**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 three residents (Resident #1) reviewed for respiratory care, the facility failed to ensure an order was obtained timely for use of a continuous positive airway pressure machine. The findings include: Resident #1's diagnoses included respiratory failure with hypoxia (low oxygen level) and COPD. The admission assessment dated [DATE] identified that Resident #1 was alert and oriented and had a continuous positive airway pressure (CPAP) machine. Nursing admission Note dated 1/9/2025 at 11:35 PM identified Resident #1 used a CPAP machine and received respiratory treatments. The Resident Care Plan (RCP) dated 1/9/2025 identified Resident #1 had a care plan for cardiopulmonary symptoms. Interventions directed to administer medications as ordered, monitor for change in breathing pattern and lung sounds, and oxygen saturation every shift. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 was alert and oriented, and used oxygen and a CPAP machine. Review of APRN's note dated 1/10/2025 at 8:12 AM identified Resident #1 received oxygen and used a CPAP machine at night. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 was alert and oriented, and used oxygen and a CPAP machine. Record review failed to identify a physician order for the use of a CPAP machine. Interview and record review with the DNS on 2/3/2025 at 1:55 PM, identified the DNS was unable to provide documentation to reflect that facility had an order for CPAP machine use. She further indicated that the facility Noninvasive Ventilation policy directed that the facility obtain an order for the use of CPAP and that a physician order should have been obtained for the use of the CPAP machine. Interview failed to identify why an order was not obtained. Review of facility Noninvasive Ventilation Policy directed in part, to provide noninvasive ventilation per physician orders. The facility will obtain an order for the use of CPAP device and settings from the practitioner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy, and staff interviews for 1 of 3 residents (Resident #96) reviewed for weight loss, the facility failed to notify the dietician in order to make recommendations when a significant weight loss occurred. The findings include: Resident #96's diagnoses include cerebral infarction, dysphagia, and cholecystitis. The Resident Care Plan dated 3/8/24 through 7/2924 identified Resident #96 was on a mechanically altered diet secondary to dysphagia. Interventions included to provide a regular ground diet with thin liquids, encouraging fluids, intake and output as needed, nutritional assessments as needed, supplements as ordered, and weights as ordered. Resident #96's admission Nutritional Evaluation from the dietician and dated 3/11/24 at 11:53 AM identified Resident #96 weighed 141.2 pounds (lbs.). The Nutritional Evaluation further identified the dietician was provided with Resident #96's food preferences and did not identify any dietary concerns, or cultural accommodation needs for meal offerings. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #96 had severe cognitive impairment, required substantial assistance with chair/bed to chair transfers, and required set-up assistance with eating. A record review of Resident #96's weights identified the following weight entries: On 3/11/24 a weight of 141.2 lbs., on 4/16/24 a weight of 132.0 lbs. (a 10.2 lb./6.25% loss in one month). On 5/11/24 Resident #96 weighed 130.8 lbs., and on 6/11/24 weighed 128.8 lbs., a 12.2 lb. loss over 3 months (8.78%). Physician's order dated 5/20/24 directed to administer House Supplement 120 milliliter (ml) twice daily (34 days after a 10.2 lb/6.25% weight loss). A Dietician's progress note dated 7/29/24 identified a weight loss of 13.5 lbs. from a pre-hospital weight (on 7/13/24) and recommended a Glucose Control supplement of 120 milliliters three times a day. Physician progress notes dated 7/31/24 identified Advanced Practice Registered Nurse (APRN) #1 evaluated Resident #96's weight loss and referred him/her to the Dietician for supplements. An interview with Registered Nurse (RN) #5 on 10/10/24 at 11:24 AM identified that nursing was responsible for the monitoring of weights and weight trends for residents. When a concern with a resident's weight was identified, nursing was responsible to notify both the dietician and the provider, but RN #5 was unable to identify that the dietician had been notified prior to 7/29/24. An interview with Advanced Practice Registered Nurse (APRN) #1 on 10/10/24 at 11:38 AM identified that she was made aware of Resident #96's weight loss all along and no medical consultation was required for the weight loss. An interview with the Dietician on 10/11/24 at 9:50 AM identified that she did not receive any notification of Resident #96's weight loss in March 2024 through June 2024. The first time she was notified of Resident #96's weight loss was on 7/29/24. Review of the Weight Assessment and Intervention Policy identified that any verified weight change of 5 lbs. or greater should be reported to both the dietician and the practitioner.

**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 #3) reviewed for abuse, the facility failed to report injuries of unknown source to the state agency (SA) timely. The findings include: Resident #3's diagnoses included vascular dementia, osteoarthritis and a fracture of the left hand. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 was significantly cognitively impaired and required substantial/maximal assistance with transfers and toileting, and supervision or touching assistance with bed mobility. The Resident Care Plan dated 5/13/24 identified a risk for skin injuries (bruising/bleeding/skin tears) and a potential for falls. Interventions included to inspect skin daily during care, encourage to call for assistance, and orient to surroundings. An APRN progress note dated 7/4/24 at 1:01 PM identified Resident #3 had an area of bruising (spontaneous ecchymosis) on the lateral side of his/her left orbital (eye) area with no concern for fracture or pain. A nurse's progress note dated 7/8/24 at 2:39 PM identified Resident #3 had a slight bluish/purple hue to his/her pinky and ring finger extending up to the top of the back of his/her hand. An APRN progress note dated 7/11/24 at 9:41 AM, for a date of service on 7/10/24, identified Resident #3's left hand had no obvious bruising or deformity with mild swelling to the left side which appeared non-tender with movement. The APRN progress note further indicated the bruise to Resident #3's left periorbital (eye) area was non-tender. An APRN progress note dated 7/11/24 at 9:56 AM identified Resident #3 had bruising of the left hand and bruising of the left eye. The APRN progress note further indicated that Resident #3 stated that he/she fell from a chair and could not recall the day. Additionally, the APRN progress note identified that after discussion with Resident #3's responsible party, an x-ray of the left hand was ordered. A radiology (x-ray) result report for Resident #3 dated 7/11/24 at 12:00 PM identified an acute hairline non-displaced fracture of the 4th metacarpal of the left hand with diffuse osteopenia and soft tissue swelling indicated. An APRN progress note on 7/11/24 at 2:15 PM identified that Resident #3's left hand x-ray had revealed an acute non-displaced fracture of the 4th metacarpal (bones that connect the finger to the wrist), and the family requested to have Resident #3 evaluated further at the hospital Emergency Department. A nurses note dated 7/11/24 at 4:23 PM identified that the DNS was notified of Resident #3's acute left hand fracture of the 4th metacarpal bone and that Resident #3 had self-reported a fall. A Reportable Event form signed as filed on 7/12/24, identified Resident #3 had new bruising and swelling noted to the left hand on 7/10/24 with x-rays taken on 7/11/24. The x-ray report dated 7/11/24 indicated a fracture of the left hand, 4th metacarpal. The DNS and APRN were notified, an investigation was initiated, and the family was present. Family requested transfer of Resident #3 to the hospital Emergency Department for further evaluation. A nurses note dated 7/12/24 at 8:11 AM identified that Resident #3 had returned from the hospital Emergency Department with a diagnosis of closed fracture of the left metacarpal bone and a left orbital contusion. Interview and record review on 10/11/24 at 10:00 AM with PT #1 indicated that she was familiar with Resident #3 as she was asked to evaluate Resident #3 post incident on 7/12/24. A review of PT #1's treatment encounter note identified Resident #3 was unable to perform fall recovery tasks and that he/she would be unable to perform floor to standing position on his/her own without physical assist. PT #1 further indicated that Resident #3 would not be able to get up on his/her own if he/she fell as he/she required moderate to maximum assistance for wheelchair to bed transfers. Although Resident #3 reported that he/she had fallen, the resident would have been unable to rise independently from a fall. Interview and record review with APRN #1 on 10/11/24 at 10:14 AM identified that she had evaluated Resident #3 on 7/10/24 and although he/she had a bruise to his/her left eye, she did not see an injury to his/her left hand. APRN #1 indicated that when she evaluated Resident #3 on 7/11/24 she did see a bruise to his/her left hand and ordered an x-ray which showed a fracture. APRN #1 further identified that due to Resident #3's advanced dementia and inability to get up on his/her own, she did not believe Resident #3's report of falling or that a fall had caused his/her injuries. Additionally, APRN #1 indicated that although she was notified and saw Resident #3 in person on both dates, she was unsure if the facility further investigated how the injury had occurred or if the facility had notified the SA timely. Interview with the facility's Medical Director, MD #1, on 10/11/24 at 12:38 PM indicated she was unable to identify a possible cause of Resident #3's injuries and that although the injuries were reported to her, she did not evaluate Resident #3 and did not know the mechanism of injury. Interview and record review with the DNS on 10/11/24 at 1:15 PM indicated that Resident #3 had sustained a left eye bruise and a left hand fracture in July 2024. The DNS identified that without a witnessed fall incident, investigation information indicating the resident fell and was assisted to rise, and with the residents advanced dementia, the facility was unable to determine the cause of the injuries. The DNS indicated that Resident #3's left eye bruise and left hand fracture were considered injuries of unknown source, and the fractured hand should have been correctly classified as a possible allegation of mistreatment (injury of unknown origin) and subsequently sent to the SA, per the facility Abuse/Neglect/Exploitation policy. The DNS was unable to identify a reason Resident #3's injuries of unknown origin were not reported timely, but she was not in the DNS role at that time. Review of the facility policy, Abuse/Neglect/Exploitation, dated 4/29/24, directed that possible indicators of abuse include physical injury of a resident of unknown source. The Abuse/Neglect/Exploitation policy further directed that all alleged violations would be reported to the SA immediately if the event resulted in serious bodily injury, and that the results of the facility's investigation would be reported to the SA. Review of the facility policy, Unexplained Injuries, dated 5/10/23, directed that an injury shall be classified as an injury of unknown source when the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident and the injury is suspicious. The policy further directed that reporting and investigation procedures for injuries of unknown source would be implemented in accordance with the facility's abuse policies and procedures.

**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 #96) reviewed for weight loss, and for 1 of 6 sampled residents (Resident #706) reviewed for unnecessary medications, the facility failed to revise the Resident Care Plan (RCP) when a change occured. The findings include: 1. Resident #96's diagnoses included cerebral infarction, dysphagia, and right sided hemiplegia and hemiparesis. An initial Nutritional Evaluation dated 3/11/24 at 11:53 AM and written by the dietician identified that on 3/11/24, Resident #96 weighed 141.2 pounds (lbs.). The Nutritional Evaluation further identified the dietician was provided with Resident #96's food preferences and did not identify any dietary concerns or cultural accommodations for meal offerings. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #96 had severe cognitive impairment, required substantial assistance with chair/bed to chair transfers, and required set-up assistance with eating. The Resident Care Plan (RCP) dated 3/8/24 through 7/29/24 identified Resident #96 was on a mechanically altered diet secondary to dysphagia. Interventions included a regular ground diet with thin liquids, encouraging fluids, intake and output as needed, nutritional assessments as needed, supplements as ordered, and weights as ordered. The RCP further identified that Resident #96 had Halal cuisine and food, and communication barriers. A record review of Resident #96's weights identified the following weight entries: An admission weight on 3/11/24 was 141.2 lbs., on 4/16/24 a weight of 132.0 lbs. was recorded for a 10.2 lb. loss (6.25% in one month). On 5/11/24 Resident #96 weighed 130.8 lbs., and on 6/11/24 weighed 128.8 lbs., a 12.2 lb. loss over 3 months (8.78%). On 9/17/24 Resident #96 weighed 115.2 lbs. (18.4% loss over 6 months), and on 10/2/24 weighed 112.2 lbs. for a total loss of 29 lbs. The RCP dated 3/8/24 through 9/11/24 failed to identify that the care plan was reviewed and revised following Resident #96's significant weight loss. An interview with the dietician on 10/11/24 at 9:50 AM identified she was notified on 7/29/2024 of Resident #96's weight loss. She was unaware of a pattern of weight loss for Resident #96 before 7/29/24. Review of the Weight Assessment and Intervention Policy identified that care planning for weight loss shall address the cause of the weight loss, goals and benchmarks for improvement, and time frames and parameters for monitoring and reassessment. 2. Resident #706's diagnoses included atrial fibrillation, hypertension, and congestive heart failure. The admission Nursing assessment dated [DATE] identified Resident #706 was cognitively intact, required staff assistance with toileting, was dependent with transfers, and was non-ambulatory. A physician's order dated 9/25/24 directed to administer warfarin 3 milligrams (mg) by mouth at bedtime every Monday, Wednesday, and Friday for atrial fibrillation. Review of the Resident Care Plan (RCP) dated 9/25/24 through 10/10/24 failed to identify Resident #706 was on an anticoagulant. A warfarin worksheet entry dated 9/26/24 identified that 1 dose of warfarin was held and not administered on 9/26/24 and then a Prothrombin Time and International Normalized Ratio (PT/INR) blood test (which monitored how well the blood thinning medication was working to prevent blood clots) was completed on 9/27/24. In an interview and clinical record review with the MDS (Minimum Data Set) Coordinator Licensed Practical Nurse (LPN) #3 on 10/10/24 at 10:30 AM, the clinical record failed to include an anticoagulation focus, goal, and intervention in the RCP. LPN #3 identified that there had been an anticoagulation focus on admission on [DATE] for Resident #706, but that she had resolved this focus on 9/26/24 when she didn't see an active order for an anticoagulant in Resident #706's electronic medical record. LPN #3 identified that due to Resident #706 being on warfarin, it should have been included in the RCP, and if there had been a hold order in the electronic medical record, she would not have resolved (discontinued) the anticoagulation focus. Subsequent to surveyor inquiry, an anticoagulation care plan was added with a potential for bleeding and interventions to administer the anticoagulant medication per the physician's order and observe for bruising or bleeding were added to Resident #706's RCP. Review of the High Risk Medications-Anticoagulants policy directed, in part, that the resident's plan of care shall alert staff to monitor for adverse consequences and risks associated with anticoagulants included bleeding such as bleeding gums, nosebleed, unusual bruising, and blood in urine or stool.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, and interviews for the only sampled resident (Resident # 46) reviewed for Hospice, the facility failed to follow a physician's order for the application of arm protectors, for 1 of 3 residents (Resident #96) reviewed for nutrition, the facility failed to obtain and document the resident's weekly weights per physician orders for a resident with a significant weight loss. The findings include: 1. Resident #46's diagnoses included dementia without behavioral disturbances, psychotic disturbance, mood disturbance, and anxiety. The quarterly MDS assessment dated [DATE] identified Resident #46 was severely cognitively impaired and totally dependent for bed mobility, upper and lower body dressing, and transfers. A Physician's order dated 9/9/24 directed to apply bilateral arm protectors to be worn at all times, may be removed for care and reapplied every shift. The Resident's Care Plan in effect from 10/1/24 to 10/11/24 identified a potential for skin impairment. Interventions included apply bilateral arm protectors to be worn at all times, may be removed for care and reapplied, observe for changes in skin integrity, and update the provider. Review of the undated nurse aid care card directed that bilateral arm protectors were to be worn at all times. Observations on 10/10/24 at 12:15 PM and 2:33 PM, and again on 10/11/24 at 10:04 AM identified Resident #46 sitting up in the wheelchair next to the bed in his/her room without the benefit of arm protectors. Resident #46 was noted to be wearing a short sleeve garment during both observations and both upper arms were exposed to his/her hands. An interview with NA #4 on 10/11/24 at 10:04 AM identified that although a review of the NA care card directed to apply bilateral arm protectors, NA #4 indicated bilateral arm protectors were not present on the care card. NA #4 stated that in the last year, sometimes bilateral arm protectors were placed on Resident #46 and sometimes not. Further, NA #4 searched Resident #46's room, drawers, and closet but was unable to locate any arm protectors which could be placed on Resident #46. Review of Resident #46's Treatment Administration Record (TAR) identified that although bilateral arm protectors were signed off as applied on 10/10/24 during the 7:00 AM to 3:00 PM shift, observations on that day failed to identify the arm protectors had been placed on Resident #46. An interview with the DNS on 10/11/24 at 10:50 AM indicated that bilateral arm protectors were noted on Resident #46's RCP and NA care card but were identified as skin protection versus what the physician's order indicated, bilateral arm protectors, and that the skin protection devices should have been applied. Although requested, the facility indicated there was no policy for the use of arm protectors. 2. Resident #96's diagnoses include cerebral infarction, cholecystitis, and dysphagia. The Resident Care Plan (RCP) dated 3/8/24 through 9/11/24 identified Resident #96 was on a mechanically altered diet secondary to dysphagia. Interventions included a regular ground diet with thin liquids, encourage fluids, intake and output as needed, nutritional assessments as needed, supplements as ordered, and weights as ordered. The Quarterly Minimum Data Set assessment dated [DATE] identified Resident #96 had moderate cognitive impairment, required substantial assistance with chair/bed to chair transfers, and required set-up assistance with eating. An Advanced Practice Registered Nurse order dated 8/7/24 directed weekly weights be taken for Resident #96 every Wednesday at shower-time by 7:00 AM to 3:00 PM staff. Review of Resident #96's electronic medical record (EMR) and Treatment Administration Record (TAR) identified missing documentation of weekly weights or documented resident refusal for the dates of 8/21/24, 8/28/24, 9/4/24, 9/11/24, and 9/25/24 (missing 5 of 9 opportunities). The Nurse Aide (NA) Care Card identified that Resident #96's weights should be monitored. The NA Care Card did not indicate when to weigh, how often to weigh, or who was responsible for weighing Resident #96. An interview with Licensed Practical Nurse (LPN) #5 on 10/10/24 at 10:44 AM identified the only place she documents a resident's weight was in the EMR. NAs do not document the weights of residents but do weigh the residents. NAs write the resident's weight on a piece of paper, which is handed to the LPN, for review and documentation within the EMR and TAR. LPN #5 was not able to identify the reason weights were not documented for the dates 8/21/24, 8/28/24, 9/4/24, 9/11/24, and 9/25/24 despite the TAR indicating a check mark as completed. An interview with Registered Nurse (RN) #4 on 10/10/24 at 11:01 AM identified that weights taken on residents should only be entered into the resident's chart. If a weight was not charted in the weights section of the EMR, it might also be referenced in a RN progress note. RN #4 was not able to locate any weights documented in a progress note for the dates 8/21/24, 8/28/24, 9/4/24, 9/11/24, and 9/25/24. RN #4 indicated RN #5 was responsible for ensuring LPNs and RNs documented weights in the resident chart. An interview with RN #5 on 10/10/24 at 11:12 AM identified that there was a pattern of weights being marked as taken by a check mark, with no weight being documented. RN #5 stated there was a step in the order entry process that was omitted which included triggering a mandatory weight value documentation at the time of documenting a weight was completed. Subsequent to surveyor inquiry, a change was made to the order that initiates a hard stop and requires a weight be documented when charting a weight was taken. Review of the Weight Assessment and Intervention Policy identified that weights are to be recorded in each resident's electronic medical record and in the unit's weight record chart.

Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents reviewed for positioning and mobility, the facility failed to provide range of motion (ROM) to a dependent resident. The findings include: Resident #357's diagnoses included fracture of the right humerus (broken bone of the upper arm), and congestive heart failure. The admission Nursing Evaluation dated 10/3/24 identified Resident #357 was cognitively intact, mobility was very limited and was unable to make significant changes independently, and his/her ability to walk was severely limited and required moderate assistance. The Resident Care Plan dated 10/4/24 identified Occupational Therapy for alteration in self-care and activities of daily living (ADLs) deficit related to decreased strength. Interventions included Occupational Therapy 5 times a week, non-weight bearing (NWB) of the right upper arm, leave the sling on at all times, may remove 3 times daily for active range of motion (AROM) of the right elbow, wrist, and fingers only. A physician's order dated 10/4/24 directed non-weight bearing of the right upper extremity (arm), sling on at all times, may remove 3 times daily to perform AROM of right elbow, wrist, and fingers only. Observation and interview with Resident #357 on 10/7/24 at 12:48 PM, identified that his/her sling was not being removed 3 times daily to perform AROM of right elbow, wrist, and fingers per what he/she was instructed to do in the hospital. The Hospital Discharge Summary instructions dated 10/2/24 directed the right upper extremity (arm) should remain in a sling at all times, however, should be removed approximately 3 times per day to perform range of motion at the elbow, wrist, and fingers to prevent stiffness. In an interview and clinical record review on 10/9/24 at 11:53 AM with Licensed Practical Nurse (LPN) #2 facility documentation failed to identify that Resident #357's sling was to be removed 3 times a day to perform AROM to the elbow, wrist, and fingers per the hospital Discharge Summary. Additionally, a review of the Treatment Administration Record (TAR) failed to direct the nursing staff to remove the sling and provide AROM 3 times daily. An interview and clinical record review with PT (Physical Therapist) #1 on 10/9/24 at 12:06 PM identified the AROM order for Resident #357 was entered into the computer system on 10/4/24 and should have been followed by staff. Interview and clinical record review with the Director of Nurses on 10/9/24 at 12:39 PM identified the order for Resident #357's sling removal for staff to provide AROM 3 times daily, but the information had been entered into the computer system inaccurately. Further, the DNS indicated although there was a physician order, the nursing staff had not been prompted to provide Resident #357 with AROM and would not have known to provide range of motion per the hospital Discharge Summary due to the way the order was entered. Subsequent to surveyor's inquiry on 10/9/24 a therapy order; NWB, Therapy to perform AROM of right elbow, wrist, fingers, as tolerated by Resident #357. Although requested, a facility policy for Physical Therapy was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, review of facility policy and staff interviews for 2 of 3 residents, (Resident #96 and #406), reviewed for nutrition and hydration, for Resident #96 the facility failed to implement interventions for a resident who continued to experience significant weight loss, and for Resident #406, the facility failed to consistently document intake and output for a resident on intravenous hydration. The findings include: 1. Resident #96's diagnoses include cerebral infarction, cholecystitis, and dysphagia. The Resident Care Plan (RCP) dated 3/8/24 through 9/11/24 identified Resident #96 was on a mechanically altered diet secondary to dysphagia. Interventions included a regular ground diet with thin liquids, encouraging fluids, intake and output as needed, nutritional assessments as needed, supplements as ordered, and weights as ordered. A Nutritional Evaluation dated 3/11/24 at 11:53 AM written by the dietician identified Resident #96's weighed 141.2 pounds (lbs.) and identified the dietician was provided with Resident #96's food preferences, did not identify the dietician had any dietary concerns, and did not make any recommendations for cultural accommodations for meal offerings. The admission Minimum Data Set assessment dated [DATE] identified Resident #96 had severe cognitive impairment, required set-up assistance with eating and required substantial assistance with chair/bed to chair transfers. A record review of Resident #96's weights identified the following weight entries: An admission weight on 3/11/24 was 141.2 lbs., on 4/16/24 a weight of 132.0 lbs. was recorded for a 10.2 lb. loss (6.25% in one month). On 5/11/24, Resident #96 weighed 130.8 lbs., and on 6/11/24 weighed 128.8 lbs., a 12.2 lb. loss over 3 months (8.78%). On 9/17/24 Resident #96 weighed 115.2 lbs. (a 26 lb/18.4% loss over 6 months), and on 10/2/24 weighed 112.2 lbs. for a total loss of 29 lbs in 205 days. A progress note by Advanced Practice Registered Nurse (APRN) #1 dated 3/8/24 identified Resident #96's albumin level, (a measure of the amount of protein in an individual's blood plasma that can be an indicator of malnutrition) was 3.8 (Normal albumin levels range from 3.5 to 5.5). A progress note by APRN #1 dated 4/2/24 identified Resident #96's albumin level, was 3.1 (Normal albumin levels range from 3.5 to 5.5). APRN #1 did not indicate within the progress note that Resident #96's albumin had decreased since the last albumin level of 3.8 obtained on 3/8/2024. A dietician progress note dated 4/15/24 identified that Resident #96 had an approximate 50%-75% meal intake, albumin levels were within normal limits per 4/2/24 labs (despite an albumin level being in the below normal range), and meal preferences were provided as requested. No diet changes were recommended. The dietician's note failed to acknowledge or address Resident #96's significant weight loss and failed to acknowledge Resident #96's albumin level per 4/2/24 labs was below normal limits. A progress note by APRN #1 dated 5/7/24 identified that she was aware of Resident #96's 11 lb. weight loss since admission and she stated the reports she had received from nursing was the resident ate well. APRN #1's progress note failed to address Resident #96's significant weight loss at that time and no interventions for the resident's continued weight loss were added to his/her plan of care. The Medication Administration Record (MAR) for July 2024 indicated a House Supplement of 120 milliliters (ml) to be administered twice a day was added to Resident #96's plan of care on 5/20/24 (35 days after the 10.2 lb./6.25% one month weight loss was documented on 4/16/24) and was discontinued on 7/20/24 when Resident #96 was hospitalized for cholecystitis. A progress note by APRN #1 dated 7/22/24 identified Resident #96's albumin level was 3.0 (Normal albumin levels range from 3.5 to 5.5). APRN #1 did not indicate within the progress note that Resident #96's had further decreased since the last albumin level of 3.1 obtained on 4/2/24. A dietician progress note dated 7/22/24 identified that Resident #96 had an approximate 50%-75% meal intake, had not lost any weight during his/her recent hospitalization for cholecystitis, and the resident was maintaining his/her weight without gain. No diet changes were recommended. The dietician's note failed to address the severe weight loss for Resident #96's since admission, (a 12.2 lb/8.8%. loss over 3 months from 3/11/24 through 6/11/24). The Medication Administration Record (MAR) from 7/30/24 through August 2024 identified a House Supplement Glucose Control Boost of 120 ml to be administered 3 times a day was added to the Resident #96's plan of care on 7/30/24. An interview with the dietician on 10/11/24 at 12:47 PM identified she was unable to determine if adding the Glucose Control Boost supplement in April would have prevented or slowed down the weight loss for Resident #96. Review of the Weight Assessment and Intervention Policy identified that any verified weight change 5 lbs. or greater should be reported to both the dietician and the practitioner. The dietician will review the unit weight record by the 15th of the month to follow weight trends over time. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort. Care plans for weight loss should include identified causes of the weight loss, goals and benchmarks for improvement, and timeframes and parameters for monitoring and reassessment. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a) 1 month - 5% weight loss is significant; greater than 5% is severe b) 3 months - 7.5% of weight loss is significant; greater than 7.5% is severe c) 6 months - 10% weight loss is significant; greater than 10% is severe 2. Resident #406 's diagnoses included dementia, malnutrition, and small bowel obstruction. A Nutritional Evaluation dated 9/16/24 identified a total fluid need of 1392 milliliters (ml) in 24 hours. A good appetite was noted on admission with poor intake noted the past few days with some meals refused. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #406 was severely cognitively impaired with long- and short-term memory loss and required total assistance with all activities of daily living. A physician's order dated 9/20/24 at 8:30 AM directed intravenous hydration (IV) of dextrose 5 percent (%), ½ normal saline at 60 milliliters (ml) per hour for 2 liters. A nurse's note dated 9/21/24 at 4:42 PM identified Resident #406's IV was patent (functioning), Foley urinary catheter output was 840 (cubic centimeters) cc, and the resident had poor oral intake. A nurse's note dated 9/22/24 at 10:57 PM identified resident #406 had independently pulled out his/her IV at 3:30 PM, the supervisor was notified, and the IV nurse was to reinsert the IV to continue therapy. Additionally, the Resident #406 had taken 25% or less of his/her meal, and that the IV nurse had reinserted the IV access at 8:00 PM. A physician's order dated 9/23/24 at 3:30 PM directed IV hydration of dextrose 5%, ½ normal saline at 75 ml per hour for 3 liters for hypernatremia (high sodium level) and anemia (low red blood cell count). Review of the intake and output worksheets for 9/23/24 failed to identify any IV intake for the 7:00 AM to 3:00 PM shift, 3:00 PM to 11:00 PM shift, or the 11:00 PM to 7:00 AM shift. Additionally, the document failed to identify if Resident #406 had any output for the 7:00 AM to 3:00 PM shift and failed to identify 24-hour totals. A nurse's note dated 9/24/24 at 4:06 PM identified that Resident #406 independently pulled out the IV. The nurse practitioner (APRN) was notified and instructed to have the IV replaced. Review of intake and output documents for 9/24/24 on the 7:00 AM to 3:00 PM shift failed to identify IV intake, on the 11:00 PM to 7:00 AM shift the documentation failed to identify IV or per orum (oral PO) intake and 24-hour totals were not calculated. Review of intake and output documents for 9/25/24 failed to identify IV intake or output on the 7:00 AM to 3:00 PM shift. Although Resident #406 should have received 600 ml of IV fluid on the 11:00 PM to 7:00 AM shift, the documentation indicated 250 ml of IV fluid was received and documentation failed to identify a 24-hr total. A physician's order dated 9/26/24 directed intravenous hydration of dextrose 5% ½ normal saline at 75 ml per hour for 1 liter. An APRN progress note dated 9/26/24 identified blood work indicating hypernatremia: Sodium 148, (normal 135-145), slowly trending down. Resident #406 has completed intravenous fluids. Oral intake is fair. Intravenous fluid dextrose 5% ½ normal saline at 75 milliliters per hour for 7 days, 3 liters, discontinue when complete. Review of the intake and output documents for 9/26/24 for the 7:00 AM to 3:00 PM failed to identify IV intake or any output. Additionally, the documents failed to identify any intake or output for the 3:00 PM to11:00 PM shift and failed to identify a 24-hour total. A nurse's note dated 9/27/24 at 6:23 AM identified IV Dextrose 5% ½ normal saline infusing at 75 milliliters per hour. Review of intake and output documents on 9/27/24 failed to identify any intake, for the 11:00PM to 7:00 AM shift, the 7:00 AM to 3:00 PM shift, failed to identify any output, and the 3:00 PM to 11:00 PM failed to identify any intake or output; no 24-hour totals were calculated. On 9/28/24 the documents failed to identify intake for 11:00 PM to 7:00 AM, 7:00 AM to 3:00 PM, or 3:00 PM to 11:00 PM shifts. Additionally, output was identified only for the 11:00 PM to 7:00 PM shift, was 100 ml, and 24-hour totals were not calculated. On 9/29/24 documents failed to identify intake for the 11:00 PM to 7:00 AM and 3:00 PM to 11:00 PM shifts and failed to identify a 24-hour total. A physician's order dated 9/30/24 at 1:00PM directed intravenous hydration dextrose 5% ½ normal saline at 75 ml per hour for 2 liters. An APRN note dated 9/30/24 in part, identified poor oral intake, hyperosmolality and hypernatremia: sodium 147 mEq /Liter (normal 135-145) intravenous fluid dextrose 5% ½ normal saline at 75 ml per hour for 2 bags. Mucous membranes dry, malnourished, thin, alert and confused. A nurse's note dated 9/30/24 at 12:53 PM identified that Resident #406 did not have an active IV site on assessment. A nurse's note dated 9/30/24 at 10:22 PM identified the APRN ordered IV therapy and IV nurse to place an IV at 4:30 PM. IV fluids were started at 5:00 PM. On 9/30/24 the intake and output documents failed to identify intake for 11:00 PM to 7:00 AM shift, failed to identify output on 7:00AM to 3:00 PM shift, and failed to identify intake or output on 3:00 PM to11:00 PM, with no 24-hour totals. A nurse's note dated 10/1/24 at 10:40 PM identified a second IV bag was hung and infusing. Resident #406 did not eat their dinner meal. On 10/1/24 the intake and output documents failed to identify IV intake or output for 7:00 AM to 3:00 PM shift, failed to identify IV intake or output for 3:00 PM to 11:00 PM shift, and failed to identify a 24-hour total. A nurses note dated 10/2/24 at 2:38 AM identified Resident #406 independently pulled out the IV at 1:30 AM. Approximately 400 ml of IV fluid was remaining and the APRN was notified and instructed to hold reinsertion and resumption of fluids until seen by the house ARPN in the morning. On 10/2/24 the intake and output documents failed to identify output on 7:00 AM to 3:00 PM, and 3:00 PM to11:00 PM shifts. Additionally, the documents failed to identify a 24-hour total. A Physician's order dated 10/3/24 at 4:00PM directed intravenous hydration dextrose 5% ½ Normal saline at 60ml per hour for 2 liters for hypernatremia. An ARPN note dated 10/4/24 for follow up for dehydration: most recent blood work shows sodium of 148 (normal 135-145). In the past Resident #406 has been given several liters of fluids, and the sodium level has stayed in the high 140's. Nursing staff report resident #406's appetite is poor, and Resident #406 gets agitated with care. The Resident Care Plan dated 10/4/24 identified nutrition and hydration. Interventions included to encourage fluids, intake and output as needed, nutritional assessment, and weight as ordered. A nurses note dated 10/5/24 identified Resident #406's IV infiltrated into the forearm and elbow. The IV was removed and a call was placed to the IV nurse for reinsertion because 1.25 liters of IV fluid was remaining. A nurse's note dated 10/5/24 at 11:21 PM identified that the IV was infusing. An APRN note date 10/6/24 identified intravenous fluid dextrose 5% ½ normal saline at 60 ml per hour for hypernatremia for 3 days to infuse 2 liters. A nurses noted dated 10/6/24 at 4:16 AM identified that Resident #406 pulled out the IV saline lock with 100ml left in bag, the APRN was notified and instructed to encourage oral fluids. A physician's order dated 10/7/24 at 1:20 PM directed to reinsert the IV, dextrose 5% ½ normal saline at 75 ml per hour for 3 liters for hypernatremia and leukocytosis. A nurse's note dated 10/8/24 identified dextrose 5% ½ normal saline infusing at 75 ml per hr. A nurse's note dated 10/9/24 identified fluids were not able to be run due to IV not being patent. The provider assessed Resident #406 and ordered STAT (immediate) labs. On 10/9/24 at 10:28 PM, IV hydration was noted, 3rd bag hung at 8:00 PM. A physician's order dated 10/9/24 directed to hold IV fluids until IV line reinserted. Observation on 10/9/24 at 11:15 AM Resident #406 noted to be restless in bed, uncovering self, without an IV running. NA #2 repositioned Resident #406 in bed for comfort. Observation on 10/10/24 at 9:25 AM, Resident #406 was lying in bed, with IV infusing in the left arm, somewhat restless but more awake. Interview with LPN #1 on 10/9/24 at 12:30 PM identified that although Resident #406 had been receiving IV fluids from 10/3/24 through 10/9/24 according to the nurse progress notes, intake and output records could not be located. LPN #1 indicated that Resident #406 should have intake and output documents since s/he was on an IV hydration. Additionally, LPN #1 stated she had not started an intake and output document for Resident #406 as yet, but she would start one for today. Interview with MDS/Case Manager LPN #3 on 10/9/24 at 3:00 PM identified that she could not locate any additional intake and output documents from 10/3/24 through 10/9/24 and could not locate 24-hour totals in the progress notes for any of the days Resident #406 had an IV from 9/20/24 until present. Interview and clinical record review with DNS on 10/10/24 at 10:21 AM identified that the facility policy was to ensure IV fluid amounts were documented on the intake and output form. Review of Resident #406's intake and output record with DNS identified numerous missing and blank intakes as noted. The DNS identified that both oral and IV intake as well as output should be recorded as well as 24-hour totals. The charge nurse was responsible to calculate the total for the shift they worked and the 11:00 PM to 7:00 AM nurse was responsible to calculate the 24 totals. The DNS was unable to explain the omissions. Review of the intake and output (I&O) recording policy directed, in part, intake and output of fluids is documented when indicated by attending physician order or by nursing per resident diagnosis and or treatment. I&O recording may be instituted per an attending physician order or by a licensed nurse for any resident with the following: intravenous therapy for hydration, and urinary catheter. Nursing staff will be responsible for completing the I&O records at the end of each shift. Information obtained from the I&O will be totaled daily and reviewed to ensure resident's intake and output are sufficient to meet the resident's needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #85) reviewed for hospitalization, the facility failed to ensure that a resident who was hospitalized for digoxin toxicity did not receive the same high risk medication (digoxin) on readmission from the hospital which resulted in a significant medication error. The findings include: Resident #85 's diagnoses included atrial fibrillation, congestive heart failure, and thrombophilia. The admission Nursing assessment dated [DATE] identified Resident #85 was cognitively intact, required staff assistance with toileting, required total/maximum assistance of two staff members for transfers, and was non-ambulatory. Review of the Resident Care Plan (RCP) in effect 9/30/24 through 10/11/24 identified Resident #85 was at risk for cardiac distress. Interventions included to administer medications as ordered and monitor for adverse effects. The RCP failed to identify that Resident #85 had been hospitalized with digoxin toxicity. A hospital discharge interagency referral form (W10) dated 9/30/24 identified Resident #85 had been admitted to the hospital after being sent out from the facility due to severe bradycardia related to digoxin toxicity and was discharged back to the facility on 9/30/24. The discharge instructions included to stop taking digoxin 250 micrograms (mcg) daily. A physician's order dated 9/30/24 directed to administer digoxin 250 mcg by mouth in the morning for atrial fibrillation. Review of the October medication administration record (MAR) for Resident #85 identified that digoxin 250 mcg had been administered on 10/1/24 at 9:00 AM. A physician's order dated 10/1/24 directed to discontinue the digoxin 250 mcg order. A nurse practitioner note (NP) dated 10/1/24 at 4:00 PM identified that Resident #85 was seen after being readmitted from the hospital. Resident #85 was in the hospital for bradycardia related to digoxin toxicity for which he/she received 7 doses of Digibind (an antidote to treat a life-threatening overdose of digoxin). The note further identified that digoxin was to be avoided. Interview with Registered Nurse (RN) #3 on 10/10/24 at 11:45 AM identified that she had entered the admission medication orders for Resident #85 into the electronic medical record (EMR) on 9/30/24. RN #3 stated that she had completed a drug regimen review (DRR) with the covering on-call Nurse Practitioner (NP). She entered the orders under the attending medical doctor's name due to the covering NP's name not being available in the Electronic [NAME] Record (EMR) system. Further RN #3 indicated that she would have documented the completion of the DRR in her nursing progress note to show the NP, not the attending physician, had completed the DRR with her. RN#3 stated she could not recall entering the order for digoxin and that she would not have entered an order for a medication that was not listed on the W10 from the hospital but could not recall the specific circumstances. RN#3 stated she was not aware Resident #85 was treated for digoxin toxicity, and that if she had known she would not have entered the order for digoxin into Resident #85's EMR. Review of the progress notes written on 9/30/24 for Resident #85 failed to identify a note authored by RN #3. Interview with the Assistant Director of Nursing Services (ADNS) on 10/10/24 at 2:00 PM identified that on 10/2/24 she had co-signed Resident #85's nursing admission assessment from 9/30/24 after verifying that the orders in the EMR matched the W10 however, she had not done the DRR. The ADNS stated that the DRR would have been done at the time of re-admission by the RN entering the medication orders. The ADNS further identified that re-admission orders are not double checked on the 11-7 shift. The policy was that re-admission orders were reviewed in morning report the following day, and the order summary report, which was used for the DRR, was printed and signed by two nurses and the MD or APRN to verify accuracy. The ADNS further identified that the order for digoxin 250 mcg for Resident #85 was seen on review in morning report and subsequently it was discontinued. Review of the order summary report used for the DRR for Resident #85 identified a signature from APRN #1 on 10/1/24, and only one nurse's signature, RN #3, on 9/30/24. Interview with Pharmacist #1 on 10/11/24 at 9:50 AM identified that digoxin being given after digoxin toxicity was a major medication error and demonstrated a deficiency in the transition of care. Pharmacist #1 stated that the facility's first priority on re-admission would have been to determine what had changed for Resident #85. Pharmacist #1 further identified that digoxin being ordered and given following Resident #85's hospitalization for digoxin toxicity was highly negligent, as digoxin was one of the worst medications for Resident #85 to have received if he/she wasn't supposed to be administered digoxin. Further digoxin would slow down an individual's heart rate and could result in cardiac insufficiency. Interview with Licensed Practical Nurse (LPN) #2 on 10/11/24 at 10:20 AM identified that she could not specifically recall administering medications to Resident #85 on 10/1/24 following his/her re-admission the previous evening. LPN #2 stated that if the EMR directed digoxin be given and the documentation showed she had administered the medication, then she did. LPN #2 stated that if a medication had not been available for Resident #85, she would have gone to retrieve it from the pyxis machine (emergency medication storage) and if it had not been available in the pyxis machine she would have called the pharmacy to have it sent to the facility. LPN #2 stated she would have then documented within the EMR the appropriate code for the medication not being available and written a progress note documenting steps she had performed to obtain the medication. Review of the Medications policy directed, in part, all medications administered to the resident should be ordered by the physician, and medications should be dispensed using the correct protocol for the mobile medications cart. Although requested, a facility policy for Drug Regimen Review was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation and interviews for the only sampled resident, (Resident #46), reviewed for hospice, the facility failed to collaborate and communicate the provision of hospice services with the contracted hospice provider. The findings include: Resident #46's diagnoses included major depressive disorder, dementia without behavioral disturbances, psychotic disturbance, mood disturbance, and anxiety. A W-10 (transfer document) signed by Resident #46's physician on 3/22/23 directed Resident #46 to be admitted to the facility on comfort care and to notify hospice with any changes in condition or needs. The Nursing admission Evaluation dated 3/23/23. Identified Resident #46 was totally dependent for personal hygiene, mobility, transfers, and toilet use. Further, Resident #46's discharge goal was to remain in the facility with hospice care coordination. The nursing admission note dated 3/23/23 at 7:42 PM identified that when Resident #46 arrived, he/she was unable to communicate due to cognitive impairment, required total care, and the contracted hospice nurse had evaluated Resident #46 and had not recommended any new orders. The APRN admission note dated 3/24/23 at 1:01 PM identified Resident # 46 was receiving hospice services. Review of Resident #46's Resident Care Plan (RCP) dated 3/23/23 through 9/16/24 identified the resident was receiving contracted hospice services. The RCP failed to include a contracted hospice provider plan of care for Resident #46. Review of Resident #46's clinical record identified an initial Hospice Election, State of Connecticut form dated 6/28/22 (9 months prior to Resident #46's admission to the facility), which was signed by the Power of Attorney (POA). Additional hospice information present in the clinical from prior to the resident's admission included an Interdisciplinary Plan of Care and revision/Physician Orders from 6/30/2022 and 9/30/2022. The only post admission documentation located in Resident #46's clinical record was 1 hospice provider comprehensive nursing assessment dated [DATE] and 6 contracted hospice provider social work notes. The clinical record post facility admission failed to contain a hospice election form signed after admission in March 2023, the initial hospice physician's certification, an every 6 month physician recertification renewal for continued hospice services, coordination of which hospice provider staff would be providing care, documentation of facility visits/notes (other than social work notes) by the hospice providers, schedules, or a hospice Resident Care Plan. Interview and review of the clinical record with Social Worker (SW) #2 on 10/9/24 at 2:00 PM identified she assumed she was responsible to coordinate hospice services for Resident #46 and that the process for facility staff to communicate with hospice was done so verbally. SW #2 indicated she believed hospice staff wrote any recommendations related to Resident #46's care in the physician orders. SW #2 was unable to explain how nursing knew when hospice staff were scheduled to visit with Resident #46. SW #2 stated she ran the Resident Care Plan conferences, but the hospice team had never attended, asked about attending the Resident Care Plan meeting, and, except for an initial meeting with a hospice nurse on Resident #46's admission (19 months prior), she has never met with any hospice provider team members to coordinate Resident #46's care. SW #2 indicated that all hospice documentation for Resident #46 should be in the resident's clinical record or in a hospice binder. Review of the clinical record and inspection of the nursing station failed to identify any hospice information with the exception of a hospice sign-in visit log, the nursing assessment dated [DATE], and the 6 social work notes since Resident #46's admission in March of 2023. Interview and review of the clinical record with the DNS on 10/10/24 at 3:28 PM failed to reflect hospice documentation in Resident 46's clinical record or a hospice binder. The DNS identified that based on documentation in Resident #46's clinical record, she was unaware of which hospice provider disciplines (staff) participated in Resident #46's care or how often visits occurred. Although hospice provider staff verbally communicated the plan of care with facility nursing and/or the APRN, the policy was that communication would be documented in the paper chart. The DNS indicated that SW #2 coordinated hospice provider care and she would have to speak to her regarding the location of documentation for Resident #46's. The DNS indicated that hospice nurses come in to see Resident #46 and according to what they determine, information should be communicated in writing and placed in the paper chart. The DNS stated she was not aware that the last hospice care plan update was on 3/23/23. The DNS stated nurses follow the facility change of condition policy when hospice needs to be notified of changes for Resident #46. The DNS reviewed the clinical record of Resident # 46 and did not locate an updated plan of care, nursing visit forms, signed hospice election form, the physician initial certification or recertifications, or any scheduled visits. The DNS was unable to explain how facility staff on other shifts would be able to review hospice information. The DNS stated the ADNS, and nursing supervisor were responsible for implementation of issues identified in Resident #46's record. The DNS indicated that the lack of information regarding hospice was due to lack of coordination with hospice. Although attempted a phone interview with hospice nurse on 10/10/24 at 2:35pm, an interview was not obtained. Subsequent to surveyor inquiry, the facility obtained updated plans of care, completed nursing weekly visit forms, a hospice election form, a physician's certification and recertifications for Resident #46's clinical record. Although requested, the facility identified that there was no policy for Hospice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews and facility documentation for one (1) of three (3) residents (Resident #1) reviewed for falls, the facility failed to report a change of condition to the physician and/or Advanced Practice Registered Nurse timely. The findings included: Resident #1 had diagnoses of unspecified congestive heart failure, unspecified osteoarthritis, and unspecified abnormalities of gait and mobility. Review of the Resident Care Plan dated 6/26/24 identified Resident #1 had a potential for falls with interventions that included the bed to be in the lowest position, encourage to call for assistance, call bell with in reach and to keep the resident's area clutter free. Review of the admission Minimum Data Set assessment dated [DATE] identified Resident #1 was cognitively intact, had no limitation with Range of Motion (ROM), required set-up assistance with eating. Review of a Reportable Event form dated 7/11/24 at 2:00 AM identified Resident #1 was found lying on the right side of his/her bed towards the window of his/her room, and had no physical injuries noted. Resident #1 further identified he/she had been dreaming and rolled out of bed. Review of nursing notes dated 7/11/24 at 2:35 AM identified the resident had an unwitnessed fall out of bed. The neurological checks were initiated per facility protocol with no changes in mental status, no bump on head noted upon head assessment, however mild pain was reported to Resident #1's right shoulder, the resident stated that it had been sore since last fall at home. Resident #1 had good range of motion to both upper and lower extremities, and the resident was lifted back to bed (via hoyer lift) with the assistance of four (4) staff members. Review of post fall event evaluation dated 7/11/24 at 8:05 AM identified that the resident had active range of Motion (ROM) in the bilateral upper extremities. A nurse's note written by Licensed Practical Nurse (LPN) #1 dated 7/12/24 at 4:18 PM identified Resident #1 could not grasp with the right hand since falling, the left hand grasp continued to be weak per baseline, that the resident needed assistance with eating during this shift, and was fed by his/her son on the previous 3:00 PM to 11:00 PM shift, the APRN was notified of the change in condition, evaluated the resident, and suggested to continue with the current pain medication regimen. Review of the neurological observation record identified that the residents hand grasps were equal until 7/12/24 at 8:45 AM when it was identified that the hand grasps were unequal and the left hand was noted to be weaker than the right. Review of the untimed Advanced Practical Registered Nurse (APRN) #2 note dated 7/12/24 identified a follow-up visit for left shoulder pain, indication that imaging was done following his/her fall and was negative for fractures, yet noted significant osteroarthritis, and the directive was to continue with tramadol (a pain medication) as needed. Review of a nursing note written by Registered Nurse (RN) #1 on 7/13/24 at 8:08 PM identified that the social worker had approached her and reported that the Resident #1 had a functional decline since his/her fall on 7/11/24 and was fed by his/her son during the week when the resident was able to perform this task independently before the fall. The resident further identified that h/she pain in both upper extremities since falling two days prior, weakness, difficulty grasping items, and was only able to take a few steps. The resident had weak hand grasps, was unable to lift his/her arms past his/her shoulders, and was unable to bend or lift his/her knees above the bed. The APRN/Physician was called at 6:26 PM, Resident #1 was sent to the emergency room for further evaluation at approximately 7:00 PM. Interview with Advanced Practical Registered Nurse (APRN) #1 on 8/14/24 at 1:35 PM identified an assessment of Resident #1 was performed on the morning of h/her 7/11/24 fall. Resident #1 had complained of left shoulder pain in the trapezius region of his/her shoulder, presented as confused a little more than usual, did not present with stroke-like symptoms, and had limited but symmetrical bilateral upper extremity range of motion, and good bilateral hand grasps. APRN #1 further indicated that he went to assess the resident and had no concerns for one-sided deficit, neck pain, or decreased ambulation, no slurred speech, that Resident #1 presented with symmetric facial movements, and that the x-ray ordered for his/her left shoulder was negative. Interview with LPN #1 who worked on 7/12/24 during the 7:00 AM to 3:00 PM on 8/14/24 identified Resident #1 was complaining of pain and weakness to both upper extremities during the nursing assessment that morning and noticed that Resident #1's hand grasp was weaker on the right side as compared to the left. LPN #1 indicated he/she informed APRN #2 (who was on duty at the facility) of his/her findings and following assessment, APRN #2 had directed LPN #1 to continue treating Resident #1's pain. Interview with Nurse Aide (NA) #1 on 8/14/24 at 3:00 PM identified he/she worked the 3:00 PM to 11:00 PM shift on 7/12/24. NA #1 indicated between 3:45 PM and 4:00 PM on 7/12/2/24, Resident #1 had reported he/she couldn't dial the phone and that he/she felt numbness and tingling in his/her hands. NA #1 indicated he/she assisted Resident #1 with dialing the phone, however when he/she handed the phone to Resident #1, the resident dropped the phone as he/she was unable to hold onto it. NA #1 indicated reporting this concern to the floor nurse, however, does not remember who she specifically informed regarding Resident #1's change in status and indicated the resident was freaking out over her hands. (The clinical record failed to identify that the resident had been assessed or that the physician was notified). Interview with APRN #2 on 8/14/24 at 2:23 PM identified he/she saw Resident #1 on 7/12/24 for a follow up visit related to his/her shoulder pain, and was not informed that the resident was complaining of weakness to both upper extremities or that the right hand grasp was weaker than the left. APRN # 2 identified that/she went to see Resident #2 specifically for a follow-up visit related to his/her fall. Interview with SW#1 on 8/14/24 at 12:26 PM identified he/she was approached by Person #1 on 7/13/24 and was informed Resident #1 was unable to feed him/herself independently, use or hold onto the phone independently, and that family was assisting Resident #1 with eating. SW#1 further identified he/she then checked in with Resident #1 who indicated a difference in his/her ability to grasp items and difficulty ambulating. SW#1 indicated he/she informed RN#1 of Resident #1's status and RN #1 went in to assess the resident. Interview with the Administrator on 8/14/24 at 5:10 PM identified his/her belief that APRN #2 had evaluated Resident #1 for the change of condition related to his/her hand grasps on 7/12/24 and that Resident #1's inability to dial/hold onto the phone during the 3:00 PM to 11:00 PM shift was related to this concern. Attempts were made to contact to RN #1 was made, however, unsuccessful. Attempts to obtain the hospital paperwork were unsuccessful. Review of the Notification of Changes policy directed to consult with the resident's physician and resident's representative when there is a significant change in the resident's physical, mental, or psychosocial condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, clinical record review, facility documentation and facility policy review for one of five sampled residents (Resident #21) reviewed for Activities of Daily Living (ADLs), the facility failed to ensure that Resident #21 was provided with incontinence care timely. The findings included: Resident #21's diagnoses included Parkinson's disease, dementia, and benign prostatic hyperplasia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #21 was mildly cognitively impaired and required one person physical assistance for toilet use and 2 person physical assistance for bed mobility and transfers. The MDS also identified Resident #21 was always incontinent of bowel and frequently incontinent of bladder. The Resident Care Plan (RCP) dated 5/6/22 identified Resident #21 was incontinent of bowel and bladder, and a goal included to assist with toileting needs. Interventions included to utilize incontinence briefs or pads. Initial observation on 6/29/22 at 9:32 AM identified Resident #21 was soiled with urine per resident report to surveyor. Resident #21 indicated I really let a lot of water out. Surveyor notified LPN #2 of report immediately following notification from Resident #21. LPN #2 was observed speaking with Resident #21, and asked if the resident would like to be cleaned up, and if the resident would like to be dressed and placed in the resident's wheelchair. Resident #21 answered yes. LPN #2 notified Resident #21 that It may be a minute since I have to find someone and you need an assist of two. Resident #21 answered Okay. Subsequent to the initial observation on 6/29/22 at 9:32 AM, at 9:37 AM (5 minutes after the initial interview with Resident #21) NA #1 was seen entering and exiting the room directly next to Resident #21. NA #1 was observed bringing clean linen into the room, and several minutes later again bringing clean linen into the room. Observation on 6/29/22 at 9:44 AM (12 minutes after the initial interview with Resident #21) identified that surveyor again spoke to Resident #21, who stated no one had come to the room to address his/her incontinence. At that time, LPN #2 was observed entering the room directly across from Resident #21 and asking a female resident in that room if she needed assistance to the rest room. LPN #2 was observed assisting the resident to the bathroom. At 9:49 AM, observation identified that NA #1 was still in the room next to Resident #21 providing care; LPN #2 was identified leaving the unit through a back stair well. Observation 6/29/22 at 9:54 AM (22 minutes after the initial interview with Resident #21) identified LPN #2 returned to the unit and was observed sitting at a computer located at the nurses' station. At 9:55 AM, Resident #21 was speaking on the telephone. At 9:58 AM surveyor spoke with Resident #21, who again reported they haven't come in yet. While exiting Resident #21's room, NA #1 was observed typing at a keyboard of a facility computer terminal located in an alcove of the resident's hallway. Interview with LPN #2 on 6/29/22 at 10:10 AM (38 minutes after the initial interview with Resident #21) at the nurses' station identified Resident #21 had still not been assisted with cleaning following his/her incontinence episode. LPN #2 further identified Resident #21 had not been provided incontinent care because his/her aide went on break, I told him it may be a little bit. LPN # 2 further indicated another aide was not available to assist Resident #21 because they were with other residents Subsequent to surveyor inquiry, LPN #2 was seen speaking to NA #1, and then NA #1 entered Resident #21's room, then requested assistance from another NA who brought a mechanical lift to Resident #21's room. Interview with NA #1 at 10:15 AM identified that she confirmed she was assigned to Resident #21 for care. Interview with the DNS on 6/29/22 at 11:00 AM identified that Resident #21 should have had incontinent care performed without waiting. The DNS identified that residents should not have to wait, and that if there was a wait, it should not take 40 minutes to receive care. Additionally, the DNS identified that the specific staff assigned to a resident are not the only staff available who can provide assistance; rather, any clinical staff who were in a role to provide care can assist a resident with incontinence care. The facility policy Incontinence dated 2/2022 identified, in part, that all residents that are incontinent will receive appropriate treatment and services. Compliance guidelines identified that residents that are incontinent of bowel or bladder will receive appropriate treatment to prevent skin breakdown, infections, and continence to the extent possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, and interviews for one of five units reviewed for respiratory equipment, the facility failed to appropriately store Resident #145's Continuous Positive Airway Pressure (C-PAP) mask while not in use. The findings include: Resident #145's diagnoses included sleep apnea, dementia, heart disease, and asthma. A Nursing admission assessment dated [DATE] did not identify Resident #145's level of cognition or assistance required for activities of daily living. The Care Pathway dated 6/22/22 identified Resident #145 had obstructive sleep apnea. Interventions included to encourage C-PAP use, monitor for sleep apnea, and monitor for snoring while asleep. An admission physician's order dated 6/22/22 directed to apply the C-PAP mask at bedtime and to cleanse the C-PAP mask, humidifier chamber, and hose daily using water and mild soap. The nurse's note dated 6/22/22 at 10:00 PM identified Resident #145 stated he/she used the C-PAP nightly, however, the resident was unable to place the C-PAP mask or turn on the machine, and stated that someone does this for him/her at home. The APRN progress note dated 6/23/22 identified Resident #145 was alert and confused. Observation on 6/27/22 at 11:07 AM identified Resident #145 asleep in bed with the C-pap mask resting on the bedside stand without the benefit of being covered. Observations on 6/28/22 at 10:12 AM and at 1:42 PM identified the C-PAP mask resting on the floor and the mask was without the benefit of being protected in a plastic bag. Interview with LPN #2 on 6/28/22 at 1:24 PM identified that the C-PAP mask should be stored in a bag and not on the floor. Interview with LPN #3 on 6/29/22 at 8:50 AM identified that proper C-PAP mask storage includes placing the mask in a plastic bag for protection and leaving next to the bedside. Subsequent to surveyor inquiry, LPN #3 indicated the respiratory provider was called, the mask and tubing were replaced, and properly stored at the bedside. The facility did not have a storage policy for a C-PAP equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, observations, facility policy review, and interviews for one of three units reviewed for medication storage, the facility failed to discard Resident #46's expired Insulin and failed to date a multidose medication vial after opening. The findings include: Resident #46's diagnoses included diabetes mellitus, dementia, and kidney disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #46 was severely cognitively impaired and required extensive assistance of one staff member for activities of daily living (ADLs). A Resident Care Plan dated 5/4/22 identified a potential for complications from diabetes with interventions that included to administer Insulin as ordered. A physician's order dated 6/28/22 directed to administer 22 units of Lantus Insulin subcutaneously at bedtime. Observation, interview and review of facility policy with LPN #2 on 6/28/22 at 1:12 PM during inspection of the medication cart identified Resident #46's vial of Lantus Insulin dated as opened on 5/25/22 (34 days prior). According to the label on the Insulin vial, the medication expired 28 days after opening (6/24/22). Additionally, a multidose vial of Lidocaine that was noted to be partially used, failed to indicate the date that the vial had been opened. LPN #2 indicated that per the facility policy, both vials of medication would need to be discarded, the Lantus because it had been expired four days earlier, and the Lidocaine as she could not identify a date when the vial had been opened or if the medication had been open beyond the Lidocaine's 28 day expiration date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, facility documentation review, facility policy review, and interviews for one of one resident (Resident #37) reviewed for medication administration, the facility failed to ensure a therapeutic diet when administering a liquid oral supplement. The findings include: Resident #37 's diagnoses included cerebral infarction, dysphagia, and diabetes. A physician's diet order dated 10/4/21 and updated monthly through June 2022 directed to provide a regular diet, puree texture, with nectar consistency. A Dietician note dated 4/14/22 at 12:21 PM indicated that Resident #37 continued to receive Glucerna supplement three times daily and was recorded as taken well, with stable weight and to continue with supplement, The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #37 was a severely cognitively impaired and required extensive assistance of 2 person for bed mobility, was dependent for transfers and required bathing with 2-person assistance. The MDS further identified Resident #37 required extensive assistance of 1 person for eating, and toilet use and required a mechanically altered diet (ex: pureed food, thickened liquids). The Resident Care Plan (RCP) dated 5/4/22 identified Resident #37 required a mechanically altered diet secondary to dysphagia with interventions that included to provide assistance with all meals, use of built-up utensils, a scoop plate for all meals and a Dycem placemat. The RCP further indicated to monitor oral intake and provide a supplement as ordered. The RCP dated 5/4/22 further indicated Resident #37 had a nutrition/hydration concern with interventions that included a regular puree diet with nectar thickened liquids and extra gravy with meals, to encourage fluids, monitor intake and output as needed, conduct a nutritional assessment and to obtain weights as ordered. The RCP dated 5/4/22 further indicated Resident #37 had a speech therapy plan of care for oropharyngeal dysphagia. Interventions included aspiration precautions, compensatory swallowing strategies, dietary meal planning, position at 90 degrees during meal and for ½ hour after eating and to provide small bites and sips of food and fluids. Observations on 6/29/22 at 8:30 AM identified LPN #2 administering liquid Glucerna poured straight from the box to a cup and administer to Resident #37 without the benefit of reconstituting the supplement to a nectar consistency. No coughing or difficulty swallowing was noted during LPN #2's assistance with drinking the supplement. Interview and clinical record review, with Speech Pathologist #1 on 6/29/22 at 11:50 AM indicated that Glucerna was considered a thin liquid that could be thickened and that it was the responsibility of the person administering the drink to thicken the Glucerna to the correct consistency ordered. Facility policy dated 4/16/16 and revised on 12/21 indicated that the facility provides thickened liquids as prescribed to residents that require them. It further indicated that a thickened liquid refers to liquids that has been altered to facilitate safe oral intake and is ordered as part of a treatment for a disease or clinical condition, such as dysphagia due to stroke or oral cancer or a neuromuscular disease. In conclusion, the facility failed to ensure that Resident #37 received supplements thickened to the safe consistency of nectar thick as ordered by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, review of facility documentation and interviews for two of three sampled residents (Resident #79 and #249) who required staff assistance with personal hygiene, the facility failed to ensure the number of designated staff in accordance with the physician orders were present while providing care. The findings include: 1. Resident #79's diagnoses included dementia. The admission Minimum Data Set assessment dated [DATE] identified Resident #79 had short term and long term memory problems, difficulty focusing attention, disorganized thinking, was totally dependent on two (2) staff with transfers in and out of the bed or chair, personal hygiene, dressing and toilet use and extensive two (2) person assistance with turning from side to side while in the bed. The Resident Care Plan dated 3/8/19 identified the resident required assistance with activities of daily living. Interventions directed assistance of two (2) staff for care. The physician's order dated 4/3/19 directed two (2) person assistance with activities of daily living. The nurse's note dated 5/30/19 at 3:00 PM identified at 10:30 AM Resident #79 was lying on the floor beside the bed on his/her right side, the legs were bent, and the arms were supporting the upper body. The note indicated Resident #79 was assessed by the Advanced Practice Registered Nurse (APRN) and then Hoyer transferred back to bed. The Reportable Event Form dated 5/30/19 at 10:30 AM identified that Resident #79 was observed on his/her right side on the floor to the left of the bed. The post fall analysis and intervention tool dated 5/30/19 identified Resident #79 was sitting on the floor next to the bed, the bed was in the low position and an air mattress was on the bed. The tool indicated Resident #79 was in bed post bed bath and the resident rolled out of the bed. The tool identified the nurse aide had completed a bed bath, turned away from the resident and heard a noise and when she turned around Resident #79 was on the floor beside the bed. The investigation in a written statement the Assistant Director of Nursing identified that during personal care Resident #79 will on occasion grab at the blankets and caregiver. The investigation identified Resident #79 had sustained an acute right trochanteric fracture. Interview with the 7AM-3PM nurse aide, Nurse Aide (NA) #1, on 10/1/19 at 2:09 PM identified that she provided personal hygiene for Resident #79 by herself. NA #1 stated she finished providing personal hygiene, turned to pick up the soiled linen, heard a loud noise behind her and Resident #79 was lying on lying on the floor. Interview with the Director of Nursing (DON) on 10/2/19 at 1:50 PM identified Resident #79 required assistance of two (2) staff with personal hygiene and NA#1 provided morning care for Resident #79 by herself. The DON stated NA #1 should have had another staff member present. The fall minimization policy directed each resident was to be evaluated the risk of falling and will receive care and services to minimize the likelihood of falls and injuries from the fall. 2. Resident #249's diagnoses included vascular dementia with behavioral disturbance, subarachnoid hemorrhage with right side hemiparesis, and rheumatoid arthritis. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #249 had no memory recall problems, required extensive one (1) person assistance with personal hygiene and dressing and one (1) person extensive assistance with eating. The Resident Care Plan dated 9/24/18 identified the resident required assistance with activities of daily living. Interventions directed two (2) person caregiver and encourage self-participation. A physician's order dated 10/8/18 directed two (2) person caregivers at all times every shift. The nurse's note dated 11/24/18 at 12:44 PM identified Resident #249 was very sad today and when asked what the problem was, the resident stated I just want to go home, can you call my family member. The nurse's note dated 11/25/18 at 3:30 PM identified that it was reported Resident #249 told a family member he/she was unhappy with the care a nurse aide provided on 11/24/18 in the morning and upon assessment, no visual injury noted, no change in mental status and no change in range of motion. The Reportable Event Form dated 11/25/18 at 3:30 PM identified that it was reported Resident #249 stated a nurse aide who fed him/her breakfast on 11/24/18 hit Resident #249 on the chest. In a written statement by the 7AM-3PM nurse aide, Nurse Aide (NA) #3, dated 11/25/18, NA #3 indicated on 11/24/18 about 9:00 AM she fed Resident #249 breakfast and nothing happened while Resident #249 was being fed. In the statement NA #3 stated about 11:15 AM, she went to get Resident #249 washed and dressed and the resident was instructing her to use Resident #249's wash cloths, which NA #3 did. The statement identified that while she was washing Resident #249 although nothing had happened she became very uncomfortable, she should have had another nurse aide present as Resident #249 required two (2) staff for care. The written statement indicted NA #3 sought the help of another nurse aide and she was able to dress Resident #249's top and the other nurse aide completed the care, NA #3 identified that nothing had happened while she was providing care to Resident #249. Interview with NA #3 on 10/1/19 at 2:40 PM identified that she began Resident #249's morning care by herself. NA #3 stated she washed Resident #249's upper body, face and hands and became uncomfortable so she went and sought the help of another nurse aide, NA #2. Interview with the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #1, on 10/2/19 at 12:39 PM identified that NA #3 provided Resident #249's morning care by herself. NA #3 began the morning care by herself and when Resident #249 started giving NA #3 hard time, NA #3 went to get the NA #2. Interview with the Director of Nursing (DON) on 10/2/19 at 1:45 PM identified that NA #3 provided Resident #249's morning care by herself, at some point while providing care NA #3 stopped because she was not comfortable, went to get NA #2 and together they completed Resident #249's morning care. The DON stated NA #3 should have provided care with two (2) staff as per the plan of care and physician's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, for one of two medication rooms reviewed during the medication storage and labeling review, the facility failed to ensure expired supplements were removed from the supply. The findings include: Observation of the first floor medication room on [DATE] at 10:45 AM identified eight Osmolite 1.5 cal 8 oz. cartons with the expiration date of [DATE]. Interview with Registered Nurse (RN) #1 at the time indicated RN #1 had removed the supplements from the cabinet but someone put them back in. RN #1 further indicated the supplements had expired and should not be used. The supplements were removed from the cabinet.