**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documents, staff interviews, and policies and procedures, the facility failed to ensure that one resident (#395) was free from neglect, by failing to ensure the resident was administered care and services to meet his needs. The deficient practice could result in residents not being provided the necessary services. Findings include: Resident #395 was admitted to the facility on [DATE] with diagnosis that included osteomyelitis, sepsis, methicillin resistant staphylococcus aureus infection, pressure ulcer of sacral region stage 4, quadriplegia, extended spectrum beta lactamase resistance, urinary tract infection, protein calorie malnutrition, and major depressive disorder. A care plan initiated on [DATE] revealed that the resident had bowel incontinence related to inability to control bowels. Interventions indicated included check resident every two hours and assist with toileting as needed. A laboratory result dated [DATE] indicated that Coranavirus was not detected. Review of a care plan initiate on [DATE] revealed that the resident is at risk for nutritional problems. The goal stated that resident will consume more that 75% of meals. Interventions included indicated to assist with meals as needed and monitor/document intakes. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating that the resident was cognitively intact. Additionally, the MDS indicated that the resident was negative for psychosis, behavioral symptoms, wandering and rejection of care. Additionally, the admission MDS assessment dated [DATE] revealed that the resident required extensive 2-person physical assistance for toilet use. The MDS also documented that the resident required extensive 1-person assist for bed mobility, dressing, and personal hygiene. The assessment indicated that for range of motion, the resident has lower extremity impairment on both sides and uses a wheelchair as a mobility device. Further review of the admission MDS assessment dated [DATE] documented that the resident did not have a prognosis that would lead to less than 6-months of life expectancy. A care plan initiated on [DATE] revealed that the resident was Coronavirus positive. Interventions indicated included administer oxygen per orders, obtain/monitor labs are ordered, and report results to provider and follow-up as needed. The Vitals Summary for Blood Pressure (BP) revealed that the last one taken was on [DATE] at 4:59 p.m. with the reading documented as 93/59. Additionally, the Vitals Summary for Pulse registered the following out of range readings on the following dates: - [DATE] (7:14 a.m.): 53 beats per minute (bpm) - [DATE] (4:01 p.m.): 54 bpm - [DATE] (1:59 p.m.): 52 bpm - [DATE] (1:59 p.m.): 50 bpm - [DATE] (10:06 p.m.): 55 bpm - [DATE] (7:30 a.m.): 109 bpm - [DATE] (3:54 p.m.): 57 bpm - [DATE] (4:59 p.m.): 56 bpm - [DATE] (2:41 a.m.): 54 bpm Further review of the Vitals Summary for Pulse revealed that the last reading documented was on [DATE] at 7:32 a.m. which indicated a pulse rate of 66 bpm. Review of the order summary revealed a physician order dated [DATE] which prescribed oxygen at 1-3 liters per minute as needed to keep saturation above 90%. The order indicated oxygen therapy every shift. However, review of the [DATE] MAR (Medication Administration Record) revealed that during the following dates/shifts the log was left blank/not documented regarding oxygen therapy: - [DATE]: 10 p.m.-6 a.m. - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 2 p.m. - 10 p.m. - [DATE]: 10 p.m. - 6 a.m. - [DATE]: 6 a.m. - 2 p.m. Additionally, review of the O2 (oxygen) summary revealed the following readings on the following dates: - [DATE] at 3:56 p.m. - 87% (oxygen via nasal cannula) - [DATE] at 3:42 p.m. - 75 % (oxygen via nasal cannula) - [DATE] at 12:59 a.m. - 88 % (oxygen via nasal cannula) Review of the [DATE] CNA (Certified Nursing Assistant) task log for Assist and encourage to turn and reposition revealed that the log was left blank/not documented on the following dates/shift: - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 10 p.m. - 6 a.m. - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 10 p.m. - 6 a.m. - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 10 p.m. - 6 a.m.; 6 a.m. - 2 p.m.; 2 p.m. - 10 p.m. The [DATE] CNA task log for Bowel and Bladder Continence revealed that the log was left blank/not documented on the following dates/shift: - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 10 p.m. - 6 a.m. - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 10 p.m. - 6 a.m.; 6 a.m. - 2 p.m. - [DATE]: 2 p.m. - 10 p.m.; 6 a.m. - 2 p.m. Review of the [DATE] CNA task log for Toilet Use revealed that the log was left blank/not documented on the following dates/shift: - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 10 p.m. - 6 a.m. - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 10 p.m. - 6 a.m.; 2 p.m. - 10 p.m.; 6 a.m. - 2 p.m. The [DATE] CNA task log for Transferring revealed that the log was left blank/undocumented for the following dates/shift: - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 10 p.m. - 6 a.m. - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 10 p.m. - 6 a.m. - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 10 p.m. - 6 a.m.; 2 p.m. - 10 p.m.; 6 a.m. - 2 p.m. Review of the [DATE] CNA task log for Eating revealed that the log was left blank/undocumented for the following dates/times: - [DATE]: 8 a.m. and 12 p.m. - [DATE]: 8 a.m. and 12 p.m. - [DATE]: 8 a.m. and 12 p.m. - [DATE]: 8 a.m. and 12 p.m. - [DATE]: 8 a.m.; 12 p.m.; 5 p.m. Review of the resident's electronic health record revealed a physician's order dated [DATE] directed for Stat (Statim meaning immediately) chest x-ray related to hypoxia. However, further review of the resident's electronic health record did not reveal any documentation regarding the result of the chest x-ray or that the provider received and reviewed the requested chest x-ray. A nurse practitioner note dated [DATE] timestamped 11: 59 a.m. indicated a late entry note which documented that the resident was Coronavirus positive. The note stated that resident later in the evening had hypoxia and later found unresponsive. The note further documented that EMS (emergency medical services) was called and resident was unable to be resuscitated and proclaimed as deceased . However, multiple eMAR (electronic Medication Administration Record) notes dated/timestamped after the NP note from [DATE] indicated that resident was receiving medications and refused medications. An eMAR note dated [DATE] timestamped 7:17 a.m. documented that the resident had expired. A health status note date [DATE] timestamped 7:55 a.m. documented that at approximately 5:00 a.m., the resident was found in bed unresponsive. The note stated that upon assessment the resident had no pulse and that cardiopulmonary resuscitation was initiated while 911 was called. The note indicated that paramedics assessed the resident and called time of death at 5:13 a.m. A subsequent health status note dated [DATE] timestamped 9:24 a.m. documented that the resident's remains was picked up by the cremation company. Review of the Human Remains Release Form dated [DATE] confirmed that the resident's date and time of death as [DATE] at 5: 13 a.m. A request for a copy of resident #395's health record was submitted on [DATE] at 3:52 p.m., which included a request for labs and diagnostics. An email from the facility dated [DATE] timestamped 8:05 a.m. regarding the record request for resident #395 stated that the facility do not have lab/diagnostics, assessments for continence, assessments for change of condition, facility investigation and POA (power of attorney). An interview with a Certified Nursing Assistant (CNA/staff #115) was conducted on [DATE] at 3:12 p.m. Staff #115 stated that ADLs (activity of daily living) were documented on the resident's electronic health record. According to the CNA there are different options used to code based on assistance given, resident refusal or not applicable. There are also spots for how many briefs were changed. Staff #115 stated that everything is coded. According to the CNA, if an item is left blank it either was not provided or the staff did not chart them. Staff #115 stated that there could be a small possibility that care was not provided. The CNA indicated that the expectation is that care provided is documented. Staff #115 said that during the Coronavirus (COVID) outbreak, the facility did not have any problem providing ADL care. The staff helped each other out and residents were rounded on every 2-3 hours. The CNA noted that ADL care provided to the residents included brushing teeth, brushing hair, dressing, assisting with transfers, brief changes, shower as scheduled. Staff #115 stated that residents were repositioned every 2 hours. During COVID, there could have been a little longer wait time. However, they tried their best to mitigate and have really good response time in the units. The CNA indicated that if there were patches of items undocumented, then they cannot verify if care was provided. Staff #115 stated that it is not appropriate if care is not provided. The CNA said that the impact on the resident is for example, sores can get worst, resident can have more skin breakdown, and it will look like neglect. Staff #115 noted that the importance of providing the care, treatment, and services to residents is to ensure that the residents' needs are met. The CNA further stated that during COVID, it was more essential to get residents' needs met since people were scared. Resident #395's CNA task logs were reviewed with staff #115 on [DATE] at approximately 3:12 p.m. Staff #115 (CNA) verified that some tasks to include eating and turn reposition had patches of missing data. The CNA commented that for meals and any tasks it should be coded if resident refused. When it is left blank, it looks like the tasks were not done. A Registered Nurse (RN/staff #38) was interviewed on [DATE] at 3:44 p.m. Staff #38 stated that the CNAs are expected to take vitals, keep an eye on resident, answer call lights promptly, and provide care to residents. Additionally, The RN noted that they expect that residents are provided hydration. Furthermore, staff #38 noted that they expect that documentation is done. The RN expressed that documentation has always been a problem as some staff do not understand the concept of documentation. Staff #38 reiterated that documentation is important. For nursing/CNA if not documented then it did not happen. The RN said that care should be provided and documented. If not documented then it can look like the task was not done. For example, for turning and repositioning if it is not documented as being done and the resident ends up with a bed sore then it looks like the staff did not do what they were supposed to do. Staff #38 indicated that during COVID there was a shutdown and residents' psychosocial was impacted and therefore it was important for staff to be there for the residents. The residents who did not have family needed the staff the most. If needs were not met it would greatly impact the residents. The RN noted that it is not appropriate to have a lack of documentation since it is hard to justify that care was given. Staff #38 noted that there is a potential that care was not given. This is not good for the resident and especially not good outcome for the resident. Care is important since the resident is dependent on staff and attention is needed since during COVID it was just the residents and the staff. Resident #395's CNA task logs were reviewed with staff #38 (RN) on [DATE] at approximately 3:44 p.m. Staff #38 confirmed that some tasks were left blank/not charted. According to the RN, items not charted could either mean it was not done or not documented. Normally, if the resident is not there, then the item will be coded with a X. Staff #38 noted that it is not acceptable that there are blanks. The expectation is that chart as N/A or coded appropriately. For the meals for example, the blanks could be not charted or not given but should have been coded. An interview with the Director of Nursing (DON/staff #8) was conducted on [DATE] at 4:05 p.m. Staff #8 stated that during COVID the expectation was not lowered. They separated people in isolation and still had same nursing staff with sufficiency. The standard was actually higher and there was more staff depending on the volume of residents. The DON said that the expectation for documentation is that staff document. Staff #8 said that they have to reflect via documentation that care was provided. There was a lot of paperwork. The DON noted that if documentation is missing in an evidence- based practice, it did not occur. However, staff #8 said that it is debatable if deserved care did not occur. The DON indicated that impact on the resident depends. Staff #8 stated that it would reflect on the resident's progress. In the case of turn and reposition, it will impact the resident adversely if care is not delivered. Resident #395's CNA task logs were reviewed with staff #8 (DON) on [DATE] at approximately 4:05 p.m. The DON confirmed that there are blank areas on the log. Staff #8 said that they do not know why there are blanks. The DON noted that X should be coded if resident was not in the facility. For the turn and reposition, it is not appropriate that there is lapse in documentation. Staff #8 stated that this log is important for pressure ulcer since this can provide answer to what is going on. The bowel and bladder lack of documentation is also inappropriate. For the eating portion, the lack of documentation is also inappropriate as they cannot confirm that the resident ate. The DON stated that based on documentation there is a possibility that the resident was not getting the care. Staff #8 reiterated that it is not appropriate to not reflect what was done for the resident. The DON noted that there is a possibility that resident will deteriorate and impact the health. Staff #8 agreed that based on documentation there could have been neglect. Review of the facility policy titled Abuse Prevention Program revised [DATE] indicated that residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The facility policy titled Resident Rights revised [DATE] stated that resident have the right to be free from abuse, neglect, misappropriation of property, and exploitation. Review of the facility policy titled Charting and Documentation revised [DATE] stated that all services provided to the resident, progress toward the care plan goals, or any changes in the resident's physical, functional or psychological condition shall be documented in the resident's medical record. The policy noted that the medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The policy directed that documentation in the medical record will be objective, complete, and accurate. Furthermore, the policy directed that the following information is to be documented in the resident's medical record: - objective observations - medications administered - treatments or services performed - changes in the resident's condition - events, incidents or accidents involving the resident

**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 one of 21 sampled residents (#82) had a referral for a Level II PASRR (pre-admission screening and resident review).The deficient practice could result in the resident not receiving specialized services needed. Findings include: Resident #82 was admitted to the facility on [DATE] with diagnoses that included acute kidney failure, anxiety disorder, post- traumatic stress disorder, and depression. Review of the clinical record revealed a Level I pre-admission screening and resident review (PASSR) dated November 27, 2024. Upon review of the document, the box indicating that a referral for Level II determination for mental illness (MI) only was selected. There was also boxes that were selected indicating that the resident had major depression, anxiety disorder, and post-traumatic stress disorder (PTSD). The form was signed and dated. Additional review of the clinical record revealed no evidence that a referral for a Level II PASRR was completed by the facility. Review of the care plan initiated November 27, 2024, revealed the resident used antidepressant medication related to depression and interventions included to administer antidepressant medications ordered by physician, monitor and document side effects and effectiveness. A minimum data set (MDS) assessment dated [DATE] included a brief interview for mental status (BIMS) summary score of 15, indicating intact cognition. Further review of the care plan initiated December 3, 2024 revealed the resident used antianxiety medications related to anxiety disorder with interventions that included administration of antianxiety medications ordered by physician, monitor and document side effects and effectiveness. An interview was conducted with the social services director (staff #31) on January 23, 2025 at 11:38 AM, who stated that the social services director and the Assistant Director of Nursing (ADON/ staff #38) were responsible for making the referral to the appropriate authority when needed. During the interview, staff #31 reviewed resident's #82's Level I PASRR and confirmed that a referral for a Level II PASRR was indicated on the form. After reviewing the clinical record during the interview, staff #31 stated that she did not see a Level II PASRR referral completed by the facility. She further stated that the risk of not completing a referral for a Level II PASRR could result in the not receiving the appropriate services for his level of care. She also stated that it did not meet facility expectations to not complete a Level II PASSR. An interview was conducted with the Director of Nursing (DON/ staff #8) on January 23, 2025 at 2:07 PM, who stated that social services was responsible for making the referral to the appropriate authority when needed. During the interview the DON reviewed resident's #82's Level I PASRR and confirmed that the form indicated the resident be referred for a Level II PASRR. The DON also stated that it did not look like a referral was completed but he was not sure. The DON further stated that it did not meet facility expectations that the resident was not referred for a Level II PASRR. Review of the facility policy, Pre-admission Screening and Resident Review (PASRR) version 0920, revealed that if the resident is positive for potential MI or intellectual disability (ID), a Level II PASRR referral must be submitted. The policy also indicated that it is the responsibility of the facility to make referrals for a Level II PASRR if it is determined to be necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on documentation, staff interviews, and the facility policy and process, the facility failed to ensure that care was provided according to professional standards and that the resident's basic needs are being met for one resident (#42). The deficient practice could result in residents not being provided the care needed to maintain or improve health. Resident #42 was admitted to the facility on [DATE], with diagnoses that included spinal stenosis, cystitis, major depressive disorder, and multiple myeloma not having achieved remission. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) assessment score of 15, indicating intact cognition. Section I revealed the resident had an active diagnosis of diabetes mellitus. A physician order dated June 18, 2021, indicated for Humalog Solution 100 unit/ml (Insulin Lispro), to inject as per sliding scale, subcutaneously before meals and at bedtime for diabetes mellitus: If blood sugar 200-250 = 2; 251-300 = 4; 301-350 = 6; 351-400 = 8; 401-450 = 10; 451-500 = 12, and for 12 units to call the medical doctor Review of the Medication Administration Record (MAR) for December 2024 and January 2025, revealed the resident had the following blood sugar (BS) readings and was administered Humalog Solution (Insulin Lispro): -December 1, at 20:00: BS = 483, 12 units administered -December 4, at 20:00: BS = 477, 12 units administered -December 15, at 17:00: BS = 500, 12 units administered -December 22, at 17:00: BS = 500, 12 units administered -January 5, at 20:00: BS= 451, 12 units administered An interview was conducted with a Registered Nurse / Unit Manager (RN / Staff #114) on January 23, 2025, at 12:33 PM. The RN stated that if a physician's order indicted to call the physician for a high blood sugar reading, that the expectation would be for the nurse to call the physician in order to get any updated orders, which could be to give the resident an extra dose of insulin or to send the resident to the hospital. The nurse stated that a nurse would then document the outcome of the phone call with the physician in the progress notes. The nurse stated that the importance of notifying the physician if a resident's blood sugar was high would be to make the physician aware of the resident's condition. An interview was conducted with an RN and Assistant Director of Nursing (ADON / Staff #38) on January 23, 2025, at 12:49 PM. The ADON stated that if a resident's blood sugar was high, and the physician's order indicated to call the physician, that the facility's staff have to follow the doctor's order. The ADON stated that the purpose of the order to call the physician with a high blood sugar reading may depend on several factors: the physician may want to give an extra dose of insulin, or the high blood sugar may be a sign of infection, or the nurse could communicate to the provider if the blood sugar was related to an event such as the resident having a big meal. The ADON stated that the nurses document the phone call to the physician and the outcome of the phone call either in a progress note, or on the eMAR, which then auto-populates to the progress notes. The ADON stated that either way, the nurses' documentation would be in the progress notes. At this time, Resident #42's clinical record was reviewed together. The ADON stated that there's no notes in regard to documentation of communication to a physician or the outcome of communication on the dates when the resident's blood sugar was greater than 450. The ADON stated that this would not meet the facility's expectation, and that there will be education happening on this, and that the facility would want the nurses to show that they called the physician and the outcome of the phone call. An interview was conducted on January 24, 2025, at 10:10 AM, with the Director of Nursing (DON / Staff #8), who stated that the importance of communicating with the physician if a resident has high blood sugar is to prevent complications: acidosis and diabetic coma, risk of infection, and decreased wound healing. The DON stated that it is the facility's expectation that nurses follow physician orders and call the provider when indicated. Review of the facility policy titled Charting and Documentation, revised July 2017, revealed all services provided to the resident or any changes in the resident's medical or physical condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation will include care-specific details including notification of physician, if indicted. Review of the facility policy titled Medications: Administering Medications, effective January 1, 2024, revealed medications are administered in a safe and timely manner, and as prescribed.

Based on personnel file review, staff interviews, and facility documentation and policy review, the facility failed to ensure the activities program was directed by a qualified professional. This deficient practice could have resulted in the activities provided not meeting the assessed needs of the residents. Findings Include: A review of the personnel file for the role of activity manager (AD/Staff #111) was conducted on May 21, 2024. However, the review did not reveal evidence that staff #111 possessed the qualifications required for the role of activities director. An interview was conducted on January 23, 2025, at 9:38 A.M. with staff #111, Activities Director. Staff #111 stated that she had been working at the facility as an Activities Director for several years. She stated that as an activities manager, she visited the residents, providing them with menus that included the activities of the day as well as the food menu. She also stated that she oversaw the smoke break. An interview was conducted on January 23, 2025, at 9:43 A.M. with staff #41, Human Resources. She was asked to retrieve staff #111's record to determine if they had an activities certificate. She stated that she did not see the certification/license. The staff later provided a document which mentioned that Staff #111's certificate was not present. An interview was conducted on January 23, 2025, at 2:35 P.M. with staff #6, Administrator. Staff #6 stated that his expectation of all staff members was to be licensed and to complete the required training and education. He stated that this should be the same for the activities director as well. He further stated that #111's license was lapsed, but not for very long. He stated that there was no risk to the residents as #111 had been working at the facility for 10 years. He stated that he could not find the old copy of the certificate as the facility underwent construction in 2018. A review of the facility policy entitled Hiring and Rehiring Employees, dated January 1, 2024, revealed that the company policy was to hire qualified applicants. The policy further stated that in order to qualify for a position, the facility considered eligibility, qualifications, skills, attitude, dependability, cooperation, and other legitimate business considerations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on documentation, staff interviews, and the facility policy and process, the facility failed to ensure that care was provided according to professional standards and that the resident's basic needs are being met for one resident (#10). The deficient practice could result in residents not being provided the care needed to maintain or improve health. Findings include: Resident #10 was admitted to the facility on [DATE] with diagnoses that included acute chronic heart failure, pleural effusion, urinary tract infection, cellulitis of left lower limb, severe sepsis without septic shock, hypoxemia, and hypokalemia. The order summary revealed an order dated: -[DATE] for oxygen as needed (PRN) at 0-5 liters per a minute to keep oxygen saturation above 90% every 8 hours as needed for oxygen therapy. -[DATE] for oxygen at 0-5 liters per minute as needed to keep saturation above 90% every shift for oxygen therapy. -[DATE] vital signs per facility protocol -[DATE] for full code CPR Review of the care plan dated [DATE] did not reveal a plan for oxygen therapy. Review of the clinical record for vitals revealed documentation for: -oxygen saturation 77% on [DATE] at 7:45 a.m. -temperature 94 degrees on [DATE] at 7:45 a.m. -respiration 18 breaths a minute on [DATE] at 7:45 a.m. -blood pressure 128/71 on [DATE] at 9:44 p.m. -pulse 82 bpm on [DATE] at 9:44 p.m. Review of the treatment administration record dated [DATE] revealed oxygen as needed (PRN) at 0-5 liters per minute to keep saturation above 90% every 8 hours as needed for oxygen therapy dated [DATE] was not administered. A physician's note dated [DATE] revealed that the patient is currently awake and resting, not in distress, and no chest pain or palpitation. Vital signs with afebrile: pulse 100, respirate 18, blood pressure 132/60. Lungs clear to Osco bilaterally with decreased air entry at the bases. Review of the progress notes did notes did not reveal any documentation of vitals, including oxygen saturation being assessed, or oxygen therapy being administered by staff. A progress note dated [DATE] revealed that the resident was found unresponsive at 5:30 a.m. Cardiopulmonary resuscitation (CPR) was initiated followed by a 911 emergency call. The emergency medical team (EMT) arrived at the facility at 5:38 a.m. The resident was pronounced dead at 5:55 a.m. by the EMT after all efforts to resuscitate the resident failed. The family on record was notified at 6:00 a.m. The medical doctor was notified at 6:05 a.m. and the facility Director of Nursing was equally notified. Review of the Public Requests Form for the City of Phoenix Fire Departement (FD) revealed the date of service, 911 response, was [DATE]. The 911 call was received at 5:38 a.m., and the FD was on scene at 5:44 a.m. Staff initially waited 15 minutes while doing CPR to call 911. Upon arrival, the resident was found supine in bed, while staff was standing behind the resident's head, performing inaccurate CPR (compressions). Staff was bagging the resident with the bag-valve- mask (BVM) inaccurately, with no oropharyngeal airway (OPA) in the resident. The FD took the resident's blood sugar level (BS) and it was LO (hypoglycemic) and administered dextrose 50% via intraosseous (IO). The BS level was rechecked after two minutes and the glucometer reading was 21.The facility staff was asked why he waited 15 minutes to call 911 and did not answer. Once the FD took over, the staff left the resident's room without giving a full report and did not return. An interview was conducted on [DATE] at 11:44 a.m. with a certified nursing assistant (CPR/staff #16), who stated that she knows how to check vitals, which includes blood pressure, pulse, temperature, and oxygen saturation, but she doesn't check vitals because the overnight shift doesn't check vitals. She stated that the CNAs check vitals once during the day shift and once during the evening shift, and the evening shift would give her a status report during shift change if there was a concern regarding a resident's vitals. She stated that if there was a concern, she would check the resident's vitals during the night. She stated that vitals are documented on a piece of paper and given to the nurse and the CNA also documents the results in the electronic record. She stated that she checks the residents every two hours throughout the night and on [DATE], she began her shift at 10:30 p.m. and completed her rounds. She checked the residents again at: 12:30 a.m., 2:30 a.m., and 4:30 a.m. She stated that she found the resident unresponsive at 4:30 a.m. She stated that the resident was not breathing and did not have a pulse, and while she was checking the resident's vitals, she radioed to (LPN/staff #2) that she needed a nurse stat and then stood by the side of the bed and began compressions. She stated that she did not count the compressions and did not provide breaths as she did not have a mouth piece. She stated that (LPN/staff #2) was in the hallway with (LPN/staff #11) immediately after she had called on the radio and staff #2 had called 911. (LPN/staff #11) came into the room and checked the resident's vitals, while she continued with compressions. Then, (LPN/staff #11) took over the compressions, while she stood at the upper right hand corner of the bed to provide breaths via the (BVM). She stated that she was not able to get behind the resident because the resident was short, and then, she stated that she was not able to get behind the resident because the bed was against the wall. She stated that the bed is on wheels and she didn't know if (LPN/staff #11) had tried to move the bed away from the wall, but stated that when she was trained to do CPR, she was trained to position herself behind the resident when using the BVM and to place the mask around the mouth creating a seal to make sure the air doesn't get out. She stated that (LPN/staff #11) did 5 or 6 compressions and told her to press the BVM bag one time. She stated that staff #11 instructed her to press the bag one or two times after every 5 to 6 compressions and when she pushed the bag, the resident's cheeks were puffing up and out, so she knew the air was going into the resident. This continued until the EMTs arrived and she could not remember what time they arrived. (LPN/staff #2) came into the room when the EMTs arrived and the EMTs asked how long the resident had been like this and she told them that she came into the room at 4:30 a.m. She stated that one of the EMTs asked (LPN/staff #2) why it took him so long to call 911 and he didn't answer. Then, (CNA/staff #16) stated that she doesn't know what time (LPN/staff #2) called 911. She stated that the EMTs were angry because no one would open the front door when they arrived. She stated that there was a male staff from the kitchen sitting by the front door and he took his time answering. She thinks the male staff may be a little slow. She stated that she was the only CNA in the resident's room during the entire incident. An interview was conducted on [DATE] at 2:25 p.m. with the Assistant Director of Nursing (ADON/staff #29), who stated that (LPN/staff #2) was responsible for completing the transfer form for the resident and would have called 911 from the nurse's station, but should have returned to the resident's room when he was done. She doesn't know why he didn't return to the resident's room to help. An interview was conducted on [DATE] at 8:41 a.m. with the dietary aide (staff #41). The Director of Nursing (DON/staff #50) was present. Staff #41 stated that he works from 6:00 a.m. to 2:30 p.m., but comes to work early because he doesn't have a car and has to get a ride to work. He stated that he gets dropped off at work about 4:30 a.m. and enters the building through the side door to the right of the main entrance. He stated that he usually goes to the employee lounge to eat breakfast and when it is 5:45 a.m. he walks up to the reception desk and waits until about 5:55 a.m. to clock in for work. On the day of the incident, he stated that he was waiting to clock in and there were two men with a stretcher at the door. He let them in because a stretcher usually means that someone needs help. An interview was conducted on [DATE] at 9:55 a.m. with a licensed practical nurse (LPN/staff #11), who stated that he was at his medication cart between rooms #147 and #150, when (LPN/staff #2) came over to tell him that there was an emergency in room [ROOM NUMBER]. He stated that he was not sure of the time. Staff #11 stated that he was not using a radio because the battery was dead. (LPN/staff #11) went with (LPN/staff #2) to room [ROOM NUMBER] where (CNA/staff #16) was performing compressions on the resident. He stated that there was a board under the resident and the crash cart was present. (LPN/staff #11) stated that he assessed the resident and instructed the (CNA/staff #16) to take the resident's vitals, while he was preparing the BVM bag. Then, he did the compressions and (CNA/staff #16) pumped the BVM bag. Staff #11 stated that he counted and completed 21 compressions to 2 breaths, and then decreased the compression to breath ratio to 15 compressions to 2 breaths because there was white foamy saliva coming out of the resident's mouth. He stated that (CNA/staff #16) tilted the resident's head and swept the mouth and he suctioned the mouth area. Then, (CNA/staff #7) entered the room and she took over the compressions because he had to help (CNA/staff #16) to tilt the resident's head correctly to use the BVM. He stated that normally staff should be positioned behind the head of the resident and (CNA/staff #16) was at the side of the resident. He pushed the bed away from the wall, so he could get behind resident's head and took over the BVM and CPR continued at a ratio of 1 compression to 2 breaths. He stated that (LPN/staff #2) came back and provided the last compression before the EMTs arrived. During a second interview conducted on [DATE] at 10:34 a.m. with the (ADON/staff #29), she stated that staff come running when they know that there is a code blue and they know there is a code blue because they hear the message on the radio. An interview was conducted on [DATE] at 10:45 a.m. with (CNA/staff #7), who stated that there are radios available to communicate with staff, but she doesn't use one because it is noisy and bothers the residents. She saw the certified medication assistant (CMA/staff #35), who told her that a resident was not waking up. She stated that (LPN/staff #2) was at the nurse's station and told her that a resident was not waking up. She stated that she the other nurse (LPN/staff #11) was doing compressions and she stepped in to help because he was so tired. She couldn't remember how many compressions she did because it all happened so fast. While she provided compressions, another CNA was standing next to the resident providing breaths via the BVM. She then stated that she thinks she did about 30 compressions and couldn't remember how breaths were done between compressions. She stated that she was trained to stand next to the resident, place the BVM over the resident's face and squeeze the bag. She stated that there were no other steps prior to placing the BVM on the resident's face and squeezing the bag. An interview was conducted on [DATE]:44 a.m. with the licensed practical nurse (LPN/staff #2), who stated that he was administering medications near rooms #136 and #137 when (CNA/staff #16) came out into the hallway to get him. Staff #16 was completing her last rounds and told him to come and check the resident now. He stated that he assessed the resident who was unresponsive. He did not detect a pulse and the chest was not rising. He went back to the cart to get his radio which was lying on the top of the cart and called for help. He stated that all staff are required to carry a radio. He stated that (LPN/staff #11) was near and all three went to the resident's room. He stated that the other nurse started compressions and the CNA did the BVM. An interview conducted on [DATE] at 2:54 p.m. with a certified medication assistant (CMA/staff #35), who stated that she was passing medications around 5:00 a.m. when staff told her that there was a code blue with one of the residents. She stated that she did not hear a code blue over the radio because her radio was charging. She stated that she went to the resident's room and the nurse asked her to start doing CPR; she and the nurse took turns providing compressions and rescue breathing via the BVM. She stated that rescue breathing was performed by standing at the side of the bed, tilting the resident's head, placing the BVM on the resident's face, but doesn't remember if the resident's cheeks were filling with air. She stated that during the emergency, she did not see any certified nursing assistants (CNAs) in the resident's room. She stated that the other nurse, a licensed practical nurse (LPN/staff #2) was at the nurse's station printing paperwork and when she went to the nurse's station, (LPN/staff #2) told her to take the paperwork and wait by the reception area for the EMTs. She went to reception area at the front of the building and there was male staff sitting there. When the EMTs arrived, at approximately 5:30 to 5:40 a.m., she let them in the building. An interview was conducted on [DATE] at 2:13 p.m. with the (DON/staff #50), who stated that all nurses and CNAs have to be CPR certified. The staff have access to radios, but are not required to use them. He stated that if a resident is unresponsive, the staff must notify at least one other staff by radio or by yelling out in the hall to call 911 and to help with CPR. The CNA can check the vitals and go get help if needed, but the nurse must be there to assess the resident and to see if CPR is required. One nurse should stay there to provide CPR and to supervise the CNA, who should be providing ventilation via the BVM bag. It is expectation that CPR is provided at a ratio of 100 compressions to 2 breaths and should be done immediately after the resident is assessed and unresponsive. He stated that a second nurse should be calling 911 and completing the transfer paperwork. He also stated that when ventilation is provided via BVM, the mask should be placed over the mouth and nose, and the staff should tilt the head. There should be no symptoms, such as the cheeks blowing up. If the cheeks do not fill up, there is no obstruction and the air should go directly to the lungs. He stated that it usually takes the EMTs about 15 minutes, sometimes 20 minutes to arrive. The facility policy, Emergency/First Aid: Emergency Procedure - Cardiopulmonary Resuscitation states that if an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or there are obvious signs of irreversible death (e.g., rigor mortis). The facility ' s procedure for administering CPR shall incorporate the steps covered in the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or facility BLS training material. After 30 chest compressions provide 2 breaths via ambu bag or manually (with CPR shield).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on documentation, staff interviews and the facility policy and procedures, the facility failed to report an allegation of abuse to the state survey agency and failed to complete and submit a 5-day written investigation timely. The deficient practice could result in residents not being protected and being abused. Findings include: Resident #17 was admitted to the facility on [DATE] with diagnoses that included hypertension, schizophrenia, multiple sclerosis, and anxiety. The care plan dated April 21, 2022 revealed that the resident had an impaired cognitive function. Interventions included to keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion and requires approaches that maximize involvement in daily decision making and activity limit choices, use cueing, task segmentation, written lists, and instructions. Resident #8 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis, unspecified dementia with mood disturbance, anxiety, and major depressive disorder. The care plan dated September 1, 2023 revealed that the resident had a impaired cognitive function/dementia or impaired thought processes related to neurological symptoms. Interventions included to keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion and use task segmentation to support short-term memory deficits. Present just one thought, idea, question or direction at a time. Review of facility documentation dated July 26, 2024 revealed that at 1:20 p.m. it was reported to the Assistant Director of Nursing (ADON/staff #151) that resident #17 told a certified medication technician (CMA/staff #27) that she was touched in the crotch area by another resident. The (ADON/staff #151) interviewed resident #17 and the resident stated that a man with glasses, a dark mustache, and a pot belly touched her in the crotch and in the hole. Resident #17 went down the hall with the ADON, and the case manager (staff #83) and identified resident #8 as the alleged perpetrator. The online report regarding the above allegation of sexual abuse was submitted to the state agency August 16, 2024 at 12:39 p.m. During an interview conducted on August 16, 2024 at approximately 11:20 am with the Administrator in Training (AIT/staff #150), he stated that about a month ago, resident #17 made an allegation about resident #8 touching her privates. Resident #17 stated that resident #8 touched her crotch area and scratched her when they were sitting in the dining room. He also stated that it was not possible for resident #8 to touch her crotch because she is a larger woman and the area could not be reached while she was sitting down. He stated that the facility did not report the allegation of sexual abuse to the state agency and no one completed a 5-day written investigation. He stated that the facility conducted there own investigation and called the regional nurse about the matter. The consensus was that resident #17 was in one of her delusional phases and it did not happen. He stated that resident #17 also said that resident #8 tried to poison her 5 years ago by putting poop in her mouth. Staff #150 stated that he didn't know what the regulations says about reporting an allegation of sexual abuse and the [NAME] President of Clinical Operations and former Administrator, made the decision to not report the allegation to the state agency. An interview was conducted August 20, 2024 at 2:24 p.m. with the Director of Nursing (DON/staff #35), who stated that allegations of sexual abuse must be reported to the state survey agency within two hours of the facility becoming aware of the allegation. The facility policy, Abuse Policy states that If abuse is witnessed or suspected, reporting and investigation will take place in this manner: -Executive Director (ED) will be notified. -ED and witness who is reporting will notify the following entities: -Adult Protective Services -Ombudsman -State Survey Agency -Law enforcement when applicable -Facility Director of Nursing (DON)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and the facility policy and procedures, the facility failed to ensure residents (#26, #25, and #3) were provided with the appropriate level of supervision. The deficient practice could result in the personal space of residents not being respected. Findings include: Resident #26 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, chronic obstructive pulmonary disease, and hypertensive chronic kidney disease. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 14 indicating the resident was cognitively intact. The care plan dated July 23, 2024 revealed an impaired cognitive function/dementia or impaired thought process related to sexual advances towards staff. Interventions included to monitor/document/report to the medical doctor any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. A nurse practioner note dated August 7, 2024 revealed that the resident has dementia issues and some history of being aggression with peers. The resident has been stable for months. Per a progress note dated July 16, 2024 at 7:04 p.m. Note Text: Writer went in to give residents medication. Resident held writer hand and writer ask if he needed anything. Resident made sexual advances to writer stating come closer and give me a kiss. Writer told resident that was not appropriate and walked out of room. Review of a progress note dated August 9, 2024 revealed that at 11:30 a.m. the resident alleged that a female resident struck him on the chest in the hallway, where staff immediately separated them and took them to safe areas. The resident stated that the female resident was blocking the pathway in front of him, when he alarmed her to move, she turned back and hit him on the chest. Upon assessment, the resident sustained no injuries, and bruises and or skin tears were not noted. The Administrator, medical doctor, social worker, and family member were informed immediately. Review of the 5-day written investigation dated August 15, 2024 revealed that the hallway was congested due to a medication cart located on one side of the hallway and an empty wheelchair on the other side of the hallway. Resident #26 was in his wheelchair behind resident #5 and was trying to get around resident #5. The Maintenance Director (staff #60) moved the empty wheelchair, so resident #26 could pass and when he passed by resident #5, she reached out and made contact with the back of resident #26's chest. Staff #60 moved resident #26 down the hallway. Resident #26 was assessed by the Director of Nursing (DON) and no injuries were noted. Review of the progress notes did not reveal documentation regarding the incident that occurred on August 19, 2024 where resident #26 touched resident #3 on the side/stomach area while seated next to each other in the dining room. -Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included radiculopathy in the lumbar region, unspecified mood affective disorder, irritability and anger, low back pain, and chronic post-traumatic stress disorder. Review of the care plan dated June 12, 2023 revealed that the resident is on an opiate medication related to chronic pain syndrome. Interventions included to review for pain medication efficacy. The (MDS) dated [DATE] included a brief interview for mental status score of 13 indicating the resident was cognitively intact. The care plan dated August 9, 2024 revealed that the resident has a behavioral problem related to physical behaviors. At times the resident may have behaviors, reaching out to residents/getting residents attention in congested areas as I may become inpatient. Intervention included to anticipate the resident's needs and to identify behavior triggers. A progress note dated August 9, 2024 revealed that resident #5 struck another patient in the chest. Both patients were separated from the situation immediately to a safe environment. Upon assessment, the resident sustained no injuries. The medical doctor, Administrator and family were notified. The care plan was updated. An interview was conducted on August 16, 2024 at approximately 10:15 a.m. with the Maintenance Director (staff #60), who stated that there was an empty wheelchair on one side of the hall and a medication cart on the other. Resident #26 was in his wheelchair behind resident #5, who was also in her wheelchair. Resident #5 looked behind her and told resident #26 to move it. Staff #60 moved the empty wheelchair and resident #26 went around resident #5. Resident #5 tried to fight with resident #26 and the backside of her left hand touched resident #26's midsection of his body, but her movement was weak because she has pain in her arm. Staff #60 reported the incident to the Administrator. An interview was conducted on August 16, 2024 at 10:30 a.m. with resident #26, who stated that he asked resident #5 if he could get by with his wheelchair and she told him to wait. He stated that he said, What do you mean wait. When he went by her, she swung at him and hit his chest with the back of her hand. He stated that it hurt and it scared him because he has a pacemaker. He stated that resident #5 doesn't like him and that about a year ago, resident #5 tried to run into the back of his wheelchair. He stated that he asked resident #5 why she is doing this to him, bullying him, but she didn't answer. An interview was conducted on August 16, 2024 at 10:36 a.m. with Resident #5, who stated that resident #26 hit her wheelchair from behind two times and now her neck hurts. She stated that she asked resident #26, what was his problem and she swung to hit him, but hit the wheelchair. She stated that resident #26 is a big baby and she wants him to stay away from her. She stated that he is always following her around, stares at her, and tries to look under her dress. Resident #5 was not able to give any details as to how, when, or where the resident tried to look under her dress and stated that she feels safe at the facility. An interview was conducted on August 16, 2024 at approximately 11:00 a.m. with a certified medication assistant (CMA/staff #27), who stated that resident #5 likes to mumble that she hates people and wants to hit them. She has a history of saying that she hates resident #26, but has never told her why she hates him. Staff #27 stated that she has reported that resident #5 hates resident #26 to a registered nurse/unit manager (RN/staff #120) and (RN/staff #53) over a year ago, before resident #5 was transferred to her current room. She stated that resident #26 does have a history of putting his hands on staff, hugs and gives a little squeeze afterwards, and one nurse said that he tried to kiss her. During an interview with the Administrator in Training (AIT/staff #150) conducted on August 16, 2024 at approximately 11:20 a.m., he stated that resident #26 told him that he was coming out of his room and told resident #5 to stop, so he could get out of his room, but she kept going. When he caught up with her, she reached out with the back of her hand and made contact with his chest. He stated that resident #5 stated that resident #26 bumped into the back of her wheelchair a little bit, and (staff #60) moved the extra wheelchair in the hallway out of the way to make more room, so resident #26 could pass by. She stated that she reached out to resident #26 to tell him not to bump her wheelchair anymore. Staff #150 stated that if resident #5 was saying that she hated resident #26, it probably should have been reported to the Administrator and he would have made sure that staff kept an eye on the residents and verbal abuse can't be tolerated. An interview was conducted on August 16, 2024 at approximately 12:00 p.m. with the Director of therapy, who stated that resident #5 doesn't have the physical ability to extend her arms fully outwards and would not be able to hold her hands up if the slightest bit of pressure was applied. He stated that the resident didn't have the physical strength to hurt resident #26. -Resident #3 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, major depression, and anxiety. The Minimum Data Set, dated [DATE] included a brief interview for mental status score of 8 indicating the resident has a moderate cognitive impairment. Review of the progress notes did not reveal documentation regarding the incident that occurred on August 19, 2024 where resident #26 touched resident #3 on the side/stomach area while seated next to each other in the dining room. Review of the facility internal investigation dated August 16, 2024 revealed that on August 19, 2024 at 5:55 p.m. resident #26 approached resident #3 in the dining room and began tickling her. Resident #3 was heard saying, no and a certified nursing assistant (CNA) rushed to separate the two residents. Resident #3 was assessed and no injuries were observed. Resident #26 was educated about inappropriate behavior. During an interview with the Administrator in Training (AIT/staff #150) conducted on August 16, 2024 at approximately 11:20 a.m., he stated that resident #26 has a history of being touchy with the staff. An interview was conducted on August 20, 2024 at approximately 11:00 a.m. with resident #3, the Business Office Manager (staff #91). Resident #3 stated that she was in the kitchen/dining room area and resident #26 was sitting next to her. Resident #26 grabbed her on her right side with one hand and she said, stop it, stop it, stop it and resident #26 continued doing it. Resident #3 stated that a nurse came into the dining room and told resident #26 to leave her alone, but resident #26 said, no, she is mine and then he went away. She stated that she thinks that resident #26 was trying to hold on to her, he was tickling her. Resident #3 stated that she felt safe, but sobbed during the interview. Staff #91 stated that during a meeting a meeting with the DON and the Administrator, resident #26 was identified as the male resident who had touched resident #3. An interview was conducted on August 20, 2024 at 12:50 p.m. with the Staffing Manager/Resident Relations Assistant (staff #32), who stated that (CNA/staff #110) was present when resident #26 touched resident #3. An interview was conducted on August 20, 2024 at 1:03 p.m. with (CNA/staff #110), who stated that she was in the dining room assisting a resident with eating. She stated that resident #26 and resident #3 were sitting at the same table. CNA #110 asked resident #26 if he wanted a tray and he said, no, she doesn't want me. CNA #110 stated that she turned back to the resident she was assisting when she heard resident #3 say, no and saw resident #26 pull his hand out from resident #3's side/stomach area. CNA #110 stated that she asked resident #3 if she had a problem and the resident said, no. She stated that later she and the medication technician asked resident #3 what resident #26 had done to her and the resident demonstrated on the medication technician's side how resident #26 had tickled her. An interview was conducted on August 20, 2024 at 1: 41 p.m. with a licensed practical nurse (LPN/staff #106), who stated that resident #3 told the (CNA/staff #110) that resident #26 kept tickling her on the stomach and she kept telling him/shouted at him, no and he kept laughing. Staff #110 assessed resident #3 and did not observe any injuries, but resident #3 told staff #110 that she did not like resident #26 putting his hands on her. Staff #106 stated that she interviewed resident #26 and he said that it did not happen, and she educated him about keeping his hands to himself. Staff #106 stated that resident #26 should not be touching resident #3 and reported the incident to the Administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure resident do not sustain preventable accidents including falls resulting in major injury. Failure to ensure this resulted increased morbidity and mortality. Findings include: Resident #157 was admitted with diagnoses of dementia, need for assistance with personal care, and cognitive communication deficit. A Quarterly Minimum Data Set (MDS) dated [DATE] included that a Brief Interview for Mental Status (BIMS) score of 5 which indicates that the resident was severely cognitively impaired. This document included that this person required 2+ person extensive physical assistance with transfers. A care plan dated 6/14/22 included that the resident has an Activities of Daily Living (ADL) self care performance deficit related to diagnoses of COPD, Dementia and weakness. This document included that the resident required staff participation in transfers. A health status note dated 2/27/23 included that patient slid out of bed while a Certified Nursing Assistant (CNA) was changing her brief and that there was no injury. However, a health status note dated 2/28/23 included that the patient verbalized pain to bilateral lower extremities and hip and that the provider ordered an X-ray. Review of the clinical record did not find that this resident was in a bariatric bed or that a second person was assisting with the resident's care. Hospital records dated 2/28/23 included that Emergency Medical Services (EMS) reported that the resident was being cleaned and they basically dropped her. This document included that the resident had an acute displaced and impacted intertrochanteric fracture of the right femoral neck. An attempt was made 9/7/23 at 11:47 a.m. to contact CNA #102, however the phone number provided was not able to receive calls at that time. An interview was conducted on 9/7/23 at 12:10 p.m. with a Licensed Practical Nurse (LPN/staff #100) who said that she remembered this patient slid out of bed while the CNA was changing her. An interview was conducted on 9/7/2023 at 1:20 p.m. with a CNA (staff #2) who said that when a patient is big, she gets another person to assist her when performing care for a resident in bed such as a bed bath or personal hygiene. She said that she gets another person so she can watch to prevent falls. An interview was conducted on 9/8/23 at 9:30 a.m. with the Administrator (staff #88) who said that staff involved in this fall were LPN /staff #100 and CNA/#102. He said that they had no way to contact the CNA (staff #102) because her phone is turned off. An interview was conducted on 9/9/2023 at 10:09 a.m. with a CNA (staff# 48) who said residents who are larger are changed with two people. She said that when they turn they are sometimes larger than bed and that she would not want the resident to fall. She said that she always takes all safety precautions. This staff said that she remembered this incident and said that the problem is with the CNA in that incident is that she did not ask for help. She said that the CNA's always get help with large residents. An interview conducted on 9/8/23 at 11:32 a.m. with the Director of Nursing (DON/staff #20) who said that safety comes first and that it is very important to consider. He said that staff must have a good reading about the patients' size and some you can assist alone, some you cannot. He said that staff should use the proper bed, and that they are investigating tall beds. He said that that resident he would need a bariatric bed for bed mobility. He said staff are required to make the determine if a second person is required because they have the background and schooling and should be able to implement it. He said that this resident had an abrupt decline and that sometimes she would assist the staff but she declined. He said that the CNA did not get a second person. He said that the next day, I changed the bed for her, I changed her care plan, but that when she left us she did not come back. A policy titled Activities of Daily Living (ADLs), Supporting, revised 3/2018, revealed that a resident's ability to perform ADLs will be measured using clinical tools, including the MDS and that functional decline or improvement will be evaluated in reference to the Assessment Reference Date (ARD). A policy titled Abuse, dated 2022, included that abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being.

Based on observations, staff interviews, facility recipes, and policy review, the facility failed to ensure the nutritive value of puree food. The deficient practice could result in residents receiving food with altered nutritive value. Findings include: During an observation conducted on September 6, 2023 at 11:42 AM in the kitchen, the cook (staff #15) was observed preparing puree food for two residents. Staff (#15) placed several large spoons of chicken and broccoli into a blender, added hot chicken broth, and blended the mixture. Staff (#15) proceeded to place the broccoli and chicken mixture into a steam pan to serve without tasting. Staff (#15) stated the chicken broccoli mixture was ready to serve. Staff (#15) was asked how did he know that the texture was at the right consistency and texture for a pureed diet. Staff (#15) stated he had been doing this work for a long time and could tell by its appearance. A request was made to taste the chicken broccoli mixture and was also tasted by Food Service Director (staff #38). the chicken broccoli mixture was noted to be gritty, with a very thick consistency. Staff (#38) asked that staff (#15) add more broth to the puree mixture and blend it further. This time the puree had a fairly smooth texture. Staff (#15) then poured the pureed chicken broccoli mixture back into the into a steam table pan. Staff (#15) proceeded to add three large spoonful's of rice to the blender for two pureed servings. This was done without first washing the blender container used from the pureed chicken broccoli mixture. After finishing with the puree rice, staff #38 was informed of the error. Staff #38 stated the risks associated with not washing the container before proceeding to puree another food item, is the potential for cross contamination and mixing of foods for someone who may have food allergies. Staff #15 was asked to toss the rice, wash the blender container and restart the process. The rice was pureed to the right consistency and texture. Food Service Director (staff #38) then took over and proceeded to puree eggrolls for two residents. Staff #38 added four eggrolls to the blender container and added unmeasured amounts of chicken stock. The eggroll mixture when tasted, found the mixture tasted overwhelmingly of chicken base and was salty. Staff #38 continued to add unmeasured amounts of water and chicken stock to the eggroll mixture, changing the flavor profile and having the mixture become a liquid consistency. Staff #38 proceeded to add a thickener, to thicken the watery mixture. The eggroll mixture once thickened, was tasted. The eggroll mixture had a salty taste and the eggroll flavor was faint. Staff #38 stated although the puree was still salty and had a strong flavor of chicken base, the flavor of eggrolls could be noted. The mixture was added to the steam table pan for serving to the residents. An interview was conducted on September 8, 2023 09:10 AM with the Food Service Manager (staff #38), who stated that when making puree food, it is best practice to not water everything down with water. Staff (#38) stated he had become frustrated with the Nutrition Alliance consultant whom he felt had made the observation process difficult, for both he and his staff. Staff (#38) stated he was not using this as an excuse for the errors made, but had asked that the consultant be removed from his kitchen. Staff (#38) stated the recipes are listed in the cookbooks, and it is his expectation that cooks follow the cookbook or ask for help if they are stuck. He stated stock for the next day's meals are pulled the night before and checked the morning of to ensure that all is ready for preparation of meals. He stated if staff do not know the recipe, the staff should have a cookbook in front of them which they can open up and check for the recipe. He stated the cook and himself are supposed to test the puree food or another staff member should taste the puree food to ensure good flavor and consistency. Staff #38 stated using exact portions is also important to ensure nutritive value. Staff #38 indicated that staff # 15 was nervous and most likely felt overwhelmed by the process. A review of the facility policy titled, Preventing Foodborne Illness-Food Handling, revealed that Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. 3. All employees who handle. Prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in those practices prior to working with food or serving food to residents. 9. All food service equipment and utensils will be sanitized according to current guidelines and manufactures recommendations

Based on observations, staff interviews, and the facility policy and procedures, the facility failed to ensure that food brought by visitors and family was properly stored. The deficient practice could result in a loss of freshness, freezer burn, taste, and loss of nutritive value. Findings include: During the initial tour of the kitchen conducted on September 5, 2023 at 8:26 AM, with the Food Service Manager (#38), the following observations were made in the large walk-in refrigerator and freezer. -a package of Delimex beef carne de res taquitos open exposed to air belonging to resident (#68). Per staff (#38) residents food should not be kept unopened in the facility freezer. -an open 48 fl oz container of salted caramel ice cream belonging to resident (#68). Per staff (#38) residents' food should not be kept unopened in the facility freezer. - a open 48 fl oz container of Blue-Ribbon Chocolate and Vanilla ice cream belonging to resident (#65). Per staff (#38) residents' food should not be kept unopened in the facility freezer. An interview was conducted on September 8, 2023 09:10 AM with the Food Service Manager (#38), who stated all food brought in by family for the residents should be labeled with the resident's name, room number dated when brought in. Staff #38 stated foods brought for the residents should not be stored in the kitchen refrigerators or freezers and are to be kept on in the refrigerators on their units. Per staff #38 nursing staff are responsible for discarding any outdated foods for the residents. Staff #38 stated the risks associated with the storage of residents food items in the commercial freezers and refrigerators are possible cross contamination of improperly cooked foods, improper hygiene from families and unsafe cooling of the residents food. A review of the facility policy titled, Foods Brought by Family/Visitors states food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and homelike environment with the nutritional and safety needs of residents.

Based on observations, staff interviews, and review of policies and procedures, the facility failed to ensure that infection control standards were maintained regarding hand hygiene and donning gloves by an LPN (Licensed Practical Nurse/staff #74) during medication administration. The deficient practice could result in the spread of infection to residents. Findings include: An observation during medication administration conducted on September 7, 2023 from 9:20 a.m. to 9:45 a.m. with an LPN (staff #74), the following was observed: -Staff #74 was observed administering medications which were handled with their bare hands. The LPN was observed popping pills out of the blister pack into her bare ungloved hand. Each resident was observed being administered the medication after it had been handled by staff #74. This occurred three times during the observation. -Staff #74 provided medications to multiple residents without sanitizing their hands between residents, after touching the residents and various objects in the resident's rooms, such as tray tables and bedding. During an interview conducted on September 8, 2023 at 10:57 a.m. with the LPN (staff #74), The LPN stated that they did not realize they were grabbing medications with their bare hands. Staff #74 further stated they should have used gloves or not touched the pills with their bare hands. During an interview conducted on September 8, 2023 at 11:05 a.m. with the DON (Director of Nursing/staff #20) Stated that it was wrong to handle the medications with an ungloved hand and that it was an infection control issue. They further stated that they have great respect for the infection control process and that their expectation is that they follow current infection control practices. A facility policy and procedure titled Medication Administrations included staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation procedures, etc.) for the administration of medications, as applicable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure food was properly stored, prepared, handled and served according to professional standards. Based on observations, staff interviews, and the facility policy and procedures, the facility failed to ensure that food was properly stored. The deficient practice could result in a loss of freshness, freezer burn, taste, and loss of nutritive value. Findings include: During the initial tour of the kitchen conducted on September 5, 2023 at 8:26 AM, with the Food Service Manager (#38), the following observations were made in the large walk-in refrigerator and freezer and the dry storage: -Two boiled eggs in a container with in by date of September 5, with no use by date or year. -a package of bacon bits with a date of August 25, 2023 and no use by date. -10 ham slices in dated September 4 with no use by date or year. -a four-pound bus tub of kale opened and exposed to air with ice chips on top of the kale. Per staff (#38) this was done to keep the kale fresh, but should have been stored in its original packaging or wrapped in plastic. -a package of Delimex beef carne de res taquitos open exposed to air belonging to resident (#68). Per staff (#38) residents food should not be kept unopened in the facility freezer. -an open 48 fl oz container of salted caramel ice cream belonging to resident (#68). Per staff (#38) residents' food should not be kept unopened in the facility freezer. - a 48 fl oz container of Blue-Ribbon Chocolate and Vanilla ice cream belonging to resident (#65). Per staff (#38) residents' food should not be kept unopened in the facility freezer. -one 160 oz open package of [NAME] elbow macaroni with no open date and improperly sealed with contents spilled out into a gray tub. No open or use by date - one package of ziti macaroni open with contents spilled out of packaging into a gray tub. No open or use by date. -two 25 lb Imperial instant food thickener with no open or use by date on either of the boxes- Per staff #38 staff are to label with an opened and use by date. -one 9 lb bag of Instant Puree bread mix with an open date of July 5, 2022. Spillage of contents inside the box from opened plastic with dust particles. Staff #38 stated that the purpose of covering/sealing food is to maintain freshness, prevent contamination from other food particles, prevent freezer burn, and maintain the quality of the food. An interview was conducted on September 8, 2023 09:10 AM with the Food Service Manager (#38), who stated that he tries to ensure that his staff labels and dates all foods in the freezer, refrigerator and dry storage. The staff are also responsible in ensuring no damage of food that has come in from the food service distributors, discarding any open, not dated and over dated food products. Staff #38 stated he tries to prevent any leftover food and if there is, it is distributed to the staff. If the staff do not want it, he has directed his staff to discard it. Staff #38 stated the risks associated with improper storage is risk for contamination of open, unsealed food or the risk of attracting insects or rodents. Staff #38 stated an in-service was conducted with his staff regarding labeling, dating and proper storage. The facility's policy titled, preventing Foodborne Illness-Food Handling states that food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #36 was admitted to the facility on [DATE] with diagnoses of alcohol dependence with alcohol induced persistent dementia, type 2 diabetes mellitus, pancytopenia, psychotic disorder with delusions due to known physiological condition. A care plan initiated on July 27, 2016 indicated that the resident had impaired cognitive function related to diagnoses of alcohol induced persistent dementia. Interventions included the need for supervision with all decision making. A care plan initiated on July 27, 2016 indicated that the resident had a history of resisting and refusing care, episodes of anger and compulsive behavior, and history of refusing medications. Interventions included a recommendation to allow the resident to make decisions about treatment regime, to provide a sense of control. Review of the PASRR Level I Screening Tool dated March 4, 2020 revealed the form was not adequately filled out. Section B. Mental Illness pertaining to the question does the individual have any of the following serious mental illnesses was left unanswered. The question of whether the individual has any of the following mental disorders was also left unanswered. The symptoms portion under the area interpersonal with the question has the individual exhibited interpersonal symptoms or behaviors was answered yes. However, the categories below it were not identified. Additionally, the concentration/task related symptoms portion was left answered. The portion pertaining to history of psychiatric treatment was also left unanswered. The question of whether the individual had a recent psychiatric/behavioral evaluation was answered yes, however, it was missing the date of the evaluation. Section D Referral Determination was also left unanswered. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating that the resident has severe cognitive impairment. Section I. Active Diagnoses indicated that the resident's diagnoses included Non-Alzheimer's Dementia and psychotic disorder other than schizophrenia. Further review of the clinical record did not reveal a PASRR Level I after the PASRR Level I dated March 4, 2020. An interview with the director of social services (staff #39) was conducted on July 27, 2022 at 2:10 p.m. Staff #39 stated that the facility tries to obtain the PASRR before a resident is admitted to the facility. She stated they conduct a BIMS which is then relayed to the MDS coordinator and nursing department. She stated that with regards to the current resident, the facility follows up with care plan reviews to identify newly evident or possible serious mental disability, intellectual disability or related condition. Staff #39 stated that it is also important for staff to get to know and be familiar with the residents in order to identify change in behavior. Staff #38 stated even the slightest things can mean something significant. She said that asking, following up and being consistent with care plan reviews are important. She stated that the Social Services Department is responsible for making the referral to the appropriate state-designated authority if and when a resident is identified as having an evident or possible mental disability, intellectual disability or related condition. The PASRR for resident #36 was reviewed with staff #39. She concurred that the form was not completely filled out. Staff #39 stated that in the case of this resident, a new PASRR would need to be done in order to determine if a PASRR II is required. She explained that she could not answer why the form was not completed appropriately since she has only been employed at the facility since March 2022. An interview with the DON (staff #9) was conducted on July 28, 2022 at 11:05 a.m. Staff #9 stated that they use the PASRR along with psychiatric note or neurology note to identify residents with a possible mental disability, intellectual disability, or a related condition. The DON stated with regards to current residents, they use psych providers or nurses who assess, refer, and order psychiatric consult to identify newly evident or possible serious mental disability, intellectual disability or related condition. The DON stated if the concern is beyond that, then it is referred for consultation for diagnoses for dementia or brain issues. He stated that the facility's social services department is responsible for making the referral to the appropriate state-designated authority if a resident is identified as having an evident or possible mental disability, intellectual disability, or related condition. The PASRR for resident #36 was reviewed with the DON (staff #9). He noted that the form was not completely filled out. He stated that he will bring it to the attention of their social services director so that it can be fixed. He did concur that the form not being adequately filled out can be problematic since it hinders the ability to determine if a PASRR level II referral is required. Review of the facility's undated policy titled Pre-admission Screening and Resident Review (PASRR) stated that PASRR level I screenings are used to determine whether the individual has a diagnosis or other presenting evidence that suggests the potential for mental illness or intellectual disability. Based on clinical record reviews, staff interviews and facility policy and procedures, the facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) level I was completed appropriately for one resident (#36) and a PASRR level I was updated for one resident (#30). The sample size was 3 residents. The deficient practice could result in specialized services not being identified and provided to residents. Findings include: -Resident #30 was admitted to the facility on [DATE] with diagnoses that included spinal stenosis, major depressive disorder, post-traumatic stress disorder, adjustment disorder and nicotine dependence. Review of the PASRR Level I screening from the hospital dated February 24, 2021 revealed the resident met the criteria for a 30-day convalescent care. The screening also revealed the nursing facility must update the Level I at such time that it appears the individual's stay will exceed 30 days. Continued review of the clinical record revealed no evidence that the PASRR Level 1 screening was updated or another one was completed once the resident's stay exceeded 30 days. During an interview conducted on July 28, 2022 at 2:06 pm with the Social Service Director (staff #39), she stated that if the resident's PASRR is marked yes on 30-day convalescent care and the resident stayed beyond 30 days then a new PASRR should be done. She stated a new PASRR level I is completed after a resident exceeds 30 day in the facility to ensure that the initial PASRR is still accurate and to see if there has been any change in the resident. She stated that in that case a new PASRR level I is completed as soon as the 30 day is passed. Staff #39 stated she will receive notification from corporate that the PASRR level I is due and she will try to get it done the week that it is due. Staff #39 reviewed the resident's PASRR level I and stated there should have been new PASRR level I for the resident. During an interview conducted with the Director of Nursing (DON/staff #9) on July 28, 2022 at 2:18 pm, he stated that a PASRR level I is done before residents are admitted to the facility. He stated he is not aware when the PASRR gets updated. The DON stated the social services department updates or does the PASRR if there is one needed. Review of the facility policy Pre-admission Screening and Resident Review (PASRR) revealed that for individuals requiring admission to a nursing facility for a convalescent period, or respite care (not to exceed 30 consecutive days), if it is later determined that the admission will last longer than 30 consecutive days, a new PASRR level I screening must be completed as soon as possible or within 40 calendar days of the admission date to the nursing facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review, staff interviews, facility documentation, and policy reviews, the facility failed to ensure one resident (#246) was consistently provided personal hygiene. The sample size was 3. The deficient practice could result in residents' hygiene needs not being met. Findings include: Resident #246 was admitted to the facility on [DATE] with diagnoses that included pneumonia, acute respiratory failure with hypoxia, malignant neoplasm of the stomach, and pressure ulcer of the sacral region. Review of the care plan initiated on December 17, 2021 revealed the resident had activities of daily living self-care performance deficit related to impaired balance. Interventions included encouraging the resident to participate to the fullest extent possible with each interaction and encouraging the resident to use the call light to call for assistance. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 indicating the resident had intact cognition. The assessment stated the resident required limited assistance of one person for personal hygiene and dressing. Review of the December 2021 Documentation Survey Report v2 for personal hygiene revealed no evidence personal hygiene was provided to the resident for 15 opportunities out of 45 opportunities. This represented a 33.3% lack of care for personal hygiene being provided. In January of 2022, the documentation revealed no evidence personal hygiene was provided for 35 opportunities out of 75 opportunities, this represented a 46.6 % lack of care for personal hygiene being provided. In February of 2022, the documentation revealed no evidence personal hygiene was provided for 5 times out of 16 opportunities for care. This represented a 31.5% lack of care for personal hygiene being provided. The discharge MDS assessment dated [DATE] revealed the resident was discharged , return anticipated to an acute hospital. During an interview conducted on July 27, 2022 at 1:57 PM with a Certified Nursing Assistant (CNA/staff #77), the CNA stated that she recalled working with the resident. She stated that she documented the resident's care on the computer. She added that the documentation is to be completed before she goes home and that if necessary she would stay over to complete the documentation of care. During an interview conducted on July 27, 2022 at 2:11 PM with a CNA (staff #76), she stated that resident care is delivered daily and as needed for each resident and that the care gets documented in the computer. She further stated that documentation needs to be done before she goes home at the end of the day. She said she did not know the resident as she had only started in the facility in March of 2022. During an interview conducted on July 27, 2022 at 2:16 PM with a Licensed Practical Nurse (LPN/staff #57), she stated that her expectation of the CNAs is to document their care of the residents in the computer program and that it is done prior to them leaving for the day. She added that if a CNA was to report something unusual, she would assess the resident and then add it in the skilled nursing chart or add a separate progress note. In an interview conducted on July 28, 2022 at 7:50 AM with a Licensed Practical Nurse (staff #6), he stated that the expectation of the CNA is that they document their care of the residents in the computer system and it needed to be done prior to them leaving at the end of their shift. In an interview conducted on July 28, 2022 at 7:59 AM with the Administrator (staff #111), he stated that the expectation is that the staff is to treat all residents respectfully and to provide the needs and required care as needed. He further stated that the charting of the care of the resident is to be accomplished before the staff member goes home at the end of their shift. In an interview conducted on July 28, 2022 at 8:20 AM with the Director of Nursing (DON/staff #9), he stated that all staff are to document care and services for the residents in the computer system as that documents the care delivered. He added that even registry staff have access to the system to enter care provided to the residents. The DON stated that he was unaware of the gaps in the CNA documentation of care being provided to resident #246 and that his expectation was that the CNAs needed to ensure all care is recorded. Review of the facility policy regarding Activities of Daily Living stated appropriate care and services will be provided for residents who are unable to carry out Activities of Daily Living independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming and oral care) and elimination (toileting). The facility policy for Charting and Documentation stated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The policy stated the following information is to be documented in the resident medical record which included treatments or services performed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, staff interviews, and policy review, the facility failed to ensure the medication rate was not 5% or greater, by failing to administer medications as ordered for two of four sampled residents (#23 and #30). The medication error rate was 8%. The deficient practice could result in additional medication errors. Findings include: -Resident #30 was admitted to the facility on [DATE] with diagnoses that included spinal stenosis, major osseous defect, and disorder of the bone. During a medication administration conducted with a Licensed Practical Nurse (LPN/staff #95) on July 27, 2022 at 7:30 AM, the LPN was observed to apply a Lidocaine 5% patch to the resident. However, review of the physician order dated July 27, 2022 stated apply a lidocaine patch to the left knee topically two times a day for left knee pain, 12 hours on/12 hours off. The order did not include a strength for the lidocaine patch. During an interview conducted on July 27, 2022 at 9:12 AM with the LPN (staff #95), she stated that after she reviewed the initial physician orders, she should have clarified the order to make sure that the resident received the correct strength patch. She added that she obtained the patch from the general stock of over the counter medications maintained in the storeroom. Additionally, the LPN stated that this was the resident's first time having a patch and that she was going to immediately contact the physician to clarify the order. The revised physician order was for Aspercreme Lidocaine Patch 4 %; apply to the left knee topically two times a day for back pain dated 7/27/2022. -Resident #23 was admitted to the facility on [DATE] with diagnoses that included sepsis and rhabdomyolysis. A medication administration observation was conducted with a Certified Medication Assistant (CMA/staff #63) on July 27, 2022 at 8:40 AM. The CMA was observed to administer one eye drop of sterile eye drops with Tetrahydrozoline HCL 0.05% to each eye. However, review of the physician order dated July 7, 2022 stated Artificial Tears Solution 1 % (Carboxymethylcellulose Sodium); instill 1 drop in both eyes four times a day for dry eyes. During an interview conducted on July 27, 2022 at 9:00 with the CMA (staff #63), she stated that it was the only eye drops for the resident which were over the counter medication. Staff #63 stated that she got the eye drops from the facility stock in the store room. She further stated that if a medication was not correct, she should stop and notify the nursing staff and the physician prior to giving the medication. In an interview conducted with the Director of Nursing (DON/staff #9) on July 27, 2022 at 9:11 AM, the DON stated that his expectation is that the residents are given the correct medication, by the correct route and at the correct time. He further stated that if there are discrepancies with the orders or the medications, then the staff should clarify those with the physician or himself to make sure the residents are getting the correct medications. Review of the facility policy, Administering Medications, revealed medications shall be administered in a safe and timely manner and as prescribed. Medications must be administered in accordance with the orders, including any required time frame. The policy also revealed that the individual administering the medication must check the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to provide physical and occupational therapy evaluation and treatment as ordered by the physician for one sampled resident (#28). The deficient practice could result in residents experiencing a decline in mobility. Findings include: Resident #28 was admitted to the facility on [DATE] with diagnoses that included traumatic hemorrhage of cerebrum, degenerative diseases of basal ganglia, and muscle weakness. Review of a care plan initiated on November 21, 2017 indicated that the resident had an activities of daily living (ADL) self-care performance deficit related to muscle weakness. Interventions stated PT/OT (physical therapy/occupational therapy) evaluation and treatment as ordered. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating that the resident was cognitively intact. A physician order dated March 21, 2022 revealed PT/OT to evaluate and treat one time only for weakness/mobility for 6 weeks. The order was marked as completed. The quarterly MDS assessment dated [DATE] revealed no evidence the BIMS had been conducted. The assessment indicated that the resident required supervision for mobility, transfer, locomotion, eating, and personal hygiene. Section O. Special Treatments, Procedures, and Programs indicated that the resident was not in therapy and that the last time the resident received physical and/or occupational therapy was in 2018. Continued review of resident #28's clinical record did not reveal any PT or OT evaluation or treatments regarding the March 21, 2022 order. Furthermore, the record did not contain any documentation regarding the discontinuation or cancellation of the PT/OT order. During an interview with the resident conducted on July 25, 2022 at 2:46 p.m., the resident expressed not receiving physical therapy and that therapy was needed in order to walk. The resident stated the authorization for therapy ran out but has since received authorization for more visits. The resident stated no therapy has been provided as of lately. An interview was conducted with a certified nursing assistant (CNA/staff #115) on July 27, 2022 at 1:10 p.m. Staff #115 stated she was not familiar with the resident. However, she stated that she observes residents and reviews their charts to find out if the resident has weakness. She stated that she asks residents to see if they know if they are to receive, and will find out if they get therapy. During an interview with a licensed practical nurse (LPN/staff #21) conducted on July 27, 2022 at 1:28 p.m., the LPN stated she was not aware of the resident's want/need for therapy to walk. She stated that she does not recall the resident mentioning wanting to get therapy. She stated that the resident can do things independently. Staff #21 said that the resident roams around the facility using a scooter. The LPN stated that to her knowledge, walking is not what has kept the resident in the facility, the resident is a long-term care resident residing in the facility. An interview with the director of rehabilitation/occupational therapy (staff #109) was conducted on July 28, 2022 at 9:26 a.m. Staff #109 stated the resident was not currently receiving therapy services. She said that based on their records, the resident had two plans of care which were both from 2018. Staff #109 conducted a search on their therapy system and it did not return any orders for evaluation and treatment for the resident. When staff #109 conducted a search on Point Click Care (PCC) it displayed an evaluation/treat order dated March 21, 2022. She concurred that the order is marked completed. She stated this meant that if it was completed then progress notes and encounter notes should have been documented for each visit. She stated that since she did not start the job until May 2022, she cannot account for why there is a completed order with no documentation. An interview was conducted with the Director of Nursing (DON/staff #9) on July 28, 2022 at 11:05 a.m. The DON stated that the order is marked completed due to the order having a duration and that duration had passed. He said discontinuation or revisions should be documented on the progress note. The DON stated that in this particular case, the writer did not document the cancellation of the order in the resident's clinical record. He stated based on progress notes, the resident's ambulation had not declined and therefore, the referral for PT/OT is not justified. The DON stated that is the reason why the order was revised and discontinued. He said the system will show a revision and that the order is marked completed due to the inputted duration. A facility policy titled Charting and Documentation revised July 2017 stated that documentation in the medical record will be objective, complete, and accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and policy review, the facility failed to ensure infection control protocol was followed during catheter care for one resident (#32). The deficient practice could result in transmission of infection in residents. Findings include: Resident #32 was admitted to the facility on [DATE] with diagnoses that included acute cystitis without hematuria, muscle weakness, dysuria, neuromuscular dysfunction of bladder and urinary tract infection. A physician order dated April 18, 2022 included catheter care with soap and water, or wipes every shift. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had an indwelling catheter. The MDS assessment also revealed the resident needed extensive, one-person assistance for personal hygiene. The Comprehensive Care plan dated June 13, 2022 revealed the resident had an indwelling catheter due to neurogenic bladder. The goal stated the resident will be free from catheter-related trauma and will show no signs and symptoms of urinary infection. The intervention included providing catheter care every shift. The physician order dated July 13, 2022 with an end date of July 20, 2022 included Cipro (antibiotic) 500 milligrams 1 tablet by mouth two times a day for UTI (urinary tract infection) related to dysuria for 7 days. The Brief Interview of Mental Status (BIMS) dated July 27, 2022 revealed the resident scored 11 which indicated the resident cognition was moderately intact. Review of the Treatment Administration Record (TAR) for July 2022 revealed the resident was provided catheter care every shift as ordered. An observation of catheter care was conducted with a Certified Nursing Assistant (CNA/staff #62) on July 27, 2022 at 1:32 PM. The CNA donned clean gloves, assisted the resident with pulling down the resident's pants, opened the brief, and used the same gloved hand to remove wipes from the packet and proceed to clean the resident's peri area. Staff #62 was observed to use the same glove hand to take out another clean wipe to clean the catheter insertion site and clean the catheter. The staff was observed to use the same glove to close the wipe packet, put clean briefs on the resident, adjust the catheter, hook the catheter bag to the bed, and cover the resident up with blankets. The staff then doffed her gloves, and emptied the trash can. The CNA was not observed to change her gloves anytime during catheter care or perform hand hygiene. The staff was observed touching the resident's tray table, wipe packet, blankets, etc. with the same glove. An interview was conducted following the observation with the staff #62 on July 27, 2022 at 1:50 PM. She stated when providing catheter care she normally changes gloves three times or more as needed. She stated she will use one pair of gloves to prepare the resident for catheter care, one for cleaning the catheter, and one after. She stated she forgot to change gloves when providing catheter care to resident #32. The CNA stated she should change gloves as there is an infection risk when not changing gloves. The CNA stated if the gloves are not changed then contaminated gloves with bacteria or poop can touch other areas and can transmit germs. An interview was conducted with the Director of Nursing (DON/staff #9) on July 28, 2022 at 9:46 AM. He stated that his expectation is for the staff to be using gloves and changing gloves when providing catheter care. He stated he does not expect staff to be touching contaminated areas and use the same gloves to clean the area. The DON stated that it is an infection risk and that it does not meet his expectation. The DON stated staff need to be changing gloves to prevent the spread of infection. Review of the facility's policy regarding urinary catheter care revised September 2014 revealed the purpose of the procedure is to prevent catheter associated urinary tract infections. Steps in the procedure part of the policy included assembling supplies, washing hands and putting on gloves, providing catheter care, discarding disposable items into designated containers, removing gloves and washing hands, making the resident comfortable and placing the call light within easy reach, and washing hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure that one resident (#56) medications were administered per physician's orders. The sample size was 5 residents. The deficient practice could result in ineffective management of residents with depression. Findings include: Resident #56 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included major depressive disorder and anxiety disorder. Review of the clinical record revealed a physician order with a start date of December 23, 2021 for Sertraline HCI (antidepressant) tablet 50 mg (milligrams) 1 tablet by mouth one time a day for depression related to major depressive disorder. A physician order with a start date of January 13, 2022 included Bupropion HCI (antidepressant) sustained-release extended release 12-hour 100 mg tablet by mouth one time a day for depression related to major depressive disorder. A care plan initiated on January 13, 2022 regarding the use of antidepressant medications included an intervention for administration of antidepressant medications per physician's orders. However, review of the June 2022 and July 2022 Medication Administration Records (MAR) revealed no evidence that Bupropion had been administered on the following dates: June 24, 2022 June 27, 2022 June 29, 2022 July 8, 2022 July 9, 2022 July 10, 2022 July 11, 2022 July 12, 2022 July 13, 2022 July 14, 2022 July 20, 2022 July 25, 2022 July 27, 2022 The clinical record revealed the following eMAR notes regarding why Bupropion had not administered: June 24, 2022: the resident was out at dialysis June 27, 2022: crossed out eMAR note indicated that the resident was discharged / at dialysis June 29, 2022: the resident was at dialysis July 8, 2022: the resident was at dialysis and medication not available. The name of the medication was not provided for the notes so it is unclear which reason was pertinent to this medication. July 9, 2022: medication was not available while another note indicated that the medication was on order. The name of the medication was not provided on the notes so it is unclear which reason was relevant to this medication. July 10, 2022: the medication was on order. The note did not specify the medication by name. July 11, 2022: the resident was at dialysis. July 12, 2022: the medication was on order. The note did not specify the medication by name. July 13, 2022: the resident was at dialysis and one noted the medication not available. The name of the medication was not provided for the notes so it is unclear which reason was pertinent to this medication. July 14, 2022: nothing by mouth and one noted on order. The name of the medication was not specified so it is unclear which reason was pertinent to this medication. July 20, 2022: crossed out eMAR note indicated the resident was discharged /at dialysis. July 25, 2022: crossed out eMAR note indicated the resident was discharged /at dialysis. July 27, 2022: crossed out eMAR note indicated the resident was discharged /at dialysis. Name of the medication was not specified on this note. There were two medications not administered. Additional review of the June 2022 and July 2022 MARs also revealed no evidence that Sertraline had been administered on the following dates: June 24, 2022 June 27, 2022 June 29, 2022 July 11, 2022 July 20, 2022 July 25, 2022 July 27, 2022 The clinical record revealed the following eMAR notes regarding why Sertraline was not administered: June 24, 2022: the resident was out at dialysis. June 27, 2022: crossed out eMAR note indicated the resident was discharged /at dialysis. June 29, 2022: the resident was at dialysis. July 11, 2022: the resident was at dialysis. July 20, 2022: the resident was discharged /at dialysis. July 25, 2022: crossed out eMAR note indicated the resident was discharged /at dialysis. July 27, 2022: crossed out eMAR note indicated the resident was discharged /at dialysis. There were two medications not administered. Continued review of the clinical record revealed no documentation that the physician had been notified of the lapse in medication administration. An interview was conducted on July 27, 2022 at 1:30 p.m., with a licensed practical nurse (LPN/staff #21). She stated that when a resident is out of the facility for an appointment the medications are held depending on what time the resident comes back. Staff #21 said that based on the medication order, the staff member administering the mediation should make a note on the MAR that the resident was at an appointment. The LPN stated that if the resident is alert and oriented the medication can be sent with the resident. Additionally, she stated that if the resident has a recurring appointment that interferes with medication administration, the provider should be contacted and asked if the medication time can be changed due to the resident being out for recurrent appointments. Staff #21 said that when a medication is out or needs to be refilled, they call the pharmacy to get the medication renewed/refilled. The LPN stated that depending on when they notify the pharmacy, the medication arrives either the same day or the next day. The LPN stated there should not be a reason why a medication on order takes a few days in which a resident has to miss taking the medication multiple days in a row. The LPN stated that if the medication is unavailable, the provider is contacted to see if the time can be changed so that the medication is administered once it arrives. An interview was conducted on July 28, 2022 at 8:46 a.m. with the consultant pharmacist (staff #113). Staff #113 stated that although she is the consultant for the facility, it is the pharmacy director for the area that knows the process and can look up to see if a medication was placed on order. An interview with the pharmacy director (staff #112) was conducted on July 28, 2022 at 10:07 a.m. He stated that during the work week there are four delivery times and, on the weekends, there are two. Staff #112 stated delivery will be based on the order being placed prior to the cutoff time. He stated if a medication is STAT and it is placed before the next delivery run then it is usually a 4-hour turnaround. When asked about the resident's prescription for Bupropion, he stated he would have to do some research before he can give details. On July 28, 2022 at 10:25 a.m., an interview was conducted with a certified medication assistant (CMA/staff #63). Staff #63 stated that if a resident has an appointment, she will administer the medication before the resident leaves. She said however, if the resident is gone then she documents it as the resident is unavailable. The CMA said depending on the time of when the medication is supposed to be administered if it is only 15 minutes difference then she would administer the medication when the resident is back. However, she said she would not administer the medication if it is past that. She said that most of the time the medication is scheduled as a.m. so residents are able to get the medications. The CMA said that it normally takes two days after an order is placed with the pharmacy for the medication to arrive. She stated that if it is past that time, then she notifies the charge nurse. On July 28, 2022 at 10:45 a.m., staff #112 called and stated that an order for Bupropion was placed on July 13, 2022 after the 9:00 p.m. run and processed at 11:27 p.m. He said the medication should have shipped on the 9:00 a.m. run and should have been received by noon. He said typically, this prescription is filled for a 14-day supply. An interview with the director of nursing (DON/staff #9) was conducted on July 28, 2022 at 11:18 p.m. Staff #9 stated that medications are to be administered per physician's orders. The DON stated if a resident refused the medication, if the medication is unavailable, or the resident is unavailable then it needs to be documented on the record. The DON stated there are scheduled deliveries for medications with the last delivery being at 6:00 p.m. A review of resident #56's July 2022 MAR was conducted with staff #9. Staff #9 said that the medication should be administered as ordered. The DON stated if the resident will not be available due to recurrent appointments, then the provider should be notified so that the provider knows what is going on. He concurred that there was an issue with the administration of the resident's medication for depression. Review of the facility's policy titled Administering Medications revised December 2012 stated medications shall be administered in a safe and timely manner, as prescribed. Additionally, it stated that if a resident is not in their room or unavailable the MAR may be flagged, and after the medication pass, the nurse will return to the missed resident to administer the medication.