**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for medication administration, the facility failed to ensure the provider was notified for each missed administration of insulin. The findings include:Resident #1's diagnoses included type 2 diabetes mellitus, end stage renal disease and morbid obesity. Review of the hospital Discharge summary dated [DATE] directed to administer Humulin R U-500 injectable pen 40 units daily before dinner. A physician's order dated 7/21/25 directed to administer Humulin R U-500 units per milliliter (concentrated) inject 40 units subcutaneously in the evening. The admission Nursing assessment dated [DATE] identified Resident #1 was alert and oriented to person, place, time and situation. The Resident Care Plan dated 7/23/25 identified Resident #1 has a diagnosis of diabetes and was at risk for hyperglycemia (elevated blood sugar) and/or hypoglycemia (low blood sugar). Interventions included administering medications as ordered. A physician's order dated 7/22/25 directed to discontinue the Humulin R U-500 units per milliliter (concentrated) inject 40 units subcutaneously in the evening and to administer Humulin-R insulin 100 units per milliliter (u/mL), inject 40 units subcutaneously every evening for type 2 diabetes mellitus. Review of the July 2025 Medication Administration Record (MAR) identified the Humulin-R insulin was not administered on 7/22/25, 7/24/25, 7/25/25 and 7/26/25 and referenced to see the progress notes. Upon further review of the MAR the Humulin-R insulin was noted to be signed off as administered on 7/23/25. The Electronic Medication Administration Record note dated 7/22/25 identified the Humulin-R insulin was on order. There was no documentation identifying the nursing supervisor, provider or pharmacy were notified of the missed administration of the Humulin-R insulin on 7/22/25. The nurse's note dated 7/24/25 at 8:21 PM identified the 7AM-7PM nursing supervisor, Registered Nurse (RN) #6, was called to the unit to help the charge nurse, RN #9, locate Resident #1's Humulin-R insulin. The note indicated after searching and unable to locate the insulin, the Advanced Practice Registered Nurse (APRN) was updated and the APRN directed to hold the 7/24/25 dose, follow-up with the pharmacy and obtain blood sugars three (3) times daily prior to meals and notify a provider if the blood sugar was greater than 400. The note indicated Resident #1's blood sugar at 6:44 PM was 273. The Electronic Medication Administration Record note dated 7/25/25 identified the Humulin-R insulin was not available. The note failed to reflect documentation the nursing supervisor, provider or pharmacy were notified of the missed administration of the Humulin-R insulin on 7/25/25. The Electronic Medication Administration Record note dated 7/26/25 identified the Humulin-R insulin was not available. The note failed to reflect documentation the nursing supervisor, provider or pharmacy were notified of the missed administration of the Humulin-R insulin on 7/26/25. Interview with APRN #1 on 8/25/25 at 11:35 AM identified he was unaware Resident #1 had not received the Humulin-R insulin multiple times until after Resident #1 had already been discharged . APRN #1 explained although Resident #1's blood sugars were stable, a provider should have been notified for each missed administration for a possible alternative order. APRN #1 stated the pharmacy should have been contacted to inquire about the medication's whereabouts. Review of the blood sugar documentation for Resident #1 identified a range from 165 to 273. Interview with the pharmacy technician on 8/25/25 at 1:10 PM identified the Humulin-R insulin 100 u/mL was not filled. Interviews with the charge nurses, Licensed Practical Nurse (LPN) #1 and LPN #2, on 8/25/25 identified they did not notify the nursing supervisor, the provider or call the pharmacy when the doses of Humulin-R insulin 100 u/mL were not administered to Resident #1 on 7/22/25, 7/25/25 or 7/26/25. They identified they were not aware they had to notify the nursing supervisor for each missed administration so that the nursing supervisor could contact the provider for possible alternative orders and they identified Humulin-R insulin was not available in the facility's emergency stock medication. Interview with LPN #3 on 8/25/25 at 3:30 PM identified she signed off the Humulin-R insulin was administered to Resident #1 on 7/23/25 when it had not yet arrived from the pharmacy. LPN #3 identified if the medication was unavailable for administration, she should have called the pharmacy to check on the status and then notified the supervisor of the missed administration and documented the conversations in the clinical record. Interviews with Registered Nurse (RN) #6, RN #7, and RN #8 on 8/25/25 identified they could not recall being notified by LPN #1, LPN #2 or LPN #3 on 7/22/25, 7/23/25, 7/25/25 or 7/26/25 that Resident #1's Humulin-R insulin was not available, explaining if they had, they would have notified the provider, wrote a note to identify the notification and any new orders that were obtained. RN #6 reported although she wrote the note on 7/24/25 identifying she was going to follow-up with the pharmacy regarding the Humulin R insulin, she did not call the pharmacy directly to speak with someone to inquire about the delay but instead faxed a request for the insulin. Interview with the Director of Nursing (DON) on 8/25/25 at 1:48 PM identified insulin was not part of the stock in the facility's emergency supply and staff should have inquired with the pharmacy and then notified the nursing supervisor of each missed administration of the Humulin R insulin so the nursing supervisor could have notified the provider for possible alternative orders. Review of the Diabetes Management policy (undated) directed, in part, that nursing staff is to administer diabetes medications, including insulin, according to physician's orders and care plans. Observe for and report any adverse reactions or side effects promptly. Keep detailed records of assessments, care plans, blood glucose readings, medication administration and any incidents. Report any significant changes in the residents' condition to the healthcare provider immediately. Although requested, facility policies for Provider Notification and MedicationAdministration were not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Residents #1) who was a new admission and reviewed for medication orders, the facility failed to collaborate with the pharmacy to ensure a medication was clarified and delivered to the facility to prevent the resident from missing four (4) days of insulin. The findings include:Resident #1's diagnoses included type 2 diabetes mellitus, end stage renal disease and morbid obesity. Review of the hospital Discharge summary dated [DATE] directed to administer Humulin R U-500 injectable pen 40 units daily before dinner. A physician's order dated 7/21/25 directed to administer Humulin R U-500 units per milliliter (concentrated) inject 40 units subcutaneously in the evening. The admission Nursing assessment dated [DATE] identified Resident #1 was alert and oriented to person, place, time and situation. The Resident Care Plan dated 7/23/25 identified Resident #1 has a diagnosis of diabetes and was at risk for hyperglycemia (elevated blood sugar) and/or hypoglycemia (low blood sugar). Interventions included administering medications as ordered. A physician's order dated 7/22/25 directed to discontinue Humulin R U-500 units per milliliter (concentrated) inject 40 units subcutaneously in the evening and administer Humulin-R solution 100 units per milliliter (u/mL), inject 40 units subcutaneously every evening for type 2 diabetes mellitus. Review of the July 2025 Medication Administration Record (MAR) identified the Humulin-R insulin was not administered on 7/22/25, 7/24/25, 7/25/25 and 7/26/25 and referenced to see the progress notes. Upon further review of the MAR the Humulin-R insulin was noted to be signed off as administered on 7/23/25. The Electronic Medication Administration Record note dated 7/22/25 identified the Humulin-R insulin was on order. There was no documentation identifying the nursing supervisor, the provider or pharmacy were notified of the missed administration of Humulin-R insulin on 7/22/25. The nurse's note dated 7/24/25 at 8:21 PM identified the 7AM-7PM nursing supervisor, Registered Nurse (RN) #6 was called to the unit to help the charge nurse, RN #9, locate Resident #1's Humulin-R insulin. The note indicated after searching and unable to locate the insulin, the Advanced Practice Registered Nurse (APRN) was updated and the APRN directed to hold the 7/24/25 dose, follow-up with the pharmacy and obtain blood sugars three (3) times daily prior to meals and notify a provider if the blood sugar is greater than 400. The note indicated Resident #1's blood sugar at 6:44 PM was 273. Review of the Electronic Medication Administration Record notes dated 7/25/25 and 7/26/25 identified the Humulin-R insulin was not available. The notes failed to reflect documentation the nursing supervisor, provider, or pharmacy were notified of the missed administration of Humulin-R insulin. Interview with the pharmacy technician on 8/25/25 at 1:10 PM identified the Humulin-R insulin 100 u/mL was not filled. Interview with the pharmacist on 8/25/25 at 1:37 PM identified the original order entered on admission 7/21/25 for Resident #1 was for Humulin R U-500 (a highly concentrated insulin, five times stronger than standard U-100 insulin which requires careful administration to avoid dangerous dosing errors) and the order was unusual and needed to be clarified with the provider prior to being filled. The pharmacist explained they are an in-house pharmacy at the facility and after hours there is a back-up pharmacy. The pharmacist stated on 7/21/25 he had asked the back up pharmacy to look into clarifying the Humulin R U-500 order, he did not hear anything about it again and was unaware a new order had been entered for Humulin-R insulin 100 u/ml. The pharmacist identified he was not sure how he missed the new order, stating it the 7/22/25 order that was not filled. Interview with the Director of Nursing (DON) on 8/25/25 at 1:48 PM identified the facility depends on the pharmacy to provide delivery of medications and the nursing staff should have followed up with the pharmacy each time it was identified the insulin was not available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review and interview for one of three residents (Resident #1) reviewed for pressure ulcers, the facility failed to complete weekly wound assessments in accordance with facility policy. The findings include: Resident #1 was admitted to the facility with diagnoses that included scoliosis and difficulty in walking. An admission MDS dated [DATE] identified Resident #1 had severely impaired cognition, was dependent for ADLs, was always incontinent, was at risk for pressure ulcer/injury, and had a Stage 2 pressure ulcer. The Resident Care Plan (RCP) dated 6/10/2024 identified Resident #1 had a potential for alteration in skin integrity and had a pressure injury on the coccyx. Interventions directed to inspect skin for breakdown, pressure reducing cushion and mattress, and monitor for signs of infection. The nursing note dated 5/31/2024 at 3:49 PM identified a Stage 2 wound was noted on Resident #1's coccyx, measuring 2.5 centimeters (cm) by 1 cm by 0.1 cm. A physician's order dated 6/1/2024 directed stage 2 coccyx, cleanse with normal saline followed by dry protective dressing daily. A skin observation tool dated 6/22/2024 identified coccyx/inner buttocks with the coccyx intact but red and almost macerated skin under dressing. A review of the weekly Wound nurse pressure ulcer logs from 5/28/2024 to July 9, 2024, identified the log dated 6/13 and 6/20/2024 documented weekly dimensions of Resident #1's coccyx wound. A review of the medical record lacked weekly wound tracking to include weekly measurements of the coccyx wound identified on 5/31/2024. a. The nursing note dated 6/3/2024 at 1:01 PM identified a new wound (right calf); a reddened area that felt slightly filled with fluid. Will apply skin prep twice daily and have resident seen by wound MD on wound rounds this week. A review of the medical record lacked weekly wound tracking to include weekly measurements of the calf wound identified on 6/3/2024. A review of the weekly Wound nurse pressure ulcer log from 5/28 to 6/13/2024 failed to identify any documentation calf blister area noted on 6/3/2024 except for a log entry dated 6/20/2024 that identified the right lower leg blister was resolved. Interview, medical record and facility documentation review with RN #1/wound nurse on 8/30/2024 at 11:34 AM identified when a new skin issue is identified, staff notify her via fax, and she would evaluate the area and document in the clinical record. RN #1 stated although residents were seen weekly by the wound physician, his/her notes were documented as a consultation. RN #1 indicated the wound logs are not part of the medical record, and she could not recall if Resident #1 was admitted with the Stage 2 coccyx wound identified on 5/31/2024, or the right calf blister identified on 6/3/2024. She could not locate any faxes to her office related to either wound. She continued she did not recall evaluating the coccyx wound and although Resident #1 had contractures, the calf wound may or may not have been pressure related, as she could not recall evaluating the wound. RN #1 indicated nursing staff were responsible for documenting weekly wound tracking in the clinical record to include measurements, drainage, and odor and stated she may have forgotten do document for Resident #1. Interview with the ADNS on 8/30/2024 at 1:00 PM identified that the wound nurse was primarily responsible to document the weekly wound assessments in the medical records for any resident with skin issues, or the charge nurse could document the assessments. The ADNS stated he/she did not know why the documentation was not completed and indicated it should have been done. The DON was unavailable for interview during the survey. The facility Treatment policy directed in part, pressure sores will be evaluated weekly, and the nurse will include size, location odor (if any), drainage (if any) and current treatment ordered. The facility policy Wound Care policy, directed in part, all assessment data should be documented in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents reviewed for medication administration, (Resident #2), the facility failed to ensure the resident was administered the correct dose of medication which resulted in a medication error. The findings include: Resident #2 had diagnoses that included dementia, heart failure, and hypothyroidism. A physician's order dated 10/27/2022 directed to administer Levothyroxine (Synthroid) 50 micrograms (MCG) ( a medication used to treat thyroid disorders) orally one (1) time a day. The quarterly MDS dated [DATE] identified Resident #2 had moderately impaired cognition and required moderate assistance with activities of daily living. The care plan dated 6/6/2024 identified Resident #2 has a diagnosis of hypothyroid and is receiving Synthroid (Levothyroxine) with interventions that directed to administer thyroid replacement therapy as ordered by the MD/APRN and monitor and document effectiveness. Review of the Physician Assistant's (PA) note dated 6/11/2024 at 9:51 A.M. identified Resident #2 has continued on Synthroid 50 MCG orally daily for hypothyroidism however, was found to have under suppressed thyroid with a TSH (thyroid stimulating hormone) level of 7.96 (reference range 0.34-5.60). PA #1 identified he was increasing Resident #2's Synthroid (Levothyroxine) increased to 75 MCG orally once per day and a repeat thyroid panel to be done in 4 weeks adjust therapy as needed. A physician's order dated 6/11/2024 directed to administer Synthroid (Levothyroxine) 75 micrograms (MCG) orally one time a day. Review of Resident #2's MAR from June 12, 2024, to July 11, 2024 identified Resident #2 was administered Synthroid 75 MCG orally once per day and Levothyroxine 50 MCG orally once per day for a total dose of 125 MCG orally once per day. Interview with PA #1 on 7/24/2024 at 11:55 A.M. identified on 6/11/2024 he directed that Resident #2 was to be administered Synthroid (Levothyroxine) 75 MCG orally once per day. PA #1 identified Resident #2 should not have been administered Levothyroxine 50 MCG and Synthroid 75 MCG orally once per day from 6/11/2024 to 7/11/2024. PA #1 identified Resident #2 should have been administered Synthroid 75 MCG orally once per day. Interview with the DNS and ADNS on 7/24/2024 at 12:05 P.M. the DNS identified although PA #1 entered Resident #2's orders into the electronic health record, she would have expected that the unit manager or charge nurse do have conducted a chart audit to ensure the orders were correct for Resident #2 on 6/11/2024, and call the PA for clarification on the 2 current orders for Synthroid. The DNS identified Resident #2 was administered Synthroid (Levothyroxine) 150 MCG from 6/12/2024 until 7/11/2024 in error and should have been administered Synthroid 75 MCG once per day. The ADNS indicated on 7/11/2024 after she confirmed with PA #1 that Resident #2's order that directed to administer Levothyroxine 50 MCG could be discontinued she discontinued the order. Review of facility physician's orders transcription policy identified all physician's orders must be dully noted and accurately transcribed by licensed nursing staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #2) reviewed for laboratory services, the facility failed to ensure the physician's ordered blood work was obtained. The findings include: Resident #2 had diagnoses that included dementia, heart failure, and hypothyroidism. The quarterly MDS dated [DATE] identified Resident #2 had an active diagnosis of hypothyroidism. The care plan dated 6/6/2024 identified Resident #2 has a diagnosis of hypothyroid and is receiving Synthroid (Levothyroxine) as ordered by the physician/APRN. Interventions directed to administer thyroid replacement therapy as ordered by the MD/APRN, monitor and document effectiveness, and obtain lab/diagnostic work as ordered report results to MD/APRN. Review of the Physician Assistant's (PA) note dated 6/11/2024 at 9:51 A.M. he identified Resident #2 has continued on Synthroid 50 MCG orally daily for hypothyroidism however found to have under suppressed thyroid with a TSH (thyroid stimulating hormone) level of 7.96 (reference range 0.34-5.60). PA #1 identified he was increasing Resident #2's Synthroid (Levothyroxine) increased to 75 MCG orally once per day and a repeat thyroid panel to be done in 4 weeks and to adjust therapy as needed. A physician's order dated 6/11/2024 directed to have blood work drawn on 7/8/2024 to assess Resident #2's thyroid stimulating hormone with reflex level, however, the physician's order was discontinued on 7/9/2024. Interview with PA #1 on 7/24/2024 at 11:55 A.M. he identified he would have expected Resident #2's laboratory blood work to have been obtained on 7/8/2024 to assess Resident #2's thyroid function as ordered. Interview and clinical record review with the DNS on 7/24/2024 at 12:05 P.M. she was unable to provide documentation to reflect that Resident #2 had blood work obtained on 7/8/2024. The DNS identified Resident #2 did not have the physician ordered blood work drawn on 7/8/2024. The DNS could not explain why. Subsequent to surveyor inquiry the DNS identified Resident #2 had the bloodwork scheduled to be drawn on 7/25/2024 to assess h/her thyroid function. Review of the facility lab and diagnostic test results policy identified the physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. The staff will process the test requisition and arrange the tests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review and interviews for one of two residents (Resident #2) reviewed for accidents, the facility failed to ensure staff utilized leg rests when moving a wheelchair dependent resident to prevent an injury. The finding included: Resident #1 was admitted to the facility with diagnoses that included dementia (Alzheimer's disease), spinal stenosis, and history of falling. An annual MDS assessment dated [DATE] identified Resident #2 had severe cognitive impairment and required extensive assistance for transfers, bed mobility, personal hygiene, and mobility. A Resident Care Plan (RCP) dated 5/20/2021 identified Resident #1 was at risk for falls due to a decline in mobility with impaired gait and balance problems. The RCP directed to transfer out of bed into wheelchair. A facility reportable event report dated 8/2/2021 at 3:00 PM identified Resident #2 was being transported by recreation staff in his/her wheelchair when Resident #2 put his/her feet down and fell forward out of the wheelchair onto the floor. Resident #2 complained of pain to the nose with slight bridge edema noted. Nasal bone x-ray identified a fracture of the nasal ridge. The report further identified leg rests were not on the wheelchair when the staff was moving the resident. A nursing note dated 8/2/2021 at 3:21 PM identified Resident #2 was observed laying on floor in the hallway on his/her back after recreation staff wheeled Resident #2 without leg rests on the wheelchair. Resident #2 dropped her/his feet on the ground, went forward and fell forward. Assessment identified a moderate amount of swelling to both sides of the nose and nasal bridge, without pain and redness. No other injuries were noted, neurological assessments were completed and staff were educated to keep wheelchair pedals on all times when residents are being wheeled by staff. A physician order dated 8/2/2021 directed facial and nasal x-ray and ice pack to nose every four (4) hours for 20 minutes as needed for swelling and comfort. A consulting imaging report dated 8/2/2021 identified that multiple views of the nasal bone demonstrated fracture of the nasal ridge with associated soft tissue swelling and without depression. Record review identified Resident #2 remained in the facility, with no change in his/her treatment plan. Interview, record review and facility documentation review with the DON on 6/5/2024 at 2:33 PM identified prior to the fall, Resident #2 was self-mobile in the wheelchair and would not have required staff assistance to be transported to or from an activity. The DON stated if a resident was independent in their wheelchair, there would not be any leg rests on the chair unless the resident required staff to transport them. The DNS indicated Recreational Aid (RA #1) had transported Resident #2 to a morning recreation program in the dining room without any leg rests attached to the wheelchair when she pushed the wheelchair. The DON stated she did not know why RA #1 was transporting Resident #2 to the activity and stated leg rests should have been on the wheelchair when RA #1 was pushing the wheelchair. Although attempted, an interview with RA #1 was not obtained during the survey. Interview and record review with RN #1 on 6/6/2023 at 9:30 AM identified TR #1 was provided re-education that if transporting a resident, leg and foot rests were required. The facility Wheelchair Policy, directed in part, that an appropriate wheelchair will be provided for non-ambulatory residents and resident's feet on a footrest for comfort.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policies and interviews for one of five sampled residents (Resident #2) who were dependent on staff with getting in and out of the bed and chair, the facility failed to utilize safety measures, a gait belt and rolling walker during a two (2) person stand-pivot transfer into the wheelchair to prevent a healing skin tear from reopening. The findings include: Resident #2's diagnoses included generalized muscle weakness, abnormal gait and mobility, history of stroke, anxiety, and long-term use of anticoagulants. The physical therapy evaluation dated 4/2/24 identified Resident #2 was receiving physical therapy services five (5) times a week for thirty (30) days. The evaluation indicated Resident #2 required maximum assistance of two (2) with sit to stand and bed to chair transfers. The admission Minimum Data Set assessment dated [DATE] identified Resident #2 made reasonable and consistent decisions regarding tasks of daily living, required maximum assistance to transfer from one (1) surface to another, and was at risk for skin injury. The Resident Care Plan dated 4/8/24 identified Resident #2 had a self-care deficit and was at risk for falls, abnormal bleeding, and skin breakdown. Interventions directed to maintain the call bell in reach, assistance of two (2) for transfers using a gait belt and rolling walker, assistance of one (1) for bed mobility, toileting assistance of two (2) from the wheelchair to the toilet, physical therapy services as indicated, skin inspections during care, and to remind the resident to use caution and to be aware of the position of his/her extremities when transferring and ambulating. The resident care card directed assistance of two (2) for transfers using a gait belt and rolling walker. The nurse's note dated 4/14/24 at 12:12 PM identified the 7AM-3PM Nursing Supervisor, Registered Nurse (RN) #1, was notified Resident #2 had sustained a laceration over a prior healed skin tear below the right knee. The note indicated Resident #2 reported the laceration occurred when the 7AM-3PM nurse aides were transferring him/her from the bed to the wheelchair and the leg hit the wheelchair. The note identified the laceration measured 3.8-centimeter (cm) x 1.8 cm x 1.0 cm and frank blood was present, the wound was cleansed with normal saline, a pressure dressing was applied, the Advanced Practice Registered Nurse (APRN) was notified and directed Resident #2 be sent to the Emergency Department (ED) for evaluation and treatment. The hospital discharge paperwork dated 4/14/24 identified Resident #2's laceration was repaired with sutures, Resident #2 was discharged back to the facility with directions for suture removal in seven (7) days and had also received a tetanus shot. Interview and review of the written statement with the 7AM-3PM nurse aide, Nurse Aide (NA) #1, on 4/22/24 at 1:10 PM identified she was transferring Resident #2 with the assistance of a student nurse aide when Resident #2 sustained a laceration to the right leg. NA #1 stated Resident #2 was being transferred from the bed to the wheelchair and during the transfer she noticed Resident #2 was only moving the upper portion of his/her body and the legs never moved. NA #1 indicated she thought Resident #2's leg was stuck to the bottom post of the wheelchair that was attached to the wheel and the footrests were not on the wheelchair. NA #1 identified the wheelchair was positioned against the side of the bed, Resident #2 was not wearing a gait belt during the transfer, and she was not sure if the facility required gait belts to be used during transfers and the rolling walker was not utilized. NA #1 identified she did not see active bleeding from Resident #2's leg and when Resident #2 identified his/her leg hurt she informed the nurse on the floor. NA #1 identified she saw the existing dressing that was on the leg was smudged and moved. Interview with the 7AM-3PM Nursing Supervisor, Registered Nurse (RN) #1, on 4/22/24 at 1:20 PM identified she was called to Resident #2's room due to the resident complaining of right leg pain after the transfer by NA #1. RN #1 stated Resident #2 informed her he/she hit his/her leg on the leg rest holders and reopened a prior healed skin tear where steri strips were still present on the leg. Review of the facility's policy on gait belt use identified gait belts were to be utilized for all residents that required assistance with transfers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #118) reviewed for discharge planning, the facility failed to ensure a second interdisplinary discharge care plan meeting, requested by the resident due to questions and concerns, took place. The findings include: Resident #118 was admitted to the facility with diagnoses that included fracture of the shaft of the humorous and Parkinson's disease. A physician's order dated 10/29/22 directed to use a mechanical lift (Sara lift) with assist of 2. The annual MDS dated [DATE] identified Resident #118 had intact cognition and required extensive assistance for bed mobility, transfers, dressing and personal hygiene. The care plan dated 12/1/22 identified Resident #118 had a self-care deficit due to decreased strength, balance, activity tolerance and endurance, inability to use the left upper extremity due to a fracture obesity, pain and Parkinson's. Interventions included to provide assistance with care, allow adequate time to perform activity, call bell on the right side, and provide privacy. The discharge planning note, written by SW #1, dated 11/14/22 at 9:46 AM identified that a discharge planning meeting was held today. Resident #118, family member, therapy, homecare representative, and SW #1 were in attendance. Discharge was anticipated for 11/30/22. Resident #118 was setting up 24-hour care giver and was having a ramp installed. Mechanical lift and hospital bed were ordered. Resident #118 was looking forward to discharge and family member was very supportive to the discharge. Interview with Resident #118 on 11/30/22 at 9:59 AM indicated he/she had requested another discharge meeting, after the 11/14/22 meeting, because he/she still had concerns about the home care service being set up, the home health aide, how he/she would be transferred at the home (platform walker or the mechanical lift), and financials. Resident #118 noted the social worker or LPN #5 had set up another meeting at the resident's request which was scheduled to be held on 11/29/22 at 11:30 AM with all the staff he/she needed to finalize all the discharge plans for discharge on [DATE]. Resident #118 indicated that on the morning of 11/29/22, the day of the discharge meeting, he/she was upset because staff did not get the resident cleaned, washed, dressed, or put in the wheelchair for meeting at 11:30 AM. Resident #118 indicated the therapist, OTR #1, had checked in that morning, many times, to see if the resident was up and ready for the meeting, but the resident was still in bed after lunch. Resident #118 indicated he/she was upset that the SW #1 and LPN #5, and MDS coordinator never came to see him/her and never informed him/her that the meeting was cancelled or when it would be rescheduled. Resident #118 indicated it was very stressful worrying about everything to get ready for going home and no one was helping. Resident #118 indicated because the nurse aides did not get him/her up in time that morning, the meeting never happened as planned. The discharge planning note written by SW #1 dated 12/1/22 indicated Resident #118 was discharged home today with skilled homecare and a 24-hour care giver. Resident #118 had a mechanical (hoyer) lift and a hospital bed delivered today. The Discharge summary dated [DATE] identified that Resident #118 was discharged home with homecare services. A transfer/discharge report packet included the resident's diagnosis, code status, and a list of medications, (did not include last administration times). The packed also included a discharge notice, and a form for the home care agency indicated resident required a hoyer lift, and hospital bed. Interview with OTR #1 on 12/6/22 at 1:04 PM indicated the discharge meeting that was planned for Tuesday 11/29/22 at 11:30 AM to be held in the social worker office did not occur because the nurse aides never got Resident #118 out of bed and Resident #118 did not want to have the meeting in his/her room because there was a roommate. Resident #118 was scheduled to be discharged on 11/30/22, however, the discharge was postponed to 12/1/22 and OTR #1 indicated he did not know why the discharge was postponed. OTR #1 indicated on 11/29/22 he had checked on Resident #118 multiple times (4 - 5 times) to see if he/she was ready for the meeting, but just after lunch Resident #118 was still in bed. OTR #1 noted he was waiting for SW #1 to text him once Resident #118 was out of bed for the meeting, but he never got a text. OTR #1 indicated he was told verbally the meeting was cancelled at the end of the day between 3:30 PM - 4:00 PM. OTR #1 indicated he was informed the discharge meeting would be changed to Thursday 11/30/22. OTR #1 indicated he had worked with Resident #118 in the gym that afternoon, on 11/29/22, but did not inform Resident #118 the meeting would be changed to 11/30/22 because he was not aware of the change at that time. OTR #1 indicated he meet on 11/29/22 with Resident #118 and the homecare caregiver for training. Interview with SW # 1 on 12/6/22 at 2:27 PM indicated on 11/14/22 Resident #118 had a discharge planning meeting, but Resident #118 had requested another meeting because he/she had more questions about transfers, financials, and homecare, so another meeting was scheduled for 11/29/22 at 11:30 AM. SW #1 indicted they did not have that meeting on 11/29/22 because the nurse aides did not get Resident #118 out of bed. SW #1 indicated Resident #118 did not want the meeting in the room with the roommate and the roommates' visitors. SW #1 indicated she had not spoken with Resident #118 about the meeting being cancelled on 11/29/22 or when the meeting would be rescheduled, because she thought LPN #5 was responsible to update the resident. SW #1 indicated the next day, each person from different services had met with the resident individually for financial, therapies, and the nurse's aide live in training. SW #1 indicated it was difficult to get everyone together for a meeting so she did the best she could do. SW #1 indicated it was very difficult because the homecare agency normally comes on Wednesdays, and they needed the 24-hour care giver to come for training with the therapy department. SW #1 indicated Resident #118 used a Sara lift at the facility, but the insurance would not cover the Sara lift but would pay for a hoyer. SW #1 indicated she ordered the hoyer but Resident #118 was confused because he/she did not understand about the hoyer versus the Sara lift and how the insurance worked. Interview with LPN #5 on 12/6/22 at 2:35 PM indicated she was informed by the Administrator that Resident #118 had called her on Wednesday 11/23/22 and requested another discharge meeting. LPN #5 indicated the Administrator informed her Resident #118 wanted another discharge planning meeting to discuss the transfer status and ordering the mechanical lift. LPN #5 indicated she had spoken to Resident #118 and scheduled another discharge meeting for 11/29/22 at 11:30 AM at the resident's request. LPN #5 indicated she had informed SW #1, the financial person, and therapy about the meeting scheduled for 11/29/22. LPN #5 indicated she and SW #1 had originally gone to the unit on 11/29/22 at 11:30 AM but Resident #118 was calling the nurses station and was upset no one had given him/her a shower and he/she was worrying about the meeting for 11:30 AM. LPN #5 indicated Resident #118 was not up for the meeting as of 12:30 PM while LPN #5 was still on the unit. LPN #5 indicated Resident #118 would not have the discharge meeting in his/her room because the roommate was present and wanted the meeting in a lounge or the social worker office. LPN #5 indicated it was not her meeting so she thought SW #1 would take responsibility over the meeting. LPN #5 noted it was about discharge and therapy, so it was the social workers responsibility to run the meeting. LPN #5 indicated she did not go back to Resident #118 to inform the resident the meeting had been cancelled on 11/29/22 or that it was rescheduled. LPN #5 indicated the meeting never took place however, everyone met individually with Resident #118. LPN #5 indicated she thought the resident would call her when the nurse aide got him/her out of bed. Although requested, a facility policy on discharge planning meetings and process it was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #14 and 50) who required assistance with care, the facility failed to ensure the call bell was within reach. The findings include: 1. Resident #14 was admitted to the facility with diagnoses that included overactive bladder, repeated falls, and diabetes. The quarterly MDS dated [DATE] identified Resident #14 had mildly impaired cognition, was occasionally incontinent of bladder and frequently incontinent of bowel and required limited assistance with transfers and locomotion in the wheelchair and required extensive assistance for toileting and personal hygiene. The care plan 10/27/22 identified Resident #14 was hard of hearing in the right ear. Interventions included to provide a safe environment with the call bell in reach. Interview with Resident #14 on 11/29/22 at 11:23 AM indicated he/she was not able to find the call light and he/she needed it because he/she needs to go to the bathroom frequently due to an overactive bladder. Observation at that time identified Resident #14 was sitting in a chair on the side of the bed and the call bell was out of the resident's reach on the floor between the 2 beds in the middle of the room. Observation and interview with LPN #1 on 11/29/22 at 11:30 AM identified Resident #14's call bell was on the floor in between the 2 beds and Resident #14 was sitting on the opposite side of the bed in the bedside chair unable to reach the call bell. LPN #1 picked up the call bell and gave it to Resident #14. LPN #1 indicated she would attach the call bell next to Resident #14. Interview with LPN #1 on 11/29/22 at 11:33 AM indicated Resident #14 uses the call light frequently throughout the day. 2. Resident #50 was admitted to the facility with diagnoses that included dementia, muscle weakness, bullous pemphigoid, and heart failure. The quarterly MDS dated [DATE] identified Resident #50 had severely impaired cognition, was always incontinent of bowel and bladder and required total care for transfers, dressing, eating, toilet use, and personal hygiene. The care plan dated 11/17/22 identified Resident #50 was at risk for falls and has poor safety awareness. Interventions included to reinforce safety awareness and have the call bell within reach and instruct the resident to call for assistance as needed. Observation on 11/28/22 at 10:00 AM and 10:45 AM identified Resident #50 was lying in bed in a semi upright position and the call bell was out of reach on the floor at the head of the bed parallel with the wall. Interview with NA #1 on 11/28/22 at 10:45 AM indicated she was a full-time nurse aide for Resident #50 who required total care and a mechanical lift out of bed. NA #1 identified the call bell for Resident #50 was on the floor against the wall at the head of the bed out of reach for Resident #50. NA #1 indicated Resident #50 does use the call light at times. NA #1 indicated she would place the call light across the resident's lap and the end in his/her hand. NA #1 indicated she would attach the call bell to the right-side rail but long enough that she could place it in the hand of Resident #50. NA #1 indicated she was not aware Resident #50's call bell was out of reach and was aware the call bell should always be in reach for all residents including Resident #50. Interview with LPN #2 on 11/30/22 at 11:50 AM indicated residents were to always have their call bell in reach. Interview with RN #2 on 11/30/22 at 10:55 AM indicated the expectation was Resident #50 should have had his/her call bell in reach and not on the floor. Additionally, RN #2 noted all residents should always have their call bell within reach. RN #2 noted Resident #50 was not able to make her needs known but occasionally does use his/her call bell. RN #2 indicated the staff do answer Resident #50's call bell but usually Resident #50 would forget why he/she rang the call bell. Interview with the DNS on 12/6/22 at 9:20 AM indicated that all resident call bells must be in reach of the residents at all times for the resident to call for assistance. Review of fall bell policy identified residents will have a call bell or alternative communication device within reach when unattended. Equipment is a bedside call bell or an emergency call bell. Answer all call bells promptly whether or not you are assigned to the resident. Review of use of call bell policy identified the procedure was to answer all call bells promptly whether or not you are assigned to the resident. Answer all call bells in a prompt, calm, and courteous manner. When providing care to a resident be sure to position the call bell conveniently showing the resident where the call bell is located.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, and interviews for 1 resident (Resident #118) reviewed for discharge planning, the facility failed to honor the resident's choice/request of being dressed, out of bed and ready to attend his/her discharge care plan meeting with the interdisciplinary team. The findings include: Resident #118 was admitted to the facility with diagnoses that included fracture of the shaft of the humorous and Parkinson's disease. A physician's order dated 10/29/22 directed to use a mechanical lift (Sara lift) with assist of 2. The annual MDS dated [DATE] identified Resident #118 had intact cognition and required extensive assistance for bed mobility, transfers, dressing and personal hygiene. The care plan dated 12/1/22 identified Resident #118 had a self-care deficit due to decreased strength, balance, activity tolerance and endurance, inability to use the left upper extremity due to a fracture obesity, pain and Parkinson's. Interventions included to provide assistance with care, allow adequate time to perform activity, call bell on the right side, and provide privacy. The discharge planning note, written by SW #1, dated 11/14/22 at 9:46 AM identified that a discharge planning meeting was held today. Resident #118, family member, therapy, homecare representative, and SW #1 were in attendance. Discharge was anticipated for 11/30/22. Resident #118 was setting up 24-hour care giver and was having a ramp installed. Mechanical lift and hospital bed were ordered. Resident #118 was looking forward to discharge and family member was very supportive to the discharge. Interview with Resident #118 on 11/30/22 at 9:59 AM indicated he/she had requested another discharge meeting, after the 11/14/22 meeting, because he/she still had concerns about the home care service being set up, the home health aide, how he/she would be transferred at the home (platform walker or the mechanical lift), and financials. Resident #118 noted the social worker or LPN #5 had set up another meeting at the resident's request which was scheduled to be held on 11/29/22 at 11:30 AM with all the staff he/she needed to finalize all the discharge plans for discharge on [DATE]. Resident #118 indicated that on the morning of 11/29/22, the day of the discharge meeting, he/she was upset because staff did not get the resident cleaned, washed, dressed, or put in the wheelchair for meeting at 11:30 AM. Resident #118 indicated the therapist, OTR #1, had checked in that morning, many times, to see if the resident was up and ready for the meeting, but the resident was still in bed after lunch. Resident #118 indicated he/she was upset that the SW #1 and LPN #5, and MDS coordinator never came to see him/her and never informed him/her that the meeting was cancelled or when it would be rescheduled. Resident #118 indicated it was very stressful worrying about everything to get ready for going home and no one was helping. Resident #118 indicated because the nurse aides did not get him/her up in time that morning, the meeting never happened as planned. The discharge planning note written by SW #1 dated 12/1/22 indicated Resident #118 was discharged home today with skilled homecare and a 24-hour care giver. Resident #118 had a mechanical (hoyer) lift and a hospital bed delivered today. The Discharge summary dated [DATE] identified that Resident #118 was discharged home with homecare services. A transfer/discharge report packet included the resident's diagnosis, code status, and a list of medications, (did not include last administration times). The packed also included a discharge notice, and a form for the home care agency indicated resident required a hoyer lift, and hospital bed. Interview with OTR #1 on 12/6/22 at 1:04 PM indicated the discharge meeting that was planned for Tuesday 11/29/22 at 11:30 AM to be held in the social worker office did not occur because the nurse aides never got Resident #118 out of bed and Resident #118 did not want to have the meeting in his/her room because there was a roommate. Resident #118 was scheduled to be discharged on 11/30/22, however, the discharge was postponed to 12/1/22 and OTR #1 indicated he did not know why the discharge was postponed. OTR #1 indicated on 11/29/22 he had checked on Resident #118 multiple times (4 - 5 times) to see if he/she was ready for the meeting, but just after lunch Resident #118 was still in bed. OTR #1 noted he was waiting for SW #1 to text him once Resident #118 was out of bed for the meeting, but he never got a text. OTR #1 indicated he was told verbally the meeting was cancelled at the end of the day between 3:30 PM - 4:00 PM. OTR #1 indicated he was informed the discharge meeting would be changed to Thursday 11/30/22. OTR #1 indicated he had worked with Resident #118 in the gym that afternoon, on 11/29/22, but did not inform Resident #118 the meeting would be changed to 11/30/22 because he was not aware of the change at that time. OTR #1 indicated he meet on 11/29/22 with Resident #118 and the homecare caregiver for training. Interview with SW # 1 on 12/6/22 at 2:27 PM indicated on 11/14/22 Resident #118 had a discharge planning meeting, but Resident #118 had requested another meeting because he/she had more questions about transfers, financials, and homecare, so another meeting was scheduled for 11/29/22 at 11:30 AM. SW #1 indicted they did not have that meeting on 11/29/22 because the nurse aides did not get Resident #118 out of bed. SW #1 indicated Resident #118 did not want the meeting in the room with the roommate and the roommates' visitors. SW #1 indicated she had not spoken with Resident #118 about the meeting being cancelled on 11/29/22 or when the meeting would be rescheduled, because she thought LPN #5 was responsible to update the resident. SW #1 indicated the next day, each person from different services had met with the resident individually for financial, therapies, and the nurse's aide live in training. SW #1 indicated it was difficult to get everyone together for a meeting so she did the best she could do. SW #1 indicated it was very difficult because the homecare agency normally comes on Wednesdays, and they needed the 24-hour care giver to come for training with the therapy department. SW #1 indicated Resident #118 used a Sara lift at the facility, but the insurance would not cover the Sara lift but would pay for a hoyer. SW #1 indicated she ordered the hoyer but Resident #118 was confused because he/she did not understand about the hoyer versus the Sara lift and how the insurance worked. Interview with LPN #5 on 12/6/22 at 2:35 PM indicated she was informed by the Administrator that Resident #118 had called her on Wednesday 11/23/22 and requested another discharge meeting. LPN #5 indicated the Administrator informed her Resident #118 wanted another discharge planning meeting to discuss the transfer status and ordering the mechanical lift. LPN #5 indicated she had spoken to Resident #118 and scheduled another discharge meeting for 11/29/22 at 11:30 AM at the resident's request. LPN #5 indicated she had informed SW #1, the financial person, and therapy about the meeting scheduled for 11/29/22. LPN #5 indicated she and SW #1 had originally gone to the unit on 11/29/22 at 11:30 AM but Resident #118 was calling the nurses station and was upset no one had given him/her a shower and he/she was worrying about the meeting for 11:30 AM. LPN #5 indicated Resident #118 was not up for the meeting as of 12:30 PM while LPN #5 was still on the unit. LPN #5 indicated Resident #118 would not have the discharge meeting in his/her room because the roommate was present and wanted the meeting in a lounge or the social worker office. LPN #5 indicated it was not her meeting so she thought SW #1 would take responsibility over the meeting. LPN #5 noted it was about discharge and therapy, so it was the social workers responsibility to run the meeting. LPN #5 indicated she did not go back to Resident #118 to inform the resident the meeting had been cancelled on 11/29/22 or that it was rescheduled. LPN #5 indicated the meeting never took place however, everyone met individually with Resident #118. LPN #5 indicated she thought the resident would call her when the nurse aide got him/her out of bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, policy and interviews for 1 of 3 residents (Resident #122) reviewed for an allegation of mistreatment, the facility failed to ensure the resident was free from abuse. The findings include: Resident #122 was admitted to the facility in June 2022 with diagnoses that included overactive bladder and a neurologic disorder. The quarterly MDS dated [DATE] identified Resident #122 had intact cognition, required extensive assistance with bed mobility, transfers, dressing toilet use and was totally incontinent of bowel and bladder. The care plan dated 8/2/22 identified Resident #122 was incontinent of bowel and bladder. Interventions included to check and change the resident a minimum of every 2 - 3 and as needed for incontinence. Keep skin clean and dry, provide good peri care, and use barrier cream. Offer frequent use of the bathroom, commode or bedpan upon waking, before/after meals, before bed and upon request. Provide peri care after each incontinent episode. A reportable event form dated 8/29/22 identified at 1:45 AM the RN Supervisor, (RN #6) was notified by the Charge Nurse of a disturbing call from Resident #122's family with a report that the resident had been treated rudely by NA #6. The reportable event form further indicated the resident reported that NA #6 ripped the brief off his/her body and told the resident she didn't need to take this, and that the resident was rude. A statement by RN #6 identified he took NA #6 to a private area to obtain a statement of what had happened with Resident #122. NA #6 stated to RN #6 that the resident was rude when she first entered the room. NA #6 identified Resident #122 felt he/she was wet and wanted the brief changed. NA #6 indicated she checked the brief and stated it was not wet and did not require a change. NA #6 identified Resident #122 still wanted the brief changed and it was eventually changed at that time by NA #6. After the statement from NA #6 was obtained, she was told she had to leave the building and was escorted out at that time. RN #6 identified that NA #6 became very rude and disrespectful toward RN #6 stating don't follow me, I don't need to be walked out, you need to do your job, don't follow me. After NA #6 left, RN #6 proceeded to assess Resident #122. Resident #122 verbalized a pain level of 8 out of 10 in the groin area which was eventually relieved by incontinent care cream applied to the groin. A body audit identified no bruises, redness or open areas. The resident's cognition was identified as intact at that time. Resident #122 gave a statement to RN #6 at that time. The resident identified NA #6 came into his/her room and was very rude. Resident #6 asked that his/her brief be changed and when the nurse aide looked at the brief she said the resident was dry, however, Resident #122 stated he/she felt wet. Resident #122 identified NA #6 became rude and loud and told the resident he/she did not need to be changed. Resident #122 identified that when NA #6 finally changed him/her, she was loud, rude and ripped the brief off him/her causing a lot of pain in the groin area. Resident #122 stated that NA #6 was very hostile toward him/her. A statement by Resident #122's roommate (Resident #118), obtained at that time by RN #6 identified the following. Resident #118 identified he/she was awakened by NA #6 taking care of Resident #122 in the next bed. Resident #118 stated that he/she heard how NA #6 was speaking to Resident #122 and that NA #6 was hostile toward Resident #122. Resident #118 stated it was an awful experience for him/her, and I felt helpless to help. Resident #118 stated that NA #6 was belligerent, loud and insisted that she was right. It woke me up. What was done was wrong. (The quarterly MDS and annual MDS dated [DATE] and 11/14/22 identified Resident #118 had intact cognition.) A statement written by NA #6, undated, identified that Resident #122 was very rude from the time she went into the room and was upset because she had 2 diapers on and she thought the time was 5:00 AM but it was 1:00 AM. NA #6 identified Resident #122 was very rude and being disrespectful and saying she wea wet and she was not wet. NA #6 stated the resident was changed and that was it. A statement by NA #7 dated 8/29/22 identified Resident #122 told NA #7 that the aide ripped his/her brief off very hard and it felt like he/she had a bruise in between his/her thighs. A statement by LPN #5 dated 8/29/22 identified he/she received a call from Resident #122's family member who stated Resident #122 had just called him/her very upset because the nurse aide had been very rude and rough and had roughly ripped the diaper off. A social service note dated 8/29/22 at 4:04 PM identified the social worker and assistant met with Resident #122 related to the reportable event and to provide emotional support. Resident #122 did not verbalize allegation of abuse but did say he/she had a bad night. The summary report dated 8/30/22 identified the investigation revealed that statements given to different disciplines by the resident were inconsistent from the original statement, I didn't like the approach the nurse aide used at night. Further, per APRN #1, when she first met Resident #122 in July 2022 the resident presented irritable, hard to please and controlling. Based on the investigation the facility did not substantiate abuse, but rather identified a customer service issue. The residents care plan was changed to have 2 staff provide care at all times and due to the history of allegations. Interview witch APRN #1 on 12/5/22 at 2:12 PM identified she was notified of the allegation of abuse on 8/29/22 and went in to see Resident #122 on 8/30/22. APRN #1 stated she did not specifically ask the resident about the incident that occurred on 8/29/22 because she did not want to add to the residents trauma. APRN #1 identified Resident #122 did not mention the incident during their conversation. Interview with Resident #122 on 12/6/22 at 1:35 PM identified that one night he/she was wet and asked to be changed. The nurse aide told the resident he/she was not wet and that she was not going to change the resident. There was a back and forth and the nurse aide was yelling and ripped the diaper off so hard. Resident #122 stated he/she was scared. Although attempts were made to interview NA #6, an interview was not obtained. The abuse policy identified the purpose of the policy is to ensure each resident is treated with kindness, compassion and in a dignified manner. Abuse or mistreatment of any kind is strictly prohibited. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual of goods and services that are necessary to attain or maintain physical, mental, and psychosocial wellbeing. Although the facility identified in their summary that (statements given to different disciplines by Resident #122 were inconsistent from the original statement), the statements within the facility investigation reviewed by this surveyor, and interview with Resident #122 indicated the statements about the allegation on 8/29/22 were consistent. Further, Resident #118, who was assessed to have intact cognition, witnessed the incident and stated NA #6 was hostile toward Resident #122, it was an awful experience for him/her, and I felt helpless to help and that NA #6 was belligerent and loud.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #387) reviewed for abuse, the facility failed to report an allegation of abuse to the state agency. The findings include: Resident #387 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, muscle weakness and osteoporosis. The care plan dated 11/16/22 identified Resident #387 had a self-care performance deficit related to cognitive deficit, recent hospitalization, weakness, sepsis and COVID19. Interventions included to have 2 caregivers provide assistance with activities of daily living (ADL) due to accusatory behavior. A physician's order dated 11/17/22 directed to stand-pivot transfer with 2 caregivers to toilet with grab bar and gait belt and provide increased time. The admission MDS dated [DATE] identified Resident #387 had intact cognition, required extensive 2-person assistance with toileting, was frequently incontinent of bladder and always incontinent of bowel. The nurse's note, written by RN #4 dated 11/27/22 at 1:10 AM identified that around 9:00 PM on 11/26/22 this writer entered the resident's room to administer scheduled medications and the resident reported that 2 nurse aides, NA #3 and NA #5 had grabbed his/her arms and lifted him/her to put him/her on the toilet. Resident #387 further stated the 2 nurse aides did not support his/her right hand, so it is now in pain. Resident #387 also stated that NA #3 dug into his/her rectum which Resident #387 described as an assault. The on-duty RN Supervisor, RN #5 was notified, and the note reported Resident #387 was given an over-the-counter pain medication for the right arm pain which Resident #387 indicated was effective. An assessment of the arm identified no swelling or redness, no external or internal rotation, no signs of distress or shortness of breath noted this evening, safety measures in place. Interview with Resident #387 on 11/29/22 at 11:10 AM identified that during toileting care on 11/26/22, 2 nurse aides held on to the resident's arms to assist in transferring. Resident #387 identified that during care, NA #3 inserted her finger into the resident's rectum. Resident #387 identified he/she reported the incident as abuse to RN #4, and the RN Supervisor, RN #5 came to the room and took a statement. Interview and review of the clinical record with the DNS and ADNS on 11/29/22 at 2:35 PM failed to reflect documentation that the allegation of abuse that occurred on 11/26/22 had been reported to the state agency. The DNS indicated she was advised of Resident #387's allegation on 11/28/22 and began an investigation at that time. The DNS further stated Resident #387 had a history of accusatory behavior resulting in 2 caregivers providing assistance at all times, and as a result the DNS did not think the allegation was an allegation of abuse. Subsequent to surveyor inquiry, the state agency was notified of the allegation of abuse on 11/29/22 at 3:00 PM, 3 days later. As part of the investigation, a statement from NA #3 identified Resident #387 stated NA #3 and NA #5 were in a hurry and became accusatory when barrier cream was applied to the resident's buttocks. NA #3's denied applying barrier cream to the resident's rectal area and stated she did not insert her finger into Resident #387's rectum. As part of the investigation, a statement by NA #5 identified Resident #387 was accusatory and both she and NA #3 were gentle with Resident #387's care during toileting on the evening of 11/26/22. Interview with the ADNS on 11/29/22 at 3:10 PM identified she received a call from RN #5 regarding the allegation on 11/26/22 at approximately at midnight. The ADNS further identified she did not notify the DNS or Administrator of the allegation at that time, and did not instruct RN #5 to initiate a reportable event form or notify the state agency or examine Resident #387. The ADNS stated she did not think the allegation was abuse because she relied on RN #5's assessment of the incident. Interview with RN #4 on 12/1/22 at 12:40 PM identified that she was notified of the incident on 11/26/22 during late evening medication administration. Resident #387 indicated that he/she was put in the bathroom in an improper way by NA #3 and NA #5. The resident indicated the nurse aides stood him/her up in the bathroom by holding his/her arm which now hurts. The resident also reported that NA #3 stuck her finger in the resident's rectum. RN #4 notified the RN Supervisor, RN #5, of the incident and also that the resident identified that he/she was in too much pain to write. RN #4 was instructed by RN #5 to write Resident #387's statement and have Resident #387 sign it. RN #4 indicated she was not instructed to initiate a reportable event form, notify the state agency, or the physician, or examine Resident #387's rectum. RN #5 identified she was only instructed to take Resident #387's statement. Interview with RN #5 on 12/1/22 at 1:00 PM identified RN #4 notified her of the allegation which occurred on 11/26/22 with Resident #387 and she notified the ADNS. RN #5 indicated she was not instructed by the ADNS to notify the Administrator, the DNS, or the physician. RN #5 indicated she got statements from NA #3 and NA #5 and due to the accusatory behavior of Resident #387, she did not think the allegation was abuse. RN #5 indicated she assessed Resident #387's arm however she did not assess the resident's rectum or instruct RN #4 to assess the rectum. Although several attempts were made, an interview with NA #3 was not obtained. Review of the facility policy for abuse identified the DNS or designee will report allegations of abuse to the state agency within 2 hours. Although the nurse's note, written by RN #4 dated 11/27/22 at 1:10 AM identified that around 9:00 PM on 11/26/22 Resident #387 reported that 2 nurse aides had grabbed his/her arms and lifted him/her to put him/her on the toilet, did not support his/her right hand, so it is now in pain and dug into his/her rectum which was described by the resident as an assault, the facility failed to report the incident to the state agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record and interview for 1 resident (Resident #69), the facility failed to ensure the Registered Nurse stayed with the resident to ensure the resident consumed medications prior to the RN leaving the room. The findings include: Resident #69's diagnoses included a degenerative nerve disease, major depressive disorder, and macular degeneration. The annual MDS dated [DATE] identified Resident #69 had intact cognition and required total 2-person assistance for transfers and extensive 2-person assistance for bed mobility. The MDS further identified Resident #69 required extensive assistance dressing and toilet use. The care plan dated 10/13/22 identified Resident #69 had a diagnoses of a degenerative nerve disease with interventions that included to administer medications as ordered by the physician/APRN. Additional interventions included to follow up with neurology and specialized clinics as ordered. Review of the electronic physician order details dated 10/27/22 directed to administer medication by clinician and not self-administer. Observation on 11/29/22 at 11:40 AM identified Resident #69 was seated in his/her room in a customized wheelchair with a medication cup that contained 12 pills in front of him/her. The medication nurse (RN #3) was observed to be in the doorway of the adjacent room pouring medication and out of eyesight of Resident #69. Constant observation at that time identified Resident #69 self-administered the medication at 11:42 AM without the benefit of RN #3's oversight. The fire drill alarmed at 11:44 AM (2 minutes after Resident #69 self-administered his/her medication). Interview with RN #3 on 11/29/22 at 12:47 PM identified that he poured Resident #69's medications which consisted of Aspirin 81mg, Carvedilol (a medication to treat hypertension) 3.125, Cetirizine (a medication to treat allergies) 5 mg, Co-Enzyme (a dietary supplement) 200 mg, Escitalopram (a medication to treat depression and anxiety) 10 mg, Ferrous Sulfate (a dietary iron supplement) 325 mg, Folic Acid (a dietary supplement) 81mg, Multivitamin, Omega 3 (a fish oil dietary supplement) 1000 mg, Senna Plus (a medication to treat constipation) one tab, Vit D 3 (a dietary supplement) 1000 IU, 2 tabs and left the medication in front of Resident #69 for the resident to self-consume. RN #3 identified that Resident #69 did not have an order to self-administer medications, and although RN #3 knew he shouldn't have left the medication with Resident #69 and left the room prior to the resident consuming the medication, he was running late and trying to catch up. Additionally, RN #3 identified the fire alarm sounded, and he returned to Resident #69 after the alarm, and the resident had consumed the medication. Interview with the DNS on 12/6/22 at 12:47 PM identified that staff are responsible to ensure that medications are consumed prior to leaving the residents room and are not to leave medication in the room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #90) reviewed for Activities of Daily Living (ADL), the facility failed to ensure the resident was provided a shower on scheduled shower days. The findings include: Resident #90 was admitted to the facility in October 2018 with diagnoses that included diabetes and obesity. Review of the nurse aide care card identified bath days were scheduled Friday 7:00 AM - 3:00 PM and Wednesday 3:00 PM - 11:00 PM. The annual MDS dated [DATE] identified Resident #90 had severely impaired cognition and required extensive assistance with personal hygiene. The care plan dated 9/14/22 identified Resident #90 had a self-care deficit due to impaired strength and decreased ability. Resident #90 enjoy showers very much, receives an additional shower on Wednesdays, and allow the resident to hold sprayer. Resident #90's representative often visits to assist on shower days. Physician's order dated 10/1/22 directed to perform an additional shower on Wednesdays during the 3:00 PM - 11:00 PM shift. Interview with Person #1 on 11/29/22 at 12:25 PM identified Resident #90 did not receive a shower 3 times in October 2022. Person #1 indicated she has to call the facility every Wednesday to remind the staff that Resident #90 has a shower that evening. Review of the MAR dated 10/1/22 - 10/31/22 failed to reflect documentation that Resident #90 had a shower on his/her scheduled day Friday 10/7/22 and Friday 10/21/22 during the 7:00 AM - 3:00 PM shift. Review of the TAR dated 10/1/22 - 10/31/22 failed to reflect documentation that Resident #90 had a shower on his/her scheduled day Wednesday 10/12/22 during the 3:00 PM - 11:00 PM shift. Review of the TAR dated 11/1/22 - 11/30/22 failed to reflect documentation that Resident #90 had a shower on his/her scheduled day Wednesday 11/16/22 during the 3:00 PM - 11:00 PM shift. Interview and review of the clinical record with the DNS on 12/5/22 at 1:05 PM identified she was not aware that Resident #90 missed three showers (10/7/22, 10/12/22, and 10/21/22) and was not able to provide documentation that the showers had been given. A second review of the October 2022 TAR dated 10/1/22 - 10/31/22 on 12/6/22 at 8:48 AM with the ADNS identified signatures were now present on the TAR that indicate showers had been given for dates previously blank (10/7/22, 10/12/22, and 10/21/22). The ADNS indicated LPN #2 (unit manager) had filled in the TAR. Interview with LPN #2 (unit manager) on 12/6/22 at 9:14 AM identified she signed the TAR for the dates of 10/7, 10/12, and 10/21/22 for the showers however she did not know if Resident #90 had received showers on those days. Interview with the DNS on 12/6/22 at 9:20 AM identified she was not aware that LPN #2 had signed the TAR to indicate that showers had been given on (10/7/22, 10/12/22, and 10/21/22) which were previously unsigned. The DNS indicated LPN #2 should not have signed the TAR in place of the nurses that were responsible for ensuring Resident #90 was showered. Review of the facility showers policy directed resident will receive a shower, assisted/and or given by the nursing staff as desired. Document the procedure. Review of the facility Activities of Daily Living (ADL's) policy directed based on comprehensive assessment of a patient and consistent with the patient's needs and choices, the facility must provide the necessary care and services to ensure that a patient's abilities in activities of daily living do not diminish unless circumstances of individual's clinical condition demonstrate that such diminution was unavoidable. Activities of Daily Living (ADL's) include: Hygiene - bathing, dressing, grooming, and oral care. ADL care is documented every shift by the nursing assistant on an ADL flow record or in PointClick Care (PCC) ADL Point of Care (POC). The ADL flow record will be reviewed by morning meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #14) reviewed for hearing services, facility failed to ensure the resident was seen by an audiologist in a timely manner. The findings include: Resident #14 was admitted to the facility on [DATE] with diagnoses that included overactive bladder, repeated falls, and diabetes. The hospital interagency report dated 7/18/22 identified Resident #14 was transferred from the hospital to the facility with a hearing aid for the right ear. The admission nursing assessment dated [DATE] at 10:30 AM identified Resident #14 was alert and oriented, was able to make needs known and was hard of hearing in the right ear. The nurse's note dated 7/18/22 at 4:58 PM identified that Resident #14 was alert and oriented, was hard of hearing in right ear and had no hearing aid. The admission MDS dated [DATE] identified Resident #14 had moderately impaired cognition, had minimal hearing difficulty and no hearing aid or other hearing appliance used. The care plan 8/4/22 identified Resident #14 was hard of hearing in the right ear. Interventions included to provide a safe environment with the call light in reach and adequate low glare light. A physician consultation order form dated 8/16/22 indicated recommended an audiology consultation for Resident #14 who was evaluated due to being hard of hearing, having decreased responsiveness, and balance (ie. recent falls, dizziness, etc). This consultation form was signed by the physician on 8/16/22. The nurse aide care card, undated, identified Resident #14 had impaired hearing and was hard of hearing in the right ear. Interview with Resident #14 on 11/29/22 at 11:23 AM indicated he/she was deaf in his/her right ear and does not have a hearing aide. Resident #14 indicated he/she could not see an audiologist in this facility because he/she was a state patient. Resident #14 indicated he/she would use a hearing aid if he/she had one, but he/she was a state patient. Resident #14 indicated the nurses where aware he/she needed a hearing aid. Interview with the Unit Manager, (LPN #2) on 11/29/22 at 12:00 PM indicated Resident #14 was on the audiology list to be seen and had only been at the facility a couple of months. LPN #2 indicated she did not know the next time the audiologist would be in the facility. Interview with Medical Record Person #1 on 12/5/22 at 9:20 AM indicated it takes a while to be seen by audiology and identified the facility had just switched over to a new company in June or July 2022. Medical Records Person #1 indicated once she gets a consent for audiology, she calls the company and audiology will schedule to come to the facility to see the resident. Medical Records Person #1 indicated audiology came in twice in August 2022 and came in again on 11/8/22 and saw 3 residents but did not see Resident #14. Medical Records Person #1 indicated she was responsible to call audiology for Resident #14, but only if the nurse had told her to call for an issue like a missing hearing aid or a broken hearing aide. Medical Records Person #1 indicated she did not receive a phone call from a nurse informing her that Resident #14 needed to be seen by audiology, she only received the physician's consultation order form for audiology. Interview with LPN #2 on 12/5/22 at 11:06 AM indicated it was the prior Unit Manager (LPN #3) that had signed the audiology consent form. LPN #2 indicated the charge nurse was responsible to fill out the form with the resident and have the physician sign the order. LPN #2 indicated she did not know if the charge nurse or someone else was responsible to fax the consent form with physicians' signature to the audiology group. Interview with LPN #3 on 12/5/22 at 12:09 PM indicated this was a new company for the facility and she was responsible to sign up any residents that needed to be seen and enroll with the new company. LPN #3 noted by signing the residents up did not mean the resident needed to be seen at that moment but could be just for an annual visit. LPN #3 indicated she was not aware that the hearing aid was missing, but she enrolled the resident to the new audiology service. LPN #3 indicated once the form was signed by the physician it went down to Medical Records Person #1 to fax over to the new audiology group. LPN #3 indicated she recalls Resident #14's family had brought in headphones for the resident to use. Interview with Medical Records Person #1 on 12/5/22 at 2:00 PM indicated the Audiologist had been in the facility on 9/8/22 for 1 resident, on 11/1/22 for another resident, and 11/8/22 for 3 more residents but indicated Resident #14 had not been seen at any of these visits. Interview with the DNS on 12/5/22 at 2:30 PM indicated once a resident requests to be seen by audiology and the physician signs the form the resident should be seen within 3 - 4 weeks. The DNS indicated she would investigate why Resident #14 was admitted in July 2022 and the audiology form was signed in August 2022, but the resident had not yet been seen. Although requested, a facility policy for audiology services was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #50) reviewed for pressure ulcers, the facility failed to ensure the air mattress was on the correct setting according to the residents weight. The findings include: Resident #50 was admitted to the facility with diagnoses that included dementia, muscle weakness, bullous pemphigoid, and heart failure. A weights summary dated 2/13/22 identified Resident #50 weighed 120 lbs. A weights summary dated 10/5/22 identified Resident #50 weighed 129.6 lbs. Physician's monthly orders for October 2022 directed an air mattress with the setting at #3. Check for placement and function every shift. A weights summary dated 10/5/22 identified Resident #50 weighed 129.6 lbs. The APRN progress note dated 10/17/22 indicated Resident #50 requires total care, was non-ambulatory, and needs to be fed by staff. A weights summary dated 11/1/22 identified Resident #50 weighed 128.8 lbs. The November 2022 MAR identified documentation that indicated nursing staff checked the placement and function of the air mattress every shift and that it was at setting #3. (This is in conflict with the observation on 11/30/22 that the resident was on an air mattress that was set by weight). The quarterly MDS dated [DATE] identified Resident #50 had severely impaired cognition, was always incontinent of bowel and bladder and required total care for transfers, dressing, eating, toilet use, and personal hygiene. Additionally, identified Resident #50 was at risk for developing a pressure ulcer and had a pressure reducing device for the chair and bed. The care plan dated 11/17/22 identified potential for alteration in skin integrity and risk for pressure ulcer. Intervention included an air mattress, nursing to check placement and function every shift with a setting of #3. Additionally, Resident #50 has a diagnosis of dementia and was able to make eye contact but was not able to make needs known. Observations on 11/28/22 at 10:00 AM and 10:45 AM identified Resident #50 was lying in bed in a semi upright position on an air mattress with the setting at 200 lbs., on the dial which ranged from 50 lbs. to 350 lbs. Interview with NA #1 on 11/28/22 at 10:45 AM indicated she was a full-time nurse aide for Resident #50 who required total care and a mechanical lift out of bed. NA #1 indicted the air mattress was always set at 200 lbs. for Resident #50 and that was where it was currently. NA #1 pointed out the air mattress had a dial that goes by weight. A weights summary dated 11/30/22 identified Resident #50 weighed 129.6 lbs. Interview and observation with RN #2 on 11/30/22 at 10:55 AM indicated Resident #50 was lying in bed on an air mattress that was set by weight. RN #2 noted the setting was between 180 lbs., to just under the 200 lbs. mark on the dial. RN #2 noted the dial for the weights was just under the 200 lbs., but was difficult to read because the increments were by 50 lbs. and the dial can be set in between the 5 lb. increments. RN #2 indicated Resident #50 would not be able to tell you if he/she wanted the mattress softer or firmer and that's why it would go by the resident's weight. RN #2 indicated she would have to review Resident #50's weight to know if that was the correct setting. After clinical record review, RN #2 noted Resident #50 weighed 149.6 lbs., and she would go back and adjust the setting to 150 lbs. on the air mattress. Interview with the ADNS on 11/30/22 at 11:00 AM identified the weight obtained of 149.6 lbs. represented a weight gain of approximately 20 lbs. from 11/1/22 to 11/20/22. The ADNS indicated she would get a reweight for Resident #50. A weights summary dated 11/30/22 (reweight) identified Resident #50 weighed 129.6 lbs. Observation on 11/30/22 at 2:00 PM identified Resident #50's air mattress was set at 150 lbs., despite the reweight that identified Resident #50 weighed 129.6 pounds. A physicians ordered dated 12/1/22 directed for pressure redistribution mattress to bed document settings. Review of the TAR dated 12/1/22-12/6/22 failed to reflect the air mattress setting. Review of nurse's notes dated 12/1/22-12/6/22 failed to reflect the air mattress setting. Observation on 12/6/22 at 10:00 AM identified Resident #50's air mattress was set at the 150 lbs. mark. Interview and observation with the DNS on 12/6/22 at 10:30 AM indicated there were a few different types of air mattresses in the facility. The DNS noted Resident #50's air mattress was set at about 140 to 150 lbs., and this dial was by weights. The DNS noted she did not know what Resident #50 weighed and indicated the physician's order would indicate if the air mattress would be set to residents' comfort or by weight. The DNS indicated she would get the manufacturer recommendations for that air mattress. Review of the Alternating Pressure Air Mattress Policy identified its purpose was to maintain adequate circulation, relieve pain due to pressure and aid in healing and/or prevent pressure ulcers. Procedure is to verify the physician order and setting according to manufacturer guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility policy and interview for 1 of 7 residents (Resident #67) reviewed for nutrition, the facility failed to ensure the prescribed supplement was monitored and the amount consumed was documented per physician's orders, for a resident at risk for weight loss. The findings include: Resident #67's diagnoses included Alzheimer's disease, dysphagia, and iron deficiency anemia. The quarterly MDS dated [DATE] identified Resident #67 had severely impaired cognition and required supervision, oversight, encouragement or cuing with eating. A physician's order dated 8/11/22 directed to start house supplement 4 ounces (oz) three times daily (TID). The care plan dated 8/16/22 identified nutritional status was at risk for decline secondary to impaired mobility, cognition, dysphagia, and weakness. Interventions included to obtain weights as ordered, house supplement three times daily, supplements as ordered to augment intake as ordered by MD/APRN and nursing to document percentage consumed. Review of Resident #67's weight history in the Electronic Medical Record (EMR) identified the most recent weight as 101.2 lbs. on 11/3/22. Further review identified that although weights since 8/12/22 have been stable, ranging between 100 and 102.8 lbs., the resident had a loss of 21.2 lbs. between 6/30/22 - 8/12/22. Review of the MAR for September 2022 through November 15, 2022, identified although nursing signatures indicated the house supplement was administered as ordered, the area designated for documentation of the percentage (%) or amount consumed for the 9:00AM and 1:00 PM times were mostly left blank. Further, the 5:00 PM scheduled supplement had inconsistent documentation with multiple missing entries for amount consumed. Review of the electronic physician's orders and MAR, which the facility converted to and began utilizing on 11/16/22 did not contain a designated area for documentation of the percentage of supplement consumed, therefore there was no documentation of the supplement amount consumed from 11/16/22 through 12/6/22m, 3 weeks. Further, the physician's order dated 11/16/22 directed to administer house supplement house supplement two times a day for supplement 120 ml orally (PO) TID, document percentage. (The order says two times daily and also TID which means three times daily). Interview and review of Resident #67's electronic and paper clinical record with LPN #4, (unit manager) on 12/6/22 at 12:00 PM identified multiple missing and overall inconsistent documentation of the amount of supplement consumed by the resident from September 2022 to current. LPN #4 identified the charge nurses administering the supplements were responsible for documenting the amount consumed by the resident to better monitor the resident's caloric intake, especially for residents at high risk for weight loss. LPN #4 identified that since they began using the EMR on 11/16/22, with many people inputting orders, they have found many mistakes. LPN #4 identified the resident's supplement order was currently unclear as to how often it was supposed to be administered because the order was put in as twice daily TID. LPN #4 identified that since 11/16/22, the supplement had only been given twice daily, not three times daily as the original order, dated 8/11/22, directed. LPN #4 identified the nurses should be documenting the supplement amount consumed by the resident but could not explain why they were not. Additionally, the supplement frequency discrepancy should have been noticed by someone and then clarified and changed to reflect the actual current order. Interview with the Dietitian on 12/6/22 at 12:30 PM identified that although the nurses should be documenting supplement intake amounts on the MAR or in the nurse's notes, she indicated that her usual practice was to observe the resident and discuss their overall intake including supplements with the nurses and nurse aides. The Dietitian identified she documents in progress notes and evaluations how the resident is eating and doesn't write specific amounts but would indicate when intake was inconsistent. Although the Dietitian indicated she was not aware of the supplement being only given twice daily instead of three times daily since 11/16/22, she identified Resident #67's weights have been stable since a significant loss was identified and addressed in August. Although a policy was requested, none was provided related to monitoring and documentation of nutritional supplements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, facility policy and interview for 1 of 1 residents (Resident #79) reviewed for enteral tube feeding, the facility failed to ensure water bolus physician orders were consistent, failed to ensure appropriate labeling of tube feeding solution and water bolus bag, and failed to ensure cleanliness of the tube feeding pump. The findings include: Resident #79's diagnoses included stroke with left sided hemiparesis, dysphagia and utilization of a gastrostomy (g-tube). The care plan dated 6/30/22 identified Resident #79 was at risk for a decline in nutritional status due to a stroke and orders for nothing by mouth (NPO)/tube feeding. Interventions included dietary consultation as needed, g-tube feedings and flushes as ordered. The quarterly MDS dated [DATE] identified Resident #79 had severely impaired cognition, required total assistance of 2 staff with bed mobility, transfers, dressing and toilet use. The MDS further identified Resident #79 required total assistance for personal hygiene and required a feeding tube. a. a physician's order dated 10/22/22 directed to flush Resident #79's g-tube with 200 ml (the order did not identify what to flush with) every 6 hours (which is 4 times a day). Additional orders on the same physician's monthly order sheet directed to flush the g-tube 3 times a day, with 200 ml of free water (the same signed orders directed to flush every 6 hours). The MAR dated 10/22/22 through 11/16/22 identified Resident #79's g-tube was flushed 5 times per day (the MD orders dated 10/22/22 directed the flush 4 times a day, and 3 times a day) with 200 ml, but failed to identify what solution was used to accomplish the flushes. The electronic MAR dated 11/16/22 through 11/30/22 identified Resident #79's g-tube was flushed with 200 ml of water every 6 hours for a total of 1800 ml (200 ml every 6 hours equals 1200 ml) in 24 hours excluding medication flushes (the total fluid volume does not match for the 24 hour period). On 12/6/22 at 12:50 PM, interview with the DNS identified there was a 24-hour chart check regarding physician orders. b. Observation on 11/29/22 at 10:53 AM identified Resident #79 was lying in bed. Although the feeding tube was not connected, a tube feeding solution of Jevity 1.5 was hanging from an infusion pole with approximately 500 ml remaining in the plastic bottle. Although the bottle was dated 11/29/22, it failed to include the time that bottle was hung and there were no staff initials of who hung the feeding. Further observation identified the water bolus bag (with approximately 500 ml of water remaining) was also hanging from the infusion pole dated 11/26/22 (3 days prior) at 4:00 AM but failed to include initials of the staff member that hung the water bolus bag. On 11/30/22 at 11:00 AM and 12/6/22 at 10:46 AM observation of Resident #79 identified a water bolus bag with approximately 500 ml remaining was disconnected from Resident #79 but was not labeled with a date/time or initials of the staff member that hung the water bolus bag. c. On 11/29/22 at 10:53 AM, 11/30/22 at 11:00 AM and 12/6/22 at 10:46 AM identified Resident #79's feeding pump was observed to be soiled with a heavy buildup of tan debris and drip marks. On the 12/6/22 observation, the tube feeding connector was uncapped and dripping tube feed solution onto the pump base and floor. On 12/6/22 at 12:50 PM, interview with the DNS identified that only a date was required on the water bolus and tube feeding bags/bottles. Additionally, the DNS identified she would need to refer to the facility policy and physician orders regarding the management of unlabeled solutions. Facility policy on Enteral Feeding via Continuous Pump identified on the formula label, document initials, date and time the formula was hung/administered and initial that the label was checked against the order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #127) reviewed for respiratory services, the facility failed to follow the physician's orders related to oxygen administration and failed to ensure oxygen tubing and nebulizer tubing were labeled and dated per facility policy. The findings include: Resident #127 was admitted to the facility with diagnoses that included acute respiratory failure with hypoxia, pneumonia, and covid-19. The significant change in condition MDS dated [DATE] identified Resident #127 had severely impaired cognition and required extensive assistance for bed mobility, dressing, toileting, and personal. Additionally, the resident required oxygen therapy. The care plan dated 9/15/22 identified the resident had congestive heart failure. Interventions included to administer oxygen at 2 liters per minute continuously, administer nebulizer treatments as ordered and to change oxygen tubing as per policy. A physician's order dated 11/2/22 directed to administer oxygen at 2 liters per minute via nasal cannula every shift. Further, change oxygen tubing weekly and label each component with the date and initial and administer DuoNeb 0.5-3mg unit inhale orally every 4 hours as needed for congestion or wheezing. The November 2022 MAR identified that DuoNeb 0.5-3mg via nebulizer was administered on 11/3/22 at 11:30 AM for shortness of breath. Observation on 11/29/22 at 10:00 AM and 11:00 AM identified Resident #127 was lying in bed, 2 side rails up, with oxygen on via nasal canula at 3 liters per minute. The oxygen concentrator was out of the residents reach. The oxygen tubing was not dated, and the nebulizer tubing with mask was resting on the nightstand unbagged and undated. Observation and interview with LPN #1 on 11/29/22 at 11:35 AM identified the oxygen was set at 3 liters and being administered via nasal cannula from the concentrator. LPN #1 indicated she would have to check the physicians order to verify if the liter flow of oxygen was correct. Further, LPN #1 identified the oxygen tubing and the nebulizer tubing/mask was not labled or dated. After review of the clinical record, LPN #1 indicated Resident #127 had a physician's order only for 2 liters of oxygen. LPN #1 was not aware that someone had increased the oxygen flow to 3 liters and indicated she did not get anything in shift-to-shift report that Resident #127 had any shortness of breath or needed the oxygen level increased. LPN #1 questioned RN #2 whom indicated there was nothing in shift report that Resident #127 was short of breath and needed oxygen increased. LPN #1 indicated she would immediately go to Resident #127 and decrease the oxygen from 3 liters to 2 liters per the physician's order. Observation identified that LPN #1 went to Resident #127's room and turned down the oxygen to 2 liters. LPN #1 did not check the resident's oxygen saturation or speak to Resident #127 prior to turning down the oxygen to 2 liters. Interview with the DNS on 12/5/22 at 11:09 AM identified the charge nurse is responsible to make sure they follow the physicians order for the liters of oxygen and notify the physician or hospice if Resident #127 needed to have the oxygen increased for comfort. Further, the DNS identified the charge nurses are responsible to change the oxygen and nebulizer tubing according to the physician's order, including to label and date the tubing and sign off in the TAR. Review of the oxygen administration policy identified to deliver low flow oxygen rates and concentrator, per the physician's order. Replace and date cannula and tubing weekly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #14) reviewed for medication administration, the facility failed to ensure the nurse used infection control practices according to professional standards during medication administration. The findings include: Resident #14 was admitted to the facility with diagnoses that included overactive bladder, repeated falls, and diabetes. The quarterly MDS dated [DATE] identified Resident #14 had moderately impaired cognition, was occasionally incontinent of bladder and frequently incontinent of bowel and required limited assistance with transfers. The care plan dated 10/27/22 identified Resident #14 had a diagnosis of hypertension and diabetes. Interventions included to administer medications as ordered by the physician. Observation on 12/1/22 at 9:13 AM identified after RN #2 left a resident's room, she moved the medication cart across the hallway, and without the benefit of hand hygiene, RN #2 began pouring medications for Resident #14. RN #2 was not wearing gloves. RN #2 was noted to pop Namenda 10mg, 1 tab, into her hand, then placed it into the medication cup. RN #2 popped Amlodipine 2.5mg, 1 tab into her hand and then placed it into the medication cup. RN #2 popped Metformin 500 mg 2 tabs, into her hand, and placed one of the Metformin 500mg tabs into the medication cup, and one back into the blister pack (only 500mg was needed). RN #2 found a second blister pack of Metformin 500mg tabs (single tabs) and with her ungloved hands, placed the Metformin 500mg tab she had just popped into the medication cup back into the blister pack and taped the blister pack shut. RN #2 then popped another Metformin 500mg tab into her hand and then put the tab into the medication cup. RN #2 popped a Myrbetriq 25mg, 1 tab into her hand and then placed it in the medication cup. Interview with the LPN #2 on 12/1/22 at 9:37 AM, who observed the medication administration, indicated she observed that RN #2 did not wash her hands or use hand sanitizer prior to pouring the medications for Resident #14. LPN #2 identified that RN #2 popped each medication into her hand and then placed the tablets into the medication cup. LPN #2 indicated nurses should never touch the medication and must pop the tablets directly into the medication cup which RN #2 did not do. Interview with the DNS on 12/5/22 at 11:30 AM indicated the nurses are to perform hand hygiene (hand wash or hand sanitizer) before preparing a resident's medication and then use hand sanitizer again once the medications have been administered. The DNS indicated the nurse should be popping the medication directly into the medication cup and not touching the pills. Review of medication administration policy identified medications are prepared by a licensed nurse. The nurse administering the medications adheres to good hand hygiene by handwashing and hand sanitizing which includes washing hands thoroughly before beginning a medication pass, prior to handling medications, and after coming into direct contact with a resident. Hand sanitizer is done with an approved sanitizer between handwashing when returning to the medication cart, at regular intervals during the medication pass such as after each room. Cleanse hands using soap and water or approved hand sanitizer before beginning a med pass, before handling medications, and before contact with a resident. Pour or push the correct number of tablets or capsules into the medication cup, taking care to avoid touching the tablet or capsule unless wearing gloves. When finished with each resident wash hands with soap and water or hand sanitizer.

Based on observation, review of facility documentation, facility policy, and interviews, the facility failed to maintain an accurate record of the dishwasher temperature. The findings include: Observation on 11/29/22 at 11:04 AM with the Nutrition Director in the kitchen identified the November 2022 dish machine temperature log had been completed, in advance, for the date of 11/29/22 for lunch, and supper. Interview on 11/29/22 at 11:05 AM with the Nutrition Director identified he was not aware that the dish machine temperature log had been filled out for lunch and supper. The Nutrition Director indicated that the Food & Nutrition Staff should not have fill out the lunch and supper column ahead of time. Interview on 12/5/22 9:55 AM with Food & Nutrition Staff #1 identified he was the one that filled out the dish machine temperature log, in advance, for lunch and supper on 11/29/22. Food & Nutrition Staff #1 indicated he does not have an answer to why he filled out the lunch and supper column in advance. Review of the facility dish room procedures identified log temperatures: #1 at breakfast, #2 at lunch, #3 at supper.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an observation, a review of the clinical record, staff interviews, and a review of the facility policy, for one sampled resident (Resident #95) reviewed for oxygen administration, the facility failed to change the oxygen tubing in accordance with the physician's orders. The findings include: Resident #95 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease (COPD), chronic respiratory failure, chronic diastolic heart failure and cerebral infarction. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified intact cognition, and extensive assistance with personal hygiene, dressing, bed mobility, transfers, and ambulation. The care plan dated 11/26/19 identified chronic obstructive pulmonary disease (COPD), chronic respiratory failure, interstitial pulmonary disease, atrial fibrillation, chronic heart failure and a history of transient ischemic attacks as problems, with a goal of stable cardiopulmonary function as evidenced by the absence of difficulty with breathing and maintaining vital signs within acceptable parameters per practitioner orders. Interventions included the administration of oxygen as ordered, and to change the oxygen tubing per the facility policy. Physician's orders dated 12/20/19 directed oxygen administration via nasal cannula at 5 liters per minute at all times. Physician's orders dated 12/20/19 directed to change the oxygen tubing and the nebulizer set up weekly, on Sunday, on the 11:00 PM to 7:00 AM shift. Observation of Resident #95 with LPN #1 on 1/21/19 at 12:30 PM identified Resident #95's oxygen tubing at his/her bedside was dated as changed on 01/05/2020. The oxygen tubing was in current use by Resident #95 with oxygen administered at 5 liters per minute. Review of the medication administration record (MAR) on 01/21/2020 at 1:40 PM identified the resident's oxygen tubing was changed on 1/5/20, and 1/12/20 (although the label on the oxygen tubing failed to indicate the tubing was changed on 1/12/20). Furthermore, the MAR failed to indicate the oxygen tubing was changed on 1/19/20. Interview with LPN #1 on 1/21/2020 at 12:35 PM identified oxygen tubing was to be dated and changed once a week. LPN #1 indicated it was the RN's responsibility on 11:00 PM to 7:00 AM shift to ensure the tubing was adequate for its intended use and changed as ordered. LPN #1 identified the oxygen tubing for Resident #95 should have been changed weekly and was not. The facility policy entitled Nasal Cannula Oxygen Administration directed in part to verify the physicians order and review the resident chart to familiarize yourself with the resident's history. Record the initiation of oxygen administration in the resident's record and replace the cannula periodically.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, for the only resident in the survey sample reviewed for dialysis (Resident #476) the facility failed to develop a baseline care plan for a resident receiving dialysis. The findings include: Resident #476 was admitted on [DATE] with diagnoses that included fractured right pubic ramus and end stage renal disease. An admission nursing assessment dated [DATE] indicated Resident #476 was alert and oriented and had a fistula on the left arm. A resident care plan dated 12/6/18 identified a problem with nutrition. Interventions included a renal diet. A Physician's order dated 12/6/18 indicated Resident #476 was a dialysis patient. A review of the clinical record and interview on 12/17/18 at 10:00 AM with Registered Nurse (RN) #1 indicated Resident #476 was a dialysis patient going to dialysis three times a week. He/she indicated resident's on dialysis should have a Physician's order for the dialysis, a careplan for dialysis, and an indication of the access device and location of the device. At that time he/she was unable to provide a Physician's order and/or baseline careplan for dialysis and/or the access device and location, and/or treatment of the access device. Review of the facility policy on hemodialysis indicated to obtain a Physician's order for hemodialysis which would include the name of the dialysis center, frequency of treatments, and the monitoring/care of dialysis site (fistula/hemodialysis catheter).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, for one of three residents reviewed for positioning (Resident #15), the facility failed to apply a positioning/splinting device in accordance with physician's orders. The findings include: Resident #15's diagnoses include dementia without behavioral disturbances. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident had severely impaired cognition, required extensive to total assistance with activities of daily living (ADL's), had no passive or active range of motion (ROM) provided and/or had no splint or brace assistance. The resident care plan dated 9/18/18 identified a problem with self care deficits. Interventions included to provide passive and active ROM with ADL's, apply a left Palmar guard with AM care and remove with PM care, check skin integrity pre/post wearing, see splint book at nurses station, and utilize a rolled wash cloth at night. A Physician's order dated 11/29/18 directed to apply a left [NAME] guard to the left hand with morning care and to remove at bedtime. A nurse's aide care card indicated to apply a left [NAME] guard donned with morning care and removed at bedtime. Observations on 12/11/18 at 11:30 AM noted Resident #15 with a wash cloth positioned in the left hand. Observations on 12/12/18 at 12:00 noon noted that the left hand contracture was without the benefit of any splinting/positioning device being utilized. Observations on 12/17/18 at 10:00 AM noted the left hand contracture was without the benefit of any splinting/positioning device being utilized. A review of the clinical record and interview on 12/17/18 at 11:15 AM with Occupational Therapist (OT) #1 indicated it was the responsibility of the nursing staff to apply the splinting device. If nursing had identified a concern with the splinting device or the splinting device was missing and/or lost, nursing would have to notify the therapy department for follow-up. Subsequent to surveyor inquiry, the left [NAME] hand guard was applied.