Based on interview and record review, the facility failed to ensure that Resident 1, a resident with dementia (loss of thinking, memory, and social abilities), was safely escorted to an outside appointment at GACH 1 for one of five sampled residents.This deficient practice resulted in the resident's safety being put at risk.During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 to the facility on 8/18/2025 with diagnoses that included hypertension (a condition when the force of the blood against the artery walls is too high), epilepsy (cell activity in the brain is disturbed), and unspecified dementia (cognitive [ability to understand and process thoughts] decline). During a review of Resident 1's History & Physical Examination -V2 (H&P), dated 8/19/2025, the H&P indicated Resident 1 had the capacity to understand and make medical decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 8/25/2025, the MDS indicated Resident 1 was cognitively intact and required substantial/maximal assistance with walking 10 feet and was dependent for transfers. During a phone interview on 9/9/2025, at 10:40 a.m., with Family (FAM 1), FAM 1 stated Resident 1 had an appointment on 9/2/2025 at 12:30 p.m. at GACH 1. FAM 1 stated FAM 1 arrived at GACH 1 at 12:20 p.m. FAM 1 stated when FAM 1 arrived at GACH 1, Resident 1 was with provider and Resident 1's wheelchair was there, but no escort was there. FAM 1 stated Resident 1 had another appointment across the street at another office on the same day to have staples removed from Resident 1's head. FAM 1 stated FAM 1 did not see an escort. FAM 1 felt it was unsafe for Resident 1 to be left alone because Resident 1 has dementia. FAM 1 stated Resident 1 was left at the appointment site with Resident 1's medical documents. During an interview on 9/10/2025, at 3:26 p.m., with the Licensed Vocational Nurse (LVN 1), LVN 1 stated the facility will always send an escort, but they also ask the family if family will be available. LVN 1 stated, We don't send them without an escort. LVN 1 stated the only reason that residents will go without an escort is if the family meets them at the appointment or family will meet at the facility and then they go to an appointment. LVN 1 stated it is important to make sure the resident is safe, and that they come back, or there is not an incident of losing the resident and the resident arrives safely. LVN 1 stated LVN 1 is unsure if there is a written Policy stating that, but this is what LVN 1 hopes they're doing it and it's the protocol. During an interview on 9/10/2025, at 4:04 p.m., with the Social Services Director (SSD), the SSD stated staff escort the resident to the appointment and back, if needed. The SSD stated if the resident had a dementia diagnosis, the resident would need an escort. The SSD stated most of the residents in the facility go with an escort. The SSD stated the escort remains at the appointment and returns with the resident unless the family is going to meet them there and the family is okay with taking care of the resident. The SSD stated they must wait for the family before leaving and they can't just leave them there. The SSD stated it is important for safety. The SSD stated that when the Director of Staff Development (DSD) arranges for transportation and an escort, the DSD looks for if the resident needs physical help, a wheelchair, and if the resident is confused or forgetful. During an interview on 9/10/2025, at 4:14 p.m., with the DSD, the DSD stated that Resident 1 was called in to see the doctor and the escort, Escort (ESC 1) stated to the nurse Resident 1's daughter would be coming. During an interview on 9/10/2025, at 5:56 p.m., with Social Services Assistant (SSA), the SSA stated it was determined by email communication, dated 8/28/2025, that Resident 1 needed an escort to ride with her because Resident 1's daughter would meet them at the appointment. The SSA stated that most likely they wait for the family to meet them at the appointment before leaving. The SSA stated if the escort needs to leave, they will call family for an estimated time of arrival (ETA) to the appointment. The SSA stated for the most part escort remains with the patient. The SSA stated it is important for the safety of the resident, so the resident is not alone. During a phone interview, on 9/10/2025, at 6:27 p.m., with ESC 1, ESC 1 stated that Resident 1's daughter was not there. During a review of the facility's Policy and Procedure (P&P), titled, Transportation and Appointments, revised December 2023, the policy and procedure indicated our facility will assist residents in arranging transportation and escort (as indicated for resident with cognitive impairment, diagnosis of Dementia and/or resident's needing physical assistance with transfers and mobility) to/from appointments including when necessary. A member of nursing staff or social services will accompany the resident when the resident's family is not available.

Based on interview and record review, the facility failed to ensure therapeutic diets were served as ordered for one of four sampled residents (Resident 1). Resident 1 had a Physician's Order (PO) for no additional salt. This failure had the potential to result in an increased blood pressure (the force of the blood against the artery walls is too high) due to increased salt levels.During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 to the facility on 8/18/2025 with diagnoses that included hypertension (a condition when the force of the blood against the artery walls is too high), epilepsy (cell activity in brain is disturbed), and unspecified dementia (cognitive [ability to understand and process thoughts] decline). During a review of Resident 1's History & Physical Examination -V2 (H&P), dated 8/19/2025, the H&P indicated Resident 1 had the capacity to understand and make medical decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 8/25/2025, the MDS indicated Resident 1 was cognitively intact and required supervision and touching assistance with eating. A review of the Order Summary Report, dated 8/31/2025, the Order Summary Report indicated that Resident 1's diet order was CCHO (Controlled Carbohydrate/NAS (no additional sodium/salt), regular texture, and regular liquid. During a phone interview on 9/9/2025, at 10:40 a.m., with Family (FAM 1), FAM 1 stated the Dietary Supervisor (DS) told FAM 1 that Resident 1 requested additional salt with meals and Resident 1 was provided with salt packets. FAM 1 stated Resident 1 had high blood pressure and should not receive salt. During a phone interview on 9/10/2025, at 1:01 p.m., with FAM 2, FAM 2 stated Resident 1 has a seizure when Resident 1's blood pressure is high. FAM 2 stated Resident 1 should not be given salt. During an interview on 9/10/2025, at 3:08 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated to follow physician diet orders. During an interview, on 9/10/2025, at 4:55 p.m., with the Dietary Supervisor (DS), the DS stated that Resident 1's diet orders were a regular diet, and no added salt. The DS stated Resident 1 always asks for additional salt. The DS stated Resident 1 was so mad. The DS stated Mrs. Dash (salt free seasoning) was offered as an alternative and Resident 1 refused it. The DS stated resident 1's preferences were followed. During a subsequent interview on 9/10/2025, at 5:10 p.m., with the DS, the DS stated that the DS did not have documentation that the DS communicated with FAM 1 or FAM 2 that additional salt packets were provided to resident. The DS stated the DS did not have documentation that the DS informed the physician that Resident 1 requested additional salt packets. The DS stated Resident 1's diet order indicated do not give Resident 1 no additional salt. During a review of the facility's Policy and Procedure (P&P), titled, Diet/Therapeutic Diets, revised October 2017, the policy and procedure indicated diets and therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. If the resident or the resident's representative declines the recommended therapeutic diet, the interdisciplinary team will collaborate with the resident or representative to identify possible alternatives.

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Change in a Resident's Condition or Status, by not notifying one of two sampled residents' (Resident 1's) Representative (R1) when Resident 1 was transferred to the General Acute Care Hospital (GACH 1). This failure resulted in the violation of Resident 1's and R1's right to be notified of any changes of condition/status of Resident 1. Cross Reference F842 Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 1/13/2025, and readmitted Resident 1 on 2/6/2025, with diagnoses that included encephalopathy (damage or disease that affects the brain), acute respiratory failure with hypoxia (a condition where the lungs do not get enough oxygen into the blood, resulting in low blood oxygen levels), and pneumonitis due to inhalation of food and vomit (a lung infection that occurs when you breathe in food or liquid instead of swallowing it). The AR indicated R1 was the first emergency contact person for Resident 1. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/16/2025, the MDS indicated Resident 1 was rarely/never understood by others and rarely/never understood others. The MDS indicated Resident 1 was dependent (helper does all of the effort) on staff for showering/bathing self, upper and lower body dressing, putting on/taking off footwear, and oral, toileting, and personal hygiene. During a review of Resident 1's Progress Notes (PN), dated 1/29/2025, timed at 7:51 am, the PN indicated Resident 1 was discharged to the hospital. During a concurrent interview and record review on 2/13/2025 at 1:57 pm with the Director of Staff Development (DSD), Resident 1's Transfer Form (TF) dated 1/29/2025 and timed at 1:12 am was reviewed. The TF indicated Resident 1 was transferred to GACH 1 at 2 am due to a respiratory infection (an infection affecting the nose, throat, airways, and lungs). The DSD stated the TF indicated Licensed Vocational Nurse (LVN) 1 transferred Resident 1 to GACH 1. The DSD stated the TF indicated the name of R1 as Resident 1's emergency contact but did not include the time LVN 1 notified R1. During an interview on 2/13/2025 at 2:29 pm with LVN 1, LVN 1 stated LVN 1 did not remember the time LVN 1 contacted R1 about Resident 1's transfer to GACH 1. During a concurrent interview and record review on 2/13/2025 at 2:41 pm with the DSD, the facility's Check-Logs ([CL] - the facility's visitor logs) were reviewed. The DSD stated the CL indicated R1 checked in and was in the facility on 1/29/2025 at 8:58 am, while Resident 1 was at GACH 1. During a concurrent interview and record review on 2/13/2025 at 2:45 pm with the Director of Nursing (DON), Resident 1's TF dated 1/29/2025 and timed at 1:12 am and PN dated 1/29/2025 were reviewed. The DON stated Resident 1's TF indicated Resident 1 was transferred to GACH 1 on 1/29/2025 at 1:12 am. The DON stated if LVN 1 did not document the notification to R1 in Resident 1's PN, LVN 1 could have documented it on Resident 1's TF under section 11 which indicated, additional relevant information. The DON stated, If it was not documented, it was not done. The DON stated notifications (to resident's representative) and whatever was relevant to the resident's condition needed to be documented on the TF. During a review of the facility's P&P titled, Change in a Resident's Condition or Status, revised May 2017, the P&P indicated, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The P&P indicated, Unless otherwise instructed by the resident, a nurse will notify the resident's representative when . there is a significant change in the resident's physical, mental, or psychosocial status . it is necessary to transfer the resident to a hospital/treatment center . The P&P indicated, The nurse will record the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Charting and Documentation, by failing to document notification to one of two sampled residents (Resident 1's) representative (R1) of Resident 1's transfer to the General Acute Care Hospital (GACH 1). This deficient practice had the potential to not provide complete information regarding Resident 1's transfer to GACH 1. Cross Reference F580 Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 1/13/2025, and readmitted Resident 1 on 2/6/2025, with diagnoses that included encephalopathy (damage or disease that affects the brain), acute respiratory failure with hypoxia (a condition where the lungs do not get enough oxygen into the blood, resulting in low blood oxygen levels), and pneumonitis due to inhalation of food and vomit (a lung infection that occurs when you breathe in food or liquid instead of swallowing it). The AR indicated R1 as the first emergency contact person for Resident 1. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/16/2025, the MDS indicated Resident 1 was rarely/never understood by others and had the ability to rarely/never understand others. The MDS indicated Resident 1 was dependent (helper does all of the effort) on staff for showering/bathing self, upper and lower body dressing, putting on/taking off footwear, and oral, toileting, and personal hygiene. During a review of Resident 1's Progress Notes (PN), dated 1/29/2025, timed at 7:51 am, the PN indicated Resident 1 was discharged to the hospital. During a concurrent interview and record review on 2/13/2025 at 1:57 pm with the Director of Staff Development (DSD), Resident 1's Transfer Form (TF) dated 1/29/2025 and timed at 1:12 am was reviewed. The TF indicated Resident 1 was transferred to GACH 1 at 2 am due to a respiratory infection (an infection affecting the nose, throat, airways, and lungs). The DSD stated the TF indicated Licensed Vocational Nurse 1 (LVN) 1 transferred Resident 1 to GACH 1. The DSD stated the TF indicated the name of R1 as Resident 1's emergency contact but did not include the time LVN 1 notified R1. During an interview on 2/13/2025 at 2:29 pm with LVN 1, LVN 1 stated LVN 1 did not remember the time LVN 1 contacted R1 about Resident 1's transfer to GACH 1. During a concurrent interview and record review on 2/13/2025 at 2:45 pm with the Director of Nursing (DON), Resident 1's TF dated 1/29/2025 and timed at 1:12 am and PN dated 1/29/2025 were reviewed. The DON stated Resident 1's TF indicated Resident 1 was transferred to GACH 1 on 1/29/2025 at 1:12 am. The DON stated if LVN 1 did not document the notification to R1 in Resident 1's PN, LVN 1 could have documented it on Resident 1's TF under section 11 which indicated, additional relevant information. The DON stated, If it was not documented, it was not done. The DON stated notifications (to resident's representative) and whatever was relevant to the resident's condition needed to be documented on the TF. During a review of the facility's undated P&P titled, Charting and Documentation, the P&P indicated All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. The P&P indicated, Documentation of procedures and treatments shall include care-specific details and shall include at a minimum . Notification of family, physician or other staff, if indicated .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promptly (quickly/with little or no delay) notify one of three sample residents' (Resident 2) Responsible Party (RP 2) when Resident 2 experienced a change in condition (CIC- a sudden clinically important deviation from a resident/patient's baseline in physical, behavioral, or functional domains) as indicated in the facility's policy and procedure (PP) titled, Change of Condition Reporting, by failing to: Ensure RP 2 was notified when Resident 2's Primary Care Provider/Medical Doctor (MD) 1 discontinued Resident 2's Avycaz (brand name for ceftazidime/avibactam- an antibiotic [medicine that stops the growth of or destroys bacteria in the body] used to treat complicated urinary tract infections [UTI- an infection in any part of the urinary tract, the system of organs that makes urine]). As a result of this failure, RP 2 was not informed timely of the change in Resident 2's treatment and plan of care. This failure caused a delay in providing the necessary care and services to Resident 2. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 1/7/2025, with diagnoses that included UTI and Carrier of CRE (CRE- a group of bacteria that are resistant to certain antibiotics and can cause serious infections). During a review of Resident 2's Physician Order (PO) dated 1/8/2025, the PO indicated Resident 2 had an order to discontinue ceftazidime-avibactam (Avycaz) intravenous (IV- soft, flexible tube placed inside a vein to administer fluids and medication directly to the bloodstream) solution 2.5 gm every eight hours on 1/8/2025, and to repeat urinalysis (UA- a medical test that examines a person's urine to detect and diagnose different health conditions) with culture and sensitivity (C&S- lab test that identifies the cause of an infection and helps determine the best treatment) on 1/9/2025. During a review of Resident 2's PO dated 1/12/2025, the PO indicated Resident 2 had an order to collect urinalysis due to (Resident 2's) confusion. During a review of Resident 2's PO dated 1/13/2025, the PO indicated Resident 2 had an order to transfer Resident 2 to GACH 1 for AMS. During a review of Resident 2's Transfer Form (TF- Transfer to Hospital Form) dated 1/13/2025, timed at 11:27 am, the TF indicated Resident 2 was noted with AMS and would be transferred to GACH 1. During a review of Resident 2's GACH 1 Emergency Department (ED) Provider Note (EDPN) dated 1/13/2025, timed at 2:01 pm, the EDPN indicated Resident 2 was brought in by emergency medical services (EMS- refers to a system that provides immediate medical care to individuals in emergency situations) due to increased confusion and abnormal laboratory test results. The EDPN indicated Resident 2 was sent to GACH 1 ED to determine alternative antibiotic to treat Resident 2's Pseudomonas UTI. The EPDN indicated Resident 2 was started on ceftazidime-avibactam and discharged from GACH 1 on 1/7/2025 (to Skilled Nursing Facility [SNF] 1) to continue the antibiotics therapy (ceftazidime-avibactam). The EDPN indicated because of the high cost of the antibiotics (ceftazidime-avibactam), SNF 1 had not given the antibiotics (ceftazidime-avibactam) to Resident 2 since Resident 2 was discharged from GACH 1 to SNF 1 (on 1/7/2025). During a review of Resident 2's GACH 1 Triage (process by which care providers such as medical professionals determine the order of priority for providing treatment) Note ED (TNED), dated 1/13/2025, timed at 2:15 pm, the TNED indicated Resident 2 was brought in by ambulance for increased confusion that started yesterday (1/12/2024), with elevated white blood cells (cells in the blood that indicate if an infection is present) and UTI. During an interview on 1/29/2025 at 11:10 am with the Administrator (ADM), the ADM stated Resident 2 was admitted to the facility for IV antibiotics therapy for treatment of complicated CRE. The ADM stated Resident 2 was on antibiotics called Avycaz. The ADM stated on 1/12/2025, RP 2 called the ADM and stated RP 2 had not been notified MD 1 discontinued Resident 2's Avycaz at SNF 1. The ADM stated facility staff (unidentified) did not notify RP 2 regarding MD 1 discontinuing the Avycaz at SNF 1 because facility staff assumed MD 1 notified RP 2. During a concurrent interview and record review on 1/29/2025 at 12:49 pm with LVN 2, Resident 2's PO dated 1/8/2025 and Progress Notes (PN) for 1/2025 were reviewed. The PN indicated no documentation that RP 2 was notified regarding Resident 2's Avycaz being discontinued on 1/8/2025. LVN 1 stated (in general), when a physician ordered licensed nurses to discontinue a medication, licensed nurses were supposed to call the resident's family/responsible party, so the family/responsible party was updated on the plan of care and was not left, wondering what was going on. During a concurrent telephone interview and record review on 1/29/2025 at 3:59 pm with MD 1, Resident 2's PO dated 1/8/2025 was reviewed. MD 1 stated Resident 2 was admitted to the facility for treatment of Pseudomonas-resistant bacteremia (bacteria in the blood). MD 1 stated MD 1 ordered another urinalysis with C&S the day MD 1 discontinued the ceftazidime-avibactam (Avycaz on 1/8/2025). MD 1 stated MD 1 ordered another urinalysis with C&S on the same day (1/8/2025) to see if another antibiotic would be effective. MD 1 stated MD 1 did not notify RP 2 on 1/8/2025 when MD 1 discontinued the Avycaz because MD 1, expected the facility to do it. During a telephone interview on 1/30/2025 at 10:31 am with RP 2, RP 2 stated Resident 2 was supposed to be admitted to the facility on [DATE] to complete a course of IV antibiotics for treatment of a very complicated UTI through 1/13/2025. RP 2 stated Resident 2 was supposed to be discharged home upon completion of the antibiotics. RP 2 stated when MD 1 discontinued Avycaz on 1/8/2025, RP 2 was not notified by the facility or by MD 1. RP 2 stated RP 2 was notified Avycaz had been discontinued on 1/12/2025 (4 days later). RP 2 stated Resident 2 had not been given any alternative treatment for Resident 2's UTI when Avycaz was discontinued on 1/8/2025. RP 2 stated Resident 2 was in pain, confused and was not communicated with regarding treatment of Resident 2's UTI. RP 2 stated RP 2 did not understand how the facility accepted Resident 2 as a resident when the facility was not going to carry out GACH 1's instructions. During an interview and record review on 1/30/2025 at 11:39 am with the Director of Nursing, Resident 2's PN from 1/8/2025 to 1/12/2025 and PO dated 1/8/2025 were reviewed. The DON stated on 1/8/2025, the DON found out MD 1 discontinued Resident 2's Avycaz order even though Resident 2 was admitted to the facility for IV antibiotics therapy. The DON stated the DON did not question why MD 1 discontinued the Avycaz even though no alternative treatment was ordered. The DON stated RP 2 should have been notified when MD 1 discontinued Avycaz. During a telephone interview on 1/30/2025, timed at 3:21 pm with Resident 2, Resident 2 stated facility did not talk to Resident 2 about what the plan was for Resident 2's UTI. Resident 2 stated Resident 2's experience at the facility made him feel, really lousy and pushed aside. Resident 2 stated, if was not for my daughter, nothing would have done. During a review of the facility's P&P titled, Change in a Resident's Condition or Status, revised 5/2017, the P&P indicated, Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.). The P&P indicated, Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: there is a significant change in the resident's physical, mental, or psychosocial status .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care and services for one of three residents (Resident 2), according to the facility's policy and procedures titled, Antibiotic Stewardship (the effort to measure and improve how antibiotics [medicine that stops the growth of or destroys bacteria in the body]) - Orders for Antibiotics, and Urinary Tract Infection (UTI- an infection in any part of the urinary tract, the system of organs that makes urine)/Bacteriuria (bacteria in urine), by failing to: 1. Ensure Resident 2's Primary Care Provider/Medical Doctor (MD) 1 continued Resident 2's intravenous (IV- soft, flexible tube placed inside a vein to administer fluids and medication directly to the bloodstream) ceftazidime-avibactam (Avycaz- an antibiotic used to treat a wide variety of bacterial infections) therapy for the treatment of Resident 2's Pseudomonas aeruginosa (Pseudomonas- a type of bacteria that are widely found in the environment that can cause infection in the body) UTI as recommended by the General Acute Care Hospital (GACH 1) Inpatient Infectious Disease Medical Doctor (MD 2- a physician who specializes in the treatment of infectious diseases)) or provided alternative treatment 2. Ensure assigned licensed nurses (Licensed Vocational Nurses [LVNs] and/or Registered Nurses [RNs]) carried out (to do or complete) a physician order dated 1/8/2025 for a urinalysis (UA- a medical test that examines a person's urine to detect and diagnose different health conditions) with culture and sensitivity (C&S- lab test that identifies the cause of an infection and helps determine the best treatment) to be obtained on 1/9/2025 As a result of these failures, Resident 2 did not receive the needed antibiotics therapy to treat Resident 2's Pseudomonas UTI from 1/8/2025 to 1/12/2025. On 1/13/2025, at 1:40 pm, Resident 2 experienced altered mental status (AMS- change in a person's level of consciousness, awareness, or cognitive function [ability to think, process information and make decisions]) and was transferred to the General Acute Care Hospital (GACH) 1 for further evaluation and treatment. Cross Reference F770 Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 1/7/2025, with diagnoses that included UTI and carrier of CRE Carbapenem-resistant Enterobacterales (CRE- a group of bacteria that are resistant to certain antibiotics and can cause serious infections). During a review of Resident 2's Order Reconciliation Manager Discharge (ORMD- the process of reviewing the patient's complete medication regimen at the time of transfer/discharge and comparing it with the regimen being considered for the new setting of care) from GACH 1 dated 1/7/2025, timed at 1:31 pm, the ORMD indicated active medications at time of discharge reconciliation included ceftazidime-avibactam (Avycaz) 2.5 gram (gm- unit of measurement) IV injection. During a review of Resident 2's GACH 1 Referral Packet for Skilled Nursing Facility (SNF 1) admission (HRP) dated 1/7/2025, timed at 2:44 pm, the HRP indicated discharge orders for Resident 2 which included IV antibiotics at SNF 1, Avycaz 2.5 gm IV every eight hours until 1/13/2025. During a review of Resident 2's admission Assessment (AA) dated 1/7/2025, timed at 9:40 pm, the AA indicated Resident 2 was on isolation (a type of infection control precaution used to prevent the spread of infection) and noted to have an antibiotic treatment order for ceftazidime-avibactam (Avycaz) IV solution reconstituted 2.5 gm and to administer 2.5 gm intravenously every eight hours for UTI. During a review of Resident 2's Interim Medication Regimen Review (IMMR) from SNF 1's Outside Pharmacy (OP) 1, the IMMR indicated Resident 2 was a new admission to SNF 1 and there were no recommendations given by the reviewing pharmacist. During a review of Resident 2's Physician Order (PO) dated 1/7/2025, the PO indicated Resident 2 had an order to admit (Resident 2) to SNF 1 under the direction of MD 1. During a review of Resident 2's PO dated 1/8/2025, the PO indicated Resident 2 had an order to discontinue ceftazidime-avibactam (Avycaz) IV solution 2.5 gm every eight hours on 1/8/2025, and to repeat urinalysis with C&S on 1/9/2025. During a review of Resident 2's PO, dated 1/8/2025, the PO indicated Resident 2 had an order for urinalysis with C&S on 1/9/2025 (indication was not specified). During a review of Resident 2's PO dated 1/12/2025, the PO indicated Resident 2 had an order to collect urinalysis due to (Resident 2's) confusion. During a review of Resident 2's PO dated 1/13/2025, the PO indicated Resident 2 had an order to transfer Resident 2 to GACH 1 for AMS. During a review of Resident 2's Transfer Form (TF- Transfer to Hospital Form) dated 1/13/2025, timed at 11:27 am, the TF indicated Resident 2 was noted with AMS and would be transferred to GACH 1. During a review of Resident 2's Progress Notes (PN) dated 1/13/2025, timed at 1:40 pm, the PN indicated Resident 2 was transferred to GACH 1 due to AMS. During a review of Resident 2's GACH 1 Emergency Department (ED) Provider Note (EDPN) dated 1/13/2025, timed at 2:01 pm, the EDPN indicated Resident 2 was brought in by emergency medical services (EMS- refers to a system that provides immediate medical care to individuals in emergency situations) due to increased confusion and abnormal laboratory test results. The EDPN indicated Resident 2 was sent to GACH 1 ED to determine alternative antibiotic to treat Resident 2's Pseudomonas UTI. The EPDN indicated Resident 2 was started on ceftazidime-avibactam and discharged from GACH 1 on 1/7/2025 (to Skilled Nursing Facility [SNF] 1) to continue the antibiotics therapy (ceftazidime-avibactam). The EDPN indicated because of the high cost of the antibiotics (ceftazidime-avibactam), SNF 1 had not given the antibiotics (ceftazidime-avibactam) to Resident 2 since Resident 2 was discharged from GACH 1 to SNF 1 (on 1/7/2025). The EDPN indicated Resident 2 would receive a dose of ceftazidime-avibactam in GACH 1 ED. The EDPN indicated MD 1 would coordinate with SNF 1 to ensure Resident 2 received the antibiotics (ceftazidime-avibactam) at SNF 1. During a review of Resident 2's GACH 1 Triage (process by which care providers such as medical professionals determine the order of priority for providing treatment) Note ED (TNED), dated 1/13/2025, timed at 2:15 pm, the TNED indicated Resident 2 was brought in by ambulance for increased confusion that started yesterday (1/12/2024), with elevated white blood cells (cells in the blood that indicate if an infection is present) and UTI. During an interview on 1/29/2025 at 11:10 am with the Administrator (ADM), the ADM stated Resident 2 was admitted to the facility for IV antibiotics therapy for treatment of complicated CRE. The ADM stated Resident 2 was on antibiotics called Avycaz. The ADM stated MD 1 discontinued Avycaz but did not discuss the reason and did not put Resident 2 on any alternative antibiotics. During a concurrent interview and record review on 1/29/2025, timed at 1:21 pm, with RN 1, Resident 2's PN from 1/8/2025 to 1/12/2025 and PO dated 1/8/2025 were reviewed. RN 1 stated Resident 2 was admitted to the facility on [DATE] for IV antibiotics therapy. RN 1 stated RN 1 was Resident 2's admitting nurse. RN 1 stated RN 1 expected Resident 2's Avycaz to be delivered by OP 1 on 1/8/2025. RN 1 stated RN 1 received information on 1/8/2025 that MD 1 discontinued Resident 2's Avycaz order. RN 1 stated MD 1 did not order an alternative treatment and/or antibiotics for Resident 2. RN 1 stated (in general) RN 1 would never accept an order from a physician to discontinue a medication because it was too expensive. RN 1 stated (in general) if RN 1 carried out a discontinuation order for antibiotics because it was too expensive, the resident could get sicker and require rehospitalization, which could affect their health in a negative way. RN 1 stated a resident's infection could get worse and cause complications that make them sicker. During a concurrent telephone interview and record review on 1/29/2025at 3:59 pm with MD 1, Resident 2's PO dated 1/8/2025 was reviewed. MD 1 stated Resident 2 was admitted to the facility for treatment of Pseudomonas-resistant bacteremia (bacteria in the blood) that included IV antibiotics therapy with Avycaz. MD 1 stated MD 1 ordered another urinalysis with C&S the day MD 1 discontinued the ceftazidime-avibactam (Avycaz on 1/8/2025) due to the high cost of the ceftazidime-avibactam (Avycaz). MD 1 stated MD 1 ordered another urinalysis with C&S on the same day (1/8/2025) to see if another antibiotic would be effective. MD 1 stated Resident 2 did not receive any antibiotics or other treatment at SNF 1 for Resident 2's UTI from 1/8/2025 through 1/12/2025 and until 1/13/2025, when Resident 2 was transferred to GACH 1 for AMS. MD 1 stated AMS was a symptom of infection. MD 1 stated Resident 2 was readmitted to SNF 1 on 1/13/2025 with another order for ceftazidime-avibactam (Avycaz) to be given until 1/16/2025. MD 1 stated it was important for Resident 2 to get the antibiotics needed and to finish the ordered course of antibiotics to treat (any) bacterial infection, otherwise the infection could get worse, and Resident 2 could end up in the hospital and the infection could lead to death. MD 1 stated if MD 1 ordered labs (in general), the labs needed to be obtained as soon as possible so they (MD 1 and facility staff) could appropriately treat Resident 2. MD 1 stated not obtaining Resident 2's urinalysis with C&S as soon as possible caused a delay in Resident 2's care which resulted in Residents 2's rehospitalization (readmitted to the hospital for a second time). During a telephone interview on 1/30/2025 at 11:25 am with Pharm 1, Pharm 1 stated OP 1 managed the fulfillment of prescriptions for SNF 1. Pharm 1 stated OP 1 delivered IV medications including antibiotics. Pharm 1 stated OP 1 carried Avycaz but it was expensive at $514 per vial without insurance coverage. Pharm 1 stated Avycaz generally required prior authorization (a process that requires health insurance approval before a service or prescription can be covered requested by a physician) because of its price. Pharm 1 stated (in general) if prior authorization was not obtained by a physician, then the recipient of Avycaz or providing facility would have to pay full price. Pharm 1 stated MD 1 did not obtain prior authorization for Resident 2 to be on Avycaz. Pharm 1 stated pharmacy staff (unidentified) from OP 1 called MD 1 to discuss the medication (Avycaz) after receiving an order for it (Avycaz) from the facility on 1/7/2025. Pharm 1 stated on 1/8/2025 at 4:28 am, MD 1 discontinued Resident 2's Avycaz due to the cost. During a telephone interview on 1/30/2025 at 10:31 am with RP 2, RP 2 stated Resident 2 was supposed to be admitted to the facility on [DATE] to complete a course of IV antibiotics through 1/13/2025 for treatment of a very complicated UTI. RP 2 stated Resident 2 was supposed to be discharged home upon completion of the antibiotics therapy. RP 2 stated Resident 2 had not been given any alternative treatment for Resident 2's UTI when Avycaz was discontinued on 1/8/2025. RP 2 stated MD 1 informed RP 2 that Avycaz, cost almost $1,000 per vial and no facility would have covered it. RP 2 stated Resident 2 had to be transferred to the ED on 1/13/2025. RP 2 stated Resident 2 had to be readmitted to SNF 1 for four more days to complete a course of Avycaz that was supposed to be completed on 1/13/2025. RP 2 stated Resident 2 was in pain, confused and was not communicated with regarding treatment of Resident 2's UTI. RP 2 stated RP 2 did not understand how the facility accepted Resident 2 as a resident when the facility was not going to carry out GACH 1's instructions (discharge orders). During an interview and record review on 1/30/2025 at 11:39 am with the Director of Nursing, Resident 2's PN from 1/8/2025 to 1/12/2025 and PO dated 1/8/2025 were reviewed. The DON stated (in general) the facility would review discharging instructions from discharging GACH for residents and should continue the discharge orders/instructions because residents were generally admitted to the facility to continue the care provided at the hospital in a less acute setting. The DON stated when MD 1 ordered a urine sample for urinalysis with C&S to be obtained on 1/9/2025, the urine sample needed to be collected that day (1/9/2025), so there was no delay in care. The DON stated Resident 2 experienced a delay in care (did not receive IV antibiotics for 5 days) because Resident 2's urinalysis with C&S was not carried out as ordered by MD 1. RN 1 stated as a result of missing Resident 2's urinalysis with C&S, Resident 2 did not receive any other treatment to treat Resident 2's UTI. The DON stated on 1/8/2025, the DON found out MD 1 discontinued Resident 2's Avycaz order even though Resident 2 was admitted to the facility for IV antibiotics therapy. The DON stated the DON did not question why MD 1 discontinued the Avycaz even though no alternative treatment was ordered. The DON stated because Resident 2 was admitted for IV antibiotics therapy and was not given the Avycaz as instructed by GACH 1 on admission, Resident 2's infection did not resolve, Resident 2 developed AMS, and required further evaluation at GACH 1 on 1/13/2025. The DON stated Resident 2's unresolved UTI, AMS, and rehospitalization could have been avoided had Resident 2 been given Avycaz as instructed by GACH 1. During a telephone interview on 1/30/2025, timed at 3:21 pm, with Resident 2, Resident 2 stated facility did not talk to Resident 2 about what the plan was for Resident 2's UTI. Resident 2 stated Resident 2's experience at the facility made him feel, really lousy and pushed aside. Resident 2 stated, if was not for my daughter, nothing would have done. Resident 2 stated when Resident 2 had to go back to the hospital, and again to the facility instead of being discharged home on 1/13/2025, Resident 2, wanted everything to end. Resident 2 stated, I wished it was over, and I had a pistol to end it right there. During a review of the facility's P&P titled, Antibiotic Stewardship- Orders for Antibiotics, revised 12/2016, the P&P indicated, Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program and in conjunction with the facility's general policy for Medication Utilization and Prescribing. The P&P indicated, Appropriate indications for use of antibiotics included . Criteria met for clinical definition of active infection or suspected sepsis; and Pathogen (bacteria) susceptibility, based on culture and sensitivity to antimicrobial (antibiotics) (or therapy begun while culture is pending). The P&P indicated, When a resident is admitted from an emergency department, acute care facility, or other care facility, the admitting nurse will review the discharge and transfer paperwork for current antibiotic/anti-infective orders. Discharge or transfer medical records must include all of the above drug and dosing elements. During a review of the facility's P&P titled, UTI/Bacteriuria- Clinical Protocol, revised 4/2018, the P&P indicated, The physician and staff will identify individuals with a history of symptomatic urinary tract infections, and those who have risk-factors for UTIs. The P&P indicated, The physician will order appropriate treatment for verified or suspected UTIs . based on a pertinent assessment. The P&P indicated, Generally, symptomatic UTIs should be treated The P&P indicated, The physician and nursing will review the status of individuals who are being treated for a UTI and adjust treatment accordingly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the laboratory (a room or building equipped for experimental study in science or for testing and analysis) services (laboratory services/laboratory tests included certain blood tests and urinalysis [UA- a medical test that examines a person's urine to detect and diagnose different health conditions], that helped healthcare professionals to detect and treat diseases) for one of three sampled residents (Resident 2) according to the facility's policy and procedures (P&P) titled, Lab and Diagnostic Test Results - Clinical Protocol, by failing to: Ensure assigned licensed nurses (Licensed Vocational Nurses [LVNs] and/or Registered Nurses [RN] carried out (to do or complete) a physician order dated 1/8/2025 for a UA with culture and sensitivity (C&S- a laboratory test that checks for bacteria or other germs in a urine sample that can cause an infection and checks to see what kind of antibiotic [a medicine that stops the growth of or destroys microorganism], will work best to treat the illness or infection) for the treatment of Resident 2's Pseudomonas aeruginosa (Pseudomonas- a type of bacteria that are widely found in the environment that can cause infection on the skin, blood, lungs, and other parts of the body) urinary tract infection (UTI- an infection in any part of the urinary tract, the system of organs that makes urine), as ordered by Resident 2's Primary Care Provider/Medical Doctor (MD) 1. As a result of this failure, Resident 2 did not receive the needed antibiotics therapy to treat Resident 2's Pseudomonas UTI from 1/8/2025 to 1/12/2025. On 1/13/2025, at 1:40 pm, Resident 2 experienced altered mental status (AMS- change in a person's level of consciousness, awareness, or cognitive function [ability to think, process information and make decisions] and was transferred to the General Acute Care Hospital (GACH) 1 for further evaluation and treatment. Cross Reference F684 Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 1/7/2025, with diagnoses that included UTI and carrier of Carbapenem-resistant Enterobacterales (CRE- a group of bacteria that are resistant to certain antibiotics and can cause serious infections). During a review of Resident 2's Physician Order (PO) dated 1/8/2025, the PO indicated Resident 2 had an order to discontinue ceftazidime-avibactam (Avycaz- medication used to treat a wide variety of bacterial infections) intravenous (IV- a method of delivering fluids or medicine directly into a vein using a needle or tube) solution 2.5 gram (gm- unit of measurement) every eight (8) hours on 1/8/2025, and to repeat urinalysis with C&S on 1/9/2025. During a review of Resident 2's PO, dated 1/8/2025, the PO indicated Resident 2 had an order for urinalysis with C&S on 1/9/2025 (indication was not specified). During a review of Resident 2's PO dated 1/12/2025, the PO indicated Resident 2 had an order to collect urinalysis due to (Resident 2's) confusion. During a review of Resident 2's PO dated 1/13/2025, the PO indicated Resident 2 had an order to transfer Resident 2 to GACH 1 for AMS. During a review of Resident 2's Transfer Form (TF- Transfer to Hospital Form) dated 1/13/2025, timed at 11:27 am, the TF indicated Resident 2 was noted with AMS and would be transferred to GACH 1. During a review of Resident 2's Progress Notes (PN) dated 1/13/2025, timed at 1:40 pm, the PN indicated Resident 2 was transferred to GACH 1 due to AMS. During a review of Resident 2's GACH 1 Emergency Department (ED) Provider Note (EDPN) dated 1/13/2025, timed at 2:01 pm, the EDPN indicated Resident 2 was brought in by emergency medical services (EMS- refers to a system that provides immediate medical care to individuals in emergency situations) due to increased confusion and abnormal laboratory test results. The EDPN indicated Resident 2 was sent to GACH 1 ED to determine alternative antibiotic to treat Resident 2's Pseudomonas UTI. The EPDN indicated Resident 2 was started on ceftazidime-avibactam and discharged from GACH 1 on 1/7/2025 (to Skilled Nursing Facility [SNF] 1) to continue the antibiotics therapy (ceftazidime-avibactam). The EDPN indicated because of the high cost of the antibiotics (ceftazidime-avibactam), SNF 1 had not given the antibiotics (ceftazidime-avibactam) to Resident 2 since Resident 2 was discharged from GACH 1 to SNF 1 (on 1/7/2025). The EDPN indicated Resident 2 would receive a dose of ceftazidime-avibactam in GACH 1 ED. The EDPN indicated MD 1 would coordinate with SNF 1 to ensure Resident 2 received the antibiotics (ceftazidime-avibactam) at SNF 1. During a review of Resident 2's GACH 1 Triage (process by which care providers such as medical professionals determine the order of priority for providing treatment) Note ED (TNED), dated 1/13/2025, timed at 2:15 pm, the TNED indicated Resident 2 was brought in by ambulance for increased confusion that started yesterday (1/12/2024), with elevated white blood cells (cells in the blood that indicate if an infection is present), and UTI. During a concurrent interview and record review on 1/29/2025 at 1:21 pm with RN 1, Resident 2's PN from 1/8/2025 to 1/12/2025 and active PO dated 1/8/2025 were reviewed. The PO dated 1/8/2025 indicated for facility staff to obtain a urinalysis with C&S from Resident 2 on 1/9/2025. Resident 2's PN from 1/8/2025 to 1/12/2025 indicated no documentation facility staff attempted to collect a urine sample from Resident 2 to carry out Resident 2's physician order to obtain a urinalysis with C&S on 1/9/2025. RN 1 stated Resident 2 was admitted to the facility on [DATE] for IV antibiotics (ceftazidime-avibactam) therapy. RN 1 stated RN 1 was Resident 2's admitting nurse. RN 1 stated if MD 1 ordered laboratory tests (labs) for Resident 2, the order needed to be carried out as soon as possible. RN 1 stated there was no documentation in Resident 2's PN indicating Resident 2's urine sample was collected/obtained for the urinalysis with C&S as indicated in Resident 2's physician order. RN 1 stated Resident 2 had a delay in care and did not receive any antibiotics or other treatment at SNF 1 for Resident 2's UTI (from 1/8/2025 to 1/12/2025). During a concurrent telephone interview and record review on 1/29/2025 at 3:59 pm with MD 1, Resident 2's PO dated 1/8/2025 was reviewed. MD 1 stated Resident 2 was admitted to the facility for treatment of Pseudomonas-resistant bacteremia (bacteria in the blood). MD 1 stated MD 1 ordered another urinalysis with C&S the day MD 1 discontinued the ceftazidime-avibactam (Avycaz on 1/8/2025) due to the high cost of the ceftazidime-avibactam (Avycaz). MD 1 stated MD 1 ordered another urinalysis with C&S on the same day (1/8/2025) to see if another antibiotic would be effective. MD 1 stated Resident 2 did not receive any antibiotics or other treatment at SNF 1 for Resident 2's UTI from 1/8/2025 through 1/12/2025 and until 1/13/2025, when Resident 2 was transferred to GACH 1 for AMS. MD 1 stated AMS was a symptom of infection. MD 1 stated Resident 2 was readmitted to SNF 1 on 1/13/2025 with another order for ceftazidime-avibactam (Avycaz) to be given until 1/16/2025. MD 1 stated if MD 1 ordered labs (in general), the labs needed to be obtained as soon as possible so they (MD 1 and facility staff) could appropriately treat Resident 2. MD 1 stated not obtaining Resident 2's urine sample for urinalysis with C&S as soon as possible caused a delay in Resident 2's care which resulted in Residents 2's rehospitalization (readmitted to the hospital for a second time). During an interview and concurrent record review on 1/30/2025 at 11:10 am with LVN 1, Resident 2's PO dated 1/8/2025 was reviewed. Resident 2's PO dated 1/8/2025, indicated Resident 2 had an order for urinalysis with C&S to be obtained on 1/9/2025. LVN 1 stated Resident 2's care was not up to par, and Resident 2 did not receive the needed antibiotics (ceftazidime-avibactam) to treat Resident 2's UTI. During an interview and record review on 1/30/2025 at 11:39 am with the Director of Nursing (DON), Resident 2's PO dated 1/8/2025 was reviewed. Resident 2's PO dated 1/8/2025, indicated Resident 2 had an order for urinalysis with C&S to be obtained on 1/9/2025. The DON stated when MD 1 ordered a urine sample for urinalysis with C&S to be obtained on 1/9/2025, the urine sample needed to be collected that day (1/9/2025), so there was no delay in care. The DON stated Resident 2 experienced a delay in care (did not receive IV antibiotics for 5 days) because Resident 2's urinalysis with C&S was not carried out as ordered by MD 1. The DON stated as a result of missing Resident 2's urinalysis with C&S, Resident 2 did not receive any other treatment to treat Resident 2's UTI. During a review of the facility's P&P titled, Lab and Diagnostic Test Results - Clinical Protocol, revised 11/2018 (most updated), the P&P indicated, The physician will identify and order diagnostic and lab testing on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. The P&P indicated, A nurse will try to determine whether the test was done .as a routine screen or follow-up .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to notify the physician of one of one sampled resident's (Resident 14) blood sugar value of 420 milligram/deciliter (mg/dL - unit of measurement) on 7/1/2024 as indicated in Resident 14's Medication Administration Record (MAR). This failure had the potential for Resident 14 to experience undesired effects of high blood sugar. Findings: During a review of Resident 14's admission Record, the AR indicated Resident 14 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type 2 diabetes mellitus (long term condition in which a high level of sugar is present in the bloodstream), liver cirrhosis (a type of liver disease where healthy cells are replaced by scar tissue) and hyperlipidemia (excess of fat or lipids in the blood). During a review of Resident 14's History and Physical (H&P) dated 2/27/2024, the H&P indicated Resident 14 did not have the capacity to understand and make decisions. During a review of Resident 14's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 4/23/2024, the MDS indicated Resident 14 was dependent (helper does all of the effort to complete the activity) on staff for toilet use and personal hygiene. During a concurrent telephone interview and record review on 7/25/2024 at 1:08 pm with Licensed Vocational Nurse 3 (LVN 3), Resident 14's MAR dated with active orders as of 7/25/2024 was reviewed. The MAR indicated Resident 14's blood sugar level was 420 mg/dL on 7/1/2024 at 4:30 pm. The MAR indicated for licensed staff to call the Medical Doctor (MD) for blood sugar level above 400 mg/dL. LVN 3 stated LVN 3 could not remember if the MD was notified but since it was not documented then it was not done. LVN 3 stated Resident 14's MD should have been notified of the elevated blood sugar according to the physician's order. During a concurrent interview and record review on 7/25/204 at 4:36 PM with Director of Nursing (DON), the facility's Policy and Procedure (P&P) titled, Change in a Resident's Condition or Status, dated 5/2017 was reviewed. The P&P indicated, The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): i. specific instruction to notify the Physician of changes in the resident's condition. The DON stated if it wasn't documented then it was not done, and the doctor should have been notified per physician's order. The DON stated it was important for the MD to be notified so that the MD can determine if Resident 14's insulin needed to be adjusted and determine the type of care needed for Resident 14.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 75) was provided with a home-like environment by not allowing Resident 75 to use the [NAME] and [NAME] restroom (a restroom that has two doors and is usually accessible from two bedrooms to share) of other residents. This failure had the potential to result in invasion of privacy for Resident 75 and other residents. Findings: During a review of Resident 75's admission Record (AR), the AR indicated, Resident 75 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including End Stage Renal Disease (ESRD, kidneys lose the ability to remove waste and balance fluids) and essential (primary) hypertension (high blood pressure). During a review of Resident 75's History and Physical Examination (H&P), dated 10/5/2023, the H&P indicated Resident 75 had the capacity to understand and make decisions. During a review of Resident 75's Minimum Data Sheet (MDS, an assessment and screening tool) dated 6/25/2024, the MDS indicated Resident 75 had intact cognition (ability to think and process information). During a concurrent observation and interview on 7/23/2024 at 8:59 a.m. with LVN 2, LVN 2 opened the door of the [NAME] & [NAME] restroom and saw Resident 75 using the restroom. LVN 2 stated, Resident 75 was from another room. During an interview on 7/24/2024 at 12:44 p.m. with the Infection Preventionist (IP), the IP stated, residents from another room should not use the shared restroom (Jack and [NAME] restroom) for privacy. The IP stated, it would be a problem if the resident using the restroom was a male and the resident in the room sharing the restroom were females. During an interview on 7/24/2024 at 1:06 p.m. with Resident 75, Resident 75 stated, he used the other residents' restroom on 7/23/2024 because Resident 75's [NAME] and [NAME] restroom was occupied, and the other restroom was not in use. Resident 75 stated, he had an appointment yesterday (7/23/2024) and had to urgently use a restroom. Resident 75 stated, a staff (unnamed) told Resident 75 to use the [NAME] and [NAME] restroom across the hallway. During an interview on 7/25/2024 at 3:11 p.m. with the Director of Nursing (DON), the DON stated, if residents are not from that area (adjoining rooms sharing the [NAME] and [NAME] restroom), staff should not allow other residents to use the restroom for reasons of privacy and dignity. The DON stated, even family members were encouraged not to use the resident's restroom. During a review of the facility's Policy and Procedure (P&P) titled, Quality of Life - Homelike Environment, revised May 2017, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify one of one sampled resident (Resident 14)'s representative of the facility's policy for bed hold. This failure had the potential for Resident 14's representative to be uninformed of their rights to return to the facility after discharge or transfer. Findings: During a review of Resident 14's admission Record, (AR), the AR indicated Resident 14 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type 2 diabetes mellitus (long term condition in which a high level of sugar is present in the bloodstream), liver cirrhosis (a type of liver disease where healthy cells are replaced by scar tissue) and hyperlipidemia (excess of fat in the blood). During a review of Resident 14's History and Physical (H&P) dated 2/27/2024, the H&P indicated Resident 14 did not have the capacity to understand and make decisions. During a review of Resident 14's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 4/23/2024, the MDS indicated Resident 14 was dependent (helper does all the effort to complete the activity) on staff for toilet use and personal hygiene. During an interview on 7/25/2024 at 3:23 PM with Admissions Coordinator (AC), AC stated the facility's bed hold notification waw part of the admission's packet and the form needed to be signed again if a resident was discharged and readmitted . The AC further stated during readmission, nursing staff was responsible for communicating with the resident or representative to inform them of their rights. The AC stated the purpose of the bed hold notification form was to inform the resident with Medi-Cal or resident's representative that the facility will save the resident's bed for seven days if they were transferred out of the facility. During a concurrent interview and record review on 7/25/2024 at 3:45 PM with Licensed Vocational Nurse 4 (LVN 4), Resident 14's Bedhold Notification (BHN) dated 1/31/2023 was reviewed. LVN 4 stated the form was incomplete as evidenced by the absence of Resident 14's representative's signature under Acknowledgement Upon Admission. LVN 4 stated LVN 4 obtained consent over the phone with Resident 14's representative but did not document. LVN 4 stated telephone consent should use two staff to verify consent and the document should be signed by each witness. During a concurrent interview and record review on 7/25/2024 at 4:36 PM with Director of Nursing (DON), Resident 14's BHN was reviewed. Resident 14's BHN did not indicate consent was obtained from Resident 14's representative. The DON stated if resident's representative cannot come to the facility to obtain consent, it can be obtained over the phone and staff should document who gave consent and add a signature of the witness.

Based on observation, interviews, and record review, the facility failed to follow the food preferences of one of four sampled residents (Resident 27) during lunch tray line (system of food preparation in which meal trays are moved along an assembly line). This failure had the potential to cause inadequate nutrition related to decreased appetite, refused meal, or meal replacement with less healthier options. Findings: During a review of Resident 27's admission Record (AR 1), AR 1 indicated the facility initially admitted Resident 27 on 4/6/2022 with diagnoses including dementia (impairment of brain functions that interfere with daily life), type 2 diabetes mellitus (long-term condition of uncontrolled blood sugar), vitamin B12 deficiency anemia (lower than normal amounts of vitamin B12 in the blood that leads to reduced healthy red blood cells), iron deficiency anemia (too little iron in the body causing reduced healthy red blood cells), ascorbic acid deficiency (vitamin C deficiency), and vitamin D deficiency. During a review of Resident 27's History and Physical Examination (H&P 1) dated 11/16/2023, H&P 1 indicated Resident 27 did not have the capacity to understand and make decisions. During a review of Resident 27's Diet Review/Food & Beverage Preference List (DR 1) dated 2/16/2024, DR 1 indicated Resident 27's food preference was No Fish. During a review of Resident 27's Minimum Data Set (MDS 1, a standardized resident assessment and care-planning tool), dated 5/14/2024, MDS 1 indicated Resident 27 had severe impairment in cognition (ability to acquire, process and, recall information). MDS 1 indicated Resident 27 was dependent with oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, personal hygiene, and mobility. MDS 1 indicated Resident 27 required substantial/maximal assistance with eating. During a review of the facility's lunch menu for 7/24/2024, the following items were prepared for the residents: Fish Italiano, Scalloped Potatoes, Italian Herb Vegetables, Red & [NAME] Salad, and Peach Crisp. During a concurrent tray line observation and interview on 7/24/2024 at 12:27 PM, Resident 27's meal tray was observed. Resident 27's meal tray card indicated No Fish under Dislikes. With prompting to verify Resident 27's prepared meal tray, [NAME] 1 stated she should have served Resident 27 chicken (instead of fish) because Resident 27 disliked fish. [NAME] 1 immediately prepared another meal plate with chicken for Resident 27. During an interview on 7/25/2024 at 3:25 PM, Dietary Services Supervisor (DSS) stated it was important to review the meal tray card during tray line to ensure the residents' food preferences were followed and adequate nutrition was delivered. During a review of the facility's Policy and Procedure (P&P 4), titled Food Preferences, dated 2018, P&P 4 indicated resident's food preferences must be adhered to within reason, and substitutes for all foods disliked must be given from the appropriate food group. During a review of the facility's Policy and Procedure (P&P 5), titled Food Substitutions During Tray Line: An Alternate for a Food Item Resident Does Not Like That is Recorded on the Tray Card, P&P 5 indicated the cook must provide a food substitute at each meal for a food item that a resident might dislike which has been noted on their tray card.

Based on observation, interview, and record review, the facility failed to implement its facility's Policies and Procedures (P&Ps) on dishwashing and standard precautions for one of one dishwasher (DW 1) observed in the facility's kitchen. This failure had the potential to for foodborne illnesses (illness caused by consuming contaminated food or beverages) to the residents related to food contamination. Findings: During an observation of DW 1's dishwashing and sanitizing practices on 7/25/2024 at 3:25 PM with the Dietary Services Supervisor (DSS), DW 1 washed and rinsed the dirty pans and trays in the sink, then touched the metal trays that were sanitized in the dishwasher. During an interview on 7/25/2024 at 3:26 PM, DSS stated DW 1 was not supposed to touch or move the sanitized metal trays while washing the dirty pans and trays. DSS stated another staff member, Dietary Aide 2 (DA 2), was assigned to put away the sanitized metal pans and trays to prevent cross-contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) of items that come in contact with food. During a review of the facility's Policy and Procedure (P&P 3), titled, Dish Washing, dated 2018, P&P 3 indicated all dishes must be properly sanitized through the dishwasher. In addition, during a review of the facility's Policy and Procedure (P&P 1), titled Standard Precautions, Enhanced Barrier Precautions and Transmission-Based Precautions, dated 6/25/2024, P&P 1 indicated the facility must provide guidelines for infection control practices to reduce the potential for transmission of pathogens. P&P 1 indicated when handling dishes, all tableware must be treated as contaminated and must be sanitized according to facility protocol.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Responsible Party (RP 85), who signed the binding arbitration agreement (BAA, contract between the facility and resident requiring disputes to be resolved by a neutral arbitrator [third party decision-maker] instead of a judge or jury in court) for one of three sampled residents (Resident 85) understood the BAA prior to signing. This failure had a potential to result in a decline in Resident 85's physical and/or psychosocial condition due to possible hardships related to arbitration proceedings. Findings: During a review of Resident 85's admission Record (AR 1), AR 1 indicated the facility originally admitted Resident 85 on 6/27/2022 and readmitted on [DATE] with diagnoses including dementia (impairment of brain functions that interfere with daily life), adult failure to thrive (worsening of physical frailty frequently accompanied by cognitive [ability to acquire, process, and recall information] impairment and/or functional disability in older adults), and polyarthritis (joint disease affecting multiple joints). AR 1 indicated Responsible Party 85 (RP 85) was Resident 85's representative. During a review of Resident 85's Initial History and Physical (H&P), dated 2/10/2024, the H&P indicated Resident 85 had increased confusion and did not have the capacity to understand and make decisions. During a review of Resident 85's Minimum Data Set (MDS, a standardized resident assessment and care-planning tool), dated 6/26/2024, the MDS indicated Resident 85 was dependent with toileting hygiene, showering/bathing, lower body dressing, putting on/taking off footwear, and mobility. The MDS indicated Resident 85 required substantial/maximal assistance with eating, oral hygiene, upper body dressing, and personal hygiene. During a review of Resident 85's undated Resident - Facility Arbitration Agreement (RFAA 1), the RFAA 1 indicated RP 85 signed RFAA 1 electronically on 7/6/2022. During a telephone interview on 7/25/2024 at 11:55 AM, RP 85 stated Admissions Coordinator (AC) sent RP 85 an electronic mail (e-mail) regarding signing the RFAA form upon Resident 85's admission to the facility. RP 85 stated RP 85 did not know what RFAA 1 was intended for. RP 85 stated no staff member explained the purpose and the terms of the RFAA 1. During an interview on 7/25/2024 at 12:55 PM, AC stated AC was responsible for offering RFAA to the resident (in general) and/or RP upon the resident's admission to the facility. AC stated AC has not met RP 85 in person and communicated with RP 85 via telephone. AC stated she recalled sending RP 85 an e-mail with the RFAA 1 and instructed RP 85 to call her for any questions. AC stated RP 85 did not call her to ask for any questions regarding RFAA 1. AC stated the space on the electronic RFAA form indicated the signature was optional. AC was unable to explain the details of the RFAA form, including the selection process of the neutral arbitrator or arbitration venue. During a review of the facility's Policy and Procedure (P&P 2), titled admission Criteria, dated 3/2023, P&P 2 indicated residents must not be required to sign the arbitration agreement as a condition of admission to the facility. P&P 2 indicated resident has the right to refuse to enter into the arbitration agreement and has the right to rescind it within 30 days if they signed the arbitration agreement on admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain the resident's dignity for six of six sampled residents (Residents 13, 15, 75, 86, 120, and 279) when: a. Facility staff failed to answer Residents 120 and 279's call light (a device used by a resident to signal his or her need for assistance from staff) in a timely manner. b. Facility staff stood next to Residents 13 and 15 while feeding lunch. c. Facility failed to ensure Residents 13, 75 and 86 were treated with dignity by protecting the residents' private space. LVN 2 and LVN 7 failed to knock multiple times prior to entering and/or opening the door of the residents' room. These failures resulted for the residents to feel frustrated and embarrassed and had the potential for the residents to experience a decline in psychosocial well-being. (Cross reference F689) Findings: a. During a review of Resident 120's AR, the AR indicated Resident 120 was admitted to the facility 6/28/2024 with diagnoses including spinal stenosis (the spaces in the spine narrow and create pressure on the spinal cord and nerve roots), muscle weakness, and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). During a review of Resident 120's care plan titled Bladder and Bowel Retraining, dated 6/28/2024, the care plan indicated facility staff should offer and assist Resident 120 use of the bathroom as needed. During a review of Resident 120's care plan titled ADL and Functional Mobility, dated 6/28/2024, the care plan indicated facility staff should offer and assist Resident 120 with Activities of Daily Living (ADLs, activities related to personal care) as needed. During a review of Resident 120's H&P dated 6/29/2024, the H&P indicated, Resident 120 had the capacity to make medical decisions. During a review of Resident 120's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/5/2024, the MDS indicated Resident 120 had no impairment in cognitive skills (the ability to make daily decisions). The MDS indicated Resident 120 was dependent on staff for toileting, dressing, and bathing. During a review of Resident 279's admission Record (AR) the AR indicated Resident 279 was admitted to the facility on [DATE] with diagnoses including osteoarthritis (type of joint disease that results from breakdown of joint cartilage [connective tissue] and underlying bone) of the left knee, cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), and hyperlipidemia ( high level of fat particles [lipids] in the blood). During a review of Resident 279's care plan titled Bladder and Bowel Retraining, dated 7/20/2024, the care plan indicated facility staff should offer and assist Resident 279 use of the bathroom as needed. During an interview on 7/22/2024 at 10:21 AM with Resident 279, Resident 279 stated on 7/21/2024, Resident 279 waited 45 minutes for staff to answer Resident 279's call light during the nighttime shift. Resident 279 stated Resident 279 had to go to the bathroom without assistance from staff because Resident 279 could not wait for staff any longer or Resident 279 would have bowel or bladder incontinence. Resident 279 stated the facility staff took a long time at night to come and help Resident 279. Resident 279 stated Resident 279 had to walk by herself to the bathroom. During a review of Resident 279's History and Physical (H&P), dated 7/23/2024, the H&P indicated Resident 279 had the capacity to make medical decisions. During an interview on 7/23/2024 at 2:56 PM with the Director of Nursing (DON), the DON stated call lights should be answered by facility staff immediately but no longer than five minutes. The DON stated residents (in general) could feel frustrated because the residents (in general) were not able to care for themselves. The DON stated residents (in general) would feel worthless if they have to wait too long for their call lights to be answered by staff. During an interview on 7/24/2024 at 3:11 PM with Resident 120, Resident 120 stated sometimes Resident 120 waited up to 2 hours for facility staff to answer the call light during the night. Resident 120 stated during these incidents, Resident 120 needed assistance with changing Resident 120's adult brief or assistance with moving Resident 120's legs because Resident 120's legs felt numb. Resident 120 stated Resident 120's legs would go numb because Resident 120 could not move Resident 120's legs due to a spinal cord injury (damage to any part of the spinal cord). Resident 120 stated when Resident 120's legs felt numb, Resident 120 needed help from staff to move the legs. Resident 120 stated moving his legs helped the numbness to go away. Resident 120 stated Resident 120 felt frustrated when Resident 120 waited a long time to get assistance from the facility staff. b. During a review of Resident 13's AR the AR indicated Resident 13 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), and asthma (a condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe). During a review of Resident 13's MDS, dated 6/1/2024, the MDS indicated Resident 13 had severely impaired cognitive skills. The MDS indicated Resident 13 was dependent on staff for toileting, dressing, and bathing. During a review of Resident 15's AR, the AR indicated Resident 15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes mellitus (elevated blood sugar levels), dementia (a group of thinking and social symptoms that interferes with daily functioning), and hypertension (high blood pressure). During a review of Resident 15's MDS, dated 5/31/2024, the MDS indicated Resident 15 had severely impaired cognitive skills (the ability to make daily decisions). The MDS indicated Resident 15 was dependent (helper does all the effort) on staff for bathing, dressing, and toileting. During a dining observation on 7/22/2024 at 12:56 PM, Resident 15 was sitting at a round table with four other residents (not identified). Speech Therapist 1 (ST 1) was standing at Resident 15's left side. ST 1 was feeding Resident 15 with lunch. During an interview on 7/22/2024 at 1:05 pm with ST 1, ST 1 stated ST 1 needed to sit next to Resident 15 to be at eye level with the resident while feeding. During an interview on 7/23/24 at 2:53 PM with the DON, the DON stated facility staff needed to sit down when feeding residents (in general) so the facility staff would be at eye level with the residents. The DON stated standing while feeding a resident would degrade (treat someone with contempt or disrespect) the resident. During a concurrent observation and interview on 7/24/2024 at 1:11 PM with Activity Assistant 1 (AA 1) , AA 1 was feeding Resident 13 with lunch. AA 1 was standing next to Resident 13. AA 1 stated AA 1 needed to sit down next to Resident 13 when feeding Resident 13. During a review of the facility's Policy and Procedure (P&P) titled, Dignity, revised February 2021, the P&P indicated, Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example .promptly responding to a resident's request for toileting assistance . The P&P indicated, Staff are expected to knock and request permission before entering residents' rooms. During a review of the facility's P&P titled, Answering the Call Light, revised September 2022, the P&P indicated, Answer the resident call system immediately. During a review of the facility's P&P titled, Assisting the Resident During Meals, revised December 20I3, the P&P indicated, Staff must be seating when feeding residents. c. During a review of Resident 13's AR the AR indicated Resident 13 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), and asthma (a condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe). During a review of Resident 13's H&P, dated 9/23/2023, the H&P indicated, Resident 13 could not make decisions. During a review of Resident 13's MDS, dated 6/1/2024, the MDS indicated Resident 13 had severely impaired cognitive skills. The MDS indicated Resident 13 was dependent on staff for toileting, dressing, and bathing. During a review of Resident 75's AR, the AR indicated, Resident 75 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including end stage renal disease (ESRD, kidneys lose the ability to remove waste and balance fluids) and essential (primary) hypertension (high blood pressure). During a review of Resident 75's H&P, dated 10/5/2023, the H&P indicated Resident 75 had the capacity to understand and make decisions. During a review of Resident 75's MDS, dated 6/25/24, the MDS indicated Resident 75 had intact cognition. During a review of Resident 86's AR, the AR indicated, Resident 86 was admitted to the facility on [DATE] with diagnoses including other specified diseases of liver, kidney failure and adult failure to thrive (a decline in older adults that manifests as a downward spiral of health and ability). During a review of Resident 86's MDS, dated 5/28/2024, the MDS indicated Resident 86 had severely impaired cognitive skills. During a review of Resident 86's H&P, dated 6/6/2024, the H&P indicated, Resident 86 did not have the capacity to understand and make decisions. During an observation on 7/23/2024 at 8:59 a.m. Resident 86 was in the room in bed and had a female visitor (unnamed). Resident 13 (Resident 86's roommate) was also in the room. Resident 13 was sitting up in a wheelchair at Resident 13's bedside. LVN 2 and LVN 7 were observed entering and exiting Resident 86 and Resident 13's room twice without knocking. LVN 2 then opened the restroom without knocking and Resident 75 was inside using the restroom. LVN 2 and LVN 7 stated, staff needed to knock the door to maintain the resident's dignity. During an interview on 7/24/2024 at 12:30 p.m. with the Director of Nursing, the DON stated, the facility's policy was for staff to knock before entering, introduce themselves and state their purpose. The DON stated, it was important for staff to knock the door, to show respect to the residents, to maintain dignity and for those residents with impaired vision to identify who the staff was. During an interview on 7/24/2024 at 1:06 p.m. with Resident 75, Resident 75 stated, Resident 75 got startled when LVN 2 opened the door to the restroom where Resident 75 was using without LVN 2 knocking first. During a review of the facility's P&P titled, Resident Rights, revised December 2019, the P&P indicated, employees should treat all residents with kindness, respect, and dignity. The P&P indicated, a list of resident's rights including right to a dignified existence and be treated with respect, kindness, and dignity. During a review of the facility's P&P titled, Dignity, revised February 2021, the P&P indicated, each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The P&P indicated, one of the many policy interpretation and implementation included residents are treated with dignity and respect at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's representative was provided education regarding the resident's right to formulate an Advance Directive (AD, a written instruction, such as a living will or durable power of attorney [legal document that allows someone to act on your behalf in certain situations] for health care, recognized under State law relating to the provision of health care when the individual is incapacitated) and the information was complete and accurate for two of eight sampled residents (Residents 4 and19). These deficient practices had the potential for the residents to receive life-sustaining care and/or treatment against their will. Findings : a.During a review of Resident 4's admission Record, (AR) dated 7/24/2024, the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- lung disease causing restricted airflow and breathing problems), type 2 diabetes mellitus (long term condition in which a high level of sugar is present in the bloodstream), and heart failure (a condition that develops when one's heart doesn't pump enough blood for the body's needs). During a review Resident 4's History and Physical (H&P) dated 5/9/2024, the H&P indicated Resident 4 did not have the capacity to understand or make decisions. During a review of Resident 4's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 5/14/2024, the MDS indicated Resident 4 required maximal assistance (helper does more than half of the effort) for toileting and personal hygiene. During a concurrent interview and record review on 7/24/2024 at 12:18 PM with Admissions Coordinator (AC), Resident 4's Advance Directive Acknowledgement (ADA) dated 5/8/2024 was reviewed. The ADA indicated the purpose of the form was to acknowledge that the resident or resident representative had been informed of their rights and of all rules and regulations regarding decisions concerning their medical care. The AC stated the ADA should be signed upon admission within three days. The AC stated the AC could not determine whether Resident 4's Representative understood the written materials provided or Resident 4's right's regarding decisions for their medical care based on the absence of check marks indicating the above. During a review of the facility's Policy and Procedure (P&P) titled, Advance Directive, dated 12/2016, the P&P indicated upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. The P&P further indicated if the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives and nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. b.During a review of Resident 19's admission Record (AR), the AR indicated Resident 19 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of bronchus or lung (lung cancer), muscle weakness, and chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems). The AR did not indicate who was Resident 19's Responsible Party. During a review of Resident 19's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/1/2024, the MDS indicated Resident 19 was severely impaired (never/rarely made decisions) in cognitive skills (ability to make daily decisions). The MDS indicated Resident 18 was dependent (helper does all the effort) on staff for toileting, dressing, and bathing. During a review of Resident 19's History and Physical (H&P), dated 6/28/2024, the H&P indicated Resident 19 did not have the mental capacity to understand and make medical decisions. During a concurrent interview and record review on 7/24/2024 at 11:54 AM with RN 1, Resident 19's POLST, dated 6/24/2024, and Resident 19's Advanced Directive Acknowledgement, dated 6/24/2024, were reviewed. RN 1 and RN 3 signed the documents indicating RN 1 and RN 3 were Resident 19's representative and legally recognized decisionmaker. RN 1 stated RN 1 and RN 3 were instructed to sign Resident 19's documents. RN 1 stated Resident 19 did not have a responsible party to represent Resident 19. RN 1 stated RN 1 did not know if the facility had a Bioethics Committee to make decisions for residents (in general) who were not capable to make decisions and did not have representatives. During an interview on 7/24/2024 at 12:00 PM with the facility's Administrator (ADM), the ADM stated if a resident was admitted to the facility and did not have a representative, but was self-responsible, the resident could sign their own admission documents (including POLST and AD Acknowledgment). The ADM stated if the resident did not have a representative and did not have the capacity to make their own decisions, the facility would refer to the facility's Bioethics Committee. The ADM stated the Bioethics Committee would consist of different staff members representing different areas affecting the resident care. The ADM stated nurses alone ( RN1 and RN 3) were not capable to make decisions for the unrepresented resident (in general). During a review of the facility's Policy and Procedure (P&P) titled, Advance Directives, revised December 2016, the P&P indicated, Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so . If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. During a review of the facility's policy and P&P titled, Bioethics, dated November 2021, the P&P indicated, It is the policy of this facility to uphold the rights of residents to participate in medical decisions. Sometimes situations arise wherein the decisions may be too complex for the surrogate decision-maker, or there is no surrogate. The P&P indicated, The Bioethics Committee is comprised of at least one physician, facility administrator, and a representative from nursing, social service, activities, dietary, rehabilitation, business office, and other departments as indicated. Furthermore, any facility staff member who has knowledge of the resident may be invited to attend.

Based on interviews and record review, the facility failed to notify the responsible party of two of three sampled residents (Residents 178 & 179) in writing regarding the Medicare Advance Beneficiary Notice (ABN, written notice that informs Medicare beneficiaries of certain items or services that Medicare may not pay for prior to receiving the items or services). This failure had the potential to negatively affect Residents 178 and 179's physical and psychosocial well-being due to responsible party's lack of information, including the resident's right to appeal. Findings: a. During a review of Resident 178's admission Record (AR 1), AR 1 indicated the facility initially admitted Resident 178 on 2/5/2024 with diagnoses including intracerebral hemorrhage (life-threatening bleeding inside the brain), hemiplegia and hemiparesis (paralysis or weakness on one side of the body), atelectasis (lung collapse), and chronic (long-standing) kidney disease. AR 1 indicated Responsible Party 178 (RP 178) was Resident 178's representative. During a review of Resident 178's History and Physical Examination (H&P 1), dated 2/6/2024, H&P 1 indicated Resident 178 did not have the capacity to understand and make decisions. During a review of Resident 178's Minimum Data Set (MDS 1, a standardized resident assessment and care-planning tool), dated 5/9/2024, MDS 1 indicated Resident 178 had moderate impairment in cognition (ability to acquire, process, and recall information). During a review of Resident 178's Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (ABN 1, Form CMS-10055), dated 5/6/2024, ABN 1 indicated Resident 178's health coverage for skilled services would end on 5/8/2024. ABN 1 indicated beginning 5/9/2024, Resident 178 would have to pay out of pocket for this care if no other insurance would cover these costs. ABN 1 indicated the facility staff notified RP 178 by telephone on 5/6/2024 at 1 PM regarding ABN 1. During a concurrent interview and record review on 7/25/2024 at 10:48 AM with the Business Office Manager (BOM), Resident 178's ABN 1 was reviewed. The BOM stated she did not provide a written copy of ABN 1 to RP 178. b. During a review of Resident 179's admission Record (AR 2), AR 2 indicated the facility initially admitted Resident 179 on 3/3/2024 wit diagnoses including type 2 diabetes mellitus (long-term condition of uncontrolled blood sugar), end-stage renal disease (kidney failure) with renal dialysis (treatment to remove extra fluid and waste products from the blood when kidneys were no longer able to function properly) dependency, heart failure, and dementia (impairment of brain functions that interfere with daily life). AR 2 indicated Responsible Party 179 (RP 179) was Resident 179's representative. During a review of Resident 179's ABN (ABN 2), dated 4/29/2024, ABN 2 indicated Resident 179's health coverage for skilled services would end on 5/1/2024. ABN 2 indicated beginning 5/2/2024, Resident 179 would have to pay out of pocket for this care if no other insurance would cover these costs. ABN 2 indicated the facility staff notified RP 179 by telephone on 4/29/2024 at 10:15 AM regarding ABN 2. During a review of Resident 179's Minimum Data Set (MDS 2), dated 5/2/2024, MDS 2 indicated Resident 179 had severe impairment in cognition. MDS 2 indicated Resident 179 required substantial/maximal assistance with toileting hygiene, showering/bathing self and required partial/moderate assistance with upper and lower body dressing, putting on/taking off footwear, and mobility. During a telephone interview on 7/25/2024 at 10:24 AM, RP 179 stated she could not recall being informed about or receiving a written copy of Resident 179's ABN 2. During a concurrent interview and record review on 7/25/2024 at 10:48 AM with BOM, Resident 179's ABN 2 was reviewed. The BOM stated she did not provide a written copy of ABN 2 to RP 179. During an interview on 7/25/2024 at 3:15 PM, Business Office Assistant (BOA) stated not providing ABN in writing per facility policy would lead to missed information relayed to the resident or responsible party (in general). During a review of the facility's policy and procedure (P&P 6), titled Medicare Advance Beneficiary Notice, dated 4/2021, P&P 6 indicated the following: 1. If the Admissions/Benefits Coordinator believes (upon admission or during the resident's stay) that Medicare Part A of the Fee for Service Medicare Program would not pay for an otherwise covered skilled service(s), the resident or representative must be notified in writing why the service(s) might not be covered and of the resident's potential liability for payment of the non-covered service(s). 2. The facility must issue the Skilled Nursing Facility Advance Beneficiary Notice (CMS form 10055) to the resident prior to providing care that Medicare usually covers but might not pay for because the care is considered not medically reasonable and necessary, or custodial.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement fall safety intervention for two of three sampled residents (Residents 55 and 279) in accordance with the facility's Policy and Procedure (P&P) titled, Falls - Clinical Protocol,, by failing to: a. Ensure the facility staff provided supervision when Resident 279 ambulated in her room and/or while ambulating to the bathroom. b. Ensure the bed for Resident 55 who was assessed as high risk for fall and had a history of falling, was at the lowest position and floor mats were in place. These failures had the potential to result in falls/injury for Residents 55 and 279. (Cross reference F550) Findings: a. During a review of Resident 279's admission Record (AR) the AR indicated Resident 279 was admitted to the facility on [DATE] with diagnoses including osteoarthritis (type of joint disease that results from breakdown of joint cartilage [connective tissue] and underlying bone) of the left knee, cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), and hyperlipidemia ( high level of fat particles [lipids] in the blood). During a review of Resident 279's care plan titled Bladder and Bowel Retraining, dated 7/20/2024, the care plan indicated facility staff should offer and assist Resident 279 use of the bathroom as needed. During a review of Resident 279's care plan titled Fall Risk, dated 7/20/2024, the care plan indicated Resident 279 had a history of falling. The care plan indicated Resident 279 required 1 person assistance from staff for assistance to transfer from the bed. During a review of Resident 279's History and Physical (H&P), dated 7/23/2024, the H&P indicated Resident 279 had the capacity to make medical decisions. During an interview on 7/22/2024 at 10:21 AM with Resident 279, Resident 279 stated on 7/21/2024, Resident 279 waited 45 minutes for staff to answer Resident 279's call light during the nighttime shift. Resident 279 stated Resident 279 had to go to the bathroom without assistance from staff because Resident 279 could not wait for staff any longer or Resident 279 would have bowel or bladder incontinence. Resident 279 stated the facility staff took a long time at night to come and help Resident 279. Resident 279 stated Resident 279 had to walk by herself to the bathroom. During an observation on 7/24/2024 at 8:33 AM, Resident 279 was walking alone in her room. There were no staff in Resident 279's room. During an interview on 7/24/2024 at 8:57 AM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 279 required one person transfer (staff person is present to give assistance) when walking to the bathroom. During an interview on 7/24/2024 at 9:10 AM with Resident 279, Resident 279 stated the facility staff did not inform Resident 279 to call for help/assistance with walking, before getting out of the bed. Resident 279 stated facility staff knew Resident 279 would get out of bed on her own and staff did not have a problem with it. b. During a review of Resident 55's AR, the AR indicated Resident 44 was admitted to the facility on [DATE] with diagnoses including wedge compression fracture of second lumbar vertebra (broken bone of the backbone), malignant neoplasm of the stomach (cancer of the stomach) and hypertension (high blood pressure). During a review of Resident 55's MDS dated 4/8/2024, the MDS indicated Resident 55 had moderately impaired cognitive skills (ability to make daily decisions). The MDS indicated Resident 55 required partial/moderate (helper does less than half the effort) from staff for toileting and bathing. During a review of Resident 55's care plan titled Fall Risk, dated 7/20/2024, the care plan indicated Resident 55 had a history of falling. The care plan indicated Resident 55 was at high risk of falling. The care plan indicated facility staff needed to place Resident 55's bed in the lowest position. The care plan indicated to place floor mats on both sides of Resident 55's bed. During a review of Resident 55's Assessment Outcome, dated 7/20/2024, the Assessment Outcome indicated Resident 55 was at a high risk of falling. During a concurrent observation and interview on 7/24/2024 at 12:36 PM, with LVN 2 in Resident 55's room, Resident 55's bed was in a raised position. There were no floor mats on either side of Resident 55's bed. LVN 2 lowered the bed to its lowest position. During an interview on 7/25/2024 at 10:00 AM with the Director of Nursing (DON), the DON stated the purpose of Resident 55's floor mats were to minimize injuries if Resident 55 fell. During a review of the facility's P&P titled, Falls - Clinical Protocol, revised March 2018, the P&P indicated, Based on the preceding assessment. the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based interview and record review, the facility failed to monitor fluid restriction on 7/2/2024, 7/4/2024, 7/5/2024, 7/9/2024, 7/14/2024, 7/15/2024, 7/21/2024 and 7/23/2024 for one of one sampled resident (Resident 49) in accordance with the physician's orders. These failures had the potential to lead to fluid overload (too much fluid volume in the body) and overall decline in health. Findings: During a review of Resident 49's admission Record (AR), the AR indicated Resident 49 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including heart failure (a condition that develops when one's heart doesn't pump enough blood for the body's needs), end stage renal disease (a condition in which a person's kidney's stop functioning on a permanent basis) and dependence on renal dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working). During a review of Resident 49's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 6/30/2024, the MDS indicated Resident 49 had severe impairment with cognitive skills (ability to make decisions, reason). The MDS indicated Resident 49 was dependent (helper does all of the effort) on staff for toileting and eating. During a review of Resident 49's Order Summary Report, (OSR) dated with active orders as of 7/24/2024, the OSR indicated fluid restriction 1000 milliliters (ml-unit of volume) per 24 hours. Dietary total limit, 600 ml: Breakfast, 240 ml Lunch - 120 ml Dinner - 240 ml Nursing total limit 400 ml: Day shift 180 ml Evening shift - 180 ml Night shift - 40 ml every shift. During a concurrent interview and record review on 7/24/2024 at 11:44 AM with Licensed Vocational Nurse 4 (LVN 4), Resident 49's Intake and Output Form (I&O) was reviewed. The I&O did not indicate any record of Resident 49's intake or output on 7/2/2024, 7/4/2024, 7/5/2024, 7/9/2024, 7/14/2024, 7/15/2024, 7/21/2024 and 7/23/2024. LVN 4 stated Resident 49 had an active order for fluid restriction and all intakes and outputs should be recorded on the I&O form by the nursing staff. LVN 4 stated Resident 49 had a fluid restriction because Resident 49 required dialysis and if the fluid restriction was not followed it would lead to fluid overload for Resident 49. During a concurrent interview and record review on 7/25/2024 at 4:36 AM with the Director of Nursing (DON), Resident 49's I&O was reviewed. The DON stated there was no documentation for input or output on 7/2/2024, 7/4/2024, 7/5/2024, 7/9/2024, 7/14/2024, 7/15/2024, 7/21/2024 and 7/23/2024 and there had been no documentation from the nightshift for any dates from 7/1/2024 to 7/23/2024. The DON stated the facility could not prove the fluid restriction was being followed because of the missing documentation and if the restriction was not followed it would result to shortness of breath, edema (water retention) and overall decline in health for Resident 49. During a review of the facility's Policy and Procedure (P&P) titled, Intake and Output dated 6/2019, the P&P indicated intake and output shall be documented when indicated by resident's condition and/or treatment. The P&P further indicated nursing staff shall be responsible for documenting the intake and output each shift and record in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 13's admission Record (AR), the AR indicated, Resident 13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements), Chronic Obstructive Pulmonary Disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) and other chronic pancreatitis (a long-standing inflammation of the pancreas). During a review of Resident 13's History and Physical Examination (H&P), dated 9/23/23, the H&P indicated Resident 13 could not make medical decisions. During a review of Resident 13's Minimum Data Set (MDS, an assessment and screening tool), dated 6/1/2024, the MDS indicated Resident cognitive (ability to think and process information) status was severely impaired. During a review of Resident 13's Order Summary Report (OSR), dated as of 7/25/2024, the OSR indicated an order dated 9/18/2023 for licensed staff to administer to Resident 13, Restasis Ophthalmic Emulsion 0.05% [Clyclosporine (Ophth], a medication for treatment of dry eye disease), instill one (1) drop in both eyes every twelve (12) hours for dry eyes. During a concurrent medication administration observation and interview on 7/23/2024 at 9:29 a.m. with LVN 2 and LVN 7, LVN 2 went inside the restroom of Resident 13 to get toilet paper from inside the restroom to use for eye drop administration of Resident 13. LVN 2 stated, LVN 2 should not use the toilet paper from the restroom because the toilet paper could be contaminated. During an interview on 7/24/2024 at 8:13 a.m. with the Infection Preventionist (IP), the IP stated, licensed staff should not use toilet paper from the restroom to use for eye drop administration for infection control. The IP stated the restroom was a shared restroom and the toilet paper in the restroom could have been touched by multiple people and could have been contaminated. During a review of the facility's P&P titled, Surveillance for Infections, revised September 2023, the P&P indicated, the facility employs an infection control surveillance program to help prevent to the extent possible the development and transmission of disease and infection. During a review of the facility's P&P titled, Instillation of Eye Drops, revised January 2024, the P&P indicated, the purpose of the procedure was to provide guidelines for instillation of eye drops to treat medical conditions, eye infections and dry eyes. The P&P indicated, one of the steps in the procedure was to gently dry the eyelid with cotton ball if dripping occurs. During a review of the facility's P&P titled, Standard Precautions, Enhanced Barrier Precautions and Transmission Based Precautions, revised 6/25/24, the P&P indicated, the purpose of the P&P was to provide guidelines for infection control practices to reduce the potential for transmission of pathogens (any organism that causes disease). Based on observation, interview, and record review, the facility failed to implement interventions to prevent and control the spread of infections in the facility in accordance with the facility's policies and procedures and national health guidelines. A. One of one Certified Nursing Assistant (CNA 1) did not don (wear) the required protective personal equipment (PPE, equipment worn to minimize exposure to a variety of hazards) prior to entering the room of one of one sampled resident (Resident 55), who was on contact isolation precautions (type of transmission-based precaution requiring the use of gown and gloves to prevent transmission of infectious agents that are spread by direct or indirect contact with the resident or the resident's environment). B. One of one Licensed Vocational Nurse (LVN 2) attempted to use the toilet paper in the shared bathroom when administering eye drops to Resident 13. These failures had the potential to result in an increased spread of infection in the facility. Findings: a. During a review of Resident 55's admission Record (AR 1), AR 1 indicated the facility admitted Resident 55 on 4/6/2024 with diagnoses including enterocolitis (inflammation of intestines) due to Clostridium difficile (C. difficile, bacterium that causes infection of the large intestine and spreads easily in hospitals and nursing homes from the caregivers' hands to the other patients/residents they provide care for and through spores that can live for months on common surfaces) and dementia (impairment of brain functions that interfere with daily life). During a review of Resident 55's Minimum Data Set (MDS 1, a standardized resident assessment and care-planning tool), dated 4/8/2024, MDS 1 indicated Resident 55 had moderate impairment in cognition (ability to acquire, process, and recall information). MDS 1 indicated Resident 55 required partial/moderate assistance with toileting hygiene, showering/bathing, lower body dressing, putting on/taking off footwear, and mobility. MDS 1 indicated Resident 55 required supervision or touching assistance with eating, oral hygiene, upper body dressing, and personal hygiene. During a review of Resident 55's History and Physical Examination (H&P 1), dated 4/9/2024, H&P 1 indicated Resident 55 had the capacity to understand and make decisions. During a review of Resident 55's Order Summary Report (OSR 1) for 7/2024, OSR 1 indicated Resident 55 was on fortified diet, mechanical soft texture, regular liquid consistency, 6 small meals per day as ordered by the physician on 7/20/2024. During a review of Resident 55's Care Plan (CP 1), titled MRSA-VRE-ORSA-ESBL-C.DIFFICILE, dated 7/20/2024, CP 1 indicated Resident 55 was placed on contact isolation (alone in the room) due to C. difficile. During a concurrent observation and interview on 7/24/2024 at 12:56 PM with Dietary Services Supervisor (DSS), Certified Nursing Assistant 1 (CNA 1) entered Resident 55's room to deliver the lunch tray without the required PPE. A Contact Isolation signage was posted on the wall, and an isolation cart with PPE was placed by Resident 55's room entrance. CNA 1 stated she did not wear the required PPE as posted because CNA 1 was only delivering a meal tray and not providing resident care. During an interview on 7/25/2024 at 5:50 PM, the Director of Nursing (DON) stated to prevent transmission of infection, all staff must wear the required PPE (gown and gloves) prior to entering an isolation room. During a review of the facility's Policy and Procedure (P&P 1), titled Standard Precautions, Enhanced Barrier Precautions and Transmission-Based Precautions, dated 6/25/2024, P&P 1 indicated contact precautions required the use of gown and gloves for all contact with body fluids and with environmental surfaces in the resident's room. During a review of the Centers for Disease Control and Prevention (CDC) guidelines, titled Transmission-Based Precautions, dated 4/3/2024, the CDC guidelines indicated donning PPE, including gown and gloves, must be done upon room entry, and properly discarding PPE must be done before exiting the resident room to contain pathogens. [Source: https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a personalized care plan for one of nine sampled residents (Resident 1) by failing to ensure Resident 1 ' s care plan indicated how many staff were needed to provide care to Resident 1. This failure had the potential to result in Resident 1 not receiving necessary and appropriate care. Cross Reference F726 and F689 Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included functional Quadriplegia (a form of paralysis that affects all four limbs), contracture (a condition of shortening and hardening of muscles, tendons, or other tissue) of muscles on both arms and legs and dementia (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 8/18/2023, indicated Resident 1 indicates the resident had severely impaired cognitive skill (ability to think and reason). The MDS indicated Resident 1 required extensive assistance of two or more persons to move to and from lying position, to turn side to side and to position body while in bed. During a review of Resident 1 ' s Admission/readmission Assessment (AA), dated on 12/6/2023, the AA indicated Resident 1 was at risk for falls. The AA indicated Resident 1 had on and off confusion, was chair bound (confined to a chair, inability to ambulate even with assistance), had balance problem while standing and sitting, decreased muscular coordination and poor vision with or without glasses. During a review of Resident 1 ' s Activities of Daily Living (ADL) Self Care Performance Deficit Care Plan, initiated on 12/6/2023, the Care Plan indicated Resident 1 required assistance with ADLs, but did not indicate how many staff were needed to provide care to Resident 1. The Care Plan indicated the Care Plan was revised on 1/2/2024 (after Resident 1's fall incident) to indicate Resident 1 required two staff participation to provide care to Resident 1. During a concurrent interview and record review on 1/5/2024 at 5:52 PM with DON in the facility ' s conference room, DON reviewed Resident 1 ' s care plan. DON stated, Resident 1 ' s care plan did not indicate how many staff were needed to provide care to Resident 1. DON stated, it was important to have a personalized care plan because it ' s our (facility staff) guide on what type of care and assistance to provide for that particular resident. During a review of facility ' s policy and procedure (P&P) titled Care Plans-Comprehensive, revised 9/2010, the P&P indicated, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident ' s medical, nursing, mental and psychological needs is developed for each resident. The P&P indicated, The comprehensive care plan is based on a thorough assessment, that includes, but is not limited to, the MDS .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) had the competency to provide care to residents who were on a low air loss (LAL) mattress (a kind of mattress used for residents who are at risk of developing pressure sores or already have pressure sores) when CNA 1 did not notify a licensed nurse to set Resident 1 ' s low air loss mattress on static mode (firm surface set in place and unlikely to move) before providing care to Resident 1. As a result, on 1/2/2024 at 11:20 AM, Resident 1 fell from her bed to the floor. Resident 1 sustained acute displaced fracture (bone breaks into two or more pieces and move out of alignment) at the neck of the right humerus (upper arm bone) and acute nondisplaced fracture (fracture in which the bone cracks or breaks but remains in proper alignment) at the neck of the right femur (thigh bone) and the sacrum (S1, a structure located at the base of the spine). Resident 1 was transferred and admitted to General Acute Care Hospital 1 (GACH 1) on 1/3/2024 at 1:00 AM for further evaluation. Cross Reference F689 and F656 Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included functional Quadriplegia (a form of paralysis that affects all four limbs), contracture (a condition of shortening and hardening of muscles, tendons, or other tissue) of muscles on both arms and legs and dementia (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning). During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1 had severely impaired cognition (ability to think and process information), and required extensive assistance (resident involved in activity, staff provide weight-bearing support) from two or more persons with physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed). During a review of Resident 1 ' s Admission/readmission Assessment (AA), dated on 12/6/2023, the AA indicated Resident 1 was at risk for falls. The AA indicated Resident 1 had on and off confusion, was chair bound (confined to a chair, inability to ambulate even with assistance), had balance problem while standing and sitting, had decreased muscular coordination, and had poor vision with or without glasses. During a review of Resident 1 ' s physician ' s order, dated 12/6/2023, the physician ' s order indicated Resident 1 may have low air loss mattress for skin management. During a review of Resident 1 ' s Activities of Daily Living (ADL) Self Care Performance Deficit Care Plan, initiated on 12/6/23 and revised on 1/2/2024 (after Resident 1's fall incident), the care plan indicated Resident 1 required two staff participation when providing care to Resident 1. During a review of Resident 1 ' s History and Physical (H&P) dated on 12/7/2023 indicated Resident 1 does not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/9/2023, the MDS indicated Resident 1 was totally dependent and had impaired movement on both arms and legs. The MDS indicated Resident 1 was dependent on staff to roll from lying on back to left and right side and return to lying on back on the bed. During a review of Resident 1 ' s Situation, Background, Appearance, Review (SBAR, a standardized communication tool between healthcare providers) Communication Form, dated 1/2/2024, the SBAR indicated CNA 1 was changing Resident 1 ' s brief and rolled Resident 1 onto the right side and Resident 1 slid off the bed. The SBAR indicated, Resident 1's Primary Physician was notified and recommended for Resident 1 to have X-ray (pictures of the inside of the body) on the right side of the body. During a review of Resident 1's X-ray report, the report dated 1/2/2024 and timed 6:24 PM indicated Resident 1 sustained acute displaced fracture (fracture in which the bone cracks or breaks the ends of the bone have come out of alignment) at the neck of the right humerus (upper arm bone) and an acute nondisplaced fracture (fracture in which the bone cracks or breaks but remains in proper alignment) at the neck of right femur. During a review of Resident 1 ' s Progress Notes, dated 1/3/2024 and timed 1 AM indicated Resident 1 was transferred to GACH 1. During a review of Resident 1 ' s GACH 1 ED Provider Note, dated 1/3/2024 and timed 7:25 AM, indicated GACH 1 ED Physician discussed Resident 1's case with Resident 1 ' s Primary Physician (PP) who agreed to admit Resident 1 to GACH 1 for treatment and to be seen by an orthopedist (a doctor who specializes on injuries and diseases affecting the bones, muscles, and joints). During a review of Resident 1 ' s GACH 1 Computed Tomography scan (CT scan, a medical imaging technique used to obtain detailed internal images of the body) of the right hip dated 1/3/2024 and timed 7:58 AM, the result indicated Resident 1 had suspicion of an acute nondisplaced fracture of S1. During a review of Resident 1 ' s GACH 1 X-ray of right shoulder dated 1/3/2024 and timed 9:58 AM the result indicated Resident 1 had a fracture of the surgical neck of the right humerus. During a review of Resident 1 ' s GACH 1 Orthopedist consultation notes, dated 1/4/2024 and timed 8:56 AM, the notes indicated the plan is non operative management, ordered sling for comfort however this is not essential given to patient is chronically bed bound and has contractures, follow up 6 weeks with new x-rays, pain control per primary and non-weight bearing on right upper extremity. During an interview on 1/4/2024 at 4:20 PM with the Director of Nursing (DON), the DON stated, Resident 1 fell on 1/2/2024 at 11:40 AM when CNA 1 was changing Resident 1 ' s brief and turning Resident 1 to Resident 1 ' s right side. The DON stated, X-ray was done on the same day and showed Resident 1 sustained a right humerus fracture. The DON stated Resident 1 ' s Primary Physician ordered to transfer Resident 1 to GACH 1. The DON stated, Resident 1 was on a LAL mattress. During an interview on 1/5/2024 at 9:30 AM with TXN 1, TXN 1 stated LAL mattress had to be set on static mode when turning and/or working with Resident 1 on the LAL mattress. TXN 1 stated, Resident 1 was unable to move in bed by herself. TXN 1 stated nursing staff (in general) had to assist Resident 1 with bed mobility. During an interview on 1/5/2024 at 3:25 PM with CNA 1, CNA 1 stated, she did not notify LVN 4 or TXN 1 to set the LAL mattress on static mode before providing care to Resident 1. CNA 1 stated, the facility trained her that the control panel for the LAL mattress was specifically for the charge nurses (LVNs) or treatment nurses (TXNs) to adjust the setting for LAL mattress. CNA 1 stated CNAs (in general) were not allowed to touch or adjust the setting for the LAL mattress. During an interview on 1/5/2024 at 5:12 PM with the DON, the DON stated, the facility ' s expectation was for CNA 1 to notify the licensed nurses (LVNs or TXNs) to set the LAL mattress on static mode when providing care to Resident 1, so the LAL mattress would not move (air inside the LAL mattress would not shift). The DON stated, when the LAL mattress was not on static mode, the mattress could move, and the distribution of the resident's weight would not be even and could cause the resident to fall out of the LAL mattress. During a review of CNA 1 ' s Competency Evaluation dated 10/14/2023, the evaluation indicated CNA 1 was trained on, Positioning/Special Mattress. During an interview on 1/5/2024 at 5:49 PM with DSD, DSD reviewed CNA 1 ' s Competency Evaluation, dated 10/14/2023. DSD stated, CNA 1 ' s Competency Evaluation, dated 10/14/2023, indicated CNA 1 was competent on providing care to residents on LAL mattress and received special mattress training which included having the licensed nurses (LVN or TXN) set the LAL mattress in static mode during bed bath or when providing care to any residents (in general) on the LAL mattress. DSD stated, setting the LAL mattress on static mode prevented the LAL from making sudden movements which could cause a fall. During a review of facility ' s policy and procedure (P&P) titled Competency of Nursing Staff, revised on 5/2019, the P&P indicated .nursing assistants employed by the facility will .demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care . During a review of the Manufacturer ' s Manual, titled DynaRest Airfloat 100, Air Mattress with Pump, the manual indicated In static mode, the mattress provides a firm surface that makes it easier for the patient to transfer or reposition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain infection prevention and control practices (a set of practices that prevent or stop the spread the of infection and/or diseases in the healthcare setting) in accordance with the facility ' s policy and procedure and Centers for Disease Control and Prevention (CDC, a federal government agency whose mission is to protect public health by preventing and controlling disease, injury, and disability) guidelines by failing to: Ensure three of four staff performed hand hygiene (procedures that included the use of alcohol-based hand rub (ABHR- containing 60%-90% alcohol) and hand washing with soap and water before entering and after providing care to one of six sampled residents (Resident 6), who was positive for COVID-19 (Corona virus 2019, a contagious virus that causes mild to severe upper respiratory infection). These deficient practices had the potential to spread infectious agents to other residents, visitors, and/or facility staff that could result in a widespread infection in the facility. Findings: 1. During a review of Resident 6's admission Record indicated Resident 6 was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of COVID-19 and chronic obstructive pulmonary disease (COPD- lung disease causing restricted airflow and breathing problems). During a review of Resident 6's Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 7/24/2023, indicated Resident 6 had intact cognition (ability to think, remember, and reason), required limited assistance with bed mobility, eating personal hygiene, and required extensive assistance with transfers, walking, locomotion, dressing, and toilet use. During a concurrent observation and interview on 9/26/2023 at 2:09 pm, Certified Nurse Assistant 1 (CNA 1) was observed performing hand hygiene with ABHR for three seconds. CNA 1 donned (put on) gloves and a gown, then entered Resident 6 ' s room to assist Resident 6 with the television (TV). CNA 1 then touched Resident 6's bedrail and bedding. CNA 1 then removed the gown and gloves and exited Resident 6 ' s room, and applied ABHR for 3 seconds. CNA 1 stated, it was important to sanitize her hands with ABHR long enough to kill the germs. CNA 1 stated, she was unsure how long ABHR should be applied for, or how long handwashing should be done. CNA 1 stated, Resident 6 had COVID-19. 2. During an observation on 9/26/2023 at 2:13 pm, Registered Nurse Supervisor 1 (RNS 1) was observed applying ABHR for 2 seconds and then shook her hands (as if to dry her hands). RNS 1 then prepared medication at the medication cart. The signage next to Resident 6 ' s door indicated to apply ABHR until hands were dry. During an observation on 9/26/2023 at 2:22 pm, of the signage at the nurses ' station across from Resident 6 ' s room, indicated staff should sanitize their hands with ABHR for 30 seconds, until hands were dry. During an interview on 9/26/2023 at 2:38 pm, RNS 1 stated, when applying ABHR, the ABHR was too applied on hands until all the ABHR was dry. RNS 1 stated, ABHR did not dry after two seconds of application. RNS 1 stated she was supposed to rub her hands until dry in order for the ABHR to stop the spread of infections. RNS 1 stated, if the ABHR was still wet on RNS 1 ' s hands, the ABHR wasn ' t effective at killing germs. RNS 1 stated, Resident 6 was positive for COVID-19. 3. During a concurrent observation and interview on 9/26/2023 at 2:17 pm, Occupational Therapist Assistant 1 (OTA 1) was observed donning gloves and a gown. OTA 1 did not perform hand hygiene before donning his gloves. OTA 1 was observed touching Resident 6 and providing care to Resident 6. OTA 1 then removed his gloves and gown and walked out of Resident 6 ' s room. OTA 1 then opened the isolation personal protective equipment (PPE, refers to protective clothing, helmets, gloves, face shields, goggles, facemasks and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness) cart and pulled out a mask, and applied ABHR for 2 seconds. OTA 1 went to the next room and took out a face shield from that room ' s isolation PPE cart. OTA 1 stated, he was supposed to perform hand hygiene before donning the PPE otherwise he could spread bacteria or other pathogens to the residents. OTA 1 stated, Resident 6 had COVID-19. OTA 1 stated, he did not know how long to perform hand hygiene for when applying ABHR. During an interview on 9/26/2023 at 5:36 pm, with the Infection Prevention Nurse (IPN, nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment) and the Director of Staffing Development (DSD), the IPN and DSD stated, hand hygiene with ABHR should be done for 30 seconds and until rubbed dry on the hands. The IPN and DSD stated, hand hygiene was done to stop the transfer of infectious agents to other residents. The IPN stated, if staff were not accurately applying ABHR or performing hand hygiene, staff could be transferring infectious agents to other residents who could get sick and die. The IPN and DSD stated, applying ABHR for two or three seconds was not effective in kill germs. The IPN and DSD stated, Resident 6 ' s room was a isolation precaution room because the resident ' s in the room were positive for COVID-19. During a review of the facility ' s policy and procedure (P&P) titled, Handwashing/Hygiene, revised 8/8/19, indicated the facility considered hand hygiene the primary means to prevent the spread of infections. The P&P indicated staff used ABHR in situations like, before and after direct contact with residents, before preparing and handling medications, and before and after entering isolation precaution rooms. The P&P indicated to apply a generous amount of ABHR to the palm of the hand and rub together. The P&P indicated to cover all surfaces of hands and fingers until hands were dry. During a review of the CDC ' s, Hand Hygiene Guidance, reviewed on 5/1/2023, the Hand Hygiene Guidance indicated healthcare personnel should use alcohol-based hand rub or wash with soap and water for the following clinical indications, including but not limited to immediately before touching a resident, after touching a resident or the resident's immediate environment. The guidance also indicated, healthcare facilities should: require healthcare personnel to perform hand hygiene in accordance with CDC recommendations. https://www.cdc.gov/handhygiene/providers/guideline.html

Based on observation, interview, and record review, the facility failed to ensure a safe and functional environment by failing to obtain the requisite permits/approval from the Department of Healthcare Access and Information (HCAI - the State agency having jurisdiction that reviews and approves plans for construction, repairs, renovations, and remodeling made to buildings to comply with State codes) for the installation/replacement of 13 HVAC (heating, ventilation, and air conditioning) units and failed to notify the State authority having jurisdiction (AHJ). This deficient practice does not ensure that the HVAC units are properly installed and may have a negative effect on the health, safety, and welfare of the residents, staff, and visitors. Findings: On 3/23/23, at 2:30 pm, a complaint investigation was initiated regarding unpermitted hot water heaters and unpermitted HVAC units at the facility. The administrator and the maintenance supervisor were informed of the complaint visit. On 3/23/23, at 2:35 pm, during an interview, the administrator stated that the facility has the HCAI permits for the hot water heaters, but the HVAC units were installed by the previous facility owner. The current owner obtained the facility over 4 years ago. The maintenance supervisor stated that there are seven hot water heaters and a total of 14 HVAC units, nine on the roof and five on the ground. On 3/23/23, between 3:20 pm and 4:30 pm, during a general observation of the facility, there were seven hot water heaters. Five HVAC units were observed on the ground level and nine HVAC units on the roof. The labels on 13 of the HVAC units had manufacture dates between 2004 and 2019. On 3/23/23, at 4:45 pm, during an interview, the administrator stated he would look for all HCAI permits for the hot water heaters and the HVAC unit. On 4/7/23, a review of two HCAI construction advisory reports, both dated 3/29/23, indicated that 13 of the 14 HVAC units were installed without HCAI involvement or approval. On 4/11/23, at 10:10 am., a revisit was conducted at the facility. The administrator was informed of the revisit. On 4/11/23, at 10:15 am, an interview was conducted with the administrator regarding the permits for the hot water heaters and HVAC units. The administrator had a valid HCAI permit for the hot water heaters, dated 12/7/21. The administrator stated he did not have any HCAI permits for the HVAC units.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain informed consent (a process by which residents or their responsible parties have the choice to opt in to certain medication therapy or treatments once they are educated about the risks and benefits) prior to prescribing psychotropic medications (medications that affect brain activities associated with mental processes and behavior) for one of five sampled residents (Resident 116.) This deficient practice could have denied Resident 116 the right to be informed regarding the risks and benefits of psychotropic medication therapy possibly resulting in diminished overall physical, mental, and psychosocial well-being. Findings: A review of Resident 116's admission Record, dated 5/21/21, indicated she was readmitted to the facility on [DATE] with diagnoses including: major depressive disorder (MDD- a mental disorder characterized by depressed mood, a lack of interest in activities or socializing, or poor appetite) and anxiety disorder (a mental disorder characterized by feeling or worry or fear that interfere with daily activities.) A review of Resident 116's Order Summary Report, dated 4/30/21, indicated on 4/26/21, the physician prescribed the following psychotropic therapy: 1. Ambien (a medication used to treat insomnia - the inability to sleep) 5 milligrams (mg - a unit of measure for mass) by mouth every 24 hours as needed for insomnia manifested by unable to sleep. 2. Lexapro (a medication used to treat MDD) 10 mg by mouth once daily for depression manifested by verbalization of feeling sadness. 3. Seroquel (a medication sed to treat hallucinations - seeing or hearing things that are not there) 25 mg by mouth at bedtime for anxiety manifested by aggressive behaviors like trying to hit or kick toward staffs. A review of Resident 116's clinical record contained no documentation that the facility obtained informed consent from the resident or the responsible party regarding the psychotropic medications prescribed on 4/26/21. On 5/21/21 at 12:22 p.m., during an interview, the director of nursing (DON) stated the facility failed to obtain informed consent for the use of psychotropic medications for Resident 116 after the resident was readmitted back to the facility on 4/26/21. On 5/21/21 at 1 p.m., during an interview, the DON stated the facility was required to obtain a new informed consent when residents were readmitted for any psychotropic medications even if the residents were on those medications before. The DON stated that the last date of informed consent for Resident 116's psychotropic therapy was from October 2020, prior to her most recent readmission. The DON stated the importance of obtaining informed consent so that residents can be informed of all the risks versus benefits of psychotropic therapy and choose to decline treatment if they wish. A review of the facility's undated policy Informed Consent for Psychotropic Medications and Physical Restraints, indicated T22 72528 requires that informed consents be obtained for all psychotherapeutic drugs . the facility staff is responsible for assure that consent was obtained .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to accommodate resident's preference for 1 of 2 sampled residents (Resident 4), to go back inside his room to keep warm rather than stay in the facility hallway without clothes and wrapped in a thin blanket while waiting for his turn to use the facility's common shower room. This failure resulted in not meeting the right to make a choice by the resident. Findings: A review of the admission Record indicated Resident 4 was admitted to the facility on [DATE] with a diagnosis that included chronic obstructive pulmonary disease (COPD, a lung disease that block airflow and make it difficult to breathe). A review of the Minimum Data Set (MDS, a standardized resident assessment and care-screening tool), dated 5/05/2021, indicated Resident 4 was independent with cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making. Resident 4 was able to make needs known and understand others. The MDS indicated Resident 4 required limited assistance (the resident was highly involved in activity and only needs a light touched to guide a hand or a shoulder) with bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. On 5/18/2021 at 10:38 a.m., during an interview with Resident 4, he stated there was always a line outside the facility's common Shower Room. Resident 4 stated he was naked and cold while sitting on a shower chair waiting for 5 to 6 minutes. Resident 4 stated the facility's nursing staff only provided him with a thin blanket to cover himself. On 5/19/2021 at 9:30 a.m., during an interview with Nurse Assistant (NA) 3, she stated residents usually wait about 15 minutes in the facility hallway outside the shower rooms waiting for their turn to shower. NA 3 stated that they would provide residents with extra towels to cover themselves if residents feel cold. On 5/20/2021 at 10:25 a.m., during a follow-up interview with Resident 4, he stated that on 5/18/2021, while waiting in the hallway for his turn to use the shower room, Resident 4 told his nurse that he was cold and asked his nurse to put him back in his room because it was warmer there. Resident 4 stated his nurse told him to stay in line for a few more minutes or else another resident would use the shower room and Resident 4 would lose his turn. Resident 4 stated the nurse provided him with extra bath blankets to keep him warm, but Resident 4 stated he still preferred to wait inside his room. Resident 4 stated this event happened a couple of times already. On 5/21/2021 at 9:05 a.m., during an interview with Certified Nurse Assistant (CNA) 6, she stated residents usually wait in the hallway outside the facility's Shower Rooms for about 10 minutes. CNA 6 stated they can put residents back in the room to wait but the residents may lose their turn to use the shower room. On 5/21/2021 at 3:18 p.m., during an interview, RN 1 stated that she had not heard any residents complaining that the facility hallway was too cold. RN 1 stated the facility usually keep temperature in the facility not too cold and not too warm. RN 1 stated that if the residents requested to go back in their rooms to wait for the Shower Room availability instead of sitting outside in the hallway, the facility staff should follow what the resident requested. On 6/1/2021 at 4:10 p.m., a phone interview was conducted with the DON. The DON stated that the residents have the right to make a choice about their schedules consistent with their interests and preferences and the facility staff are expected to follow those choices. A review of the facility's policy and procedure (P&P) titled, Resident Rights, revised on 12/2016, indicated federal and state laws guarantee certain rights to all residents of the facility. These rights include the resident's right to self-determination.

Based on interview and record review, the facility failed to provide Resident 323's representative access to residents' medical records when requested. This deficient practice resulted in Resident 323's representative not receiving documents on a timely manner. Findings: During a telephone interview on 5/19/2021 at 10:30 a.m., Resident 323's Legal Representative (LR) stated he requested for Resident 323's medical records on 2/25/2021 but did not receive any response from the facility. LR stated he requested Resident's 323's medical records by fax. A review of Resident 323's Face Sheet (admission record), indicated the facility admitted the resident on 1/14/2021, with diagnoses including Type 2 Diabetes Mellitus (long term condition that affects the way the body processes blood sugar), essential hypertension (high blood pressure that does not have a known secondary cause) and polyneuropathy (when multiple peripheral nerves [nerves outside the brain and spinal cord] become damaged). A review of Resident 323's History and Physical dated 1/16/2021 indicated Resident 323 does not have the capacity to understand and make decisions. A review of Resident 323's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 1/20/2021, indicated the resident required supervision (oversight, encouragement or cueing) when eating and required extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, transfer , dressing, toilet use and personal hygiene. A review of 323's medical records indicated, Resident 323 was transferred to the hospital on 1/20/2021 and was not readmitted back to the facility. During an interview on 5/20/2021 at 1:31 p.m., the medical records director (MRD) and the medical records assistant (MRA) stated they did not receive any medical records request for the month of February 2021 from a discharged resident or from their resident representative or third party. MRD stated residents or their representative could request a copy of residents' medical records by filling out an authorization form and submit the completed form to medical records staff. MRD stated the facility could send the requested medical records within three to four days for non-emergency or non-urgent request. MRD stated if the resident that requested medical records were discharged , the resident or their representative could come in the facility to sign the authorization form. MRD stated the resident or the representative could request the authorization form to be mail, physically or electronically (email). During an interview and record review with the Administrator (ADM) on 5/20/2021 at 2:30 p.m., the ADM stated he does not remember receiving a request for medical records from a discharged resident around February 2021. The ADM checked his email/electronic fax email one by one and found an unopened and unread email on 2/25/2021. The ADM stated the email was from Resident 323's LR requesting for Resident 323's medical records. The ADM stated he checks email everyday and for some reason it was missed. The ADM stated they would contact the legal representative and would take care of the issue right away. The ADM stated all department heads receives electronic mail (email) and electronic fax (eFax) including medical records staff. During an interview on 5/20/2021 at 2:35 pm with MRD and the ADM, MRD stated she was responsible for checking the email and fax on for requested documents. MRD stated she checked her email every day, but she did not receive the request for Resident 323's medical records. The ADM stated he verified that MRD's name was not included as one of the recipients of electronic fax email and he just added her as a recipient to correct and avoid same problem in the future. During an interview on 5/21/2021 at 9:31 a.m., the director of nursing (DON) stated all requested documents received by mail, email, and/or fax has to be completed within 72 hours after they receive the authorization form. A review of facility's policy and procedure (P&P) titled Release of Information revised on 11/2009 indicated, a resident may obtain photocopies of his or her records by providing the facility with at least 48 hour excluding weekends and holidays) advance notice of such request.

Based on interview and record review, the facility failed to complete an advance directives (a written instruction, such as a living will or durable power of attorney for health care recognized under state law) to four of six sampled residents (Resident 35,48, 223 and 224). This deficient practice had the potential to delay emergency treatment or had the potential to execute emergency, life sustaining procedures against the resident's personal preferences. Findings: During a concurrent interview and record review with Social Services Assistant (SSA) on 5/19/2021 at 10:30 a.m., SSA confirmed that Resident 244 have no advanced directives on the chart and no documentation or any evidence showing that the resident's representative was given an option to formulate advance directive. SSA stated she has to call the family right away, obtain advance directives document from the resident's representative if available, if not, SSA will provide the resident and the resident's representative advance directives information on how to obtain and formulate advance directives. 1.A review of Resident 224's Face Sheet (admission record), indicated the facility admitted the resident on 5/1/2021 with diagnoses including Parkinson's Disease (brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination), essential hypertension (high blood pressure that doesn't have a known secondary cause) and muscle weakness. A review of Resident 224's History and Physical dated 5/9/2021 indicated Resident 224 does not have the capacity to understand and make decisions. A review of Resident 224's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 5/5/2021, indicated the resident required extensive assistance (resident involved in the activity, staff provide weight-bearing support) with bed mobility, dressing, eating, personal hygiene and was totally dependent (full staff performance every time during entire 7-day period) on transfer and toilet use. During an interview on 5/21/2021 at 8:40 a.m., Licensed Vocational Nurse (LVN) 2 stated licensed nurses should make sure all residents have advance directives or should provide information to the residents and/or their representatives on how to formulate one. LVN 2 stated the facility has to send a copy of resident's advance directives when transferring residents to a hospital, so healthcare personnel can decide on what treatment or emergency measures they need to execute when the time comes resident not capable to decide. 2.A review of Resident 35's Face Sheet (admission record), indicated the facility admitted the resident on 3/7/2021, with diagnoses including Type 1 Diabetes Mellitus (is a disease in which the body does not make enough insulin to control blood sugar levels, acute respiratory failure (when the usual exchange between oxygen and carbon dioxide in the lungs does not occur, as a result, enough oxygen cannot reach the heart, brain, or the rest of the body. A review of Resident 35's History and Physical dated 3/7/2021 indicated Resident 35 has the capacity to understand and make decisions. A review of Resident 35s Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 3/12/2021, indicated the resident required extensive assistance with bed mobility, transfer, dressing, eating, toilet use and personal hygiene. 3.A review of Resident 48's Face Sheet (admission record), indicated the facility admitted the resident on 12/24/2020, with diagnoses including Type 2 Diabetes Mellitus (long term condition that affects the way the body processes blood sugar), heart failure (severe failure of the heart to function properly) and Chronic Obstructive Pulmonary Disease (group of lung diseases that block airflow and make it difficult to breathe.) A review of Resident 48's History and Physical dated 4/17/2021 indicated Resident 48 does not have the capacity to understand and make decisions. A review of Resident 48's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 4/2/2021, indicated the resident required limited assistance (highly involved in the activity) when eating, required extensive assistance with bed mobility, dressing, toilet use, personal hygiene and totally dependent with transfer. 4.A review of Resident 223's Face Sheet (admission record), indicated the facility admitted the resident on 5/16/2021, with diagnoses including Type 2 Diabetes Mellitus (long term condition that affects the way the body processes blood sugar), Parkinson's Disease (brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination), malignant neoplasm of sigmoid colon (cancer of the colon or rectum) and chronic kidney disease (gradual loss of kidney function). A review of Resident 223's History and Physical dated 5/17/2021 indicated Resident 223 does not have the capacity to understand and make decisions. During an interview on 5/21/2021 at 9:15, SSA verified and confirmed that Residents 35, 48 and 224 have no advance directives on the chart and no documentation or evidence showing resident's representatives were given information nor offered any assistance on how to formulate advance directives. SSA stated advance directives should be obtained as soon as possible upon admission before the resident become incapable of making decision regarding healthcare decisions. SSA stated upon admission, the admissions coordinator and social services will coordinate in obtaining advance directives. SSA stated, if there's no advance directives available, admissions coordinator has to give the resident or their representative a packet with advance directive information and instruction on how they can obtain advance directives. SSA stated when the resident or their representative refused to provide or formulate advance directives, they should sign an acknowledgment form showing that the facility staff offered the necessary information to them. During an interview on 5/21/2021 at 9:31 am. the Director of Nursing (DON) stated advance directives should be acknowledge by resident and/or resident's representative within 72 hours. The DON stated, social services staff has to determine if advance directives were available, and provide advance directive information to the residents and/or resident representatives and instruct them to include the advance directives acknowledgment form at the same time when they return the admission packet to the facility. The DON stated the SSD and SSA's responsibility to update resident's advance directives. During an interview on 5/21/2021 at 1:23 p.m., the Administrator (ADM) stated they are working on completing and updating residents' advance directives. The ADM stated Social Services Director was on medical leave and SSA has to call families of Residents 35,28, 223 and 224 to obtain advance directives if available. A review of facility's policy and procedure (P&P) titled Advance Directives dated 5/20/2021 indicated the following: 1.Prior to or upon admission of a resident, the SSD or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 2.Information about whether the resident has executed an advance directive shall be displayed prominently in the medical record. 3.If the resident indicates that he or she has not established advance directives, the facility staff will help in establishing advance directives. The resident will be given an option to accept or decline the assistance, and care will not be contingent on either decision. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance.

Based on observation, interview and record review, the facility failed to provide an orderly (uncluttered physical environment that is neat and well kept), sanitary (preventing the spread of disease causing organisms by keeping care equipment clean and properly stored), and home-like environment for Resident 14. This deficient practice had the potential to result in an environmental hazard (danger or threat), increased the risk for falls or injury, and increase the spread of infectious disease and illnesses. Findings: During an observation of Resident 14's room on 5/18/2021 at 10:31 a.m., Resident 14's personal belongings that included books, two basins, a toothbrush, crackers, and eyeglasses (were observed laid on the floor to the right side of Resident 14's bed, by the glass sliding door leading to the facility patio. During the observation, Resident 14's urinal was filled with urine and placed adjacent to Resident 14's personal belongings on the floor. Resident 14 was observed lying in bed and had a cast to the left upper extremity and left lower extremity. A review of Resident 14's admission Record indicated an admission to the facility on 4/28/2021 with medical diagnoses including fracture (complete of partial break to the bone) to the left leg, fracture to the left hand, and cataracts (clouding of the normally clear lens of the eye). A review of Resident 14's History and Physical (H&P) Examination dated 4/28/21, indicated the resident had the capacity to understand and make decisions. A review of Resident 14's Minimum Data Set (MDS- a care area screening and assessment tool) indicated Resident 14 required extensive assistance (staff provide weight bearing support) with one person physical assist with bed mobility, transfers, dressing, toilet use, and personal hygiene The MDS indicated the source of locomotion was a wheelchair. The MDS indicated Resident 14 required supervision with set up only for when eating. During an interview on 5/18/2021 at 10:35 a.m., Resident 14 stated that his previous room had a drawer by the bed. Resident 14 stated that his current room did not have a bedside drawer when Resident 14 was transferred to the new room, approximately two weeks ago. Resident 14 stated his other belongings were placed in a closet located the front of the room (far from his reach). Resident 14 stated he preferred to have personal belongings close in reach, as it would be a challenge to get items especially during the night. Resident 14 stated he requested a bedside drawer to the facility more than once, but Resident 14 had not received one. Resident 14 stated he did not the prefer to have his personal belongings on the floor. Resident 14 stated he preferred to have his needed items to be within his reach. During another observation of Resident 14's room on 5/19/2021 at 8:23 a.m., the facility placed a bedside drawer to the right side of Resident 14's bed. Resident 14 stated that he had difficulties opening the top drawer placed in his room on 5/19/2021 because the drawer was missing a handle. Resident 14 stated he could not completely close the drawer because he had difficulties opening the drawer. During an interview on 5/21/2021 at 10:50 a.m., Nursing Assistant (NA) 2 stated that Resident 14 was previously in another room. NA 2 stated she was aware that Resident 14's new room did not have a bedside drawer when the resident was transferred to the new room. NA 2 stated Resident 14 placed all belongings on the floor beside the bed to keep items within reach. NA 2 stated that Resident 14 requested for a bedside drawers, but does not recall when and whom she notified. NA 2 stated she recalled reminding Resident 14 more than two times, not to keep personal belongings on the floor because of infection control and its potential hazard. NA 2 observed the newly placed bedside drawer in Resident 14's room and stated the drawer was missing a handle. NA 2 stated the handle was broken and it was difficult for Resident 14 to open the top drawer. During an interview on 5/21/2021 at 11:16 a.m., the social service assistant (SSA) stated when a resident's room change is initiated, it was a facility practice for residents to become familiar with the room. SSA stated that a bedside drawer should be provided to the rooms if a room did not have one. SSA stated she was not aware of Resident 14's personal belongings being on the floor. SSA stated that Resident 14's personal belongings placed on the floor was not appropriate, and that items placed in a resident's room should be maintained and that if items were broken, it should be fixed immediately. During an interview on 5/21/2021 at 11:27 a. m., the maintenance supervisor (MS) stated broken items/furniture should not be given to residents. If an item was identified as broken, it should be fixed immediately A review of the facility's policy and procedure (P&P), titled, Accommodation of Needs, revised 01/2020, indicated that the residents individual needs and preferences will be accommodated to the extent possible, which include the need for adaptive devices and modifications to the physical environment that would be evaluated upon admission and reviewed on an ongoing basis.

Based on observation, interview, and record review, the facility failed to ensure Nursing Assistant (NA) 1, NA 2, and Certified Nursing Assistant (CNA) 2 reported an alleged injury of unknown origin/source was reported immediately, but not later than two (2) hours to the local, state and federal agencies and thoroughly investigated by facility management for one of one sampled residents (Resident 76). Resident 76 informed FM 2 that someone pinched her to the arm. Resident 76's family member (FM 2) asked NA 1 and another unidentified staff on 5/14/21 about new bruises found in the resident's bilateral arms. FM 2 did not notify NA 1 about Resident 76's allegation of someone pinching her. NA 1 did not inform the charge nurse of the resident's bruises (from unknown source), to initiate an investigation immediately. NA 2 found the bruises to the resident's arms on 5/18/21 and reported it to CNA 2. CNA 2 did not report it to the charge nurse immediately. Resident 76's bruises to bilateral arms was reported to the facility administrator on 5/19/21. The administrator reported to the Department and Ombudsman on 5/19/21 (5 days after it was first observed and known by NA 1). These deficient practices had the potential for the facility to under report alleged injuries of unknown origin, which could lead to failure to investigate alleged injuries of unknown origin that could be a result of abuse or neglect, in a timely manner. Findings: A review of Resident 76's admission Record, indicated the facility admitted the resident on 8/14/2020, with diagnoses including Parkinson's Disease (a brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination), dementia with Lewy bodies (a brain disorder that leads to a decline in thinking, reasoning and independent function due to abnormal microscopic deposits that damage brain cells over time), attention to gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), and severe protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). A review of Resident 76's Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 3/30/21, indicated the resident had severely impaired cognitive skills (how the brain remembers, thinks, and learns) but sometimes able to communicate. The MDS indicated the resident required extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, transfer, locomotion on and off unit, dressing, toilet use, and personal hygiene and total assistance (staff provided care 100% of the time) with bathing. A review of Resident 76's Skin Integrity Care Plan, revised on 4/3/21, indicated the resident was at risk for skin breakdown and poor healing related to decreased mobility, fragile skin, incontinence, mental illness, and advanced dementia. The care plan goal indicated the resident's skin breakdown will be minimized after interventions daily for 90 days. The approaches included to monitor skin integrity daily during care, provide adequate skin care daily, and assist in bed mobility and repositioning as needed. During an interview on 5/18/21 at 3:25 p.m., Family Member (FM) 2 stated she visited Resident 76 on 5/14/21 and noticed new bruises on the resident's right and left arms. FM 2 stated she asked Resident 76 what happened, and the resident told FM 2 someone pinched her. FM 2 stated she did not report the alleged pinching to the staff because she was not sure if Resident 76's answer was valid due to her dementia. FM 2 stated, that on the same day (5/14/21), she asked NA 1 and another unidentified facility staff (FM 2 unable to recall who) about the resident's bruises. FM 2 stated the unidentified facility staff told her that Resident 76 probably became aggressive during care and hit her arms somewhere. During an observation and concurrent interview on 5/19/21 at 10:06 a.m., Wound Treatment Nurse (TXN) 1 stated Resident 76 had discoloration (bruising) to her bilateral forearms. TXN 1 stated she did not see the discoloration (bruising) the previous day when she provided the resident's wound treatment. TXN 1 stated Resident 76 probably hit her arms on the side rails. TXN 1 notified the DON of Resident 76's bruising to both arms, on 5/19/21. During an interview on 5/19/21 at 10:33 a.m., Licensed Vocational Nurse (LVN) 4 stated she did not notice any bruising or discoloration on Resident 76's arms. LVN 4 stated she did not receive any report of bruising, discoloration, or allegation of abuse from any of the staff or family member. During an interview on 5/19/21 at 12:32 p.m., NA 2 stated she was assigned to care for Resident 76 the previous day (5/18/21). NA 2 stated she noticed the discoloration (bruising) to Resident 76's arm the previous day but could not remember which arm had the discoloration (bruising). NA 2 stated the discoloration (bruising) did not look new, so she did not report it to the charge nurse. NA 2 stated she reported it to her lead CNA (CNA 2) on 5/18/21. During an observation and concurrent interview on 5/20/21 at 8:09 a.m., translated by Health Facilities Evaluator (HFE) 1, Resident 76 stated she obtained the right arm bruises from hitting something on the side of her bed. Resident 76 stated the bruises on her left arm was from a female staff (unable to recall who) pinching her. Resident 76 stated she did not report this to anyone. During an interview on 5/21/21 at 9:05 a.m., CNA 2 stated NA 2 reported Resident 76's arm discoloration (bruising) to her on 5/18/21. CNA 2 stated she saw the discoloration (bruising) on 5/18/21 and it did not look new. CNA 2 stated she did not report the discoloration (bruising) to the charge nurse because she thought NA 2 already reported it. During a telephone interview on 5/21/21 at 10:51 a.m., NA 1 stated she was assigned to care for Resident 76 on 5/14/21. NA 1 stated FM 2 was in the facility and visited Resident 76 on 5/14/21. NA 1 stated FM 2 asked her and showed her the discoloration on the resident's arm. NA 1 stated she could not remember which arm had the discoloration (bruising). NA 1 stated she told FM 2 she did not know where Resident 76's discoloration (bruising) came from and to ask the charge nurse about it. NA 1 stated she did not report the discoloration (bruising) to the charge nurse herself. During an interview on 5/21/21 at 11:22 a.m., the administrator stated he was the facility's abuse coordinator. The administrator stated any suspicion or allegation of abuse should be reported to him or to any highest role available in the building immediately. The administrator stated any injuries of unknown origin should be first reported to the charge nurse. A change of condition will be initiated, and an investigation will be started. The administrator stated he reported the alleged abuse involving Resident 76 to the Department and the Ombudsman on 5/19/21 and started the investigation as soon as he was made aware of it on 5/19/21. During an interview on 5/21/21 at 11:55 a.m., the director of nursing (DON) stated any staff who sees a resident's injury of unknown origin must notify the resident's charge nurse right away. The charge nurse or supervisor will then assess the injury, call the resident's physician, and notify the family. The charge nurse will complete an incident report and notify her. The DON stated she will then conduct a follow-up investigation and will discuss it with the rest of the team during the stand-up meeting. A review of the facility's policy and procedures titled, Investigating Injuries, revised in 12/2016, indicated the administrator will ensure that all injuries are investigated. The policy indicated the director of nursing services or a designee will assess all injuries and document clinical findings in the clinical record. If an incident/accident is suspected, a nurse or nurse supervisor will complete a facility-approved accident/incident form. The form will be disseminated to the appropriate individuals, for example the administrator and director of nursing services. The investigation will follow the protocols set forth in the facility's established abuse investigation guidelines. A review of the facility's policy and procedures titled, Abuse Investigation and Reporting, revised in 7/2017, indicated reports of resident abuse, neglect, exploitation, misappropriation of resident property, and/or injuries of unknown source (''abuse'') shall be promptly reported to local, state and federal agencies and thoroughly investigated by facility management. The policy indicated an alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury; or twenty-four (24) hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.A review of Resident 116's admission Record, dated 5/21/21, indicated she was readmitted to the facility on [DATE] with diagnoses including: epilepsy (a seizure disorder.) A review of Resident 116's Order Summary Report, dated 4/30/21, indicated on 4/26/21, the physician prescribed the following medications for seizures: 1. Keppra (a medication used to treat seizures) 500 milligrams (mg- a units of measure for mass) by mouth twice daily for seizures. Further review of Resident 116's Order Summary Report indicated on 4/27/21 the physician ordered laboratory monitoring of Resident 116's Keppra level every month. A review of Resident 116's care plan for seizure disorder, last reviewed 4/26/21, indicated that the care plan had not been updated to include Laboratory test as ordered, and relay result to MD as an intervention for Resident 116 in the Approaches and Plan section. On 5/21/21 at 12:22 p.m., during an interview, the Director of Nursing (DON) stated the facility failed to update Resident 116's seizure disorder care plan to include the physician's order for laboratory monitoring of the Keppra level. The DON stated that it is important to ensure the care plan is up-to-date with the physician's orders in order to ensure that care is coordinated and that those orders actually get carried out. The DON stated that if the care plan doesn't get updated, there is a risk that certain things, like laboratory monitoring, might not get done as ordered by the physician which could negatively affect the resident. A review of the facility's policy Care Plans, Comprehensive Person-Centered, revised December 2016, indicated Assessments of residents are ongoing and care plans are revised as information about the residents and residents' conditions change. Based on observation, interview, and record review, the facility failed to revise the plan of care for one of seven sampled residents (Resident 76 and 116): 1. Resident 76's family member (FM 2) asked Nursing Assistant (NA) 1 and another unidentified staff on 5/14/21 about new bruises found in the resident's bilateral arms. NA 1 did not inform the charge nurse of the resident's bruises (from unknown source), to initiate an investigation immediately and revise the plan of care. 2. Resident 76 who had an existing Stage IV pressure ulcer [full thickness tissue loss with exposed bone, tendon or muscle with or without slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft and stringy in texture) or eschar (dead tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like)] on the coccyx (tailbone) did not have a revised plan of care to include the frequency of repositioning while the resident was up in the wheelchair and/or the duration that the resident should be sitting up in the wheelchair, based on the resident's current risk in accordance with the facility's policy and procedures. 3. Resident 116 who had diagnosis of seizure (a medical condition caused by uncontrolled electrical activity in the brain) did not have updated plan of care to include routine laboratory monitoring for drug levels of seizure medication as ordered by the physician. These deficient practices had the potential for Resident 76 and 116 not to receive the necessary care and services to meet the resident's needs. Findings: 1. A review of Resident 76's admission Record, indicated the facility admitted the resident on 8/14/2020, with diagnoses including Parkinson's Disease (a brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination), dementia with Lewy bodies (a brain disorder that leads to a decline in thinking, reasoning and independent function due to abnormal microscopic deposits that damage brain cells over time), attention to gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), and severe protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). A review of Resident 76's Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 3/30/21, indicated the resident had severely impaired cognitive skills (how the brain remembers, thinks, and learns) but sometimes able to communicate. The MDS indicated the resident required extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, transfer, locomotion on and off unit, dressing, toilet use, and personal hygiene and total assistance (staff provided care 100% of the time) with bathing. A review of Resident 76's Skin Integrity Care Plan, revised on 4/3/21, indicated the resident was at risk for skin breakdown and poor healing related to decreased mobility, fragile skin, incontinence, mental illness, and advanced dementia. The care plan goal indicated the resident's skin breakdown will be minimized after interventions daily for 90 days. The approaches included to monitor skin integrity daily during care, provide adequate skin care daily, and assist in bed mobility and repositioning as needed, provide gel cushion in the wheelchair and low air loss (LAL; designed to prevent and treat pressure wounds) mattress. During an interview on 5/18/21 at 3:25 p.m., Family Member (FM) 2 stated she visited Resident 76 on 5/14/21 and noticed new bruises on the resident's right and left arms. FM 2 stated she asked Resident 76 what happened, and the resident told FM 2 someone pinched her. FM 2 stated she did not report the alleged pinching to the staff because she was not sure if Resident 76's answer was valid due to her dementia. FM 2 stated, that on the same day (5/14/21), she asked NA 1 and another unidentified facility staff (FM 2 unable to recall who) about the resident's bruises. FM 2 stated the unidentified facility staff told her that Resident 76 probably became aggressive during care and hit her arms somewhere. During an observation and concurrent interview on 5/19/21 at 10:06 a.m., Wound Treatment Nurse (TXN) 1 stated Resident 76 had discoloration (bruising) to her bilateral forearms. TXN 1 stated she did not see the discoloration (bruising) the previous day when she provided the resident's wound treatment. TXN 1 stated Resident 76 probably hit her arms on the side rails. TXN 1 notified the DON of Resident 76's bruising to both arms, on 5/19/21. During an interview on 5/19/21 at 10:33 a.m., Licensed Vocational Nurse (LVN) 4 stated she did not notice any bruising or discoloration on Resident 76's arms. LVN 4 stated she did not receive any report of bruising, discoloration, or allegation of abuse from any of the staff or family member. During an interview on 5/19/21 at 12:32 p.m., NA 2 stated she was assigned to care for Resident 76 the previous day (5/18/21). NA 2 stated she noticed the discoloration (bruising) to Resident 76's arm the previous day but could not remember which arm had the discoloration (bruising). NA 2 stated the discoloration (bruising) did not look new, so she did not report it to the charge nurse. NA 2 stated she reported it to her lead CNA (CNA 2) on 5/18/21. During a telephone interview on 5/21/21 at 10:51 a.m., NA 1 stated she was assigned to care for Resident 76 on 5/14/21. NA 1 stated FM 2 was in the facility and visited Resident 76 on 5/14/21. NA 1 stated FM 2 asked her and showed her the discoloration on the resident's arm. NA 1 stated she could not remember which arm had the discoloration (bruising). NA 1 stated she told FM 2 she did not know where Resident 76's discoloration (bruising) came from and to ask the charge nurse about it. NA 1 stated she did not report the discoloration (bruising) to the charge nurse herself. During an interview and concurrent record review on 5/19/21 at 1:03 p.m., the assistant director of nursing (ADON) could not find a documented assessment of Resident 76's new bruises in the resident's clinical record prior to 5/19/21. The ADON stated the resident's plan of care was not revised to address Resident 76's bruises when NA 1 first observed the bruises on 5/14/21. A review of the facility's policy and procedures titled, Goals and Objectives, Care Plans, revised in 4/2009, indicated care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. When goals and objectives are not achieved, the resident's clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established. Care plans will be modified accordingly. The policy indicated goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and can report whether or not the desired outcomes are being achieved. Goals and objectives are reviewed and/or revised: when there has been a significant change in the resident's condition; when the desired outcome has not been achieved; when the resident has been readmitted to the facility from a hospital/rehabilitation stay; and at least quarterly. 2. A review of Resident 76's physician's order, dated 8/14/2020, indicated the resident may have a gel cushion (a foam shell with a gel insert sealed on the inside for two layers of comfort and stability) while up in the wheelchair. A review of Resident 76's MDS, dated [DATE], indicated the resident had a Stage IV pressure ulcer that was not present upon admission or reentry to the facility. The MDS indicated the resident had a pressure reducing device for her chair and bed. During an observation on 5/18/21 at 10:30 a.m., Resident 76 was observed inside her room, sitting in the wheelchair while coloring a book. Resident 76 was alert to her name but did not speak English. Resident 76's wheelchair was observed with a seat cushion in place. During an observation on 5/18/21 at 12:08 p.m., Resident 76 was observed inside her room, sitting in the wheelchair with a seat cushion in place. During an observation on 5/18/21 at 12:31 p.m., Resident 76 was observed inside her room, sitting in the wheelchair with a seat cushion in place. Resident 76 was eating her lunch meal. During an observation on 5/18/21 at 1 p.m., Resident 76 was observed inside her room, sitting in the wheelchair with a seat cushion in place. During an observation on 5/19/21 at 7:38 a.m., Resident 76 was observed inside her room, sitting in the wheelchair with a seat cushion in place. Resident 76 was eating her breakfast meal. During a wound treatment observation with Wound Treatment Nurse (TXN) 1 and TXN 2 on 5/19/21 at 10:06 a.m., Resident 76 had a Stage IV pressure ulcer on the coccyx which measured 2 centimeters (cm) by 1 cm by 0.1 cm. The wound was moist with minimal amount of serosanguineous (containing or consisting of both blood and serous fluid) drainage. TXN 1 cleansed the wound with normal saline (salt water), patted it dry, applied collagen powder (supports new blood vessel formation, granulation tissue formation and debridement of the wound) and calcium alginate (highly absorbent dressing that promotes healing and the formation of granulation tissue), and covered the wound with a foam dressing. During an observation on 5/20/21 at 9:50 a.m., Resident 76 was observed inside her room, sitting in the wheelchair with a seat cushion in place. During an interview and concurrent record review on 5/20/21 at 10:05 a.m., TXN 1 and TXN 2 stated the current care plan interventions for Resident 76 included providing the resident with wound treatment daily, LAL mattress, gel cushion on the wheelchair, dietary supplements to aid with wound healing, and weekly visits by the wound specialist, and keeping the head of the bed low as tolerated and turning and repositioning the resident every two hours. The care plan was not revised to indicate the frequency of repositioning while up in the wheelchair or the duration that the resident should be sitting up in the wheelchair, based on the resident's current risk factors such as Stage IV pressure ulcer to the coccyx. During an observation and concurrent interview on 5/20/21 at 10:34 a.m., Resident 76 was observed inside her room, sitting in the wheelchair with a seat cushion in place. TXN 1 and TXN 2 was asked what type of seat cushion Resident 76 was using, TXN 1 and TXN 2 stated they did not know the type of wheelchair seat cushion Resident 76 was currently using. TXN 1 and 2 stated they did not know whether the seat cushion was a gel cushion or a type of pressure reducing device (as ordered by the physician). TXN 1 stated Resident 76 had a pressure reducing device in her wheelchair previously, but it was misplaced during the resident's room changes. TXN 1 stated Resident 76 should not be sitting in the wheelchair for long periods of time to reduce pressure to the coccyx wound. A review of the facility's policy and procedures titled, Prevention of Pressure Injuries, revised in 4/2020, indicated reposition all residents with or at risk of pressure injuries on an individualized schedule as determined by the interdisciplinary care team. Choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines. The policy indicated select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice. Review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application, and ability to secure the device. Monitor regularly for comfort and signs of pressure-related injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary care and treatment for 2 of 28 sampled residents (Resident 76 and 95) in accordance with the plan of care and the facility's policy and procedures by failing to: 1. Ensure facility staff assessed and monitored Resident 76's bilateral arms bruises/discoloration in a timely manner. This deficient practice had the potential to result in a delay in providing the necessary care and treatment to Resident 76. 2. Ensure facility staff addressed Resident 95's complaint of constipation and administered medication as needed for constipation as ordered by the physician. This deficient practice had the potential to result in abdominal discomfort, fecal impaction, and lead to complication such as bowel obstruction and lead to death. Findings: 1. A review of Resident 76's admission Record, indicated the facility admitted the resident on 8/14/2020, with diagnoses including Parkinson's Disease (a brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination), dementia with Lewy bodies (a brain disorder that leads to a decline in thinking, reasoning and independent function due to abnormal microscopic deposits that damage brain cells over time), attention to gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), and severe protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). A review of Resident 76's Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 3/30/21, indicated the resident had severely impaired cognitive skills (how the brain remembers, thinks, and learns) but sometimes able to communicate. The MDS indicated the resident required extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, transfer, locomotion on and off unit, dressing, toilet use, and personal hygiene and total assistance (staff provided care 100% of the time) with bathing. A review of Resident 76's Skin Integrity Care Plan, revised on 4/3/21, indicated the resident was at risk for skin breakdown and poor healing related to decreased mobility, fragile skin, incontinence, mental illness, and advanced dementia. The care plan goal indicated the resident's skin breakdown will be minimized after interventions daily for 90 days. The approaches included to monitor skin integrity daily during care, provide adequate skin care daily, and assist in bed mobility and repositioning as needed. During an interview on 5/18/21 at 3:25 p.m., Family Member (FM) 2 stated she visited Resident 76 on 5/14/21 and noticed new bruises on the resident's right and left arms. FM 2 stated she asked Resident 76 what happened, and the resident told FM 2 someone pinched her. FM 2 stated she did not report the alleged pinching to the staff because she was not sure if Resident 76's answer was valid due to her dementia. FM 2 stated, that on the same day (5/14/21), she asked NA 1 and another unidentified facility staff (FM 2 unable to recall who) about the resident's bruises. FM 2 stated the unidentified facility staff told her that Resident 76 probably became aggressive during care and hit her arms somewhere. During an observation and concurrent interview on 5/19/21 at 10:06 a.m., Wound Treatment Nurse (TXN) 1 stated Resident 76 had discoloration (bruising) to her bilateral forearms. TXN 1 stated she did not see the discoloration (bruising) the previous day when she provided the resident's wound treatment. TXN 1 stated Resident 76 probably hit her arms on the side rails. TXN 1 notified the DON of Resident 76's bruising to both arms, on 5/19/21. During an interview on 5/19/21 at 10:33 a.m., Licensed Vocational Nurse (LVN) 4 stated she did not notice any bruising or discoloration on Resident 76's arms. LVN 4 stated she did not receive any report of bruising, discoloration, or allegation of abuse from any of the staff or family member. During an interview on 5/19/21 at 12:07 p.m., Certified Nursing Assistant (CNA) 4 stated she was currently Resident 76's CNA. CNA 4 stated she did not notice any bruising or discoloration on the resident's body during care. During an interview on 5/19/21 at 12:32 p.m., Nursing Assistant (NA) 2 stated she was assigned to care for Resident 76 the previous day. NA 2 stated she noticed the discoloration (bruising) to Resident 76's arm the previous day but could not remember which arm had the discoloration (bruising). NA 2 stated the discoloration (bruising) did not look new, so she did not report it to the charge nurse. NA 2 stated she reported it to her lead CNA (CNA 2) on 5/18/21. During an interview and concurrent record review on 5/19/21 at 1:03 p.m., the assistant director of nursing (ADON) could not find a documented assessment of Resident 76's bilateral arms discoloration in the resident's clinical record prior to 5/19/21. The ADON stated Resident 76's bilateral arms discoloration was not assessed and monitored timely. During an interview on 5/21/21 at 9:05 a.m., CNA 2 stated NA 2 reported Resident 76's arm discoloration (bruising) to her on 5/18/21. CNA 2 stated she saw the discoloration (bruising) on 5/18/21 and it did not look new. CNA 2 stated she did not report the discoloration (bruising) to the charge nurse because she thought NA 2 already reported it. During a telephone interview on 5/21/21 at 10:51 a.m., NA 1 stated she was assigned to care for Resident 76 on 5/14/21. NA 1 stated FM 2 was in the facility and visited Resident 76 on 5/14/21. NA 1 stated FM 2 asked her and showed her the discoloration on the resident's arm. NA 1 stated she could not remember which arm had the discoloration (bruising). NA 1 stated she told FM 2 she did not know where Resident 76's discoloration (bruising) came from and to ask the charge nurse about it. NA 1 stated she did not report the discoloration (bruising) to the charge nurse herself. During an interview on 5/21/21 at 11:55 a.m., the director of nursing (DON) stated any staff who sees a resident's injury of unknown origin must notify the resident's charge nurse right away. The charge nurse or supervisor will then assess the injury, call the resident's physician, and notify the family. The charge nurse will complete an incident report and notify her. The DON stated she would conduct a follow-up investigation and will discuss it with the rest of the team during the stand-up meeting. The DON stated a care plan for the injury would be developed and the resident will be continuously monitored and reassessed. A review of the facility's policy and procedures titled, Acute Condition Changes - Clinical Protocol, revised in 3/2018, indicated direct care staff, including nursing assistants would be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation or changes in skin color or condition) and how to communicate these changes to the nurse. Nursing assistants are encouraged to use the Stop and Watch Early Warning Tool to communicate subtle changes in the resident to the nurse. 2. A review of Resident 95's admission Record, indicated the facility admitted the resident on 1/7/21, with diagnoses including metabolic encephalopathy (a condition in which the brain function is disturbed due to different diseases or toxins in the body), diabetes mellitus (high blood sugar), and iron deficiency anemia (insufficient iron in the body). A review of Resident 95's plan of care, dated 1/7/21, indicated the resident was at risk for constipation related to multiple medication intake, decrease gastrointestinal (relating to the stomach and intestines) motility due to aging process, and inadequate fluid intake. The care plan goal indicated the resident will have bowel movement at least every three days for 90 days. The approaches included to encourage the resident to be out of bed daily as tolerated, encourage and offer increased fluid intake as tolerated, monitor bowel movement status daily, and administer medications such as softener, enemas (the injection of a fluid into the rectum to cause a bowel movement), laxative (medicine that stimulates bowel movement) etc. as ordered. A review of Resident 95's physician's orders, dated 1/7/21, indicated the following orders: a. Docusate sodium tablet 100 milligrams (mg), give one tablet by mouth every 12 hours for bowel management. Hold for loose stools. b. Milk of Magnesia (MOM) suspension 400 mg per 5 milliliters (ml), give 30 ml by mouth every 24 hours as needed (PRN) for constipation. Give if stool softener is ineffective. c. Bisacodyl suppository (a medication inserted into the rectum, vagina, or urethra to be broken down and absorbed by the body) 10 mg, insert one suppository rectally every 24 hours PRN for constipation. Give daily if no results for Milk of Magnesia (MOM). d. Lactulose solution 20 grams (gm) per 30 ml, give 30 ml by mouth every 12 hours PRN constipation. Give if no bowel movement for two to three days. A review of Resident 95's MDS, dated [DATE], indicated the resident usually was able to communicate and had moderate impairment in her cognitive skills. The MDS indicated the resident required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) with eating, extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene, and total assistance with bathing. The MDS indicated Resident 95 was always incontinent of bowel movements. During an interview translated by the liaison (LS) on 5/19/21 at 1:59 p.m., Resident 95 complained that she was feeling constipated. Resident 95 stated she could not remember her last bowel movement. Resident 95 stated she did not tell the nurse about her constipation. During a follow-up interview translated by the LS on 5/20/21 at 2:01 p.m., Resident 95 stated she was still feeling constipated. Resident 95 stated she did not have a bowel movement today. During an interview on 5/20/21 at 2:01 p.m., the LS stated she did not tell the charge nurse about Resident 95's complaint of constipation. During an interview and concurrent record review on 5/20/21 at 2:23 p.m., CNA 3 stated Resident 95 did not have a bowel movement yesterday and today. CNA 3 stated the resident's last documented bowel movement was on 5/18/21 during his shift. CNA 3 stated the resident's bowel movement on 5/18/21 was a smear. CNA 3 stated he was unaware of the resident's complaint of constipation. During an interview and concurrent record review on 5/20/21 at 2:25 p.m., LVN 2 stated Resident 95 had a small bowel movement on 5/17/21 at 11:29 a.m. and 5/18/21 at 11:09 a.m. LVN 2 stated there was no documented bowel movement on 5/19/21 and 5/20/21 in the resident's clinical record. LVN 2 stated she did not administer any PRN medication for constipation to Resident 95 because she was unaware that the resident was having constipation. During an interview on 5/20/21 at 2:35 p.m., the director of nursing (DON) stated the LS should report any resident concerns to the department head in charge of the concern or to the DON.

Based on observation, interview, and record review, the facility failed to ensure that interventions were implemented for a resident who had an existing Stage IV pressure ulcer [full thickness tissue loss with exposed bone, tendon or muscle with or without slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft and stringy in texture) or eschar (dead tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like)] on the coccyx (tailbone) by failing to: 1. Reposition Resident 76 while up in the wheelchair to reduce the pressure in the coccyx area. 2. Provide a gel cushion (pressure reducing device) while up in the wheelchair as indicated in the resident's physician order. This deficient practice had the potential to delay Resident 76's wound healing and placed the resident at risk for further skin breakdown. Findings: A review of Resident 76's admission Record, indicated the facility admitted the resident on 8/14/2020, with diagnoses including Parkinson's Disease (a brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination), dementia with lewy bodies (a brain disorder that leads to a decline in thinking, reasoning and independent function due to abnormal microscopic deposits that damage brain cells over time), attention to gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), and severe protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). A review of Resident 76's physician's order, dated 8/14/2020, indicated the resident may have a gel cushion (a foam shell with a gel insert sealed on the inside for two layers of comfort and stability) while up in the wheelchair. A review of Resident 76's Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 3/30/21, indicated the resident had severely impaired cognitive skills (how the brain remembers, thinks, and learns) but sometimes able to communicate. The MDS indicated the resident required extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, transfer, locomotion on and off unit, dressing, toilet use, and personal hygiene and total assistance (staff provided care 100% of the time) with bathing. The MDS indicated the resident had a Stage IV pressure ulcer that was not present upon admission or reentry to the facility. The MDS indicated the resident had a pressure reducing device for her chair and bed. During an observation on 5/18/21 at 10:30 a.m., Resident 76 was observed inside her room, sitting in the wheelchair while coloring a book. Resident 76 was alert to her name but did not speak English. Resident 76's wheelchair was observed with a seat cushion in place. During an observation on 5/18/21 at 12:08 p.m., Resident 76 was observed inside her room, sitting in the wheelchair with a seat cushion in place. During an observation on 5/18/21 at 12:31 p.m., Resident 76 was observed inside her room, sitting in the wheelchair with a seat cushion in place. Resident 76 was eating her lunch meal. During an observation on 5/18/21 at 1 p.m., Resident 76 was observed inside her room, sitting in the wheelchair with a seat cushion in place. During an observation on 5/19/21 at 7:38 a.m., Resident 76 was observed inside her room, sitting in the wheelchair with a seat cushion in place. Resident 76 was eating her breakfast meal. During a wound treatment observation with Wound Treatment Nurse (TXN) 1 and TXN 2 on 5/19/21 at 10:06 a.m., Resident 76 had a Stage IV pressure ulcer on the coccyx which measured 2 centimeters (cm) by 1 cm by 0.1 cm. The wound was moist with minimal amount of serosanguineous (containing or consisting of both blood and serous fluid) drainage. TXN 1 cleansed the wound with normal saline (salt water), patted it dry, applied collagen powder (supports new blood vessel formation, granulation tissue formation and debridement of the wound) and calcium alginate (highly absorbent dressing that promotes healing and the formation of granulation tissue), and covered the wound with a foam dressing. During an observation on 5/20/21 at 9:50 a.m., Resident 76 was observed inside her room, sitting in the wheelchair with a seat cushion in place. During an observation and concurrent interview on 5/20/21 at 10:34 a.m., Resident 76 was observed inside her room, sitting in the wheelchair with a seat cushion in place. The seat cushion was made of a thick material, contoured, and black in color. TXN 1 and TXN 2 was asked what type of seat cushion Resident 76 was using, TXN 1 and TXN 2 stated they did not know the type of wheelchair seat cushion Resident 76 was currently using. TXN 1 and 2 stated they did not know whether the seat cushion was a gel cushion or a type of pressure reducing device (as ordered by the physician). TXN 1 stated Resident 76 had a pressure reducing device in her wheelchair previously, but it was misplaced during the resident's room changes. TXN 1 stated Resident 76 should not be sitting in the wheelchair for long periods of time to reduce pressure to the coccyx wound. A review of Resident 76's Skin Integrity Care Plan, revised on 4/3/21, indicated the resident was at risk for skin breakdown and poor healing related to decreased mobility, fragile skin, incontinence, mental illness, and advanced dementia. The care plan goal indicated the resident's skin breakdown will be minimized after interventions daily for 90 days. The approaches included to monitor skin integrity daily during care, provide adequate skin care daily, assist in bed mobility and repositioning as needed, provide gel cushion in the wheelchair and low air loss (LAL; designed to prevent and treat pressure wounds) mattress. During an interview and concurrent record review on 5/20/21 at 10:05 a.m., TXN 1 and TXN 2 stated the current care plan interventions included providing Resident 76 with wound treatment daily, LAL mattress, gel cushion on the wheelchair, dietary supplements to aid with wound healing, and weekly visits by the wound specialist, and keeping the head of the bed low as tolerated and turning and repositioning the resident every two hours. The care plan did not indicate the frequency of repositioning while up in the wheelchair or the duration that the resident should be sitting up in the wheelchair, based on the resident's current risk factors such as Stage IV pressure ulcer to the coccyx. A review of the facility's policy and procedures titled, Pressure Ulcer/Skin Breakdown - Clinical Protocol, revised on 4/2018, indicated the physician will order pertinent wound treatments including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. A review of the facility's policy and procedures titled, Prevention of Pressure Injuries, revised in 4/2020, indicated reposition all residents with or at risk of pressure injuries on an individualized schedule as determined by the interdisciplinary care team. Choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines. The policy indicated select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice. Review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application, and ability to secure the device. Monitor regularly for comfort and signs of pressure-related injury.

Based on observation, interview and record review, the facility failed to maintain an unobstructed urine flow and secure the catheter for two of two sampled residents (Resident 14 and 67). This deficient practice had the potential to increase tension to the catheter and cause urethral tear or potential dislodgment, and decrease the urine flow by increasing kinks in the catheter. Findings: 1. During an observation on 5/18/2021 at 9:22 a.m., Resident 67 was lying in bed with a urinary catheter attached to a drainage bag. Resident 67 was observed holding the urinary catheter tubing in the left hand. The urinary catheter was not secured to Resident 67's inner thigh. A review of Resident 67's admission Record indicated an admission to the facility on 1/4/2019, with medical diagnoses that included obstructive uropathy (blockage of urine flow), history of urinary tract infection (UTI- infection of the urinary system), and dementia (loss of cognitive function). A review of Resident 67's Minimum Data Set (MDS- a care area screening and assessment tool) indicated extensive assistance requiring weight-bearing assistance from staff, with one-person physical assistance for bed mobility, transfers, dressing, eating, and personal hygiene. Resident 67 was totally dependent to staff for toilet use. The MDS indicated Resident 67 did not have the capacity to understand and make decisions. A review of Resident 67's Care Plan for the use of the urinary catheter dated 4/17/2020, indicated under approaches and plans to maintain proper alignment of the urinary catheter to promote proper drainage. During an interview, on 5/18/2021 at 9:30 a.m., Licensed Vocational Nurse (LVN) 2 stated Resident 67 was confused and had a tendency of pulling at things, especially the urinary catheter tubing. During an interview on 5/19/2021 at 9:37 a.m., CNA 10 stated that Resident 67 was confused and had a habit of pulling on the urinary catheter tubing. CNA 10 stated to prevent Resident 67 from tugging or pulling on the catheter tube, the catheter tubing was positioned behind Resident 67's leg to prevent dislodgement or discomfort from continuous pulling. CNA 10 stated that the clip attached to the resident's catheter tubing had never been used. CNA 10 stated Resident 67's catheter tubing would be secured with the clip attached to the catheter tubing to prevent further tugging on the catheter tubing and to secure it. 2. During an observation, on 5/19/2021 at 8:06 a.m., Resident 14 was sitting in a geriatric chair (Geri Chair- a large padded chair that assist seniors or disabled individuals with limited mobility.) Resident 14's urinary catheter drainage bag was observed hanging on the front frame of the geriatric chair. The urinary catheter tubing was not secured to Resident 14's inner thigh. Resident 14 was observed seated on the urinary catheter tubing. A review of Resident 14's admission Record indicated an admission to the facility on 2/27/2021 with medical diagnoses that included cancer, encephalopathy (inflammation of the brain), hydronephrosis (excess fluid in a kidney due to a backup of urine), neuromuscular dysfunction of the bladder (lack of bladder control). A review of Resident 14's History and Physical (H&P) Examination dated 2/28/2021, indicated no capacity to understand and make decisions. A review of Resident 14's MDS indicated extensive assistance with staff providing weight bearing support with one to two-person physical assist with bed mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 14's Care Plan for the use of the urinary catheter indicated under approaches and plan to maintain proper alignment of the urinary catheter to promote proper drainage. During an observation on 5/19/2021 at 9:31 a.m., Treatment Nurse (TN) 1 was providing treatment care to Resident 14's urinary catheter. TN 1 stated when providing care for residents with a urinary catheter, checking for sediments, signs and symptoms of infections, and drainage should be observed. TN 1 stated that the catheter tubing should be secured to prevent tugging or discomfort, since it could cause pain and dislodge the catheter. TN 1 stated the use of a clip or a leg strap should be utilized. TN 1 validated that Resident 14's urinary catheter tubing was not anchored or secured. During an interview on 5/21/2021 at 8:25 a.m., Registered Nurse (RN) 1 stated the facility practices for residents with urinary catheters included to use a privacy bag, keep the drainage bag lower than the bladder, and to secure the urinary catheter tubing with the clip attached to the catheter tubing or leg strap, to secure the tubbing so that the catheter line would not dislodge. RN 1 stated the catheter tubbing should always be anchored and secured. During an interview on 5/21/2021 at 9:18 a.m., the director of staff development (DSD) stated an in-service for urinary catheter was provided to certified nurse assistants (CNA) that directed CNA's to provide peri care, to position the catheter at an appropriate level to promote urine drainage flow, and to secure the catheter tubing with a clip, anchored to resident's bedding sheet to keep the tubing in place. The DSD stated that the catheter was secured by inflating the balloon inside of the resident, therefore the catheter must be stabilized in place, using the clip attached to the catheter line or a leg strap, to prevent dislodgement and tugging of the catheter. A review of the facility in-services indicated Foley catheter care dated 12/2/2020 with objectives to prevent catheter associated UTI's, to ensure proper placement of catheter, notify charge nurse of unusual observations. An in-service for urinary catheter care was provided on 5/11/2021 with objectives to prevent catheter associated urinary tract infections. A review of the facility's Catheter Care, Urinary Policy and Procedure (P&P), revised 9/2014, indicated to prevent catheter-associated urinary tract infections, unobstructed urine flow should be maintained. The policy indicated the resident should be checked frequently to ensure the resident were not lying on the catheter and to keep the catheter and tubing free from kinks. The policy indicated to ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site and that the catheter should be strapped to the resident's inner thigh. The P&P indicated to utilize a leg band to secure the catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide respiratory care and treatment consistent with professional standards of practice for two of three sampled residents (Resident 6 and 20) who required oxygen administration by failing to: 1. Ensure facility staff provided Resident 20 with a working Bilevel Positive Airway Pressure (BiPAP; a device that helps push air into the lungs) machine at bedtime for sleep apnea (a sleep disorder in which breathing repeatedly stops and starts) as ordered by the physician. 2. Ensure facility staff monitored Resident 20's oxygen saturation (refers to the amount of oxygen in the bloodstream) every shift to titrate (adjust based on oxygen need) the oxygen flow rate from 2 liters per minute (L/min) to 5 L/min via nasal cannula (NC; a lightweight tubing with prongs placed in the nose) to maintain the resident's oxygen saturation above 92% continuously as ordered by the physician. 3. Ensure facility staff monitored Resident 6's oxygen saturation every shift to titrate the oxygen flow rate from 2 L/min to 5 L/min via NC to maintain the resident's oxygen saturation above 92% continuously as ordered by the physician. These deficient practices had the potential to result in inconsistencies in providing the appropriate care and treatment for Resident 6 and 20 and placed Resident 6 and 20 at risk for respiratory complications such as hypoxia (lack of oxygen in the tissues to sustain bodily functions) or oxygen toxicity (lung damage that happens from breathing in too much extra supplemental oxygen). Findings: 1. A review of Resident 20's admission Record, indicated the facility admitted the resident on 2/17/21, with diagnoses including acute respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions), diabetes mellitus (high blood sugar), and chronic kidney disease. A review of Resident 20's physician's order, dated 2/17/21, indicated BiPAP settings with respiratory rate = 4, fraction of inspired oxygen (FiO2; the concentration of oxygen in the gas mixture) = 30%, and expiratory positive airway pressure (EPAP; set to maintain upper airway patency) = 4 centimeters of water (cmH2O) at bedtime. BiPAP on at 9 p.m. and off at 6 a.m. for sleep apnea and remove per schedule. The order indicated may or may not need heated humidification (uses heat to warm water in the humidifier chamber to produce moisture which is carried by the breathed air). A review of Resident 20's care plan, dated 2/17/21, indicated the resident was at risk for respiratory distress due to respiratory failure and required oxygen as needed (PRN). The care plan goal indicated the resident will have minimal signs and symptoms of respiratory distress daily and the shortness of breath (SOB) will be resolved after oxygen intervention daily for 90 days. The approaches included to monitor the resident for SOB, wheezing (high-pitched whistling sound made while breathing), coughing, etc. and notify the physician if present or if with no improvement after intervention, administer oxygen inhalation at 2 liters per minute (L/min) via NC every shift. A review of Resident 20's Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 2/23/21, indicated the resident was able to communicate and was cognitively (how the brain remembers, thinks, and learns) intact. The MDS indicated the resident required supervision (oversight, encouragement or cueing) with eating, extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, dressing, and personal hygiene, and total assistance (staff provided care 100% of the time) with transfer, toilet use, and bathing. The MDS indicated Resident 20 was on oxygen therapy and non-invasive mechanical ventilator (air is moved toward and from the lungs through an external device connected directly to the resident [BiPAP]) within the last 14 days. During an observation on 5/18/21 at 10:32 a.m., Resident 20 was observed in bed receiving oxygen inhalation at 3 L/min via NC continuously. During an observation and concurrent interview on 5/19/21 at 7:46 a.m., Resident 20 was observed in bed receiving oxygen inhalation at 3 L/min via NC continuously. Resident 20 complained that she did not have her BiPAP machine on the previous night because the machine would not turn on. Resident 20 stated she notified the facility staff (unable to recall who) about her BiPAP not working but the facility staff did not do anything about it. Resident 20 stated no one helped her with her BiPAP machine. During an interview on 5/19/21 at 1:37 p.m., Licensed Vocational Nurse (LVN) 4 stated she did not receive any complaints from Resident 20 the morning of 5/19/21. LVN 4 stated the night shift nurse (LVN 6) informed her during change of shift report that Resident 20's BiPAP machine was not working and for her to call the BiPAP machine company. LVN 4 stated she did not call the BiPAP machine company yet. During an interview on 5/19/21 at 1:41 p.m., Wound Treatment Nurse (TXN) 1 stated she just checked on Resident 20's BiPAP machine and the machine was not powering on properly. TXN 1 stated the BiPAP machine kept indicating check power. TXN 1 stated she already called the company and the company will be bringing a replacement today. During an interview on 5/20/21 at 4:54 p.m., Licensed Vocational Nurse (LVN) 5 stated she was Resident 20's charge nurse on 5/18/21 during the 3 p.m. to 11 p.m. shift. LVN 5 stated Resident 20 was on continuous oxygen inhalation with stable oxygen saturation. LVN 5 stated Resident 20 was alert and able to apply the BiPAP machine on her own at bedtime. LVN 5 stated she did know know that the resident's BiPAP machine was not working during her shift. A review of the facility's policy and procedures titled, CPAP/BiPAP Support, revised in 3/2015, indicated review the physician's order to determine oxygen concentration and flow and the PEEP pressure (CPAP, EPAP, IPAP) for the machine. Review and follow manufacturer's instruction for machine setup and oxygen delivery. The policy indicated document the following in the resident's medical record: time the CPAP was started and the duration of the therapy, mode and settings for the CPAP, oxygen concentration and flow if used, how the resident tolerated the procedure and oxygen saturation during therapy. 2. A review of Resident 20's physician's order, dated 2/17/21, indicated administer oxygen at 2 L/min via nasal cannula and may titrate up to 5 L/min to maintain oxygen saturation above 92% continuously for SOB and wheezing every shift. During an interview and concurrent record review on 5/20/21 at 11:54 a.m., LVN 3 stated the licensed staff were not monitoring Resident 20's oxygen saturation every shift. LVN 3 stated the resident's oxygen saturation should be monitored at least once a shift to be able to titrate the oxygen flow rate from 2 L/min to 5 L/min accordingly and keep Resident 20's oxygen saturation above 92% per physician's order. A review of the facility's policy and procedures titled, Oxygen Administration, revised in 10/2010, indicated before administering oxygen and while the resident is receiving oxygen therapy, assess for the following: signs and symptoms of cyanosis (i.e., blue tone to the skin and mucous membranes), hypoxia (i.e. rapid breathing, rapid pulse rate, restlessness, confusion) and oxygen toxicity (i.e., tracheal irritation, difficulty breathing, or slow, shallow rate of breathing), vital signs, lung sounds, arterial blood gases and oxygen saturation if applicable, and other laboratory results if applicable. 3. A review of Resident 6's admission Record, indicated the facility admitted the resident on 7/13/2020, with diagnoses including progressive supranuclear ophthalmoplegia (a condition that affects the movement of the eyes), Parkinson's disease (a brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination), and diabetes mellitus (high blood sugar). A review of Resident 6's care plan, dated 7/13/2020, indicated the resident was at risk for respiratory distress due to asthma, pulmonary insufficiency, respiratory failure, and chronic interstitial lung disease (a large group of diseases that cause scarring of the lungs) and required continuous oxygen. The care plan did not indicate a specific goal. The approaches included to give oxygen inhalation of 2 L/min to 5 L/min via NC continuously as ordered and give breathing treatment as ordered. A review of Resident 6's physician's order, dated 10/30/2020, indicated administer oxygen at 2 L/min via NC continuously and may titrate up to 5 L/min to maintain oxygen saturation above 92% for SOB and wheezing every shift. A review of Resident 6's MDS, dated [DATE], indicated the resident was rarely/never able to communicate and had short and long-term memory problem and severely impaired cognition. The MDS indicated the resident required total assistance with bed mobility, transfer, locomotion on and off unit, dressing, eating, toilet use, personal hygiene, and bathing. The MDS indicated the resident was on oxygen therapy within the last 14 days. During an observation on 5/18/21 at 10:50 a.m., Resident 6 was observed in bed with eyes closed, receiving oxygen inhalation at 2 L/min via NC continuously. During an observation 5/20/21 at 7:44 a.m., Resident 6 was observed sitting up in a geriatric chair (padded reclining chair) with eyes closed, receiving oxygen inhalation at 2 L/min via NC continuously. During an interview and concurrent record review on 5/20/21 at 11:39 a.m., LVN 3 stated the licensed staff were not monitoring Resident 6's oxygen saturation every shift. LVN 3 stated the resident's oxygen saturation should be monitored at least once a shift to be able to titrate the oxygen flow rate from 2 L/min to 5 L/min accordingly and keep Resident 6's oxygen saturation above 92% per physician's order. During an interview on 5/20/21 at 1:27 p.m., the assistant director of nursing (ADON) stated Resident 6's oxygen saturation should be monitored and documented every shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the attending physician responded to two recommendations made by the consultant pharmacist (CP) regarding medication therapy for two of five sampled residents (Residents 13 and 116) between 2/24/21 and 4/28/21. 1. For Resident 13's, the clinical record did not indicate documented evidence of the attending physician's response to the consultant pharmacist's recommendation to justify continued use of Protonix on 2/24/21. 2. For Resident 116, the facility failed to obtain a response from the physician regarding the pharmacist's recommendation to add a 14-day stop date to Ambien or limit the PRN Ambien to 14 days. This deficient practice increased the risk that medication therapy for Residents 13 and 116 may not have been optimized for the best possible health outcomes. This deficient practice had the potential to cause a negative impact on the resident's overall physical, mental, and psychosocial well-being. Findings: 1. A review of Resident 13's admission Record, dated 5/21/21, indicated she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including gastro-esophageal reflux disease (GERD - chronic heartburn.) A review of Resident 13's Order Summary Report, dated 4/30/21, indicated on 6/30/2020, the physician prescribed Protonix (a medication used to treat GERD) 40 milligrams (mg- a unit of measure for mass) by mouth once daily. A review of Consultant Pharmacist's Medication Regimen Review, dated 2/24/21 indicated the consultant pharmacist made a recommendation to the attending physician to justify long-term therapy with Protonix as the length of therapy had exceeded 12 weeks and identified the risks of long-term therapy. Further review of the consultant pharmacist's recommendation indicated that under the Follow-Through section, the facility documented Per RP [responsible party], no changes. MD made aware 2/27/21. A review of Resident 13's clinical record indicated there was no apparent response from her attending physician regarding the pharmacist's recommendation listed above. On 5/21/21 at 10:29 a.m., during an interview, the director of nursing (DON) stated the facility is supposed to contact the physician first, obtain the physician's response to the pharmacy recommendations and then if any changes are proposed, convey those to the resident or RP. The DON stated that it appears from the note that Resident 13's RP was contacted first, declined any changes in treatment and then the facility informed Resident 13's attending physician. The DON stated that Resident 13's attending physician should review the consultant pharmacist recommendation first and then make a decision to agree and take action or disagree and provide a rationale. On 5/21/21 at 10:30 a.m., during an interview, the nurse consultant (NC) stated that Resident 13's progress notes and the resident's clinical record did not indicate documented evidence of the physician's response to the consultant pharmacist's recommendation to justify continued use of Protonix. NC stated that per the documentation, it appears that the MD was only informed that the RP did not want any changes made to the medication therapy. NC stated that the physician should have the opportunity to weigh in first, so the RP can fully understand the risks vs benefits of any changes in therapy as recommended by the physician. 2. A review of Resident 116's admission Record, dated 5/21/21, indicated she was readmitted to the facility on [DATE] with diagnoses including: major depressive disorder (MDD- a mental disorder characterized by depressed mood, a lack of interest in activities or socializing, or poor appetite) and anxiety disorder (a mental disorder characterized by feeling or worry or fear that interfere with daily activities.) A review of Resident 116's Order Summary Report, dated 4/30/21, indicated on 4/26/21, the physician prescribed Ambien (a medication used to treat insomnia - the inability to sleep) 5 mg by mouth every 24 hours as needed for insomnia manifested by unable to sleep. A review of the Interim Medication Regimen Review, dated 4/28/21, indicated the consultant pharmacist made a recommendation to add a 14-day stop date to Ambien. A review of Resident 116's clinical record indicated there was no apparent response from her attending physician regarding the pharmacist's recommendation listed above and no stop date indicated on the PRN order for Ambien. On 5/21/21 at 12:22 p.m., during an interview, the DON confirmed no duration or stop date had been specified for Resident 116's PRN Ambien order. The DON stated that the facility failed to obtain a response from the physician regarding the pharmacist's recommendation or limit the PRN Ambien to 14 days. A review of the facility's policy Medication Regimen Reviews, revised May 2019, indicated The attending physician documents in the medical record that the irregularity had been reviewed and what (if any) action was taken to address it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Limit the use of PRN (as needed) Ambien (a medication used to treat the inability to sleep) to 14 days in one of five sampled residents (Resident 116.) 2. Monitor for adverse effects (unwanted or dangerous medication side effects) of psychotropic medications (medications that affect brain activities associated with mental processes and behavior) in one of five sampled residents (Resident 116.) 3. Monitor for behaviors tied to psychotropic medication use in one of five sampled residents (Resident 116.) These deficient practices increased the risk that Resident 116 to experience adverse effects of psychotropic medication therapy leading to an overall negative impact on her physical, mental, and psychosocial well-being. Findings: A review of Resident 116's admission Record, dated 5/21/21, indicated she was readmitted to the facility on [DATE] with diagnoses including: major depressive disorder (MDD- a mental disorder characterized by depressed mood, a lack of interest in activities or socializing, or poor appetite) and anxiety disorder (a mental disorder characterized by feeling or worry or fear that interfere with daily activities.) A review of Resident 116's Order Summary Report, dated 4/30/21, indicated on 4/26/21, the physician prescribed the following psychotropic therapy: 1.Ambien (a medication used to treat insomnia - the inability to sleep) 5 milligrams (mg - a unit of measure for mass) by mouth every 24 hours as needed for insomnia manifested by unable to sleep. 2.Lexapro (a medication used to treat MDD) 10 mg by mouth once daily for depression manifested by verbalization of feeling sadness. 3.Seroquel (a medication sed to treat hallucinations - seeing or hearing things that are not there) 25 mg by mouth at bedtime for anxiety manifested by aggressive behaviors like trying to hit or kick toward staffs. A review of Resident 116's Medication Administration Record (MAR - a record of medications, behaviors, and adverse effect monitoring done by licensed nursing staff) for May 2021 indicated the facility was not monitoring for behaviors of verbalization of feeling sadness or aggressive behaviors like trying to hit or kick toward staffs tied to the use of Lexapro and Seroquel, respectively. Further review of Resident 116's MAR for May 2021 indicated the facility was also not tracking her number of hours of sleep each night tied to her use of the Ambien. A review of Resident 116's MAR for May 2021 also indicated the facility was not monitoring for side effects common to Seroquel. A review of Resident 116's clinical record indicated the facility did not indicate a stop date or specify a duration for her PRN order for Ambien. On 5/21/21 at 12:22 p.m., during an interview, the Director of Nursing (DON) stated that the facility did not monitor behaviors and adverse effects for Resident 116's psychotropic therapy as specified in the resident's plan of care for those medications and failed to add a stop date or duration to the resident's order for PRN Ambien. On 5/21/21 at 12:47 p.m., during an interview, the nurse supervisor (RN 1) confirmed Resident 116's clinical record contained no orders to monitor behaviors tied to her psychotropic medication therapy and no order to monitor for the adverse effects of Seroquel. RN 1 stated that without behavioral monitoring the facility staff could not implement the resident's care plan accurately because there's no way to objectively verify whether the medications are improving the behaviors they were prescribed for. RN 1 stated that monitoring adverse effects is essential to ensure that the medications were not causing more harm than good. RN 1 stated that it looks like the licensed nurse who readmitted this resident on 4/26/21 did not indicate the appropriate monitoring orders for adverse effects and behaviors along with the medication orders. On 5/21/21 at 1:00 p.m., during an interview, the DON stated it is important to monitor behaviors associated with psychotropic medication use to determine if the medications are effective or not at controlling the resident's behaviors. The DON stated that monitoring side effects of psychotropic medications is important to ensure that the medications don't cause significant side effects that can diminish a resident's quality of life such as drowsiness, dizziness, dry mouth, or constipation. A review of the facility's Policy Antipsychotic Medication Use, revised December 2016, indicated The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order . Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the Attending Physician. General/anticholinergic .Cardiovascular .Metabolic .Neurologic . Review of the facility's policy Behavioral Assessment, Intervention and Monitoring, revised March 2019, indicated The residents on psychotropic drug behavior monitoring will be done by the license nurse each shift. Behavior manifested will be documented in the medication administration record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to follow food accommodation for five of five sampled residents (Residents 39, 65, 73, 102, and 276) for food preferences, intolerance, and/or allergies. 1. Resident 39 had a preference to not eat salad, red sauce, and corn and stated he/she received salad, red sauce, and corn on her/his meal tray. 2. Resident 65 had an intolerance to dairy products and stated he continued to receive milk on his meal tray. 3. Resident 73 had allergies to fish and stated she had received fish on her meal tray. 4. Resident 102 was a vegetarian and stated she received poultry on her meal tray. 5. Resident 276 stated she preferred not to have citrus products, dairy, and wheat on her meal trays, but continued to receive wheat on her meal tray. These deficient practices had the potential for residents to refuse meals, cause unavoidable weight loss, and allergic reactions, to foods provided by the facility. Findings: 2. During an interview on 5/18/21 at 11:20 a.m., Resident 65 stated an intolerance to milk and stated the facility would serve milk and milk products to Resident 65. Resident 65 stated milk and milk products upset his stomach. A review of Resident 65's admission Record indicated an admission to the facility on 9/29/2017, with diagnoses that included hemiplegia (partial weakness or loss of strength on one side of the body) and hemiparesis (severe or complete loss of strength or paralysis on one side of the body) affecting left non-dominant side, and diabetes (high blood sugar). A review of Resident 65's History and Physical (H&P) examination, dated 12/16/2020, indicated the resident had the capacity to understand and make decisions. A review of Resident 65's Minimum Data Set (MDS- a care area screening and assessment tool) indicated extensive assistance with one-person physical assist for bed mobility, transfers, and personal hygiene. Resident 65 required limited assistance (guided maneuvering with non-weight bearing support) with one-person physical assist. A review of Resident 65's Care Plan for Nutritional Status indicated for dietary staff to inquire and provide resident food preferences. There was no indication on Resident 65's Care Plan indicating his milk intolerances and or preferences. A review of Resident 65's meal tray ticket indicated under dislikes: milk, yogurt, sour cream, ice cream, cottage cheese, cheese, cheddar or yellow cheese, chicken, beef, turkey, rice, and tuna salad. 3. During an interview on 5/18/2021 at 8:30 a.m., Resident 73 stated an allergy to foods including fish and citrus products. Resident 73 stated although she had verbalized to the facility that she had an allergy to fish, and was indicated on Resident 73's meal tray ticket, Resident 73 stated she continued to receive a meal tray with fish. A review of Resident 73's admission Record indicated an admission to the facility on [DATE], with diagnoses that included cirrhosis of the liver (severe scaring of the liver with poor liver function), hepatomegaly (enlarged liver), and anemia (lack enough healthy red blood cells to carry adequate oxygen to your body's tissues). Resident 73's admission Record indicated under allergies: citrus, citrus products, fish, and iodine. A review of Resident 73's History and Physical (H&P) Examination indicated the capacity to understand and make decisions. A review of Resident 73's Minimum Data Set (MDS- a care area screening and assessment tool) indicated on the Brief Interview for Mental Status (BIMS- a short performance-based cognitive screener for nursing home (NH) residents) indicated Resident 73's cognition was intact. A review of Resident 73's meal tray ticket indicated citrus, citrus products, fish and iodine as allergies. Resident 73's dislikes indicated egg salad and eggs. A review of Resident 73's Care Plan for Nutritional Status, dated 1/27/21, under approach and plans, indicated no citrus products or fish. 4. During an interview on 5/19/2021 at 9:40 a.m., Resident 102 stated having several conversations with the dietary supervisor regarding adjustments to Resident 102's diet. Resident 102 stated not eating poultry but does eat fish. Resident 102 stated recently there was a mistake from the kitchen and Resident 102 was served poultry one time. Resident 102 stated it was a big mistake and very stressful that Resident 102 refused to eat. Resident 102 stated when mistakes on food occurs, Resident 102 would not eat any food from the kitchen that day. A review of Resident 102's admission Record indicated an admission to the facility on 1/13/2021 with diagnoses of heart failure and hypertension (high blood pressure). A review of Resident 102's MDS indicated supervision with one-person physical assist with bed mobility, transfers, dressing, eating, toilet use and personal hygiene. A review of Resident 102's Dietary Quarterly/Annual Progress Note, dated 4/21/21, indicated under current diet order: Regular no added salt (NAS) Vegetarian, Fish ok. A review of Resident 102's Care Plan for Nutritional Status indicated for dietary staff to inquire and provide resident food preferences. The Care plan indicated on 1/29/2021 regular diet, no added salt, vegetarian, ok with fish, no meat or chicken. A review of Resident 102's meal tray ticket indicated vegetarian, and under dislikes indicated beef, pork, ham, sausage, chicken, turkey, turkey salad, and gravy. 5. During an interview on 5/18/2021 at 11:14 a.m., Resident 276 stated she preferred not consume dairy or wheat products. Resident 276 stated she had an asthma attack (sudden worsening of asthma symptoms caused by the tightening of muscles around your airways) a few nights ago, which Resident 276 believed was due to the diet provided at the facility. A review of Resident 276's admission Record indicated an admission to the facility on 5/4/2021 with diagnoses of heart failure, hypertension (high blood pressure), and malnutrition (body doesn't get enough nutrients). The admission Record indicated under allergies: flagyl (antibiotic used to treat various infections), citrus products, milk and milk products, wheat products, pollen (fine, dust like mass of grains), catapres (medication used to treat hypertension), Cipro (antibiotics used to treat infections), and tussends (decongestants help relieve stuffy nose symptoms. A review of Resident 276 meal tray ticket indicated allergies to citrus products. Resident 276 dislikes indicated orange juice, lemonade, ice cream, yogurt, sour cream, cottage cheese, cheese, whole milk, and cold cereal. There was no indication indicating no wheat products. A review of Resident 276's Care Plan for Nutritional Status dated 5/4/21, indicated for dietary staff to inquire and provide resident food preferences (likes and dislikes). The Care Plan did not indicate Resident 276's allergies, intolerances, and/or preferences. During an interview on 5/20/2021 at 11:08 a.m., dietary supervisor (DS) stated meal tray tickets were printed daily and verified by the DS checking preferences and allergies. The DS stated awareness to Resident 276's preference in not receiving wheat on her meal tray. The DS validated that the preference was not identified on Resident 276's meal tray ticket, and that the DS will add Resident 276's preference to her diet and meal tray ticket. The DS stated when new requests or preferences are reported by the residents, the DS will make meal rounds on food updates. The DS stated that usually the first rounds are done on the resident's admission. The DS could not recall when the last meal rounds were conducted, since she was new to the facility since February 2021. The DS stated that her notes were hand written and not documented on the facility's electronic medical records. The DS stated that meal trays were checked while in the kitchen, and then by the nurse supervisor, charge nurse, or the DSD, once on the meal cart. The DS stated a third check is conducted prior to giving the meal tray to the resident. The DS stated a resident should not be receiving a meal tray with food that they dislike if it was listed on their preferences and should not receive foods with identified allergies. The DS stated if situations arise where residents are given foods that they do not prefer, intolerable or are allergic to, it must immediately be brought up to the dietary department During an interview on 5/21/2021 at 8:18 a.m., the DS stated the importance for following resident's diet order was to ensure safety, and that resident's would not get sick or have an allergic reaction to food provided by the facility. The DS stated the facility should provide foods according to the resident's preferences to increase their appetite. During an interview on 5/21/2021 at 9:26 a.m., the DSD stated the practice in assisting on checking meal trays once the meal tray cart comes out of the kitchen is that she compares the meal tray list to resident's meal trays, and checks resident's diet, allergies, and preferences. The DSD states clearly observing all meal trays by lifting the meal tray plate cover to ensure correct diet. The DSD stated a third check is done by the CNA's prior to dispersing the meals trays to the residents, therefore residents should not be receiving meals that are not within their diet including preferences and allergies. The DSD stated if a problem with a resident's meal is encountered, such as the residents receiving foods they are allergic and intolerable to, or food preferences not accommodated, immediate notification to the kitchen was done for a substitute meal. The DSD stated it was important to follow resident's diet orders for the residents' safety. A review of the facility's policies and procedures (P&P) titled Resident Food Preferences, revised on 07/2017, indicated upon admission or within 24 hours after admission, the dietician or nursing staff will identify resident's food preferences. The P&P indicated nursing staff would document the resident's food and eating preferences in the care plan. The food service department will offer a variety of food at each meal. A review of the facility's Optimal Registered Dietician Nutrition (RDN) Solutions In-service for Tray line Accuracy and Menu Compliance, Substitutions, revised on 4/2021, indicated tray inaccuracies may affect the treatment of resident's medical condition and can result in citations from regulatory agencies. The Tray line Accuracy and Menu Compliance indicated to read cards carefully for diet order, food likes/ dislike, texture modifications, and supplements. A review of the facility's Optimal RDN Solutions In-services for Food Allergies versus Intolerances, revised 01/2021, indicated it was the facility's responsibility to ensure that the food that residents consume are free from substance that can cause adverse reactions, Residents who have allergies to very common foods that are widely used, such as milk, wheat or eggs, may need to have an individualized menu developed for meal and snacks. 1.A Review of Resident 39's admission Record, Resident 39 was admitted to the facility on [DATE] with diagnoses that included wedge compression fracture of the spine, obesity (over weight) anxiety disorder and history of falling, and allergies to sulfa antibiotics. A Review of Resident 39's MDS dated [DATE] indicated the resident was cognitively intact and had no impairments with communication. A review of Resident 39's dietary preference list - a list attached to the resident's Nutritional Screen-Food Preferences dated 3/16/21, indicated Resident 39 was on mechanical soft diet with no added salt, dislike turkey, turkey salad, corn, salad and red sauce. A review of Resident 39's care plan dated 3/15/21 indicated the dietary staff would inquire and provide resident food preferences (like & dislike). During an interview, on 5/20/21 at 9:18 a.m., Resident 39 stated the resident's emergency contact (EC 1), had talked with the facility's administrator and the DS that Resident 39 could not eat salad, red sauce, and corn. Resident 39 stated the facility continued to serve the salad, red sauce, and corn to her. During an interview, on 5/20/21 at 10:16 a.m., the ADM and DS, stated that he had conversation over the phone with EC 1 about Resident 39's food preferences. The DS stated that they indicated Resident 39's food preferences in the resident's food preference list.

Based on observation, interview and record review, the facility failed to maintain resident record in accordance with standard of practice by failure to 1.Keep residents' medical records safe when facility's storage room for medical records were left open and unlock. 2.Accurately document on resident's medical records Resident 20's use of Bilevel Positive Airway Pressure machine (BIPAP-machine used by people having trouble breathing; it can help push air into lungs) use on the Medication Administration Record (MAR). These deficient practices had the potential for an unauthorized person to access residents' medical records, other personal information and violate HIPAA (Health Insurance Portability and Accountability Act- a federal law that requires the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge) regulation and potential for inappropriate or lack of care. Findings: 1.During a concurrent observation and interview on 5/20/2021 at approximately 2:45 p.m. the Maintenance Supervisor (MS) 1 by another surveyor, Registered Environmental Health Specialist (REHS), two opened storage rooms in the facility's basement were open and unlock. Each room had 100 filing boxes, with medical records inside each box. MS 1 stated facility stored medical records inside the two rooms. During an interview on 5/21/2021 at 10:55 a.m., Medical Records Assistant (MRA) stated storage rooms downstairs were used as medical records storage. MRA stated they store medical records that were three years old in a sealed box and keep it in the facility's storage room. MRA stated the storage room should always be locked to prevent unauthorized person in accessing residents' medical records. MRA stated only maintenance supervisors and medical records should have access to the storage room. During an interview on 5/21/2021 at 11:27 a.m., MS 1 stated storage rooms downstairs always has to be locked. MS 1 stated there was a small room inside the main room, that has several sealed boxes and inside those boxes were medical records. MS 1 stated both doors always has to be locked. During an interview on 5/21/2021 at 1:23 p.m., the Administrator (ADM) stated medical records storage rooms downstairs should always be close, lock and only medical records personnel should have access. b. A review of Resident 20's admission Record, indicated the facility admitted the resident on 2/17/21, with diagnoses including acute respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions), diabetes mellitus (high blood sugar), and chronic kidney disease. A review of Resident 20's physician's order, dated 2/17/21, indicated BiPAP settings with respiratory rate = 4, fraction of inspired oxygen (FiO2; the concentration of oxygen in the gas mixture) = 30%, and expiratory positive airway pressure (EPAP; set to maintain upper airway patency) = 4 centimeters of water (cmH2O) at bedtime. BiPAP on at 9 p.m. and off at 6 a.m. for sleep apnea and remove per schedule. The order indicated may or may not need heated humidification (uses heat to warm water in the humidifier chamber to produce moisture which is carried by the breathed air). A review of Resident 20's care plan, dated 2/17/21, indicated the resident was at risk for respiratory distress due to respiratory failure and required oxygen as needed (PRN). The care plan goal indicated the resident will have minimal signs and symptoms of respiratory distress daily and the shortness of breath (SOB) will be resolved after oxygen intervention daily for 90 days. The approaches included to monitor the resident for SOB, wheezing (high-pitched whistling sound made while breathing), coughing, etc. and notify the physician if present or if with no improvement after intervention, administer oxygen inhalation at 2 liters per minute (L/min) via nasal cannula (NC; a lightweight tubing with prongs placed in the nose) every shift. A review of Resident 20's Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 2/23/21, indicated the resident was able to communicate and was cognitively (how the brain remembers, thinks, and learns) intact. The MDS indicated the resident required supervision (oversight, encouragement or cueing) with eating, extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, dressing, and personal hygiene, and total assistance (staff provided care 100% of the time) with transfer, toilet use, and bathing. The MDS indicated Resident 20 was on oxygen therapy and non-invasive mechanical ventilator (air is moved toward and from the lungs through an external device connected directly to the resident [BiPAP]) within the last 14 days. During an observation and concurrent interview on 5/19/21 at 7:46 a.m., Resident 20 was observed in bed receiving oxygen inhalation at 3 L/min via NC continuously. Resident 20 complained that she did not have her BiPAP machine on the previous night because the machine would not turn on. Resident 20 stated she notified the facility staff (unable to recall who) about her BiPAP not working but the facility staff did not do anything about it. Resident 20 stated no one helped her with her BiPAP machine. During an interview on 5/19/21 at 1:37 p.m., Licensed Vocational Nurse (LVN) 4 stated she did not receive any complaints from Resident 20 the morning of 5/19/21. LVN 4 stated the night shift nurse (LVN 6) informed her during change of shift report that Resident 20's BiPAP machine was not working and for her to call the BiPAP machine company. LVN 4 stated she did not call the BiPAP machine company yet. During an interview on 5/19/21 at 1:41 p.m., Wound Treatment Nurse (TXN) 1 stated she just checked on Resident 20's BiPAP machine and the machine was not powering on properly. TXN 1 stated the BiPAP machine kept indicating check power. TXN 1 stated she already called the company and the company will be bringing a replacement today. During an interview and concurrent record review on 5/20/21 at 4:54 p.m., Licensed Vocational Nurse (LVN) 5 stated she was Resident 20's charge nurse on 5/18/21 during the 3 p.m. to 11 p.m. shift. LVN 5 stated Resident 20 was alert and able to apply the BiPAP machine on her own at bedtime. LVN 5 stated she did know that the resident's BiPAP machine was not working during her shift. LVN 5 stated she initialed the resident's medication administration record (MAR) and documented that the resident's BiPAP was applied at 9 p.m. LVN 5 stated she documented and initialed the resident's MAR by mistake. During an interview and concurrent record review on 5/21/21 at 8:33 a.m., the director of nursing (DON) stated LVN 5 documented that she applied the BiPAP on the resident at 9 pm on 5/18/21 and LVN 6 documented that she removed the BiPAP at 6 a.m. on 5/19/21 on the resident's MAR. The DON stated the documentation was inaccurate. A review of the facility's policy and procedures titled, CPAP/BiPAP Support, revised in 3/2015, indicated review the physician's order to determine oxygen concentration and flow and the PEEP pressure (CPAP, EPAP, IPAP) for the machine. Review and follow manufacturer's instruction for machine setup and oxygen delivery. The policy indicated document the following in the resident's medical record: time the CPAP was started and the duration of the therapy, mode and settings for the CPAP, oxygen concentration and flow if used, how the resident tolerated the procedure and oxygen saturation during therapy.

Based on interview and record review, the facility failed to ensure the designated and existing infection preventionist (IP-responsible for the facility's Infection Prevention and Control Plan) completed the required initial specialized training in infection prevention and control no later than 1/1/2021 that meets the minimum set of requirements (14 hours) indicated by the Centers for Disease Control and Prevention (CDC). This deficient practice had the potential to result in the IP not having current knowledge and/ or training on surveilling and monitoring infection control practices and had the potential to further increase the development and transmission of communicable disease and infection in the facility. Findings: During an interview on 5/21/2021 at 9:31 a.m., the DON stated that the IP has been the facility's designated IP since 2019. The DON stated the IP has not begun or completed the current CDC training. The DON stated there was no one else in the facility who have completed the CDC training. The DON stated that the IP was to complete the CDC training within 90 days. A review of the IP's certification indicated a Certification of Training in Infection and Control, dated 11/2018 with 16 hours of completion. The facility could not provide current certification on required CDC training for the IP. A review of the Centers for Medicare and Medicaid (CMS) requirements of participation, reference number QSO-19-10-NH, dated 03/11/2019 indicated that infection preventionist requirements are effective 11/28/2019 and must have completed specialized training in infection prevention and control. A review of All Facilities Letter (AFL) 20-84 titled Infection Prevention Recommendations and Incorporation into the Quality and Accountability Supplemental Payment (QASP Program) dated 11/4/2020 indicated that the California Department of Public Health (CDPH) acknowledges the need for a more focused infection prevention program as well as a full-time infection preventionist (IP). The AFL highlighted that according to Assembly [NAME] 2644 directs Skilled Nursing facilities to have a plan in place for infection prevention quality control and have a full-time dedicated IP. The AFL indicated the facility's designated IP or both IPs if there are two part-time staff designated, should complete their initial IP training within 90 calendar days of hire if the IP is an existing employee who was recently designated to this role. An existing IP who has not completed initial IP training must complete the training no later than 1/1/2021. The initial training should include the following topic areas and include a minimum of 14 hours: a. Role of Infection Preventionist b. Infection Prevention Plan c. Standard, Enhanced Standard, and Transmission-Based Precautions d. Hand Hygiene e. Infection Safety f. Healthcare Associate Infection (HAI) Prevention g. Infection Surveillance h. Cleaning, Disinfection, Sterilization, and Environmental Cleaning i. Microbiology j. Outbreaks k. Outbreaks l. Antibiotic Stewardship m. Laws and Regulations (e.g. reporting requirements) n. Preventing Employee Infections

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the needs for eight out of 28 sampled residents were met (Resident 54, 65, 95, 103, 106, and 177) by failing to: 1. Ensure call lights were answered in a timely manner to address the residents needs for Residents 54, 65, 95, 103, 106, and 177. This deficient practice had the potential to affect residents' quality of care and quality of life due to nursing services were not provided to the residents in timely manner. 2. Ensure residents (Residents 95 and 103) were assisted with incontinent care, bathroom use, and with maintaining wellbeing to the extent possible in accordance with their own needs. This deficient practice had the potential for residents' lack of care and not maintaining their well-being in accordance with their own needs. Findings: 1. During an interview on 5/18/2021 at 9:00 a.m., Resident 95 stated no one helps her and facility staff takes a long time to come when she pressed the call light. Resident 95 stated that happens usually during the morning shift and there were times when she had to wait for an hour, and she needed to urinate and be changed. A review of Resident 95's admission Record indicated Resident 95 was admitted to the facility on [DATE], with diagnoses that included Type 2 diabetes mellitus (a chronic condition characterized by high levels of sugar in the blood), hypertension (high blood pressure), and chronic kidney disease (condition characterized by a gradual loss of kidney function). A review of Resident 95's History and Physical (H&P) dated 1/20/2021, indicated the resident did not have capacity to understand and make decisions. A review of Resident 95's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 4/14/2021, indicated that Resident 95 required extensive assistance (staff provide weight bearing support) on bed mobility, transfers, toilet use, dressing, and personal hygiene. 2. During an interview on 5/18/2021 at 9:00 a.m., Resident 106 stated she had been in the facility for three weeks. Resident 106 stated she could not walk. Resident 106 stated she sometimes had to wait for an hour when she pressed the call light for assistance. Resident 106 stated it happens all shifts but worst at night. A review of Resident 106's admission Record indicated Resident 106 was admitted on [DATE]. A review of resident's MDS dated [DATE] indicated that Resident 106 required extensive assistance (staff provide weight bearing support) on bed mobility, transfers, eating, toilet use, and personal hygiene. During a follow up interview on 05/19/2021 at 2:05 p.m., Resident 106 stated it took a long time for the facility staff to answer the call light. Resident 106 stated it takes about 30 minutes to 45 minutes for facility staff to respond to her call light. Resident 106 stated this usually happened from 3 pm to 11 pm shift (evening shift). Resident 106 added that she does not call much but would call for incontinence care and adult brief changes. Resident 106 stated at times, she had to wait in wet adult briefs for a long time. 3. During an interview on 5/18/2021 at 9:51 a.m., Resident 103 stated that sometimes if the resident needed assistance it takes a very long time for facility staff to come. Resident 103 stated the facility staff wanted to do their routine tasks. Resident 103 stated it takes from 30 minutes to 2.5 hours because she watched the clock. Resident 103 stated she tracked the time by watching the wall clock and track between the time of the call and when facility staff come in. Resident stated that during nighttime she calls the staff for bathroom assistance. A review of Resident 103's admission Record indicated Resident 103 was admitted to the facility on [DATE], with diagnoses that included right knee osteoarthritis (joint (connection between two bones) disease in which tissues in the joint break down overtime), low back pain, systemic lupus erythematosus (an inflammatory disease when immune system attacks its own tissue), and asthma (condition when airways narrow and swell making breathing difficult). A review of Resident 103's H&P dated 4/20/2021, indicated the resident had the capacity to understand and make decisions. A review of Resident 103's MDS dated [DATE] indicated intact cognitive response. MDS also indicated that the Resident 103 required extensive assistance (staff provide weight bearing support) on bed mobility, transfers, eating, toilet use, and personal hygiene. 4. During an interview on 5/18/2021 at 11:20 a.m., Resident 65 stated that he had been living in the facility for three years and was unable to get up from the bed. Resident 68 stated that the facility staff come and assist him sometimes but not regularly. Resident 65 stated when he pressed the call light, the facility staff comes in the room Pretty late. Resident 68 stated the facility staff sometimes took two hours to respond to call lights. Resident 68 stated he looks at the wall clock in his room to track the time the facility staff responds after pressing the call light. A review of Resident 65's admission Record indicated Resident 65 was admitted to the facility on [DATE], with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body that affects the arms, legs, and facial muscles) following cerebral infarction (damage to tissues in the brain due to loss of oxygen to the area) affecting left non-dominant side, contracture of muscles, multiple sites (tightening of the muscles that prevents normal movement of the associated body parts), hypertension (high blood pressure) and Type 2 diabetes (condition in which blood sugar is high). A review of Resident 65's H&P dated 12/16/2020, indicated the Resident 65 had the capacity to understand and make decisions. A review of Resident 65's MDS dated [DATE] indicated mild cognitive impairment (slight decline in cognitive abilities included memory and thinking skills that does not significantly impact daily functioning). The MDS indicated Resident 65 was totally dependent on staff for transfers and toilet use and required extensive assistance (staff provide weight bearing support) on bed mobility, dressing, and personal hygiene. 5. During an interview on 5/18/2021 at 12:00 p.m., Resident 54 stated when he pressed the call light, the facility staff do not come right away. Resident 54 stated that there was an incident when his left leg was falling off the bed. Resident 54 stated it took two hours for a facility staff to assist in repositioning his/her leg. Resident 54 stated he checked the time from the wall clock in his room. A review of Resident 54's admission Record indicated Resident 54 was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis following cerebral infarction (damage to tissues in the brain due to loss of oxygen to the area) affecting left non-dominant side, hypertension, muscle spasms (involuntary contractures of the muscles), and pain in left hip. A review of Resident 54's H&P dated 9/19/2020, indicated the Resident 54 had the capacity to understand and make decisions. A review of Resident 54's MDS, dated [DATE] indicated intact cognitive response. The MDS indicated that Resident 54 required extensive assistance (staff provide weight bearing support) on bed mobility, transfers, locomotion (movement between locations) on and off units, toilet use, personal hygiene, and dressing. 6. During a concurrent observation and interview on 5/20/2021 at 1:54 p.m., Resident 177's Family Member (FM) 1, stated I called a half an hour ago, nobody comes. FM 1 stated he called 45 minutes ago and requested coffee and creamers for Resident 177. A review of Resident 177's admission Record indicated Resident 177 was admitted to the facility on [DATE], with diagnoses that included spinal stenosis (narrowing of the spaces within spine which can put pressure on nerves), hypertension, repeated falls, and weakness. During the Resident Council Meeting conducted on 5/19/2021 at 11:06 a.m., residents verbalized concerns with call light response times. Resident 73 stated the average call light response time in the facility varied and were dependent on facility staffing. Resident 73 stated the night shift staff were not as responsive as during the day. Not as much staff at night. Residents 73 stated would wait 15 minutes and longer at nighttime. 7. A review of Resident 73's admission Record indicated Resident 73 was admitted to the facility on [DATE], with diagnoses of hypertension, GERD (GERD - gastroesophageal reflux disease a disease when stomach acid irritates the food pipe lining), and cirrhosis (chronic liver damage leading to liver failure). A review of Resident 73's MDS dated [DATE] indicated intact cognitive response. The MDS also indicated that Resident 73 required limited assistance (staff provide non-weight bearing support) on bed mobility, personal hygiene, and dressing. During an interview on 5/21/2021 at 9:31 a.m., the DON (Director of Nursing) stated call lights should be answered as soon as possible. The DON stated the facility have enough staff even if they had a staffing waiver. During an interview on 5/21/2021 at 9:53 a.m., the DSD (Director of Staff Development) was unaware of residents' concerns regarding call lights not being answered promptly until they got a complaint visit about resident care. The DSD stated that it had been brought up during Resident Council meeting: takes a little longer for call light to be answered on certain period of the day like shower times, morning care, meal time, change of shift - explained to them that certain times were busier, but facility is making sure to attend to them promptly. The DSD stated that the facility staff make frequent rounds, and everybody should be responsible for answering call lights. During an interview on 5/21/2021 at 2:10 p.m., CNA 8 stated that she was currently assigned at the facility's Yellow Zone (a cohort for residents who have direct or potential exposure to individuals with confirmed Covid-19). CNA 8 stated when the residents pressed their call lights, the light would light up as well at the Nursing Station. CNA 8 stated when the light is on in the nursing station, someone would call me and let me know. CNA 8 stated that they go as soon as possible. During an interview on 5/21/2021 at 2:16 p.m., LVN 4 stated she was assigned in the Yellow Zone that day and had approximately 30 assigned residents. LVN 4 stated the appropriate response time to the resident's call light should be a minute or two. During an interview on 5/21/2021 at 4:05 p.m., the DON stated that the appropriate response time to the residents' call lights should be immediately. The DON stated that there was no set time for the facility staff to respond to call light. The DON stated the facility staff should respond immediately. A review of the facility's policy and procedures titled Answering the Call Lights revised on 10/2010, indicated the purpose of the policy as to respond to the resident's requests and needs, answer the resident's call lights as soon as possible, and be courteous in answering the resident's call.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1.A review of Resident 25's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses including but not limited to quadriplegia, contracture of muscle at multiple sites. A review of the resident's MDS dated [DATE] indicated the resident had minimal cognitive impairment. It indicated the resident required extensive assist with bed mobility, dressing and eating. The MDS indicated the resident had impairments in range of motion on both sides of the upper extremities and both sides of the lower extremities and the resident did not walk. A review of the resident's active order summary indicated an order dated 5/12/2021 and revised 5/20/2021 of RNA to do provide the resident a passive range of motion to both lower extremities daily five times per week as tolerated. During an interview and review of Resident 25 medical records on 5/20/2021 at 3:37 p.m., the Director of Staff Development (DSD) stated the resident was receiving RNA treatments and services, but care plan was not completed in a timely manner. DSD confirmed that the care plan titled, Resident Care Plan RNA Program, was completed on 5/20/2021 as a late entry for 5/12/2021. DSD stated the care plan should have been completed on 5/12/2021 when the order for RNA treatment was entered. DSD stated all residents on RNA required a care plan and it was important to have a care plan for staff, residents, and/or responsible party would know the problem or concern the facility's approach and the goals and plan of care. These would be initiated and reviewed and has to follow-through the interventions were not working. DSD stated resident care plan has to be re-evaluated and change the plan as needed. DSD stated It would help identify if the physician or rehabilitation department, and anyone involves on the resident care has to be notified. A review of the facility's policy revised 7/2017 titled, Resident Mobility and Range of Motion, indicated the care plan will be developed by the interdisciplinary team based on the comprehensive assessment, and will be revised as needed. The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. A review of the facility's policy revised 7/2017 titled, Restorative Nursing Services, indicated restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care. Based on observation, interview, and record review, the facility failed to develop a person-centered comprehensive care plan timely for three of 28 sampled residents (Residents 20, 24, and 25) by failing to: 1. Resident 25 who was on a restorative nursing aide (RNA) program (nursing aide program that help residents to maintain their function and joint mobility) for both lower extremities (hips, knee, ankle, foot) passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises did not have a care plan for RNA. 2. Resident 20 who had sleep apnea (a sleep disorder in which breathing repeatedly stops and starts) did not have a care plan to address her sleep apnea and the use of a Bilevel Positive Airway Pressure (BiPAP; a device that helps push air into the lungs) machine at bedtime. 3. Resident 24 who had on and off episodes of edema (swelling) to her bilateral lower extremities (BLE) did not have a care plan to address her BLE edema. These deficient practices had the potential for lack of individualized care and evaluation of the interventions and goals of RNA program for Resident 25, hindering the resident progress and adjustment of services and treatments as needed and had the potential to result in inconsistencies and delay of care for Resident 20 and 24. Findings: 2. A review of Resident 20's admission Record, indicated the facility admitted the resident on 2/17/21, with diagnoses including acute respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions), diabetes mellitus (high blood sugar), and chronic kidney disease. A review of Resident 20's physician's order, dated 2/17/21, indicated BiPAP settings with respiratory rate = 4, fraction of inspired oxygen (FiO2; the concentration of oxygen in the gas mixture) = 30%, and expiratory positive airway pressure (EPAP; set to maintain upper airway patency) = 4 centimeters of water (cmH2O) at bedtime. BiPAP on at 9 p.m. and off at 6 a.m. for sleep apnea and remove per schedule. The order indicated may or may not need heated humidification (uses heat to warm water in the humidifier chamber to produce moisture which is carried by the breathed air). A review of Resident 20's care plan, dated 2/17/21, the resident was at risk for respiratory distress due to respiratory failure and required oxygen as needed (PRN). The care plan goal indicated the resident will have minimal signs and symptoms of respiratory distress daily and the shortness of breath (SOB) will be resolved after oxygen intervention daily for 90 days. The approaches included to monitor the resident for SOB, wheezing (high-pitched whistling sound made while breathing), coughing, etc. and notify the physician if present or if with no improvement after intervention, administer oxygen inhalation at 2 liters per minute (L/min) via nasal cannula (NC; a lightweight tubing with prongs placed in the nose) every shift. A review of Resident 20's Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 2/23/21, indicated the resident was able to communicate and was cognitively (how the brain remembers, thinks, and learns) intact. The MDS indicated the resident required supervision (oversight, encouragement or cueing) with eating, extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, dressing, and personal hygiene, and total assistance (staff provided care 100% of the time) with transfer, toilet use, and bathing. The MDS indicated Resident 20 was on oxygen therapy and non-invasive mechanical ventilator (air is moved toward and from the lungs through an external device connected directly to the resident [BiPAP]) within the last 14 days. During an observation and concurrent interview on 5/19/21 at 7:46 a.m., Resident 20 was observed in bed receiving oxygen inhalation at 3 L/min via NC. Resident 20 complained that she did not have her BiPAP machine on the previous night because the machine would not turn on. Resident 20 stated she notified the facility staff (unable to recall who) about her BiPAP not working but the facility staff did not do anything about it. Resident 20 stated no one helped her with her BiPAP machine. During an interview on 5/19/21 at 1:37 p.m., Licensed Vocational Nurse (LVN) 4 stated she did not receive any complaints from Resident 20 the morning of 5/19/21. LVN 4 stated the night shift nurse (LVN 6) informed her during change of shift report that Resident 20's BiPAP machine was not working and for her to call the BiPAP machine company. LVN 4 stated she did not call the BiPAP machine company yet. During an interview on 5/19/21 at 1:41 p.m., Wound Treatment Nurse (TXN) 1 stated she just checked on Resident 20's BiPAP machine and the machine was not powering on properly. TXN 1 stated the BiPAP machine kept indicating check power. TXN 1 stated she already called the company and the company will be bringing a replacement today. During an interview and concurrent record review on 5/20/21 at 1:19 p.m., the assistant director of nursing (ADON) stated Resident 20 had sleep apnea and had a physician's order for BiPAP machine at bedtime. The ADON was unable to find a care plan for Resident 20's sleep apnea and the use of the BiPAP machine in the resident's clinical record. The ADON stated there must be a care plan in the clinical record. 3. A review of Resident 24's admission Record, indicated the facility admitted the resident on 2/23/21, with diagnoses including unspecified fracture (a complete or partial break in a bone) of sacrum [a triangular bone at the base of the spine, above the coccyx (tailbone), that forms the rear section], cirrhosis of liver (chronic liver damage from a variety of causes leading to scarring and liver failure), and thrombocytopenia (a low number of platelets [colorless blood cells that help blood clot] in the blood). A review of Resident 24's physicians order, dated 2/23/21, indicated monitor the resident's edema to left and right lower extremity every shift for the use of Lasix (diuretic medication used to eliminate water and salt from the body). Document grade: 1+ = 2 millimeters (mm), 2+ = 4 mm, 3+ = 6 mm, and 4+ = 8 mm. A review of Resident 24's MDS, dated [DATE], indicated the resident had short-term memory problem and modified independence in her cognitive skills. The MDS indicated the resident required supervision with eating and limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) with bed mobility, transfer, walking in room and corridor, locomotion on and off unit, dressing, toilet use, personal hygiene and bathing. The MDS indicated the resident received a diuretic during the last seven days. During an interview on 5/18/21 at 10:15 a.m., Resident 24 stated she went to the hospital last week for weakness, BLE edema, and vomiting. Resident 24 stated she received blood transfusion at the hospital. During an observation and concurrent interview on 5/19/21 at 7:36 a.m., Resident 24 was observed in bed, watching television. Resident 24 showed her right and left lower extremities and stated her legs were very swollen. Resident 24 stated she did not inform her nurse yet. Shortly after, LVN 3 knocked and entered the resident's room. Resident 24 notified and showed LVN 3 her edematous BLE. During an interview and concurrent record review on 5/19/21 at 7:38 a.m., LVN 3 stated Resident 24 was already on Lasix and Spironolactone (medication used to treat high blood pressure and fluid retention [edema]) once a day for her edema. During an observation and concurrent interview on 5/20/21 at 7:37 a.m., Resident 24 was not in her room. LVN 3 stated Resident 24 was transferred to the acute care hospital the previous day (5/19/21) for further evaluation of her increasing abdominal girth and edema. LVN 3 stated the resident left the facility in stable condition. During an interview and concurrent record review on 5/20/21 at 12:38 p.m., the ADON stated Resident 24 would have episodes of on and off BLE edema due to her liver cirrhosis. The ADON was unable to find a care plan to address Resident 24's BLE edema in the resident's clinical record. A review of the facility's undated policy and procedures titled, Care Planning - Interdisciplinary Team, indicated the facility's Care Planning/Interdisciplinary Team (IDT; a team of healthcare workers working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) is responsible for the development of an individualized comprehensive care plan for each resident. A comprehensive care plan for each resident is developed within seven days of completion of the resident assessment (MDS).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that two out of five sampled residents (Residents 25 and 76) who had limited joint range of motion received restorative nursing aide (RNA) program (nursing aide program that help residents to maintain their function and joint mobility) treatments and services; a. Resident 76 was not provided an RNA program to put on and take off left and right knee splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) for both knee contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). b. For Resident 25, 1. the RNA order dated 5/12/2021 did not specify site and location to perform RNA exercises to both lower extremities. 2. The RNA program for passive range of motion (PROM, movement at a given joint with full assistance from another person) on both upper extremities (BUE) was not provided since 3/30/2021 when the RNA order was discontinued without indication. These deficient practices had the potential to cause further decline on the residents' range of motion and ability to participate on activities of daily living, development of contractures, and skin breakdown. Findings: a. A review of Resident 76's admission record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to Parkinson's disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement) and dementia (brain diseases that cause a long-term and often gradual decrease in the ability to think and remember that interferes with daily functioning). A review of the resident's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 3/30/2021 indicated the resident had severe impairment in cognition. It indicated the resident required extensive assistance with bed mobility, transfers, and dressing. It indicated the resident had limitations in range of motion on both lower extremities (BLE) and no impairments on both upper extremities (BUE). On 5/19/2021 at 11:13 a.m., during an observation, Resident 76 was sitting up in bed and able to move both arms to reach for items. The resident observed both knees bent and could not straighten both knees. The resident did not have any knee splints on. A review of resident's order summary report indicated an order dated 3/5/2021 for RNA to do active assistive range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) to BUE daily five times per week as tolerated. It indicated an order dated 3/15/2021 to recommend resident to use bilateral knee splints. It indicated an order dated 4/23/2021 for RNA to do AAROM to BLE daily five times per week as tolerated. During an interview on 5/20/21 at 8:47 a.m., Restorative Nursing Aide 1 (RNA 1) stated that the orders for RNA was AAROM exercises for BUE and BLE and there was no order for any splints. RNA 1 stated he was not putting on any splints for the resident. During an interview and record review on 5/20/2021 at 10:46 a.m., the Director of Rehabilitation (DOR) stated that the resident was on skilled physical therapy treatment from 1/18/2021 until 4/23/2021. The DOR stated when the resident discharged from physical therapy treatment, an RNA program started. The DOR stated the resident has an order for knee splints due to knee contractures. The DOR stated the physical therapy staff have to assess the resident's ability to tolerate the splints for up to three hours. DOR stated that on 4/20/2021 the physical therapist trained the RNA in applying the splint and that the resident tolerated wearing both knee splints for three hours. DOR stated that when PT discharged the resident on 4/23/2021 and ordered the RNA program for both lower extremities, an order for RNA to put on and take off both knee splints was not ordered and was missed. DOR stated that the order should have been written for RNA treatment to include putting on and taking off the knee splints. DOR stated the knee splints was not put on the resident because the order was not written. DOR stated the resident was at risk for worsening of knee contractures in her knees because the splints were not put on. The DOR stated it could cause the resident to have more knee pain and discomfort and could make it difficult for repositioning and skin breakdown. b. A review of Resident 25's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses including but not limited to quadriplegia (weakness or paralysis to all four extremities), contracture of muscle at multiple sites. A review of Resident 25's MDS dated [DATE] indicated the resident had minimal cognitive impairment. It indicated the resident required extensive assist with bed mobility, dressing and eating. It indicated the resident had impairments in range of motion on both sides of the upper extremities and both sides of the lower extremities and indicated the resident did not walk. 1. A review of the resident's order summary indicated an order dated 5/12/2021 for RNA to do PROM to (specify site) daily five times per week as tolerated. During an interview and record review on 5/20/2021 at 9:27 a.m., Restorative Nursing Aide 2 (RNA 2) stated the order she received from PT 1 did not indicate where to perform the RNA PROM exercises. During an interview and record review on 5/20/2021 at 9:10 a.m., Physical Therapist 1 (PT 1) stated that she forgot to specify the location of what joints and extremities the RNAs need to perform PROM exercises for Resident 25. The order for RNA program would be for RNA to complete PROM exercises on both lower extremities. PT 1 stated when the order did not specify the location and site to complete the exercises, the RNAs would not know what specific exercises to provide to the resident. 2. A review of Resident 25's Occupational Therapy Discharge summary dated [DATE] indicated the occupational therapist recommended RNA to perform PROM exercises on BUE five times a week or as tolerated to maintain current BUE ROM. A review of the resident's Restorative Nursing Program Referral dated 1/13/2021 indicated RNA to perform PROM exercise on BUE once a day five times a week (Thursday to Monday) or as tolerated. A review of the resident's order summary indicated there were no active RNA orders for PROM exercise for BUE. During an interview and record review on 5/20/2021 at 11:28 a.m., Occupational Therapist 2 (OT 2) confirmed that the resident currently had no active RNA orders to perform BUE PROM exercises as previously ordered. OT 2 reviewed the resident's records and stated the order was discontinued by nursing on 3/30/2021 and therapy was not aware of the reason for the discontinuation of services. OT 2 stated the Occupational Therapy department did not discharge the resident from RNA for her BUE PROM exercises and the resident should still be receiving her RNA exercises to her BUE because of the resident's BUE contractures. A review of the resident's Restorative Nursing Monthly documentation indicated that there were no RNA treatments completed for BUE PROM exercises from April 2021 until present. On 5/20/2021 at 2:56 p.m., during an observation, interview, and record review, RNA 1 and RNA 2 performed PROM exercises to Resident 25's ankles, knees, and hips as tolerated while resident was in bed. RNA 1 and RNA 2 stated they were only doing RNA exercises for the resident's lower extremities as ordered and has no exercises for the resident upper extremities. On 5/20/2021 at 3:37 p.m., during an interview and record review, the Director of Staff Development (DSD) stated the order for RNA for BUE PROM exercises five times a week was discontinued by nursing on 3/30/2021 but could not state the reason for discontinuation of the RNA order. DSD stated the resident has to receive RNA exercises for her BUE because the resident has severe contractures on both her upper extremities. DSD stated the RNA program has to be reviewed during weekly RNA meetings, but it was not discussed. DSD stated the reason residents were prescribed RNA treatments was to help maintain the resident's ROM and level of functioning for a resident. DSD stated if RNA treatments and services were not provided as recommended and ordered by therapy department, then the resident could decline in their daily function and increase their risk for further contractures. A review of the facility's policy revised 7/2021 titled, Resident Mobility and Range of Motion, indicated residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure licensed nursing staff did not administer expired insulin (a medication used to treat high blood sugar) to two residents (Residents 67 and 77) whose insulin was found to be expired during the inspection of one of two medication carts (Medication Cart 1.) As a result, Residents 67 and 77 received a combined total of eight doses of expired insulin between [DATE] and [DATE]. This deficient practice had the potential to cause Residents 67 and 77 to experience serious health complications due to uncontrolled blood sugar levels possibly resulting in hospitalization or death. Findings: A review of Resident 67's admission Record, dated [DATE], indicated she was admitted to the facility on [DATE] with diagnoses including diabetes mellitus type 2 (a medical condition characterized by the inability to control blood sugar.) A review of Resident 67's Order Summary Report, dated [DATE], indicated on [DATE] and [DATE] the physician prescribed Novolog (a brand of insulin) to be given per a sliding scale (dosing plan whereby the amount of insulin administered to the resident depends on the blood sugar reading) by subcutaneous (under the skin) injection before twice daily. A review of Resident 77's admission Record, dated [DATE], indicated she was admitted to the facility on [DATE] with diagnoses including diabetes mellitus type 2. A review of Resident 77's Order Summary Report, dated [DATE], indicated on [DATE] the physician prescribed insulin lispro (a type of insulin) to be given per a sliding scale by subcutaneous injection before meals and at bedtime. On [DATE] at 2:45 p.m., during an inspection of Medication Cart 1, the following insulin was found for Resident 67 and 77: a. One vial of Novolog insulin for Resident 67 labeled with an open date of [DATE] (expired [DATE].) b. One vial of Admelog (a brand of insulin lispro) for Resident 77 labeled with an open date of [DATE] (expired [DATE].) During a concurrent interview, the licensed vocational nurse (LVN 1) stated that Admelog and Novolog were only good for 28 days once opened and so the vials found for Residents 67 and 77 were currently expired. LVN 1 stated that giving expired insulin to a resident may result in serious health complications. A review of Resident 67's Medication Administration Record (MAR - a record of all medications given to a resident) for April and [DATE] indicated she received four doses of Novolog on or after 4/30 on the following dates: 4/30, 5/2, 5/3, and [DATE]. A review of Resident 77's MAR for [DATE] indicated she received four doses of Admelog on or after [DATE] on the following dates: 5/13, 5/14, 5/15, and [DATE]. On [DATE] at 1:22 p.m., during an interview, LVN 1 stated

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Ensure one single-use vial of injectable haloperidol (a medication used to treat hallucinations - seeing or hearing things that are not there) was discarded for one resident (Resident 35) in one of two inspected medication carts (Medication Cart 1.) 2. Ensure expired insulin (a medication used to treat high blood sugar) was discarded for five residents (Residents 27, 51, 67, 77, and 374) in one of two inspected medication carts (Medication Cart 1) and one of two inspected Medication Rooms (Medication room [ROOM NUMBER].) 3. Ensure medications were labeled with an open date per the manufacturer's requirement for eight residents (Residents 3, 35, 58, 78, 88, 95, 103, and 373) in two of two inspected medication carts (Medication Carts 1 and 2) and one of two inspected medication rooms (Medication room [ROOM NUMBER].) These deficient practices increased the risk that Residents 3, 27, 35, 51, 58, 67, 77, 78, 88, 95, 103, 373, and 374 could have received medication that had become ineffective or toxic due to improper storage or labeling possibly leading to health complications resulting in hospitalization or death. Findings: On 5/18/21 at 2:03 p.m., during an inspection of Medication Cart 2, the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications: a. One Levemir Flextouch pen (a brand on insulin) for Resident 95 was found open but unlabeled with an open date. b. Per the manufacturer's product labeling, once opened or stored at room temperature, Levemir Flextouch pen must be used or discarded within 42 days. c. Three open foil pouches of ipratropium/albuterol (a medication used to treat breathing problems) vials (one each) for Residents 58, 88, and 373 were found open but unlabeled with an open date. Per the manufacturer's product labeling, once removed from the foil pouch, the vials should be used within one week. During a concurrent interview, on 5/18/21 at 2:03 p.m., the licensed vocational nurse (LVN 8) confirmed the medications above are not labeled with an open date as required by the manufacturer. LVN 8 stated that if the medications were not labeled with a date once they were opened, there's no way to assign them an accurate beyond use date and it increases the risk that residents may still receive doses from them once they become expired. LVN 8 stated that if insulin or breathing treatments do not work properly, the resident could experience health complications that may result in hospitalization or death. On 5/18/21 at 2:45 p.m., during an inspection of Medication Cart 1, the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications: a. One vial of insulin lispro (a type of insulin) for Resident 51 was found labeled with an open date of 4/14/21 Per the manufacturer's product labeling, once opened or stored at room temperature, insulin lispro must be used or discarded within 28 days. b. One vial of insulin aspart (a type of insulin) for Resident 3 was found stored at room temperature unlabeled with an open date. Per the manufacturer's product labeling, once opened or stored at room temperature, insulin aspart must be used or discarded within 28 days. c. One vial of Novolog insulin (a type of insulin) for Resident 67 was found labeled with an open date of 4/2/21 Per the manufacturer's product labeling, once opened or stored at room temperature, Novolog must be used or discarded within 28 days. d. One vial of Admelog insulin (a type of insulin) for Resident 77 was found labeled with an open date of 4/14/21 Per the manufacturer's product labeling, once opened or stored at room temperature, Admelog must be used or discarded within 28 days. f. One vial of Novolog R insulin (a type of insulin) for Resident 27 was found labeled with an open date of 4/14/21 Per the manufacturer's product labeling, once opened or stored at room temperature, Novolin R must be used or discarded within 31 days. g. One open foil pouch of ipratropium/albuterol vials for Resident 78 was found open but unlabeled with an open date. Per the manufacturer's product labeling, once removed from the foil pouch, the vials should be used within one week. h. One foil pouches of budesonide (a medication used to treat breathing problems) vials for Resident 77 was found open but unlabeled with an open date. Per the manufacturer's product labeling, once removed from the foil pouch, the vials should be used within two weeks. i. One vial of single-use injectable haloperidol for Resident 35 was found open Per the manufacturer's product labeling, vials should be discarded after use. j. One Wixela (a medication used to treat breathing problems) inhaler for Resident 103 was found open unlabeled with an open date Per the manufacturer's product labeling, once removed from the protective foil pouch, the inhaler should be used within six weeks. During a concurrent interview, on 5/18/21 at 2:45 p.m., LVN confirms the medications listed above were not stored or labeled properly in accordance with the manufacturer's requirements or facility policy. LVN stated that giving expired medications or medications which have not been stored properly to residents could cause harm as they may not work as intended. On 5/18/21 at 3:14 p.m., during an inspection of Medication room [ROOM NUMBER] one vial of injectable lorazepam (a medication used to treat anxiety - a mental condition whereby fear or worries interfere with normal day to day activities) for Resident 35 was found opened, unlabeled with an open date. Per the manufacturer's product labeling, once opened, vials of injectable lorazepam should be used or discarded within 28 days. During a concurrent interview, on 5/18/21 at 3:14 p.m., LVN 1 confirmed that the lorazepam injectable for Resident 35 was opened but did not have a label with an open date. LVN 1 stated that if injectable products are used on residents after their beyond use date, there is a risk that the resident may contract an infection, as the product may no longer be sterile (free of infectious bacteria.) On 5/18/21 at 3:40 p.m., during an inspection of Medication room [ROOM NUMBER], one vial of Novolin N (a type of insulin) for Resident 374 was found labeled with an open date of 3/3/21. Per the manufacturer's product labeling, once opened or stored at room temperature, Novolin N must be used or discarded within 31 days. During a concurrent interview, on 5/18/21 at 3:40 p.m., the nurse supervisor (RN 1) stated that even though this resident is no longer at the facility, this product is expired and should have been removed and discarded per facility policy. On 5/19/21 at 1:22 p.m., during an interview, LVN 1 stated there is not a consistent method of clearing the medication cart of expired medications on a regular basis. LVN 1 stated that usually the overnight shift is responsible to check the cart for the expired meds and dispose of them regularly but is not sure if it happens regularly. On 5/19/21 at 1:36 p.m., during an interview, the director of nursing (DON) stated she agrees that giving expired insulin to the residents could cause health complications that may result in hospitalization. DON stated that medications should be reordered from the pharmacy five days before they run out or are expired and should be removed from the cart and set aside for destruction as soon as they are expired. A review of the facility's policy Administering Medications, revised April 2019 indicated The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container . Vials labeled as 'single dose' or 'single use' are note used on multiple residents. Such vials are used only for one resident in a single procedure. A review of the facility's undated policy Medication Storage in the Facility indicated Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier . Outdated, contaminated or deteriorated medications . are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report laboratory (Lab) work in a timely manner to the resident's oncologist (doctor that specializes in treatment of cancer) for one of five sampled residents (Resident 60.) This deficient practice resulted in a delay in Resident 60's oncology care and Resident 60 did not receive Sprycel (a medication used to treat CML) medication between 5/5/21 and 5/21/21 (17 days). This deficient practice could have resulted in a negative impact to his overall physical, mental, and psychosocial well-being. Findings: A review of Resident 60's admission Record, dated 5/20/21, indicated the resident was readmitted to the facility on [DATE] with diagnoses including chronic myeloid leukemia (CML - a type of blood cancer.) A review of Resident 60's Order Summary Report, dated 4/30/21, indicated on 1/6/21 the oncology physician prescribed Sprycel (a medication used to treat CML) 100 milligrams (mg- a unit of measure for mass) by mouth once daily. A review of Resident 60's Medication Administration Record (MAR - a record of all medications given to a resident) for May 2021 indicated Resident 60 did not receive Sprycel between 5/5/21 and 5/21/21 (17 days). A review of Resident 60's progress note, dated 2/5/21, indicated his oncologist ordered BCR/ABL 1 (a laboratory test used to manage treatment for CML) to be completed in preparation for the resident's follow up oncology visit on 5/7/21. A review of Resident 60's progress note, dated 5/7/21 indicated the oncologist was not able to see Resident 60 because they had not received the results of his BCR/ABL 1 and would reschedule his appointment for 5/21/21. A review of Resident 60's progress note, dated 5/19/21, indicated that the oncologist office needed to reschedule Resident 60's appointment again to 6/7/21 as they still had not received the results from his BCR/ABL 1 test. A review of Resident 60's BCR/ABL 1 lab test, dated 4/21/21, indicated the results were reported to the facility by the Lab company on 4/26/21. On 5/20/21 at 11:46 a.m., during an interview, the licensed vocational nurse (LVN 1) stated that the facility received orders for lab work for Resident 60 from the oncologist office a few months ago that were never carried out. LVN 1 stated, as a result, the resident's oncology visit had to be postponed and rescheduled. LVN 1 stated that later the lab work was done but was incomplete, so the visit had to be postponed again. LVN 1 stated Resident 60's oncologist did not provide any order to discontinue or hold the Sprycel, but the oncologist did not want to refill the medication without seeing the resident first. LVN 1 stated that the oncologist could not see Resident 60 until the lab work they ordered was completed. On 5/20/21 at 12:24 PM, during an interview, the nurse supervisor (RN 1) stated she received orders for Resident 60's oncology lab work on 2/5/21. RN 1 stated the lab for the BCR/ABL1 was ordered on 4/21/21 and lab result reported by the lab company on 4/26/21. RN 1 stated that she put the orders for the other labs in for 5/7/21. RN 1 stated she put the BCR/ABL1 lab order in further ahead of time because that lab usually takes much longer to receive results back. RN 1 stated that no one from the facility reported that result to the oncologist. RN 1 stated that because the facility did not report the BCR/ABL1 results to the oncologist, the initial oncology appointment was rescheduled from 5/7/21 to 5/21/21. RN 1 stated that on 5/19, the facility still had not reported the BCR/ABL 1 results to the oncologist office which caused them to delay the appointment again until 6/7/21. RN 1 stated that she did not know why no one from the facility ever reported the lab result from 4/26/21 to the physician. RN 1 stated it was the charge nurse's responsibility to report lab works to the physicians for their residents. RN 1 stated LVN 1 was Resident 60's charge nurse. On 5/20/21 at 2:25 PM, during an interview, LVN 1 stated that as Resident 60's charge nurse, she was responsible to report the lab work to the oncologist once it was completed. LVN 1 stated that she missed the result reported on 4/26/21 because the other labs of Resident 60 were ordered and reported on 5/7/21. LVN 1 stated she did not see the BCR/ABL 1 lab reported on the 5/7/21 results so she assumed that it was not ordered. LVN 1 stated there was no alert given to the nursing staff when new lab work was available, so she overlooked that the result was already received and did not report it to the oncologist. LVN 1 stated that she reordered the BCR/ABL 1 at that time because she still did not think lab work had been done. LVN 1 stated that the lab communicated a request to redraw the lab on the same day to a different licensed nurse who worked the night shift but that licensed nurse failed to reorder the lab again and so the BCR/ABL 1 appeared still missing on 5/19/21 when nursing staff were preparing for his oncology visit. LVN 1 stated that as a result, the oncology appointment was rescheduled again for 6/7/21. LVN 1 stated that it was not until 5/20/21 that the facility staff realized that they had the lab work already reported and forwarded the results to the oncologist's office. On 5/20/21 at 2:30 PM, the assistant director of nursing (ADON) stated that she spoke with the office manager at the oncologist's office concerning the missing BCR/ALB 1 lab. The ADON stated the oncologist office was able to move Resident 60's appointment up to 5/27/21 now that they had complete lab results. A review of the facility's policy Lab and Diagnostic Test Results - Clinical Protocol, revised November 2018, indicated A physician can be notified by phone, fax, voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent (for example, office staff). Facility staff should document information about when, how, and to whom the information was provided and the response.