**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure one (#15) of two residents reviewed for communication out of 28 sample residents was provided appropriate treatment and services to maintain or improve their abilities. Specifically, the facility failed to provide Resident #15, who had difficulties with speech due to a stroke, with an appropriate communication tool to ensure the resident was able to effectively communicate her needs to staff. Findings include: I. Resident #15 A. Resident status Resident #15, under age [AGE], was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), the diagnoses included cerebral infarction (stroke). The 3/8/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a (BIMS) score of 14 out of 15. She needed substantial assistance from one staff member for transferring and needed supervision or hands on assistance of one staff member for eating and personal hygiene. The MDS assessment indicated Resident #15 was usually understood with difficulty communicating some words or finishing thoughts but was able if prompted or given time and was able to understand others with clear comprehension. B. Observations and interview On 4/15/24 at 9:31 a.m. Resident #15 was sitting in her room pointing at her chest and using her index finger to draw a line from her throat to her chest area. Certified nurses aide (CNA) #2 asked Resident #15 if she needed something to drink or eat, Resident #15 shook her head to indicate no. CNA #2 asked Resident #15 if she needed something for her throat and the resident shook her head to indicate no and continued using her index finger to draw a line from her throat to her chest. CNA #2 asked the resident if her chest was bothering her. Resident #15 attempted to verbally communicate but was unable to pronounce words clearly. CNA #2 said she was unable to understand what Resident #15 was trying to say and left to find assistance from another staff member. CNA #2 did not return, unit care coordinator (UCC) #1 returned instead, approached Resident #15 and asked if the resident was trying to something about her throat to CNA #2. Resident #15 shook her head indicating no and looked at the ground. UCC #1 asked the resident if she wanted juice and Resident #15 shrugged her shoulders and shook her head to indicate yes. C. Record review The communication care plan, revised on 10/23/24, revealed Resident #15 had a communication problem related to cerebral infarction and unclear speech. It indicated the resident would be able to make basic needs known on a daily basis through the review date. Pertinent interventions included using alternative communication tools as needed. -The care plan did not indicate what communication tool to utilize when communicating with Resident #15. D. Staff interviews CNA #2 was interviewed on 4/15/24 at 9:35 a.m. CNA #2 said staff needed to take their time with Resident #15 when trying to understand what she was trying to communicate or find another staff member who was better at communicating with the resident. CNA #2 said Resident #15 expressed frustration in the past when she could not be understood. CNA #2 said she was not aware of any communication devices being used by staff to assist in communicating with Resident #15. CNA #1 was interviewed on 4/15/24 at 9:31 a.m. He said he was aware of Resident #15 having a communication board but had never used it with her. He said another staff member informed him of Resident #15 having a communication board and he would not have known of it otherwise. CNA#1 was unable to locate a communication board in Resident #15's room. Registered nurse (RN) #1 was interviewed on 4/15/24 at 9:40 a.m. She said Resident #15 had a communication board available to staff in her room but the resident may have thrown it away. RN #1 said she did not know why Resident #15 threw her communication board away. RN #1 said there was a communication board at the nurses station that was kept in the narcotic count book. RN #1 said she did not know how direct care staff would know to look in the narcotic count book for a communication board for Resident #15. UCC #1 was interviewed on 4/15/24 at 10:00 a.m. UCC #1 said using alternative communication tools for Resident #15 was indicated to CNAs in the [NAME] (tool utilized by staff to provide person centered care). UCC #1 said the [NAME] did not specify what the alternative communication tools were. UCC #1 said the care plan would be updated to specify the communication board as an alternative tool. -However, despite UCC #1 indicating the communication care plan would be updated, it was not updated prior to the end of survey on 4/16/24. The speech therapist (ST) was interviewed on 4/16/24 at 11:00 a.m. The ST said prior to 4/16/24 Resident #15 had never been on her caseload. She said she was going to assess the resident for swallowing issues. The ST said Resident #15 had not been assessed by therapy for the use of a communication board and she was unsure when the resident started using it or who recommended it to be used. Social services assistant (SSA) #1 was interviewed on 4/16/24 at 12:43 p.m. She said she was unaware Resident #15 had a communication board prior to 4/15/24. II. Facility follow up The education material that was provided to the CNAs and nurses was provided on 4/14/24 at 2:30 p.m. by the director of nursing (DON). It read in pertinent: Be aware of having difficulty communicating with Resident #15 there is a communication board taped to the inside of her closet. In addition, one is always available on the nurses cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews the facility failed to ensure one (#55) of one resident received treatment and care in accordance with professional standards of practice out of 28 sample residents. Specifically, the facility failed to ensure Resident #55 was assisted with applying her compression stockings to treat her bilateral lower leg edema. Findings include: I. Facility policy and procedure The Anti Embolism (compression) Stocking Application policy, revised 9/8/23, was received by the director of nursing (DON) on 4/16/24 at 10:43 a.m. It read in pertinent part, The facility will provide anti embolism stocking application in accordance with professional standards of practice. The services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet the professional standards of quality. The facility will utilize [NAME] (nursing) procedures for anti embolism stocking application. The Anti Embolism stocking application checklist, undated, was provided by the DON on 4/16/24 at 10:43 a.m. It read in pertinent part, To apply knee-length anti embolism stockings according to standard of care; -Insert your hand into the stocking from the top, grasp the heel pocket from the inside, and turn the stocking inside out; -Position the stocking over the patient's foot and heel; -Grasp a few inches of the stocking and begin pulling it up around the patient's ankle and calf; -Continue pulling the stocking up the patient's leg using short pulls, alternating from the front to the back, until the bottom of the stocking's band falls one to two inches below the knee; -Smooth out wrinkles in the stocking; -Make sure the patient's toes are visible through the toe inspection area; and, -Document the procedure. II. Resident #55 A. Resident status Resident #55, over the age of 65, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included pain in fingers, low back pain, pain in the shoulder and congestive heart disease. The 3/10/24 minimum data set (MDS) assessment revealed Resident #55 was cognitively intact with a brief interview for mental status (BIMS) score of 15 of 15. Resident #55 was independent with putting on her shoes and socks and dressing her upper and lower body. -However, the resident needed assistance in applying her compression stockings. B. Resident interview and observations On 4/11/24 at 10:30 a.m., Resident #55 said staff did not help her put on her compression stockings. She said the stockings helped control the swelling in her feet. She said she was unable to pull them up on her own. Resident #55's feet were observed to be swollen. She was wearing slippers that went over the top of her foot and had open heels to accommodate the swelling in the resident's feet. On 4/15/24 at 9:15 a.m., Resident #55 had slippers on her feet and her feet were swollen. Resident #55 was in the hallway outside her room and asked certified nurse aide (CNA) #1 to assist her. She said staff would not help her put on the compression stockings. CNA #1 said he did not know the resident. He said he did not feel comfortable applying the compression stockings because her feet were so swollen. CNA #1 spoke with licensed practical nurse (LPN) #1. LPN #1 said staff was supposed to put her compression stockings on every morning. CNA #1 said he needed larger stockings because the stockings for Resident #55 were too small to fit over her legs due to the increased swelling. The unit care coordinator (UCC) #1 walked up to where CNA #1 and LPN #1 were talking in the hall. UCC #1 said Resident #55 was supposed to put the stockings on herself. Resident #55 said she was unable to pull the stockings up on her own because it was too difficult for her to do. Resident #55 said she previously told staff but no one helped her apply the compression stockings. On 4/16/24 at 9:15 a.m., Resident #55 was in her room and was observed without her compression stockings on. Resident #55 said staff had not offered to assist her in putting her compression stockings on. She said staff did not help her with the stockings on 4/13/24 or 4/14/24. III. Record review Review of Resident #55's medical records revealed a physician's order, dated 4/9/24, which read in pertinent part, Please give resident compression stockings to wear during the day while awake. The edema care plan, initiated on 3/9/21 revealed the resident had edema related to her diagnosis of congestive heart failure. -A review of the comprehensive care plan did not reveal an updated intervention to include the 4/9/24 physician's order for compression stockings. IV. Nursing interview The DON was interviewed on 4/16/24 at 9:45 a.m. The DON said Resident #55 had a history of refusing to wear compression stockings. The DON was unable to find documentation in April 2024 that Resident #55 refused to wear the compression stockings. The DON said the physician's order for compression stockings was entered incorrectly and did not prompt the staff to assist the resident with the compression stockings. The DON said because the physician's order was not correctly entered, it did not prompt the staff to document when they assisted the resident in putting on the compression stockings. She said when UCC #1 confirmed the physician's order on 4/9/24 she should have clarified the order to ensure it was entered correctly. The DON was interviewed again on 4/16/24 at 10:40 a.m. The DON said staff had just helped Resident #55 apply the compression stockings. The DON said she clarified the physician's order for the resident to have compression stockings applied and removed daily. The DON said she updated Resident #55's care plan to include the application of the compression stockings and to apply the compression stockings and monitor Resident #55's edema.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#1) out of three sample residents reviewed for falls, received adequate supervision and assistance to prevent accidents. Specifically, the facility failed to ensure: -Resident #1 received adequate supervision during the occupational therapy treatment to prevent an avoidable fall with injury; and, -Post fall nursing assessment of Resident #1's injuries was done timely and appropriately by a registered nurse. Findings include: I. Resident status Resident #1, age [AGE], was admitted to the facility on [DATE]. According to the computerized medical record, diagnoses included hemiplegia and hemiparesis (paralysis) following cerebral infarction (stroke) affecting right dominant site, cerebellar stroke syndrome, depression and anxiety. The 9/6/23 minimum data set (MDS) assessment revealed Resident #1's cognition was moderately impaired with a brief interview for mental status (BIMS) score 11 out of 15. No behavioral symptoms or rejection of care were noted. She required one person limited assistance with bed mobility, dressing and toilet use, two staff limited assistance with transfers, and was independent with eating. Medications included an antidepressant and anticoagulant. II. Record review A. Care plan The comprehensive care plan review revealed the following: -(Resident) is at risk for falls r/t (related to) impaired mobility, psychotropic medication use and impaired cognition with decreased safety awareness. Date Initiated: 9/2/23 Interventions included: Assist with ADLs (activities of daily living) as needed. Call light within reach. Complete fall risk assessment. Orient resident to room. Provide adaptive equipment or devices as needed. -(Resident) has hemiplegia/hemiparesis affecting right dominant side r/t (related to) cerebral infarction. Date Initiated: 9/19/23 Interventions included: Discuss with resident/resident and family any concerns, fears, issues regarding diagnosis or treatments. PT (physical therapy), OT (occupational therapy), ST (speech therapy) evaluate and treat as ordered. B. Interdisciplinary notes On 9/3/23 a registered nurse documented: CVA (cerebrovascular accident) with right sided weakness and decreased sensation. HX of A-fib and HTN (history of atrial fibrillation and hypertension). Slight BLE (bilateral lower extremities) edema elevation as tolerated .Pt (patient) currently with right sided weakness and requiring limited assist with transfers . Pt (patient) currently on ASA (aspirin) and eliquis (a blood thinner medication that reduces blood clotting) for DVT (deep vein thrombosis) prevention .Pt (patient) currently cooperative with all cares and therapies at this time. On 9/10/23 an occupational therapist documented in the Occupational Therapy Treatment Encounter Note the following: Patient completed toilet routine with min A (minimum assistance) for transfer from toilet to standing utilizing 3-in-1 commode and grab bars and min A (minimum assistance) for clothing management to promote ind (independence) in the toileting routine. Patient completed self-care tasks seated in w/c (wheelchair) in front of sink with SBA (stand-by-assistance) for safety. Patient participated in functional mobility tasks with FWW (front wheeled walker) across various obstacles requiring CGA (contact-guard-assistance) and vc's (verbal cues) to slow down and pick up feet. Patient fell toward L (left) side requiring dep A (assistance) to transition back into w/c (wheelchair). Therapist discussed fall with nurse and PT (physical therapist) and provided first aid (band-aid) to tip of 3rd digit. Patient benefited from fall prevention training focused on body awareness and foot placement with teach back method to enhance carryover. -The occupational therapist failed to inform the nurse of Resident #1's fall and failed to ask for an assessment. (see nursing note below and interviews) On 9/11/23 a registered nurse documented: This nurse was told by the day shift nurse on 300 hall of the resident's finger looking swollen and bleeding. Other information gathered at the time, which this writer was unaware of, is the resident had a fall with therapy the day prior. When entering the room, the POA (power of attorney), (spouse) explained his wife had a fall with therapy the day prior and had a swollen finger on the right and was having pain to the left shoulder. ROM (range of motion) decreased on left shoulder, ROM (range of motion) of finger WNL (within normal limits). This nurse examined the residents skin focusing on the shoulder, elbows, hips/buttock, and head. When questioned the resident was not able to recollect how she fell nor whether she struck an object during. Resident did state she did not think she struck her head. No other injuries were noted at the time of assessment. This nurse had shift nurse call to gain orders for X-rays for hand as well as shoulder. Awaiting results of X-ray. MD (physician) was notified. On 9/11/23, a follow-up note by a registered nurse revealed: Pt (patient) alert and oriented x2-3 (person, place, time), periods of forgetfulness. Pt (patient) will ask the same questions multiple times. Unable to remember that she had already asked the questions. Easy to re-orient. Husband at bedside 24hours a day. No c/o (complaints) of chest pain or discomfort noted at this time. History of hypertension . Pt (patient) a 1 (one) person assist with transfers and ADL's (activities of daily living). Needs queuing at times. Weakness to right side due to previous CVA (cerebrovascular accident). Pt (patient) fell this weekend working with therapy and has been c/o (complaining) of shoulder pain. New orders for stat x-ray to left shoulder, elbow and hand .Pt (patient) c/o (complained) of 10/10 pain to left shoulder from fall. PRN (as needed) Tylenol given with positive effect. On 9/11/23 a physician documented: Lost balance while attempting to transfer. Fell .According to report the patient is reportedly stable with respect to contusion of left ring finger w/o (without) damage to nail init. Swelling of distal phalanx .With regards to cerebellar stroke syndrome the patient has been stable. Patient has significant dizziness which she reports has been present since stroke, fits with patient's stroke location. Patient has good days and bad days, this does hinder mobility and puts her at higher risk for falls. The 9/11/23 radiology report revealed no acute fracture or dislocation of left shoulder, elbow and hand. On 9/13/23 a nurse practitioner documented: Lost balance while attempting to transfer. Fell. Pain and reduced ROM (range of motion) to L (left) shoulder .The patient is reportedly stable with respect to pain in left shoulder. Pain since fall patient reports mod (moderate)/severe, unable to lift arm actively above 90 degrees when was prior to fall full ROM (range of motion). Pain prevents full passive ROM (range of motion), on palpation pain is worst just lateral of acromion process. X-ray neg (negative) .Pain in left shoulder. No medication changes with respect to (resident's) pain in left shoulder. Continue to monitor. MRI (magnetic resonance imaging). Pain and movement pattern suspicious for rotator cuff injury. Tylenol. Patient should be careful not to push herself too hard while injury being evaluated. The 9/26/23 magnetic resonance imaging (MRI) report revealed the following: 1. Acute mildly displaced distal clavicle fracture practically at the acromioclavicular joint. 2. Full-thickness retracted tear of the anterior supraspinatus tendon insertion with associated disuse atrophy of the supraspinatus muscle suggesting that the injury is chronic. 3. Longitudinal split tear of the biceps tendon at the upper bicipital groove level and possibly within its intra-articular course. On 9/29/23 a nurse practitioner documented: Discharge to home today. Patient feels like she has made progress here and is safe to go home .The patient is reportedly stable with respect to pain in left shoulder. Slow but reasonably full AROM (active range of motion) today on my rounds. MRI (magnetic resonance imaging) results show full-thickness or practically full thickness tear of the anterior supraspinatus tendon insertion. Tendon retracted almost to the acromioclavicular joint level. Distal defect measures approximately 13 mm (millimeters) in anteroposterior dimension. Reactive intraosseous cystic changes along the posterior supraspinatus and anterior infraspinatus insertion as well as subscapularis insertion. III. Interviews The director of rehabilitation (DOR) was interviewed on 11/7/23 at 8:48 p.m. He said he was aware Resident #1 fell during occupational therapy treatment on 9/10/23. He said the occupational therapist (OT) did not call a registered nurse to assess Resident #1 after the fall in therapy room. He said the OT was a new staff member in the facility and was not aware of the facility policy to immediately call for a nurse to assess resident's injuries after a fall. He said according to the facility policy she should not transfer Resident #1 from the floor to the wheelchair by herself. He said the OT received a general facility and therapy orientation on her first day of employment. He said the orientation did not include post fall facility policy. He said he provided the education on the facility post fall policy and procedures for the OT immediately after the incident. Registered nurse (RN) #1 was interviewed on 11/7/23 at 10:55 a.m. She said Resident #1 had right side weakness in upper and lower extremity. She required staff assistance with stand pivot transfers, was able to stand from a toilet using a grab bar and was not allowed to walk with nursing staff. RN#1 said she was called to Resident #1's room on 9/11/23, in the morning, approximately at 8:00 a.m. She said the resident's ring finger was swollen and bleeding, and she complained of left shoulder pain. She said she called the resident's physician and stat x-ray was ordered. She said it was the facility policy a registered nurse must do a head to toe assessment after a resident's fall. She said the nurse (RN) who was on duty on 11/9/23 reported the OT came to her desk and asked for a band aid. She said the OT did not tell the RN about Resident #1's fall. The nursing home administrator (NHA) was interviewed on 11/7/23 at 11:25 a.m. She said it was the facility policy each resident after a fall must be evaluated for injuries by a registered nurse before the resident's transfer from the floor. She said the occupational therapist received additional training on the post fall policy from the director of rehabilitation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, document review, and facility policy review, the facility failed to protect the resident's right to be free from physical and verbal abuse by a family member (FM) for 1 (Resident #36) of 1 resident reviewed for abuse. Specifically, a staff member witnessed FM #1 yell at and shake the shoulders of Resident #36; however, this staff member did nothing. Later on the same day, it was reported FM #1 had been witnessed to forcefully hit Resident #36 on their shoulder multiple times. Findings included: Review of a facility policy titled, Area of Focus: Abuse & Neglect, reviewed 11/21/2022, specified, Residents must not be subjected to abuse by anyone. This includes but is not limited to staff, other residents, consultants, volunteers, staff from other agencies serving our residents, family members, the resident representative, friends, or any other individuals. The policy further specified, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. A review of an admission Record indicated the facility admitted Resident #36 with diagnoses that included muscle weakness, history of falling, pain in right and left shoulders, cognitive communication deficit, and other abnormalities of gait and mobility. A review of an Annual Exam, dated 06/08/2021, revealed Resident #36 had additional diagnoses of anoxic brain damage and altered mental status. The quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #36 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The resident required limited assistance with bed mobility, transfers, dressing, and toilet use; extensive assistance with locomotion on and off the unit; and supervision with personal hygiene. A review of a facility investigation report, dated 12/08/2022, revealed Resident #36's family member (FM #1) was observed to strike Resident #36 twice on the resident's shoulders. Per the report, FM #1 was made to leave the facility, pending an investigation, and Resident #36 was assessed and determined to have no injuries. Following the investigation, the facility determined the allegation of physical abuse by FM #1 was substantiated. During an interview on 01/17/2023 at 10:05 AM, Resident #36 stated something bad happened recently. The resident stated one of the nursing staff mistook a family member's (FM #1) mannerisms for abuse. According to Resident #36, FM #1 was not abusive, the occurrence was all wrong; it was not abuse, and the resident was not afraid of FM #1. During an interview on 01/18/2023 at 10:20 AM, Certified Nursing Assistant (CNA) #7, a hospice CNA, stated as she attended to Resident #36's roommate, FM #1 asked her why Resident #36 was no longer on hospice. CNA #7 stated FM #1 became very angry, yelled at her, and stated Resident #36 was dying and needed care. Per CNA #7, FM #1 reported they did not know the resident was no longer on hospice. CNA #7 further stated FM #1 was very animated, flailed their arms, and made statements and then would forcefully hit Resident #36 on their shoulders. CNA #7 stated that each time FM #1 hit Resident #36 on the shoulder, the resident grimaced. CNA #7 stated she was not able to calm FM #1, so she stepped out of the room to get the nurse on the hall for help. According to CNA #7, the nurse (Registered Nurse [RN] #5) admitted to her that FM #1 had yelled at her earlier. Per CNA #7, the situation got out of control and the police were called. CNA #7 stated Resident #36 did not appear to be fearful but grimaced every time FM #1 hit their shoulder. During an interview on 01/18/2023 at 10:51 AM, Licensed Practical Nurse (LPN) #6 stated she did not witness the incident involving Resident #36 and FM #1. LPN #6 stated she had not ever witnessed FM #1 being rough or cruel to Resident #36, though she had observed FM #1 become very impatient and a little loud with the resident. According to LPN #6, when Resident #36 was interviewed by the police, the resident denied feeling he/she was in danger around FM #1 and that FM #1 had struck them. LPN #6 indicated the resident did state FM #1 had pushed the resident really hard. On 01/18/2023 at 11:05 AM, an attempt to interview the police officer was made; however, a message was left, and the police officer did not return the surveyor's call prior the end of the survey. During an interview on 01/18/2023 at 11:40 AM, RN #5 stated Resident #36 was an at risk adult because of some of the interactions she had observed between the resident and FM #1. RN #5 stated FM #1 was verbally and physically aggressive at times, exhibited high anxiety with odd behavior that made her antennas go up. RN #5 stated that on 12/08/2022, FM #1 had called the facility at 4:00 AM and demanded medical information from a nurse. When FM #1 was denied the information as FM #1 was not Resident #36's representative, FM #1 became very angry. RN #5 stated on 12/08/2022 at 7:30 AM, FM #1 was at the nurse's station asking why the nurses refused to release information to them and why the resident was not ready to go on a breakfast date with FM #1. RN #5 informed FM #1 that Resident #36 was in the dining room. Per RN #5, FM #1 went to the dining room and brought Resident #36 out. RN #5 stated she observed FM #1 yell at Resident #36 and state, See, you have to tell them they have to talk to me, then FM #1 would shake the resident's shoulder. RN #5 stated after this incident Resident #36 seemed fine, FM #1 took the resident into their room, and she continued with her medication pass. RN #5 stated then later the hospice CNA (CNA #7) came to her and told her that FM #1 just hit Resident #36 two times in front of her. RN #5 stated she asked the unit manager to join her in Resident #36's room and observed the resident seated in their wheelchair and FM #1 going through [their] things. RN #5 stated she went to the administrative offices to request assistance and advised the staff that she called the police. Per RN #5, other staff members came to Resident #36's room and escorted FM #1 out of the room at that time. During an interview on 01/18/2023 at 12:30 PM, the Social Services Director (SSD) stated FM #1 became upset when CNA #7 stated she was unable to provide a shower to Resident #36, as the resident was no longer on hospice. Per the SSD, CNA #7 witnessed FM #1 become increasingly agitated and strike Resident #36 on the shoulder several times as FM #1 argued with CNA #7. The SSD reported the resident was upset because FM #1 was upset. The SSD stated she did not know the final disposition of the investigation, only that abuse occurred because FM #1 was witnessed hitting Resident #36. During an interview on 01/18/2023 at 3:49 PM, FM #3 stated FM #1 was pretty volatile, got very angry one day, and became inappropriately physical with Resident #36. During an interview on 01/19/2023 at 10:06 AM, the Director of Nursing (DON) stated she had been in the role of DON for about three weeks. The DON stated if abuse was suspected or there was a report of abuse, the allegation would immediately be reported to the Executive Director (ED), who was the Abuse Coordinator. The DON further stated she would ensure the resident was in a safe place and the alleged perpetrator was removed from the facility. The DON stated she was not involved in the incident involving Resident #36 and the FM #1 on 12/08/2022. During an interview on 01/19/2023 at 10:39 AM, the ED stated if abuse was suspected or reported, the staff would ensure the threat was removed, or the residents separated if it was a resident-to-resident incident. The ED further stated if she was in the building she would go to the area and talk to everyone to get the picture, and if not in the building she would talk to the witness or reporter on the telephone. The ED stated she would determine next steps based on the findings of assessments and would initiate the report to the State.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to ensure a resident with a new mental health diagnosis was referred for a level two pre-admission screening and resident review (PASRR) for 1 (Resident #49) of 1 sampled resident reviewed for PASRR. Findings included: A review of a facility policy titled, Pre-admission Screening and Resident Review (PASARR), dated as issued 06/06/2019 and revised 10/06/2022, revealed, A negative Level I screen permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. The policy also indicated, 9. As part of the PASARR process, the facility is required to notify the appropriate state mental health (SMH) authority or state intellectual disability authority when a resident with a mental disorder or intellectual disability (ID) has a significant change in their physical or mental condition. This will ensure that residents with a mental disorder or intellectual disability continue to receive the care and services they need in the most appropriate setting. 10. Referral to the SMH/ID authority should be made as soon as the criteria indicative of a significant change are evident. A review of an admission Record revealed the facility admitted Resident #49 on 09/17/2021 with a primary diagnosis of other symptoms and signs involving the nervous system. The admission Record indicated the resident's other diagnoses included: - anxiety, added on 04/22/2022 - delusional disorders and obsessive-compulsive disorder (OCD), added on 04/26/2022. A review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS indicated the resident had active diagnoses of anxiety disorder, psychotic disorder, and OCD. A review of a care plan, dated as initiated 06/21/2022, revealed Resident #49 had a potential for a decline in mood state related to diagnoses of delusional disorder, OCD, and anxiety. The planned interventions included administering medications as ordered and observing the resident's mood to determine if problems seemed to be related to external causes. Review of a care plan dated as initiated 09/20/2022 and revised 11/08/2022 revealed Resident #49 used psychotropic medications related to diagnoses of depression and delusional disorder. A planned intervention was to administer psychotropic medications as ordered by the physician. Review of the January 2023 Medication Administration Record (MAR) revealed that beginning on 12/22/2022, Resident #49 received Zoloft, an antidepressant medication, 100 milligrams (mg) by mouth (po) one time a day for delusional disorder and anxiety. The MAR further revealed, beginning on 01/03/2023, the resident received Abilify, an antipsychotic medication, 10 mg po at bedtime related to delusional disorders. A review of Resident #49's level one PASRR results, dated 09/23/2021, revealed no level two PASRR was required. Further review of Resident #49's medical record on 01/18/2023 revealed no other PASRR screening documentation. A review of a level one PASRR submitted on 01/18/2023 revealed Resident #49's diagnoses of other symptoms and signs involving the nervous system, delusional disorders, OCD, and anxiety disorders. During an interview on 01/19/2023 at 8:33 AM, the Social Services Director (SSD) stated a level one PASRR was completed for each resident on admission. Per the SSD, if a resident was not on any psychoactive medications, the PASRR evaluation automatically triggered that a level two evaluation was not required. The SSD indicated if a resident started on any new psychoactive medications or had a significant change in condition, she submitted an additional PASRR screen request to the state for another evaluation. The SSD stated Resident #49 was on her list to submit another PASRR screen to the state and that she submitted it on 01/18/2023. According to the SSD, when Resident #49 first admitted to the facility, the resident did not require a level two evaluation but had recently had delusions and was started on Abilify. The SSD indicated Resident #49 probably qualified for a level two evaluation now, with their current diagnoses and medications. During an interview on 01/19/2023 at 9:40 AM, the Medical Director (MD) stated he took over Resident #49's care in late December 2022. Per the MD, Resident #49 had a diagnosis of delusional parasitosis, and the use of antidepressants was validated in the treatment of this disorder. The MD further stated Resident #49 was stable with their current plan of care. During a follow-up interview on 01/19/2023 at 9:53 AM, the SSD stated Resident #49 was started on a couple psychoactive medications when their behaviors started but none were effective. According to the SSD, another level one PASRR was not done when those medications were started, and she did not have a reason for not submitting the request to the state prior to 01/18/2023. The SSD stated Resident #49 probably qualified for a level two PASRR and would be offered additional counseling services for the treatment of their mental health diagnosis once they qualified for a level two PASRR. During an interview on 01/19/2023 at 1:20 PM, the Director of Nursing (DON) stated the SSD was responsible for submitting the level one PASRR screens to the state, but she was not sure of the required timeline. The DON further stated if a resident had a new mental health diagnosis, she expected that information to be sent to the PASRR authority to see if that resident qualified for a level two PASRR and additional services. During an interview on 01/19/2023 at 1:41 PM, the Executive Director (ED) stated the SSD screened residents upon admission to see if they met the requirements for a level two PASRR. The ED further stated she was not sure what triggered another level one PASRR or what changed it from a level one to a level two screening. The ED stated, moving forward, she was going to have the medical records staff notify the SSD if they coded any new international classification of diseases codes for new diagnoses, so the SSD was aware of new diagnoses to update the PASRR screens as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, document review, and facility policy review, the facility failed to review and revise the comprehensive care plan for 1 (Resident #36) of 16 sampled residents, following a substantiated allegation of physical abuse by a family member. Findings included: Review of a facility policy titled, Person Centered Care Planning, initiated 08/16/2022, specified Each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. A review of an admission Record indicated the facility admitted Resident #36 with diagnoses that included muscle weakness, history of falling, pain in right and left shoulders, cognitive communication deficit, and other abnormalities of gait and mobility. A review of an Annual Exam, dated 06/08/2021, revealed Resident #36 had additional diagnoses of anoxic brain damage and altered mental status. The quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #36 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The resident required limited assistance with bed mobility, transfers, dressing, and toilet use; extensive assistance with locomotion on and off the unit; and supervision with personal hygiene. A review of a facility investigation report, dated 12/08/2022, revealed Resident #36's family member (FM #1) was observed to strike the resident twice on the resident's shoulders. Per the report, FM #1 was made to leave the facility, pending an investigation, and Resident #36 was assessed and determined to have no injuries. Following the investigation, the facility determined the allegation of physical abuse by FM #1 was substantiated. A review of Resident #36's comprehensive care plan revealed there was no information or interventions implemented to ensure the resident's continued safety in the facility after there was a substantiated allegation of physical abuse perpetrated by FM #1 to the resident on 12/08/2022. During an interview on 01/18/2023 at 12:30 PM, the Social Services Director (SSD) stated there was no written directive to nursing that described the plan to keep Resident #36 safe from potential abuse by FM #1. The SSD stated she had not revised the resident's care plan at the time of the incident; she had not thought about it but would do it today (01/18/2023). The SSD repeated she would update the resident's care plan. During an interview on 01/19/2023 at 10:39 AM, the Executive Director (ED) stated the care plan was not updated at the time of the incident between Resident #36 and FM #1, as the team was waiting on a more permanent fix. The ED stated her expectation was for care plans to be updated immediately and all staff to be educated on any new interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, document review, and facility policy review, it was determined that the facility failed to provide medically-related social services by failing to monitor a resident following a substantiated abuse incident and failing to assist with discharging from the facility for 1 (Resident #36) of 1 resident reviewed for abuse. Findings included: Review of a facility policy titled, Social Services Personnel, reviewed 09/30/2022, specified, All facilities are required to provide medically related social services for each resident. The policy further specified, The facility must provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The policy specified, Procedure 14. Meet the needs of residents who are grieving from losses and coping with stressful events. A review of an admission Record indicated the facility admitted Resident #36 with diagnoses that included muscle weakness, history of falling, pain in right and left shoulders, cognitive communication deficit, and other abnormalities of gait and mobility. A review of an Annual Exam, dated 06/08/2021, revealed Resident #36 had additional diagnoses of anoxic brain damage and altered mental status. The quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #36 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The resident required limited assistance with bed mobility, transfers, dressing, and toilet use; extensive assistance with locomotion on and off the unit; and supervision with personal hygiene. A review of a facility investigation report, dated 12/08/2022, revealed Resident #36's family member (FM #1) was observed to strike the resident twice on the resident's shoulders. Per the report, FM #1 was made to leave the facility, pending an investigation, and Resident #36 was assessed and determined to have no injuries. Following the investigation, the facility determined the allegation of physical abuse by FM #1 was substantiated. A review of Resident #36's comprehensive care plan revealed there was no information or interventions implemented to ensure the resident's continued safety in the facility after there was a substantiated allegation of physical abuse perpetrated by FM #1 to the resident on 12/08/2022. During an interview on 01/17/2023 at 10:05 AM, Resident #36 stated something bad happened recently. The resident stated one of the nursing staff mistook a family member's (FM #1) mannerisms for abuse. According to Resident #36, FM #1 was not abusive, the occurrence was all wrong; it was not abuse, and the resident was not afraid of FM #1. Resident #46 further commented that they did not want to be in the facility, since FM #1 was banned from the facility. Per Resident #36, they wished for FM #1 to visit the facility, so that FM #1 could assist the resident in packing their belongings to leave the facility. Resident #36 reported they wanted to move in with FM #1, once FM #1 got an apartment. A review of Resident #36's Progress Notes revealed the last Psychosocial Note entered by social services was dated 11/11/2022. The note indicated the resident was interviewed for their cognition and mood state and displayed no behaviors during the review period. During an interview on 01/18/2023 at 12:30 PM, the Social Services Director (SSD) stated she was not informed of the final disposition of the abuse investigation completed for the incident on 12/08/2022 involving Resident #36 and FM #1. The SSD acknowledged the resident was upset about the situation, and the resident wanted to leave the facility to live with FM #1. The SSD was unable to provide any assessments and/or documentation as evidence of conversations she had with Resident #36 to determine the resident's mental health following the substantiated physical abuse perpetrated by FM #1, and the SSD was unable to provide documentation she assisted Resident #36 with their plans to leave the facility. During an interview on 01/19/2023 at 10:06 AM, the Director of Nursing (DON) stated she had only been in this position for a few weeks and had not been involved with the incident between Resident #36 and FM #1. The DON stated the SSD was responsible for checking on residents during morning rounds, asking staff if they have noticed any changes in the resident, and then following up accordingly. The DON stated she would not expect any further assessments to be done if there were no changes reported/observed. During an interview on 01/19/2023 at 10:39 AM, the Executive Director (ED) stated she expected the SSD to document interactions with residents. The ED further stated the SSD should check in and talk to any residents affected by abuse, and the staff needed to do a better job documenting what they did.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and policy review, the facility failed to assess a resident for medical contraindications and provide education on the influenza vaccine prior to the administration of the influenza vaccine for 1 (Resident #7) of 5 residents reviewed for immunizations. Findings included: A review of the facility's Influenza Vaccine & Pneumococcal Vaccine Policy for Residents, revised 12/06/2022, revealed, Procedure-Influenza Vaccine 1. Starting on October 1st and extending to March 31st, residents are offered the influenza vaccine each year, unless the immunization is medically contraindicated, or the resident has already been immunized during this time period. 2. Education is provided to the resident or the resident's representative regarding: i. The benefits and potential side effects of the immunization. ii. The resident or resident's representable has the opportunity to refuse immunization. iii. The resident and/or responsible party is provided with the vaccine information statement for the vaccine to be administered. The policy further revealed, 3. The resident is assessed for possible contraindications that may include: i. Allergy to eggs, chicken, feathers, or chicken dander ii. Hypersensitivity to other components of the vaccine iii. Acute febrile illness iv. Having received another type of vaccine within the past 14 days v. In addition, the package insert is reviewed for additional contraindications and directions. Also, the policy revealed, 7. Education, assessment findings, administration, refusal or did not receive due to medical contraindications, and monitoring are documented in the resident's medical record. A review of Resident #7's admission Record revealed the facility admitted the resident with diagnoses that included acute respiratory failure with hypoxia, heart failure, chronic obstructive pulmonary disease, personal history of pneumonia and dependence on supplemental oxygen. A review of Resident #7's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Per the MDS, Resident #7 received the influenza vaccine on 11/02/2022. A review of Resident #7's November 2022 Medication Administration Record revealed a registered nurse (RN) administered the influenza vaccine to Resident #7 on 11/02/2022 at 9:18 AM. A review of Resident #7's medical record, including progress notes, revealed there was no documentation to indicate an assessment for medical contraindications or education regarding the benefits and potential side effects of the influenza immunization was provided to the resident prior to the administration of the influenza vaccine. On 01/19/2023 at 10:30 AM, the Infection Preventionist (IP)/RN stated Resident #7 had initially refused the flu shot, but when their roommate got their flu shot, Resident #7 decided to get one as well, so the flu shot was given to the resident at that time on 11/02/2022. The IP/RN indicated ideally, a consent form should have been completed, that showed the resident gave consent. On 01/19/2023 at 1:23 PM, the Director of Nursing (DON) indicated Resident #7 had previously requested not to have the flu vaccination but had later indicated they wanted one after seeing their roommate get one. The DON revealed a new consent form should have been completed prior to the administration of the vaccination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to ensure that the resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for two (#19 and #21) of five residents reviewed for quality of care of 42 sample residents. Specifically, the facility failed to: -Accurately document skin assessments, and provide care and treatments for abrasion on resident 21's right knee; and, -Have a physician order for the Lidocaine lotion (anesthetic) that was applied to Resident #19's hand. Findings include: I. Failure to accurately document skin assessments, and provide care and treatments for abrasion A. Resident status Resident #21, age [AGE], was admitted on [DATE]. According to the October 2021 computerized physician orders (CPO), diagnosis included gastroenteritis and colitis, dementia with behavioral disturbance, communication deficit, depressive disorder, and history of falling. The 9/8/21 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of seven out of 15. She had adequate hearing, clear speech, made herself understood and understood others. She did not display any behaviors or rejection of care. She required extensive assistance of two and more people for transfers, bed mobility, dressing and personal hygiene. She used a wheelchair for mobility, but was not able to propel herself. B. Resident interview Resident #21 was interviewed on 10/11/21 at 2:30 p.m. The resident was in bed on her back. She stated she was very hard of hearing and initially could not understand the questions. Communication with the resident was established by typing questions on the computer, and the resident was able to answer all questions. Two dressings observed on the resident's right knee. Dressing #1 was covering the entire resident's right knee, it had no date on it and it had visible stains of dark red blood about 1 centimeter in diameter. Dressing #2 located below the right knee dressing #1 and had no date on it as well. The resident stated she had a fall at home and landed on both of her knees. She believed the injuries were still healing from that fall. C. Record review Comprehensive care plan for ADLs was initiated on 5/7/21 (previous admission) and revised on 9/27/21 revealed the resident had ADL self care performance deficits, related to impaired balance, and limited mobility. Interventions included: reclining wheelchair with tall foam backrest with side huggers in place. The resident required total assistance with bathing, dressing and bed mobility. She was totally dependent on one to two staff members for personal hygiene and oral care. At times the resident refused to go to the dining room as well as having staff assist her to eat. Resident was transferred by Hoyer (mechanical) lift. -The resident had no current care plan for skin integrity. She had an old care plan for skin integrity that was initiated and revised in May 2021 during the resident's previous stay in the facility. None of the problems, goals and interventions were applicable to the resident's current stay. The admission skin assessment completed on 9/1/21, revealed the resident had an area of blanchable redness and shearing to buttocks, and multiple pin-point scabbed areas to right knee and shin. The weekly skin assessments on 9/8/21 and 9/15/21 documented the resident's skin was intact and she had no new problems. The skin assessment on 9/23/21 documented resident had ongoing wound that heals/scabs over then reopens on right knee, and blanchable redness to sacrum. On 9/29/21 skin assessment was marked as skin intact; and, On 10/6/21 skin assessment was marked as skin intact with blanchable redness to right and left buttok. -The resident's October 2021 medication administration record (MAR)/treatment administration record (TAR) and physician orders were reviewed. The resident had no orders for skin treatments. -There were no interdisciplinary progress notes mentioning skin treatments. D. Observations Skin observations were conducted on 10/13/21 at 5:15 p.m. in the presence of licensed practical nurse (LPN) #2. Dressing #1 covering the right knee with no date on it was removed by LPN # 2. Unhealed abrasion draining sero sanguinous fluid observed under the dressing. Bright red blood was oozing from the wound. There were no visible wound edges to determine the size of the wound. Overall wound area was measured as 5 centimeters (cm) by 3 cm. The surrounding area of the wound had dark red to black blood stains on the skin. LPN #2 cleaned the wound with normal saline and applied foam dressing. Dressing #2 with no date on it was removed by LPN #2. Three bright to dark red abrasions were observed under the dressing. No drainage. The abrasions were clustered and measured as 4 cm by 1.4 cm. LPN #2 stated she will keep abrasions open to air. Coccyx observations revealed small scattered abrasions in the sacral region. LPN #2 applied barrier cream to the area. E. Staff interviews LPN #2 was interviewed on 10/13/21 at 5:30 p.m. She said she did not know the resident had an abrasion on her knee. She said the resident had no orders in place for skin treatments. She said it was not a standard of care. She said all abrasions and skin problems must be documented on skin assessment and have a physician's order for treatments. She said all skin should be checked weekly and any resolved issues should be marked as resolved. She said she did not know why resident's skin abrasions were not documented and did not have orders for treatment. She said all dressings should be dated to ensure consistent care. LPN #2 stated she would contact the physician to obtain treatment orders for the resident's skin. The DON was interviewed on 10/14/21 at 3:06 p.m. She said skin assessment should be completed weekly and all skin issues documented unless resolved. The treatment orders should be obtained from the physician and documented on the TAR. She said she was not aware that Resident #19 did not have skin treatments for her abrasions. II. Failure to obtain a physician order prior to providing Lidocaine treatment A. Resident status Resident #19, age [AGE], was admitted on [DATE]. According to the October 2021 computerized physician orders (CPO), diagnosis included type two diabetes, chronic kidney disease and dependence on hemodialysis. The 8/3/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She had adequate hearing, clear speech, made herself understood and understood others. She did not display any behaviors or rejection of care. She required limited assistance of one person with mobility and transfers, and supervision and set up help with other ADLs. B. Resident interview Resident #19 was interviewed on 10/12/21 at 3:56 p.m. Resident #19 stated she was happy with the care she received in the facility and did not have any complaints. She said occasionally she had a discomfort in her left upper hand at the dialysis fistula site. But that was managed well with the lotion that CNAs (certified nurse aides) helped her to apply to her hand. She reached out to the draw and pulled a tube of lotion that read Lidocaine 2%. She said she always kept it in her drawer and on the dialysis days before she left, she asked nurses or CNAs to apply the lotion to the area of the dialysis port. C. Record review The resident's October 2021 MAR and TAR, and physician orders were reviewed. There was no mention of Lidocaine two percent lotions for the dialysis site. The resident's dialysis care plan did not mention application of the lotion prior to the dialysis appointment. D. Staff interviews CNA #5 was interviewed on 10/14/21 at 2:30 p.m. She said the resident occasionally asked for help with lotion to be applied to her left hand. She said she helped the resident but was not sure what kind of lotion it was. CNA #4 was interviewed on 10/14/21 at 2:45 p.m. She said the resident was able to apply lotion to her hand by herself and sometimes asked her as well. She said she did not know what kind of lotion it was, but the resident only asked for it on the dialysis days before she left. LPN #1 was interviewed on 10/13/21 at 10:40 a.m. He said the resident had a lotion that was applied to her dialysis hand prior to the dialysis appointment. He said he recalled applying it a few days ago. He reviewed the orders and was not able to locate the order for the lotion. He said he will talk to the resident and would try to find out what the lotion was and where the order was for it. LPN #2 was interviewed on 10/13/21 at 5:33 p.m. She said she had more information regarding the Lidocaine lotion. She said the Lidocaine lotion was given to the resident at the dialysis center and therefore they did not have an order for it. She said she contacted the physician, obtained the order and the resident was educated on self administration of the lotion. She said lotion will be kept at the bedside in a locked draw. The DON was interviewed on 10/14/21 at 3: 06 p.m. She said all medications should be administered by nurses and order from the physician should be obtained prior to the administration of any medications. She said she was not aware that Lidocaine lotion was administered by CNAs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** II. Resident #29 A. Resident status Resident #29, age [AGE], was admitted on [DATE]. According to the October 2021 computerized physician orders (CPO), diagnosis included a history of stroke with weakness to one side of the body. The 8/16/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident did not reject the care that was necessary to achieve the resident's goals for health and well-being, and did not display any behaviors. She required extensive assistance from one person for transfers, bed mobility, dressing and personal hygiene. The resident had functional limitation in range of motion on one side of her upper and lower extremity. She used an electric wheelchair for mobility in the building. B. Resident interview Resident #29 was interviewed on 10/11/21 at 3:30 p.m. She said she was very happy with the care she received in the facility except for the restorative program. She said she had a stroke, and she was supposed to walk with the restorative aide every day. She said the treatment was missed three to four times a week because the restorative aide was working on the floor as a CNA, and had no time to provide the restorative program. The resident was upset as she was not able to walk on her own without assistance. C. Record review The comprehensive care plan revealed the resident had weakness on one side due to the stroke. The care plan was initiated on 8/23/21 (13 days after admission). The goals were to maintain optimal status and quality of life within the current limitations. Interventions included providing medications as ordered, and continuing therapy services as ordered by the physician. The resident did not have a care plan for the restorative program. According to the progress note by LPN #4 on 9/24/21, the resident was enrolled into a restorative nursing program as of 9/24/21 up to six times a week as tolerated. The order was entered on 9/24/21 to the resident's electronic medical record for the resident to participate in a restorative nursing program. The restorative program log was reviewed from 9/24/21 to 10/14/21. In September 2021, the resident participated in therapy on four out of eight occasions. In October 2021, she received six out of 13 possible sessions of therapy. No follow-up notes regarding missed therapy and offers to the resident to participate at a later time were located in the interdisciplinary progress notes. D. Staff interviews Restorative certified nurse aide (RCNA) #1 was interviewed on 10/14/21 at 2:00 p.m. She said she was the only restorative aide in the building. She said they used to have two restorative aides, but one recently left. She said on many occasions she was asked to work on the floor when the facility was short on CNAs. She said on the occasions when she was working as a CNA on the floor she was not able to provide a restorative program to residents. Since she was the only restorative aide, residents were not offered a restorative program on those days. She said management was aware of this situation. Licensed practical nurse (LPN) #4 was interviewed on 10/14/21 at 2:30 p.m. She said she was a manager of the restorative program. She said sometimes she also worked as a floor nurse and in addition she was overseeing the restorative program. As a restorative program manager her duties included monitoring the residents who were on the restorative program, making sure they had orders and were receiving appropriate therapy. She said once a week she would meet with the restorative CNA and therapy manager to discuss the course of treatment for the residents on the restorative program. She said she was aware that RCNA #1 was occasionally pulled to work on the floor and could not offer the restorative program to the residents. She said she did not know it was that frequently. The therapy manager was interviewed on 10/14/21 at 2:30 p.m. He said the resident was discharged from occupational and physical therapy with the recommendation for a restorative nursing program. He said he was not aware the resident missed several sessions of restorative therapy. He said lack of participation in therapy could result in decreased range of motion and eventually a decrease in physical functioning and abilities. Based on observations, record review and interviews, the facility failed to ensure that two (#17 and #29) out of five residents reviewed with limited range of motion received appropriate treatment and services, out of 42 sample residents. Specifically, the facility failed to: -Provide range of motion services to Resident #17's lower extremities, and -Provide a restorative program on a regular basis to Resident #29. Findings include: I. Resident #17 A. Resident status Resident #17, age [AGE], was admitted on [DATE]. According to the October 2021 computerized physician orders (CPO), diagnoses included quadriplegia, muscle weakness and incontinence. The 8/3/21 minimum data set (MDS) assessment documented the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 13 out of 15. The MDS coded the resident required extensive assistance of two with transfers, mobility, and personal hygiene. The MDS coded the resident as having limited range of motion on bilateral lower extremities. The MDS indicated the resident was not receiving range of motion. B. Observations On 10/11/21 at 10:30 a.m., the resident was sitting in his wheelchair. The wheelchair was at a 60 degree angle. His legs were supported with foot rests. The resident was not observed to move his legs. C. Resident interview The resident was interviewed on 10/13/21 at 12:30 p.m. The resident said he did not receive range of motion exercises and he would like to receive them. He said that he was able to propel his wheelchair a bit, but was unable to move his legs. D. Record review The care plan, last updated 8/17/21, identified the resident had an activity of daily living (ADL) self care performance deficit related to quadriplegia and generalized weakness. Pertinent approaches included the resident required a mechanical lift for transfers with the assistance of two staff members. The medical record failed to show the resident received range of motion exercises on his lower extremities. E. Staff interview Restorative certified nurse aide (RCNA) #1 was interviewed on 10/14/21 at 2:00 p.m. She said the resident was not on a restorative program. She said he used to be on a program for his neck, however, it was discontinued in August 2021. Licensed practical nurse (LPN) #4 was interviewed on 10/14/21 at 11:30 a.m. She said she was a manager of the restorative program. The LPN said the resident was not on a restorative program. She said if the resident needed range of motion then it was completed by the restorative aide. She said the CNA on the floor did not complete passive range of motion. The therapy manager was interviewed on 10/14/21 at 2:30 p.m. He said the resident was not currently on physical or occupational therapy. He said the resident was discontinued from the restorative program in August 2021 for his neck. He said that the decision was made with LPN #4 and RCNA #1 when it was decided the resident was maintaining. The therapy manager said the 6/9/21 therapy notes showed his legs were within functional limits. The therapy manager said that everybody benefits from range of motion to maintain function.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, and interviews, the facility failed to ensure medication error rate was not greater than five percent. Specifically, the facility failed to administer heart failure medication to Resident #16, and failed to complete a safety check/priming of the needle prior to insulin administration to Resident #16 out of 25 opportunities, resulting in a medication error rate of eight percent. Findings include: I. Facility policy The Medication Administration policy, with no revision date, was provided by the nursing home administrator (NHA) on 10/13/21 at 10:00 a.m. According to the policy, Medications are administered in accordance with written orders of the attending physician and resident ' s schedule. A. Manufacturer's recommendations The Lantus flexpen package insert (2018) read in pertinent part: Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by: ensuring that pen and needle work properly, and removing air bubbles. - Select a dose of 2 units by turning the dosage selector. - Take off the outer needle cap and keep it to remove the used needle after injection. - Take off the inner needle cap and discard it. - Hold the pen with the needle pointing upwards. - Tap the insulin reservoir so that any air bubbles rise up towards the needle. - Press the injection button all the way in. Check if insulin comes out of the needle tip. You may have to perform the safety test several times before insulin is seen. - If no insulin comes out, check for air bubbles and repeat the safety test two more times to remove them. If still no insulin comes out, the needle may be blocked. Change the needle and try again. - If no insulin comes out after changing the needle, your insulin pen may be damaged. Do not use this pen. B. Resident #16 status Resident #16, age under 79, was admitted on [DATE]. According to the October 2021 computerized physician orders (CPO), diagnoses included heart failure, and diabetes type two. According to the medical administration record (MAR) for October 2021, the resident was scheduled to receive the following medications: -Lantus Pen Injection (insulin) 100 Units per milliliter (U/ml) Inject 14 unit subcutaneously two times a day. -Isosorbide Mononitrate (nitrate medication for heart failure) extended release, give 30 milligrams (mg) by mouth one time a day in the morning. C. Observations of medication administration On 10/13/21 at 8:20 a.m registered nurse (RN) #1 was observed during medication administration. She pulled out several blister cards and popped morning medications into a small plastic cup. When she was ready to go to the room to administer the medications, she was asked to review them on the MAR. The MAR had six morning medications. She had five in the plastic cup. The review and comparison of the MAR revealed that she did not add Isosorbide 30 mg to the cup. During insulin administration, RN #1 prepared to administer 14 units of insulin to the resident. She turned the dial on the lantus flex pen to 14 units, attached the needle and administered the insulin. She did not conduct the safety test by priming the insulin needle. Cross-reference F760 for significant medication error. The above observations were reported to the unit manager/licensed practical nurse (LPN) #2 on 10/13/21 around 8:35 a.m. II. Staff interviews RN #1 was interviewed 10/13/21 at 8:25 a.m. She repeated all the steps of insulin administration as demonstrated above and said she followed all the steps for insulin administration. The unit manager/LPN #2 was interviewed on 10/13/21 at 8:50 p.m. She said the insulin needle had to be primed prior to insulin injection to ensure that the resident received the appropriate amount of insulin. She said she would provide immediate education to all nurses on the floor and for oncoming shifts as well, and she would contact the resident's physician to report the inaccurate insulin administration. Regarding medications she said the nurse was nervous and made some mistakes as a result of that. She said the nurse was full time in the facility and always administered medications without errors. The director of nursing (DON) was interviewed on 10/14/21 at 4:30 p.m. She said the education to all nursing staff regarding proper insulin administration and priming of the needle was given on 10/13/21 (after being identified, see above). She said the insulin needle had to be primed prior to insulin injection to ensure that the resident received the appropriate amount of insulin. She said all medications should be administered as ordered by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to keep one (#16) of free residents on one of two hallways free of any significant medication errors. Specifically, the facility failed to prime the flex pen insulin needles prior to administering insulin injections for Resident #16. Findings include: I. Facility standards The Medication Administration policy, with no revision date, was provided by the nursing home administrator (NHA) on 10/13/21 at 10:00 a.m. According to the policy, Medications are administered in accordance with written orders of the attending physician and resident's schedule. II. Manufacturer's recommendations The Lantus flexpen package insert (2018) read in pertinent part: Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by: ensuring that pen and needle work properly, and removing air bubbles. - Select a dose of 2 units by turning the dosage selector. - Take off the outer needle cap and keep it to remove the used needle after injection. - Take off the inner needle cap and discard it. - Hold the pen with the needle pointing upwards. - Tap the insulin reservoir so that any air bubbles rise up towards the needle. - Press the injection button all the way in. Check if insulin comes out of the needle tip. You may have to perform the safety test several times before insulin is seen. - If no insulin comes out, check for air bubbles and repeat the safety test two more times to remove them. If still no insulin comes out, the needle may be blocked. Change the needle and try again. - If no insulin comes out after changing the needle, your insulin pen may be damaged. Do not use this pen. III. Resident #16 status Resident #16, age under 79, was admitted on [DATE]. According to the October 2021 computerized physician orders (CPO), diagnoses included heart failure, and diabetes type two. A. Record review According to the medical administration record (MAR) for October 2021, the resident was scheduled to receive the following medications: -Lantus Pen Injection 100 Units per milliliter (U/ml) Inject 14 unit subcutaneously two times a day. B. Observations On 10/13/21 at 8:20 a.m registered nurse (RN) #1 was observed during medication administration. She prepared to administer 14 units of insulin to the resident. She turned the dial on the flex pen to 14 units, attached the needle and administered the insulin. -However, RN #1 failed to follow the manufacturer's recommendation to prime the insulin pen before administration of dose. The above observations were reported to the unit manager/licensed practical nurse (LPN) #2 on 10/13/21 around 8:35 a.m. III. Staff interviews RN #1 was interviewed 10/13/21 at 8:25 a.m. She repeated all the steps of insulin administration as demonstrated above and said she followed all the steps for insulin administration. The unit manager/LPN #2 was interviewed on 10/13/21 at 8:50 p.m. She said the insulin needle had to be primed prior to insulin injection to ensure that the resident received the appropriate amount of insulin. She said she would provide immediate education to all nurses on the floor and for oncoming shifts as well, and she would contact the resident's physician to report the inaccurate insulin administration. The director of nursing (DON) was interviewed on 10/14/21 at 4:30 p.m. She said the education to all nursing staff regarding proper insulin administration and priming of the needle was given on 10/13/21 (after being identified, see above). She said the insulin needle had to be primed prior to insulin injection to ensure that the resident received the appropriate amount of insulin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Resident #44 1. Resident status Resident #44, age [AGE], was admitted on [DATE]. According to the October 2021 computerized physician orders (CPO), diagnoses included Parkinson's disease, dementia, incontinence, and generalized muscle weakness. The 8/30/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The resident was dependent on two staff members for transfers and required extensive assistance for activities of daily living. It indicated the resident did not have any behaviors related to refusal of care. It indicated the resident was at risk for developing pressure ulcers. 2. Observation Resident #44 was observed on 10/13/21 from 8:37 a.m. to 1:15 p.m continuously. At 8:37 a.m., Resident #44 was observed seated in her wheelchair in her room. At 8:39 a.m., certified nurse aide (CNA) #4 entered the room and asked Resident #44 if she wanted to lie down. The resident declined. Resident #44 continued to sit in her wheelchair in her room until lunch. Resident #44 ate lunch in the dining room. Resident #44 was taken back to her room at 12:32 p.m. At 1:15 p.m., CNA #4 asked the resident if she wanted to lie down and if she could check her brief and empty her catheter. The resident agreed. CNA #4 and CNA #5 used a Hoyer lift to transfer the resident and checked her brief. CNA #4 said the resident had had a bowel movement. Observations revealed the resident had not received incontinence care or repositioning assistance for more than four and a half hours. 3. Record review A Braden scale for predicting pressure sore risk was completed on 10/3/21. The resident had a score of 15 indicating a mild risk. It indicated the resident's mobility was very limited and she could not make significant position changes independently. Other risk factors included bowel incontinence, history of pressure injuries, weight loss, and diabetes. A weekly skin assessment was completed on 10/10/21. It indicated the Resident #44 had no skin issues. 4. Staff interviews CNA #4 was interviewed on 10/13/21 at 1:20 p.m. She said Resident #44 should be repositioned and her brief checked every two to three hours. Licensed practical nurse (LPN) #2 was interviewed on 10/14/21 at 11:11 a.m. She said Resident #44 was at risk for pressure injuries due to limited mobility and dependence on staff. She said the resident needed to be repositioned every one to two hours. She said she was not aware that the resident was not repositioned the morning of 10/13/21. The director of nursing (DON) was interviewed on 10/14/21 at 3:43 p.m. She said Resident #44 should be repositioned at least every two hours to reduce the risk of pressure injuries. C. Resident #21 1. Resident status Resident #21, age [AGE], was admitted on [DATE]. According to the October 2021 computerized physician orders (CPO), diagnoses included gastroenteritis and colitis, dementia with behavioral disturbance, communication deficit, depressive disorder, and history of falling. The 9/8/21 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of seven out of 15. She had adequate hearing, clear speech, made herself understood and understood others. She did not display any behaviors or rejection of care. She required extensive assistance of two or more people for transfers, bed mobility, dressing and personal hygiene. She used a wheelchair for mobility, but was not able to propel herself. 2. Resident interview Resident #21 was interviewed on 10/11/21 at 2:30 p.m. She was in bed on her back. She stated she was very hard of hearing and initially could not understand the questions. Communication with the resident was established by typing questions on the computer, and the resident was able to answer all questions. Specifically, she said she was frequently left in her chair for prolonged periods of time either in her room or the dining room. She said she was not able to change her position or move her wheelchair. 3. Record review The comprehensive care plan for activities of daily living (ADLs), initiated on 5/7/21 and revised on 9/27/21, revealed ADL self care performance deficits, related to impaired balance and limited mobility. Interventions included: reclining wheelchair with tall foam backrest with side huggers in place. The resident required total assistance with bathing, dressing and bed mobility. She was totally dependent on 1-2 staff members for personal hygiene and oral care. At times the resident refused to go to the dining room as well as having staff assist her to eat. The resident was transferred by Hoyer lift. -The care plan did not specify what kind of assistance the resident required when she was in a wheelchair and what her preferences were. -The resident did not have a care plan for refusal of care. 4. Observations Resident #21 was observed on 10/12/21: -at 8:00 a.m. she was asleep in front of her finished breakfast at the dining room table. Kitchen staff were observed cleaning tables. -at 9:00 a.m. she was still in the dining room, sleeping at the table. All the tables in the dining room had been cleaned. No other residents were in the dining room. -at 9:46 a.m. she was taken to her room. Resident #21 was observed on 10/13/21: -at 8:30 a.m. she was sitting upright in bed in her room in front of her breakfast tray. -at 10:44 a.m. she was transferred to a wheelchair, taken to the dining room, and was left at the table. -at 11:30 a.m. she was served her lunch meal, a Caesar salad with a muffin and two drinks in sippy cups. -at 11:59 a.m. she was taken out of the dining room to continue her lunch in her room as she had a visitor. -at 1:15 p.m. she was sleeping in her wheelchair in her room in front of the table. Her call light was on the floor behind the headboard of the bed. -at 1:40 p.m. she was taken to the dining room for a music activity. -at 3:04 p.m. she was asleep in her wheelchair during the live music activity program. -at 3:20 p.m. she was taken back to her room and left in her wheelchair facing the window with closed blinds. Her call light was on the floor behind the headboard of the bed. -at 3:50 p.m. she was asleep in the same position as above. -at 4:42 p.m. CNA#6 entered the resident's room, stated she would make the resident's bed, but would not put the resident to bed as the resident would stay in the chair for dinner. The resident reported to CNA #6 that she had been sitting in her wheelchair for 13 hours and she could not reach her phone or call light. CNA #6 stated she would assist the resident to bed. -at 5:00 p.m. the resident was transferred to bed by Hoyer lift. 5. Staff interviews CNA #1 was interviewed on 10/13/21 at 1:23 p.m. She said the resident required assistance of one to two people with bed mobility and other tasks. She said the resident was able to say what she liked and disliked. She said staff made frequent rounds to check on her position, and helped her reposition in bed every two hours. She said she assisted the resident in the morning when she came in around 6:00 a.m. As far as her preferences, she said the resident liked to stay in bed for breakfast, but attended lunch in the dining room. CNA #6 was interviewed on 10/13/21 at 4:50 p.m. She said the resident had dementia and was not always understood. She said she worked with the resident during the day and evening shift, from 2:00 to 10:00 p.m., and she usually would make the resident's bed before dinner. The resident would usually stay in the wheelchair until dinner. Today, when she was making her bed, the resident told her she had been sitting in the chair for too long, so she offered to transfer her to bed. She said the resident was dependent on staff for all ADLs. Registered nurse (RN) #1 was interviewed on 10/13/21 at 5:06 p.m. She said the resident was alert and oriented, and slightly hard of hearing. She said the resident was able to make all her needs known, she required assistance of two people with transfers, one person with other needs, and was able to eat with set up assistance only. She said she was not sure what the resident's preferred routine was, but the resident was able to say what she liked and disliked. She said the resident did not refuse care. The DON was interviewed on 10/14/21 at 3:06 p.m. She said the resident was dependent on staff members for care, and required assistance with transfers and repositioning every two hours. She said staff were expected to honor the resident's wishes regarding daily schedules and make sure that her call light was within the reach when leaving the resident in the room. Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for six (#13, #272, #61, #17, #44 and #21) of seven residents reviewed out of 42 sample residents. Specifically, the facility failed to ensure: -Residents #13, #272 and #61 received assistance with showers as scheduled; and -Residents #17, #44 and #21 were repositioned in their wheelchairs timely. Findings include: I. Showers A. Resident #13 1. Resident status Resident #13, age [AGE], was admitted on [DATE]. According to the October 2021 computerized physician orders (CPO), diagnoses included congestive heart failure and chronic respiratory failure with hypoxia. The 7/27/21 minimum data set (MDS) assessment documented the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 13 out of 15. The MDS coded the resident required supervision/oversight with personal hygiene, which included showers. -However, the resident's care plan (below) documented she needed extensive assistance with activities of daily living (ADLs). 2. Resident interview The resident was interviewed on 10/13/21 at 2:10 p.m. The resident said that she was upset that she had not received her shower as scheduled. She said that she was supposed to have a shower on 10/6/21 and 10/9/21 and she was hoping that she would get her shower today. The resident said that when her shower was skipped it made her feel as if she was not important. She said that when she complained she was told it was due to staffing. 3. Record review The care plan, last updated 7/26/21, identified the resident had an activities of daily living (ADL) self-care performance deficit related to congestive heart failure. Pertinent approaches were the resident required extensive assistance of one. The [NAME] showed the resident's shower days were Wednesday and Saturdays. The bathing record confirmed the resident last received a shower on 10/2/21, and that she had not received a shower until 10/13/21. The documentation report provided by the director of nursing (DON) showed the same information, which indicated the resident did not receive her showers on 10/6/21 or 10/9/21. The September 2021 shower documentation showed the resident received a shower on 9/15, 9/22 (seven days later), and 9/29/21 (seven days later). 4. Staff interview The unit manager (UM) was interviewed on 10/14/21 at 2:50 p.m. The UM reviewed the medical record and confirmed that the resident's last shower was on 10/2/21, 12 days earlier. The UM reviewed the bath logs which the certified nurse aides (CNAs) completed and was unable to locate evidence the resident received a shower. B. Resident #272 1. Resident status Resident #272, age [AGE], was admitted on [DATE]. According to the October 2021 CPO, diagnoses included paraplegia, spinal stenosis (spinal narrowing), and chronic pain. The 9/22/21 MDS assessment indicated the resident was cognitively intact with a BIMS score of 15 out of 15. It indicated the resident required extensive, two person assistance for activities of daily living. It indicated the resident did not have behaviors related to refusal of care. 2. Resident interview Resident #272 was interviewed on 10/11/21 at 2:45 p.m. She said the shower schedule had changed and it had led to her missing showers. She said she recently returned from the hospital and had not had a shower since her return. During the interview, the resident's hair appeared greasy and unkempt. Resident #272 was interviewed again on 10/12/21 at 3:45 p.m. She said her last shower was on 10/1/21. She said she was out at the hospital from [DATE] to 10/8/21 and did not receive a shower while there. She said she wanted a shower since her return to the facility and asked a staff member but had not heard anything. She said showers made her feel better. Resident #272 said she was not offered a bed bath or any alternative to a shower. 3. Record review Reviewed from 9/13/21 to 10/11/21, the bathing record revealed the resident had received seven out of 10 showers. The record indicated one shower was missed while the resident was out of the facility and two showers were refused on 10/8/21 and 10/11/21. There was no documentation if a shower was offered at a later time or day. The resident went 12 days without a shower. The CNA task list indicated Resident #272's preferred shower days were Monday, Wednesday, and Friday. 4. Staff interviews CNA #5 was interviewed on 10/13/21 at 9:02 a.m. She said residents have showers two to three times a week and it is based off their preference. She said there is a designated bath aide who completes them. LPN #2 was interviewed on 10/14/21 at 2:46 p.m. She said Resident #272's last shower was on 10/1/21. She said the resident had refused two showers since her return from the hospital. She said if a resident refuses a shower, the staff should notify the nurse and reapproach later. She said she did not know if the resident was approached later after her refusals. The DON was interviewed on 10/14/21 at 3:05 p.m. She said when a resident refuses a shower, the nurse should be notified. She said the resident should be offered an alternative time or day and staff should try to accommodate the resident's preference. She said the facility had had changes to their bath aides and had initiated training with the bath aides on how to document and address refusals. C. Resident #61 1. Resident status Resident #61, age [AGE], was admitted on [DATE]. According to the October 2021 CPO, diagnoses included orthopedic aftercare and fusion of the spine. The 9/21//21 MDS assessment documented the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. The MDS coded the resident required extensive assistance with personal hygiene, which included showers. 2. Resident interview The resident was interviewed on 10/11/21 at 3:30 p.m. The resident said she did not always get her shower as scheduled. 3. Record review The care plan, last updated 9/27/21, identified the resident had an ADL self-care performance deficit related to an acute hospital stay with status post lumbar fusion (back surgery). A pertinent approach documented the resident required total assistance with bathing. The bathing record in the computerized system failed to show any showers were provided. The bath logs showed the resident refused a shower on 9/22/21, 9/29/21 and 10/2/21. Otherwise the bath log did not contain any information for Resident #61. The medical record failed to show any evidence when the resident refused a shower, that another one was offered, or that the facility attempted to determine the reason the shower was refused. The care plan failed to identify any approaches to use when the resident refused showers. 4. Staff interview The unit manager (UM) was interviewed on 10/14/21 at 2:50 p.m. The UM reviewed the medical record and she confirmed she was unable to find any documentation which showed the resident received a shower since admission. The UM said that she had just entered Resident #61's information into the electronic record for showers. The UM said if the resident refused then the nurse was to be informed so she could ask the reason. D. Performance improvement plan The DON was interviewed on 10/14/21 at 4:00 p.m. The DON said the facility had a performance improvement plan (PIP) developed on 8/9/21. She said the PIP included the resident preferences for showers, and that they had not been receiving their showers. She said the PIP was to ensure resident choice was provided and residents received their showers. She said shower sheets were printed out from each floor. She said interdisciplinary team (IDT) discussed any concerns from the forms. She reviewed the print outs and confirmed Resident #61 was not on the list, that performance improvement plan discussions had not identified showers were not completed for Resident #13, and Resident #272 had received a shower on 10/1/21. The PIP was scheduled to end in November 2021. The DON said the documentationand ensuring showers were provided was a huge struggle. II. Positioning A. Resident #17 1. Resident status Resident #17, age [AGE], was admitted on [DATE]. According to the October 2021 CPO, diagnoses included quadriplegia, muscle weakness and incontinence. The 8/3/21 MDS assessment documented the resident had moderate cognitive impairment with a BIMS score of 13 out of 15. The MDS coded the resident required extensive assistance of two with transfers, mobility, and personal hygiene. 2. Observations On 10/11/21 at 10:30 a m., the resident was sitting in his wheelchair. The wheelchair was at a 60 degree angle. -At 4:04 p.m., the resident remained in his wheelchair at a 60 degree angle. -At 5:00 p.m., the resident remained in the same position. Continuous observations were completed on 10/13/21 from 8:21 a.m. to 12:45 p.m. -At 8:21 a.m., the resident was in his room. He was in his wheelchair sitting at a 60 degree angle. -At 9:01 a.m., CNA #2 assisted the resident to the halloween movie activity. The resident was not offered any repositioning. -At 11:03 a.m., the movie was over, and he started to self propel himself out of the movie room. CNA #2 walked up to the resident and asked if he enjoyed the movie. The CNA began to assist the resident out of the movie room. The CNA did not offer to reposition the resident while he assisted the resident to the dining room. -At 11:30 a.m., the resident was sitting at the dining room table eating his meal. He had not been repositioned in his chair. -At 12:24 p.m., the resident was assisted from the dining room to his room. CNA #3 told the resident she would return to help him with a shower. The resident was not offered to be repositioned prior to her leaving the resident. -At 12:45 p.m., the resident remained in his wheelchair and had not been repositioned. 3. Resident interview The resident was interviewed on 10/13/21 at 12:30 p.m. The resident said he was unable to move himself in his wheelchair, besides with some self propelling. He said he was not offered to be repositioned frequently enough. 4. Record review The care plan, last updated 8/17/21, identified the resident had an ADL self care performance deficit related to quadriplegia and generalized weakness. Pertinent approaches included assistance of one staff member to turn and reposition the resident in bed. -The care plan failed to include the need for the resident to be repositioned while in his wheelchair. 5. Staff interviews Registered nurse (RN) #3 was interviewed on 12/13/21 at 12:37 p.m. The RN was notified the resident had not been repositioned in over four hours. She said she was not aware of how frequently the resident needed to be repositioned. She said he was at risk for pressure ulcers. CNA #2 was interviewed on 10/13/21 at 12:45 p.m. CNA #2 said the resident needed to be repositioned at least every two hours. The CNA confirmed that after the movie the resident went straight to the dining room without being repositioned. He said the resident was supposed to have a shower prior to lunch but it had not happened yet. He said after his shower he would lay him down. The director of nursing (DON) was interviewed on 10/13/21 at 12:50 p.m. The DON said the resident should be repositioned at least every two hours. She said she would provide education on the importance of repositioning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to ensure six (#70, #25, #52, #43, #17 and #26) of 10 residents reviewed for respiratory care were provided such care in accordance with professional standards of practice out of 42 sample residents. Specifically, the facility failed to: -Administer oxygen therapy as ordered by the physician for six of 10 residents. -Label/date oxygen tubing for six out of 10 residents. Findings include: l. Facility policy The Oxygen Administration policy, revised August 2021, was provided by the director of nursing (DON) on 10/14/21 at 3:45 p.m. It read in pertinent part, The purpose of this policy is to assure that oxygen is administered and stored safely within the healthcare center. Change oxygen supplies weekly and when visibly soiled. Equipment should be labeled with a patient name and dated when setup or changed out. All facility staff will be educated on oxygen administration, safety and storage upon hire, annually, and as indicated thereafter. II. Resident #70 A. Resident status Resident #70, age [AGE], was admitted on [DATE]. According to the October 2021 computerized physician orders (CPO), diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, encounter for attention to gastrostomy, aphasia, and dysphagia. According to the 9/28/21 minimum data set (MDS) assessment, the resident was severely cognitively impaired with a brief mental status (BIMS) score of two out of 15. The resident was totally dependent on two people for transfers, bathing, toileting, eating and all activities of daily living (ADLs). The resident had limited range of motion for upper and lower extremities. He required oxygen therapy at night. B. Record review The 8/5/21 revised care plan identified the resident needed staff assistance to set up oxygen and follow the oxygen rate ordered via nasal cannula. The care plan specified a flow rate of two liters per minute (LPM) at night (NOC). The October 2021 CPO documented a physician order for oxygen at two liters per minute at night per nasal cannula. C. Observations and interview On 10/11/21 at 10:42 a.m. Resident #70 was lying in bed with his nasal cannula (tube to administer oxygen) on and the oxygen concentrator was set at 3 LPM. The oxygen tubing was not dated. On 10/11/21 at 4:22 p.m. Resident #70 was observed in bed with his nasal cannula on and the oxygen concentrator was set at 3 LPM. On 10/13/21 at 8:50 a.m. Resident #70 was observed in bed with his nasal cannula on and the oxygen concentrator was set at 3 LPM. On 10/13/21 at 9:45 a.m. Resident #70 was repositioned and provided personal care. He continued to have oxygen provided after staff left the room. He was observed in bed with his nasal cannula on and the oxygen concentrator was set at 3 LPM. On 10/13/21 at 12:04 p.m. Resident #70 was observed in bed with his nasal cannula on and the oxygen concentrator was set at 3 LPM. The registered nurse (RN) #2 was interviewed on 10/13/21 at 2:39 p.m. She said the oxygen order for Resident #70 read two liters per minute at night per nasal cannula. She said the nurses or the certified nurse aides could change the oxygen tubing and it should be done weekly. She said she did not label the tubing when she changed it because she knew it needed to be done weekly. She said the resident's concentrator was set at three liters and said it should be set on two liters based on his current physician order. She changed the liter flow to two liters per minute. She said the order read he should have his oxygen on at night but that meant at night or when in bed. He was in bed most of the day and had his oxygen on when in bed. She said the order did not specify while in bed but that was what it meant. She said she would ask the physician to change the order. She said she changed his oxygen tubing yesterday but did not label the tubing. She said the policy was to label the tubing but she did not label the tubing. She said if there was an order to change the tubing then staff would document it was done. She said if there was not an order then there would not be documentation to show the tubing was changed. III. Resident #25 A. Resident status Resident #25, age [AGE], was admitted on [DATE]. According to the October 2021 computerized physician orders (CPO), diagnoses included acute systolic congestive heart failure, hemiplegia and hemiparesis following cerebral infarction affecting left side non dominant side, dementia and chronic respiratory failure with hypoxia. According to the 9/1/21 minimum data set (MDS) assessment, the resident was cognitively intact with a brief mental status (BIMS) score of 15 out of 15. The resident required extensive two person assistance with bed mobility, transfers, dressing, bathing, toileting and personal hygiene. She required oxygen therapy during the day and at night. B. Record review The 8/25/21 care plan identified the resident needed staff assistance to set up oxygen and follow the oxygen rate ordered via nasal cannula. The care plan specified a flow rate of two liters per minute (LPM) continuously via nasal cannula. The October 2021 CPO documented a physician order for oxygen at three liters per minute continuously via nasal cannula. The oxygen tubing should be changed every night shift every Sunday. C. Observations and interviews On 10/13/21 at 8:46 a.m. Resident #25 was observed in bed with her nasal cannula on and the oxygen concentrator was set at 3.5 LPM. On 10/13/21 at 10:05 a.m. Resident #25 was observed in bed with her nasal cannula on and the oxygen concentrator was set at 3.5 LPM. Resident #25 was interviewed on 10/13/21 at 10:05 a.m. She said she wore her nasal cannula during the day and her oxygen flow was usually set at 3.5 liters per minute. She said the nurse helped her set up her oxygen during the day and at night. She said she was not able to reach her concentrator because it was on the floor and she was not able to get out of bed on her own. Registered nurse (RN) #2 was interviewed on 10/13/21 at 2:39 p.m. She said Resident #25 had oxygen therapy during the day and at night. She said her current physician's order read three liters per minute continuously via nasal cannula. The oxygen tubing should be changed every night shift every Sunday. She said her concentrator was set at 3.5 liters per minute, and turned the flow down to 3 liters per minute. She said she was not sure why it was set at 3.5 LPM. She said they recently changed oxygen companies and she wondered if the flow raised on its own. She said a certified nurse aide was not allowed to adjust the oxygen flow because oxygen was a medication. Only a nurse could change the oxygen liter flow. IV. Resident #52 A. Resident status Resident #52, age [AGE], was admitted on [DATE]. According to the October 2021 computerized physician orders (CPOs), diagnoses included congestive heart failure, chronic obstructive pulmonary disease, and chronic respiratory failure. The 9/7/21 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The resident was independent with activities of daily living, and received oxygen therapy. B. Record review The physician orders, dated 3/5/21, documented oxygen at two liters/minute continuously per nasal cannula. The orders also indicated that as of 8/10/21, the oxygen concentrator should be checked for proper functioning every shift. The medication administration record (MAR) indicated the concentrator was checked by the nurse every shift. There were no orders for the oxygen tubing to be changed. C. Observation On 10/11/21 at 2:25 p.m., Resident #52's oxygen tubing was observed connected to the concentrator. The oxygen tubing was not dated and labeled. The oxygen flow rate from the concentrator was set at 3.5 liters per minute (LPM). On 10/13/21 at 9:56 a.m., Resident #52's oxygen tubing was observed connected to the concentrator. The oxygen flow rate from the concentrator was set at 3.5 LPM. D. Interview Licensed practical nurse (LPN) #1 was interviewed on 10/13/21 at 4:41 p.m. He said the resident's physician orders were for 2 LPM. He said the resident was at 3.5 LPM. LPN #1 said he was unsure when the oxygen tubing was last changed and he was unsure who was supposed to change the tubing. V. Resident #17 A. Resident status Resident #17, age [AGE], was admitted on [DATE]. According to the October 2021 CPO, diagnoses included quadriplegia, muscle weakness and incontinence. The 8/3/21 MDS assessment documented the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 13 out of 15. The MDS coded the resident required extensive assistance of two with transfers, mobility, and personal hygiene. The MDS coded the resident as using oxygen. B. Record review The October 2021 CPO documented a physician order for oxygen at two liters per minute (LPM) via nasal cannula with a start date of 6/25/21. The care plan, last updated 8/17/21, identified the resident used oxygen related to congestive heart failure. Pertinent approaches included the oxygen was to be at 2 LPM via nasal cannula continuously. C. Observations On 10/11/21 at 10:30 a.m., the resident was sitting in his wheelchair. The resident did not have the oxygen on. On 10/12/21 at approximately 2:00 p.m., the resident did not have the oxygen on. On 10/13/21 at 4:38 p.m., registered nurse (RN) #3 observed and confirmed the resident was not wearing a nasal cannula and connected to any oxygen. D. Interview The unit manager (UM) was interviewed on 10/13/21 at 5:15 p.m. The UM said the resident was wearing the oxygen at night after his recent hospitalization. She said that he had been weaning off of it; however, after reviewing the record she confirmed he had an active order for oxygen at 2 LPM. VI. Resident #43 A. Resident status Resident #43 was admitted on [DATE]. According to the October 2021 CPO, diagnosis included chronic obstructive pulmonary disease (COPD), asthma, and respiratory failure with hypoxia. The 9/7/21 MDS assessment documented the resident had no cognitive impairment with a BIMS score of 15 out of 15. The MDS coded the resident required limited assistance of two with activities of daily living. The MDS coded the resident as using oxygen. B. Record review The October 2021 CPO documented a physician order for oxygen at 4 LPM via nasal cannula continuously with a start date of 9/28/21. The care plan, dated 9/10/21, identified the resident had COPD. Pertinent interventions included administer oxygen at 4 LPM via nasal cannula continuously. C. Observations On 10/11/21 at 4:30 p.m., the resident received oxygen through a nasal cannula while she was in her room. The oxygen concentrator was set at 3LPM. The tubing was not dated. On 10/12/21 at approximately 2:00 p.m., the resident's oxygen concentrator was set at 3LPM. On 10/13/21 at 4:44 p.m., an observation with registered nurse (RN) #3 revealed the resident received oxygen through a nasal cannula while she was in her room. The oxygen concentrator was set at 3LPM. The tubing continued to be undated. D. Interview The unit manager was interviewed on 10/13/21 at 5:15 p.m. The UM reviewed the medical record and confirmed the resident was to be on 4 LPM. She said that the tubing should be dated to indicate when it was changed. She said she did not know who was responsible to ensure the tubing was changed and when. She said they used to have a respiratory therapist from the oxygen company who changed the tubing weekly. The director of nursing (DON) was interviewed on 10/14/21 at 3:40 p.m. The DON said the licensed nurses were responsible to ensure the oxygen concentrator was set at the correct liter flow according to physician orders. She said the nurses were also responsible to ensure the tubing was marked and dated when changed. VII. Resident #26 A. Resident status Resident #26, age [AGE], was admitted on [DATE]. According to the October 2021 CPO, diagnoses included congestive heart failure, history of falling and anemia. The 8/21/21 MDS assessment documented the resident had moderate cognitive impairment with a BIMS score of 10 out of 15. The MDS coded the resident required extensive assistance with activities of daily living. The MDS coded the resident as using oxygen. B. Record review The October 2021 CPO documented a physician order for oxygen at 2LPM via nasal cannula continuously with a start date of 5/8/21. The care plan, dated 8/13/21, identified the resident had congestive heart failure. Pertinent interventions included administer oxygen at 2 LPM via nasal cannula continuously. C. Observations On 10/11/21 at 2:20 p.m., the resident received oxygen through a nasal cannula. The oxygen concentrator was set at 3LPM. The tubing was not dated. On 10/12/21 at approximately 2:00 p.m. the resident was observed to be transferred from her wheelchair to the bed. The oxygen cannula fell on the floor, and the unidentified certified nurse aide (CNA) replaced the cannula; however, it was not dated when it was changed. Observations on 10/13/21 revealed: -At 8:58 a.m., the resident was assisted from her room to the shower without her oxygen. -At 9:12 a.m., the resident was assisted back to her room after the shower. -At 9:31 a.m., she continued to not have her oxygen cannula on. -At 10:14 a.m., the occupational therapist (OTR) spoke to the resident about positioning. The oxygen concentrator was set at 2.5 LPM, but the oxygen cannula was not on the resident. The OTR was observed to turn off the concentrator and to tell the resident she was only on it at night. The resident told the OTR she was supposed to be wearing the oxygen continuously. The OTR left to get the vitals machine. She took the resident's pulse oximetry and it was at 84. The OTR placed the oxygen cannula on the resident and told her to deep breathe. D. Interview The unit manager was interviewed on 10/13/21 at 5:15 p.m. The UM said the resident should have the oxygen concentrator set at 2 LPM. She said the resident should have had her shower with the oxygen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A Based on observations, interviews, and record review, the facility failed to have an effective infection control program. Specifically, the facility failed to: -Ensure staff offered hand sanitation prior to resident meals; -Perform appropriate source control for staff and visitors; and, -Ensure housekeeping staff completed proper hand hygiene during cleaning of resident rooms. Findings include: I. Staff not offering hand sanitation prior to serving residents their meals A. Professional reference The Centers for Disease Control (CDC) Hand Hygiene updated 5/17/2020, retrieved on 10/19/21 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html, revealed in part, Hand hygiene is an important part of the U.S. response to the international emergence of COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in healthcare settings. CDC recommendations reflect this important role. The exact contribution of hand hygiene to the reduction of direct and indirect spread of coronaviruses between people is currently unknown. However, hand washing mechanically removes pathogens, and laboratory data demonstrate that ABHR formulations in the range of alcohol concentrations recommended by CDC, inactivate SARS-CoV-2. ABHR effectively reduces the number of pathogens that may be present on the hands of healthcare providers after brief interactions with patients or the care environment. The CDC recommends using ABHR with greater than 60% ethanol or 70% isopropanol in healthcare settings. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and are effective in the absence of a sink. B. Facility policy The Hand Hygiene policy, revised on 12/4/2020, provided by the director of nursing (DON) on 10/14/21 at 3:45 p.m. It read, in pertinent part: Handwashing/hand hygiene is generally considered the most important single procedure for preventing nosocomial infections. The purpose is to decrease the risk of transmission of infection by appropriate hand hygiene. The facility should place wall mounted dispensers within the workflow, inside and outside of resident rooms to help them do hand hygiene at the right times. Individual pocket sized dispensers may be an alternative to wall mounted dispensers. Staff should perform proper hand hygiene with alcohol based hand rubs (ABHR) and with soap and water: -before and after all resident contact; -before applying gloves; -after removal of gloves; -after contact with potentially infectious material; -prior to eating or drinking. C. Observations On 10/11/21 at 11:24 a.m., the residents in the 100 hall dining room approximately 10 residents were not provided towelettes on their meal trays and the staff did not offer or encourage hand sanitizer or hand washing. On 10/11/21 at 11:24 a.m the staff in the 100 hall dining room did not use hand sanitizer before entering and exiting the dining room. Approximately four staff did not use hand sanitizer before or after serving the residents in the dining room. The dining room had two wall sanitizer dispensers, one by each door. On 10/11/21 at 12:24 p.m. the resident rooms did not have wall sanitizer dispensers in them and there were limited wall sanitizer dispensers available for residents' use in the hallway. There were two wall hand sanitizer dispensers available to the residents in the 100 hall. There were 12 resident rooms with two dispensers for the entire hall. There was one wall sanitizer dispenser behind the nurses station for staff. On 10/11/21 at 2:04 p.m., a volunteer was observed passing out ice cream and popcorn to the residents' rooms. He was observed entering three separate resident rooms without sanitizing his hands and did not encourage resident hand hygiene. On 10/12/21 at 2:29 p.m. housekeeper #2 was observed cleaning resident room [ROOM NUMBER]. She was observed changing out her gloves between tasks but did not use hand sanitizer before or after she changed her gloves. She did not have hand sanitizer on her cleaning cart. On 10/13/21 at 11:05 a.m., the residents in the main dining room were not provided or offered hand hygiene. The towelettes were provided, but approximately six residents who were dependent on staff out of 13 total residents in the dining room were not offered assistance to open the towelettes before their meal. On 10/13/21 at 11:32 a.m. Resident #23 was observed sitting in his wheelchair at the facility's water cooler dispenser. He was observed touching multiple plastic cups before using one cup to get a drink of water. Resident #23 put the unused cups back in the basket holding the clean cups for other residents and staff to use. Resident #23 did not use hand sanitizer prior to touching the cups or touching the water cooler spout. There was no hand sanitizer available to use at the water cooler. II. Staff and visitor source control A. Professional reference According to the CDC last updated 9/10/21, Interim infection prevention control recommendations for healthcare personnel during COVID-19 retrieved on 10/21/21, read in pertinent part, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Finfection-control-after-vaccination.html Implement Source Control Measures Source control refers to the use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. Indoor visitation (in single-person rooms; in multi-person rooms, when roommates are not present; or in designated visitation areas when others are not present): The safest practice is for patients and visitors to wear source control and physically distance, particularly if either of them are at risk for severe disease or are unvaccinated. If the patient and all their visitor(s) are fully vaccinated, they can choose not to wear source control and to have physical contact. Visitors should wear source control when around other residents or HCP (healthcare personnel), regardless of vaccination status. Unvaccinated HCP, patients and visitors should be offered resources and counseled about the importance of receiving the COVID-19 vaccine. B. Observations On 10/11/21 at 9:40 a.m. licensed practical nurse (LPN) #4 was observed with her mask down under her chin talking to another staff member. She said she was drinking her coffee and put her mask over her nose and mouth. On 10/11/21 at 9:53 a.m. LPN #4 was observed with her mask down under her chin walking and talking with another staff member down the hall. She immediately placed her mask over her nose and mouth once observed. On 10/12/21 at 9:30 a.m., a registered dietitian (RD) was observed sitting in her office with her mask down under her chin. She was meeting with two family members in her office who were wearing a mask. On 10/12/21 at 11:35 a.m. the RD was observed sitting in her office with her mask down under her chin. She was meeting with two family members in her office who were wearing a mask. On 10/13/21 at 11:07 a.m. the social services director (SSD) was observed sitting behind the nurses station talking on the phone with her mask down under her chin. She was observed talking with a male resident standing next to the nurses station with her mask down under her chin. On 10/13/21 at 11:58 a.m. Resident #14 had her son visit. He wore a mask down the hall and into the dining room. He removed his mask at the dining room table and ate lunch with Resident #14 during the regular lunch time. The dining room was full with other residents and there was one other resident sitting at the same table with Resident #14 and her son. All of the residents in the dining room were eating and not wearing a mask. The residents were sitting one or two to a table and were not all six feet apart. C. Staff interviews Registered nurse (RN) #2 was interviewed on 10/12/21 at 2:45 p.m. She said she carried a pocket hand sanitizer with her so it is readily available. She said there are not very many wall sanitizer dispensers on the unit. She said it would be helpful to have a wall sanitizer dispenser outside of each room instead of carrying a pocket sanitizer. Dietary aide (DA) #1 was interviewed on 10/13/21 at 8:50 a.m. He said he carried a pocket sanitizer in his pocket to use before he entered resident rooms. He said there are not very many wall sanitizer dispensers on the hall and it would be easier to have a sanitizer dispenser on the wall outside of each room instead of carrying his own or walking down the hall to find a wall sanitizer dispenser. He said he forgot to bring his today and walked down the hall to use the wall sanitizer dispenser. The director of nursing (DON) was interviewed on 10/14/21 at 3:21 p.m. She said all of the staff have received infection control and hand hygiene training. The training covered staff hand hygiene and offering hand hygiene to residents. The staff development coordinator (SDC), who was also the infection preventionist (IP), was interviewed on 10/14/21 at 1:14 p.m. She said there were seven residents who were not fully vaccinated and 8% of the staff were not vaccinated. She said they were conducting weekly testing for the unvaccinated staff and residents. She said they offered a COVID-19 booster clinic in October 2021 and will continue to offer the clinics when available. She said all visitors were screened at the front desk and should be wearing a mask during the visit. She said visitors who were allowed to visit in the building were vaccinated and the visitors who were not vaccinated visit in the front of the building and were supervised by the front desk staff. She said Resident #14's son was fully vaccinated and should not be allowed to eat in the dining room with other residents. She said he should have his mask on at all times. She said the staff should be wearing their masks at all times in resident care areas and if they were not alone in their office. She said all staff were provided hand hygiene training at time of hire and during surveillance and periodically. She said the training includes hand hygiene for staff before and after resident care, before and after glove placement and removal, and for staff to encourage the residents to wash their hands before meals. She said staff were provided a pocket hand sanitizer to carry with them at all times. She said they were trained to keep the pocket sanitizer in a designated pocket so they were not contaminating the bottle and alternating pockets. She said the staff should be encouraging and offering hand hygiene to the residents before meals and should assist them to use the towelettes on the meal tray. She said she would consider adding more wall sanitizer dispensers on the halls but had a concern with dementia care residents having access to the sanitizer. She said she would talk to her corporate support to come up with a plan. III. Facility COVID-19 status The director of nurses (DON) was interviewed on 10/14/21 at 3:21 p.m. She said they had no COVID-19 positive residents and no COVID-19 positive staff. She said there were no presumptive positive COVID-19 residents or staff.