 2 episodes of constipation in January. The RN stated there are no nursing entries regarding constipation or treatment. Staff #95 said the process is to document this in the notes and start the Bowel Care standing orders. The RN stated that she did received a flag in the EMR today that the resident has not had a BM in 4 days. She stated that she will initiate the Bowel Care standing orders. The facility's Bowel Care Protocol policy revised 11/2020 revealed the purpose is to ensure regular bowel elimination. Nurses are to observe, ask resident, chart on MAR, follow the medical provider order for bowel care, i.e. standing orders and individual orders. Nurses are to communicate via bowel care sheet between shift. The policy stated nurses are to notify the medical provider of constipation if there is a lack of BM after 9 shifts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure a splint was applied according to the physician's order for one sampled resident (#21). The deficient practice could result in splints not being applied as ordered for residents. Findings include: Resident #21 was admitted to the facility on [DATE] with diagnoses that included Chronic Atrial Fibrillation and Right-hand contracture. Review of the care plan initiated on January 2, 2019 revealed a category for Activities of Daily Living (ADL)/Rehab Potential. The goal included the resident would have all ADLs completed daily with staff assistance. Interventions included ensuring the resident was wearing bilateral hand splints during the day to reduce contractures, off at bed time. A physician order dated May 1, 2020 revealed an order to ensure the resident was wearing a right-hand splint during the day to reduce contracture. On in am, off in pm-twice daily. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's cognitive skills for daily decision making was severely impaired. The MDS assessment included the resident required extensive assistance of one person for dressing, personal hygiene, bed mobility, and transfer; and had functional limitation in range of motion impairment of the upper extremities on one side. The assessment also included the resident received passive range of motion for 3 days but did not receive splint or brace assistance from restorative nursing during the lookback period. Review of the Treatment Administration Record (TAR) for December 2021 and January 1-12, 2022 revealed documentation that the right-hand splint was applied and removed as ordered. During observations conducted on January 10, 2022 at 2:50 pm and January 12, 2022 at 9:53 am, the resident was observed with no right-hand splint on. An interview was conducted on January 12 2022 at 1:32 pm with a Certified Nursing Assistant/Restorative Nursing Assistant (CNA/RNA/staff #20), who stated that she works with resident #21 for the RNA program. Staff #20 stated that she understood that am on and pm off to imply that the splint is to be worn in the morning up to noon, when the time changes from am to pm. Staff #20 stated the resident has been refusing to wear the right-hand splint and she has informed the nurse who would document the refusal on the TAR. An interview was conducted on January 12, 2022 at 1:45 pm with a Registered Nurse (RN/staff #95), who stated that an order that has am on pm off implies that the splint would be worn from 8 am - 8 pm. The RN stated the splint would be on during day shift and taken off on the evening shift. She stated that she would document if a resident refused to wear the splint including in a nursing note. The RN reviewed the TAR and stated the splint should be on. An interview was conducted on January 12, 2022 at 2:17 pm with the Director of Nursing /Administrator (staff #92), who stated that an order with am on pm off implies that a splint would be on from 6 am - 6 pm or worn until bedtime and then would be removed. Staff #92 reviewed the TAR and stated the green highlight means staff signed off with their initials that the resident was wearing the splint and if the resident refused to wear the splint, it would be indicated in red for refusal. Staff #92 stated that the splint should be on or it should be documented the resident refused to wear it on the TAR. The facility policy titled Restorative Nursing Program updated July 2019, revealed it is the policy of the facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. A resident's restorative nursing plan will include: the type of activities to be performed, frequency of activities and duration of activities.

Based on observation and staff interview, the facility failed to ensure expired foods were not available for resident use. The deficient practice could result in an increased risk for foodborne illness for residents. Findings include: The initial kitchen observation was conducted on 1/10/22 at 10:55 am with the Director of Dining Services (staff #96). Four boxes of Matzo ball soup were observed with a best by date of 9/14/19 and three boxes were observed with a best by date of 9/1/19. Continued observation revealed one bag of diced onions with an expiration date of 1/6/22 and five 32 ounce (oz) flavored yogurt containers with an expiration date of 12/21 in the refrigerator. An interview was conducted with the Director of Dining Services (staff #96) on 1/12/22 at 11:14 am. He said that food beyond its best buy or use by date should be discarded. Staff #96 also said that the kitchen manager should check for expired foods weekly on Sundays.