Based on observations, interviews, and record review the facility failed to provide privacy for the health care information for residents as evidenced by observations of three computer screens open with resident information visible while unattended on the fourth floor. There were 112 residents residing in the facility at the time of survey. The findings included: On 9/24/24 at 10:17 AM; surveyor walked down the hallway on the fourth floor and observed a computer screen with resident's health care information visible and unattended on medication cart number one. (photo evidence) Staff E, Registered Nurse (RN) observed exiting a resident's room and returned to medication cart one. When asked by surveyor the protocol for privacy of resident's information Staff E, Registered Nurse (RN) replied, I am supposed to close the screen before I leave the cart. I left the screen open because I was answering a call light, and it was my mistake. The purpose is for the privacy of residents and only the nurses can view resident information. On 9/24/24 at 10:29 AM; surveyor informed Staff F, Licensed Practical Nurse (LPN) that a resident asked for assistance. Staff F, Licensed Practical Nurse (LPN) then stood up and walked away from the computer screen at the nursing station on the 4th floor, screen remained open with resident information visible. Staff F, Licensed Practical Nurse (LPN) returned to desk and was asked by surveyor the protocol and reason the screen was left open Staff F, Licensed Practical Nurse (LPN) stated: I should have closed it for privacy, I just got up to wash my hands and didn't notice that I left it open. I always close the screen before I walk away for privacy for residents. On 9/25/24 at 5:50 AM; surveyor approached Staff B, Licensed Practical Nurse (LPN) and asked if a medication storage check could be completed on medication cart and Staff B, LPN asked, Can you wait a moment? and removed out a 30 milligram (ml) medication cup with pills from the top drawer inside medication cart two and walked away; medication cart two remained unlocked and the computer screen open with residents' information visible.(photo evidence) Staff B , Licensed Practical Nurse (LPN) returned to cart; when asked about the facility' policy related to residents' health information privacy. Staff B, Licensed Practical Nurse (LPN) replied, The protocol is when I walk away from the cart to close the computer screen and lock the cart. I left it open because you asked me to see the cart and I had to give something to the other nurse. I am not supposed to leave the medication cart open for anyone to provide privacy and for safety of the residents. On 09/26/24 at 11:15 AM, the Director of Nursing (DON) stated, Computer screens should be closed and resident information not visible while unattended. Record review of Policy entitled, Confidentiality of Information and Personal Privacy 2001 Revised January 2024 Policy Statement: Our facility will protect and safeguard resident confidentiality and personal privacy. Policy Interpretation and Implementation: 1. Facility will safeguard the personal privacy and confidentiality of all resident personal and medical records.

Based on observations, interviews and record review the facility failed to provide an environment free from potential safety hazards for one resident (Resident #79) out of nine residents sampled as evidenced by an observation of a shaving razor on the top of the light fixture and bed control with exposed wires next to the resident who was in bed asleep. The findings Included: On 9/23/24 at 9:28 AM Resident#79 was observed in bed with eyes closed. The bed control with exposed wires was observed on the bed next to Resident #79. A blue shaving razor was observed on the top of the light fixture above Resident#79. (photo evidence) On 9/23/24 at 9:33 AM, Staff J, Registered Nurse (RN) was notified, and the razor was removed and placed the trash in a clear plastic bag. Staff J tied the clear plastic bag and entered the Soiled Utility room and placed the clear bag into a biohazard bag and into the Biohazard box and performed hand hygiene. Staff J, RN revealed the shaving razors are kept in the medication room and the nurses give the Certified Nursing Assistants (CNAs); after use the CNAs are responsible for disposing the used razor. When surveyor asked where the razors should be discarded; Staff J, RN revealed the razors should be placed in the sharps container the razor was not placed into the sharps container because there weren't any close by. On 9/24/24 at 12:42 PM, the Corporate Maintenance Director presented the bed control with exposed wires from Resident#79's bed into conference room and stated, I replaced the control, and it is a low voltage so there's no potential to be electrocuted. On 9/24/24 at 1:51 PM This situation was referred to the Life Safety Surveyor. Record review of demographic face sheet for Resident #79 revealed an admission date of 6/25/24 and readmission of 7/23/24 with diagnosis that included: Alzheimer's Disease. Record review of a Significant Change Minimum Data Set (MDS) with a reference date of 8/5/2024 Section C (cognitive status) revealed a Brief Interview of Mental Status score of 00 indicated, severe cognitive impairment. Section GG (Functional Status) revealed Resident#79 was dependent for all activities of daily living. Record review of a Care Plan revealed Residnet#79 was at risk for falls related to Cognitive Deficit, History of Falls, Impulsivity, Unaware of safety needs, Unsteady Gait/Poor Balance, Use of antihypertensive medications, Use of psychotropic medications, Seizure Disorder/ Epilepsy, and Sarcopenia with a goal of The resident potential for sustaining a fall-related injury will be minimized by utilizing fall precautions/interventions though next review date and interventions included: Encourage and remind resident to use call bell and to wait for staff assistance with transfers, ambulation, toileting, etc. as indicated and assist resident to use bed in the lowest position as tolerated. On 09/26/24 at 11:04 AM The Infection Preventionist and The Director of Nursing stated, Sharps are to be discarded into the sharps container. There is a sharps container in the Biohazard room. Record review of Policy entitled, Safety Precautions, Nursing Services 2001 Revised January 2024 Policy Statement; All personnel shall follow safety precautions established by this facility when providing nursing care/services. Policy Interpretation and Implementation: the following safety precautions have been established for all personnel to follow when providing nursing care/services. Others may be added or amended as necessary. 6. Report all broken or defective equipment to your supervisor. 11. Follow established policies and procedures for discarding used needles or syringes.

Based on observation, interview and record review the facility failed to be free from significant medication error for one Resident (Resident # 5) out of nine sampled as evidenced by during observation of medication administration Nifedipine Extended-Release tablet was crushed by the Registered Nurse. There were 112 residents residing in the facility at the time of survey. The findings included: On 9/25/24 at 8:18 AM a medication administration observation was done with Staff C, Registered Nurse (RN) on the third floor's medication cart one. Staff C, RN was observed crushing a Nifedipine ER (Extended Release) 60mg (milligrams) TB24 (tablet extended release 24 hours) and then placed it in applesauce with other medications. Staff C, After Staff C closed the cart and computer screen and was about to enter Resident #5's room; the surveyor asked Staff C, RN to return to the medication cart and asked if this form of medication can be crushed. Staff C, a Registered Nurse (RN) replied, I am not sure because pharmacy did not indicate on the label that it could not be crushed. When the surveyor asked Staff C about the listing of medications that should not be crushed, there was none was available on that medication cart. Staff C, RN then stated: The extended tablet is released throughout the day and if I crush the pill the action is more quickly release and could harm the resident. I should not have crushed the medication. The Assistant Director of Nursing (ADON) approached, and Staff C, RN asked the ADON if Extended-Release tablets can be crushed and the ADON replied, No. On 9/25/24 at 12:28 PM The Pharmacy consultant stated, Extended-release tablets are never to be crushed. On 9/26/24 at 11:17 AM The Director of Nursing stated, Extended-release tablets are not to be crushed. Record review of the facility's Policy entitled, Administering medication 2001 Revised January 2024 Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 4. Medications are administered in accordance with prescriber orders, including any required tie frame.

Based on observations, interviews and record review the facility failed to store medications properly as evidenced by two medication carts on the floor out of the six medication carts in the facility were observed unlocked and unattended. The findings Included: On 09/24/24 at 4:45 PM, a medication administration observation was completed with Staff A, Registered Nurse (RN) on the fourth-floor medication cart two. Staff A, (RN) left the cart open, knocked on the resident's door; surveyor asked what the facility's protocol for securing medication in medication carts is. Staff A, RN replied, I left the cart unlocked because I am nervous. Whenever I leave the medication cart I am supposed to lock it. The purpose of locking the cart is for the safety of residents. On 9/25/24 at 5:50 AM; surveyor approached Staff B, Licensed Practical Nurse (LPN) and asked if a medication storage check could be completed on medication cart and Staff B, LPN replied, Can you wait a moment? and pulled a 30 milligram (ml) medication cup with pills inside of it out of top drawer of medication cart two and walked away from medication cart two leaving the cart unlocked, Staff B, LPN returned to the cart and when asked what the protocol is for storing medications, Staff B LPN revealed the cart should be locked when walking away from the cart. I left it open because you asked me to see the cart and I had to give something to the other nurse. I am not supposed to leave the medication cart open for anyone to provide privacy and for safety of the residents. On 09/26/24 at 11:16 AM The Director of Nursing stated, The medication carts are to be locked while unattended. Record review of the facility's policy titled, Storage of Medications 2001 Revised January 2024 Policy Statement: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and implementation: 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls.

Based on record reviews and interviews the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiency in the problem area related to repeated deficient practice for F880-Infection Prevention and Control. As evidenced by staff observed not wearing correct PPE during care of residents on Enhanced Barrier Precautions (EBP) and an enteral feeding syringe not labeled during observations on a recertification survey ending 09/26/24. There were 112 residents residing in the facility at the time of survey. The findings included: Record review of the facility's survey history revealed, during a recertification conducted on June 19, 2023, through June 22, 2023, F 880- Infection Prevention and Control was cited as the facility failed to ensure infection control practices related to hand hygiene was implemented during dining observations. Review of the facility's policy and procedures titled Quality Assurance and Performance Improvement (QAPI) revision dated 01/2024 states: It is the policy of this facility to develop, implement, and maintain an effective, comprehensive data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Interview with the Administrator/Quality Assurance (QA)on 09/26/2024 at PM. Stated, The QAPI Committee meets every month on the third week of the month. The QAPI committee members are Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, Infection Prevention, Maintenance Director, Registered Dietitian, Activities Director, Social Services Director, admission Director, Maintenance Director, Housekeeping Director and Departments Heads/Representatives. On the prior recertification survey, we were cited for F880 infection control during dining, we provided education to all the staff on hand hygiene, Director of Nursing (DON) and Assistant Director of Nursing (ADON) observed random audits of staff practicing hand hygiene during dining and no concerns were found, we also completed hand hygiene competencies for all the nursing staff. The purpose of QAPI is identify any potential issues or any concerns that need improvement and put in place a plan to improve the areas that need improvement or change. We have monthly QAPI meetings and daily continuous quality improvement meetings. In the daily meetings we discussed the findings and issues from the prior day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure infection control standards were followed for two Residents (Resident #101 and Resident #92) out of two of the nine sampled residents as evidenced by observations a tube feeding syringe not labeled, a staff member not wearing a gown while providing hygiene care for a resident receiving tube feeding and an observation of no sign posted for Enhanced Barrier Precaution (EBP) for a Resident with an IV (intravenous)site. There were 122 residents residing in facility at the time of survey. The findings included: Observation on 09/23/24 at 10:15 AM, Resident #92 was asleep in bed; next to the bed was a tube feeding pole with an unlabeled plastic bag containing an enteral feeding syringe hanging on it. (photo evidence) On 9/24/24 at 11:34 AM Resident #92 was observed in bed awake; an unlabeled plastic bag containing an enteral feeding syringe was hanging on the tube feeding pole next to the bed. (photo evidence) Record review of demographic sheet for Resident#92 revealed an admission date of 3/13/24 with diagnosis that included: Dysphagia Oropharyngeal Phase and Anorexia. Record review of a Quarterly Minimum Data Set (MDS) with reference date of 6/20/2024 Section C (Cognitive status) revealed a - Brief Interview for Mental Status score of 14, indicated no cognitive impairment. Section GG (Functional Status) revealed Resident#92 required substantial maximal assistance for eating and oral hygiene, dependent for personal hygiene and bathing. Record review of a Care Plan initiated on 6/14/2024 revealed Resident#92 required enhanced barrier precaution related to open wound, tube feeding with a goal of Enhanced Barrier Precaution will be maintained through next review date and interventions included: Follow infection control guidelines as indicated, Maintain enhanced barrier precaution as indicated during dressing, bathing/showering, transferring. providing hygiene, changing linens, changing briefs or assisting with toileting, device care or intravenous access line care, urinary catheter care, feeding tube care, tracheostomy/ventilator care, ostomy care, or during wound care and educate resident, responsible party or caregivers regarding enhanced barrier precaution. Record review of a physician's order sheet for Resident#92 revealed orders dated 5/5/24-Enhanced Barrier Precaution directions: Encourage and assist resident to maintain enhanced barrier precautions for Percutaneous endoscopic gastrostomy (PEG) tube every shift and 4/3/24 Enteral Tube directions: Flush with 30 mil Liters (mL) to 50 ml of water before and after medication administration and five ml to ten ml of water between each medication every shift and 4/3/24 to check for residual every shift every shift. On 9/25/24 at 6:47 AM, Staff I, Certified Nursing Assistant was observed wearing a mask and gloves while rendering hygiene care to Resident #92. No gown was worn. On 9/25/24 at 7:03 AM Staff I, Certified Nursing Assistant was approached by surveyor and asked what Personal Protective equipment is required while rendering hygiene care to Resident#92. Staff I, Certified Nursing Assistant replied, I gave care to resident #92 and I wore gloves and a mask. I do not need to wear a gown. On 9/24/24 at 11:34 AM Resident#92 was observed in bed with eyes open. Hanging on the tube feeding pole next to the bed was an unlabeled plastic bag containing an enteral syringe. (photo evidence. On 9/25/24 at 12:08 PM a side-by-side observation with Staff H, License Practical Nurse (LPN) and surveyor conducted in Resident#92's room of the tube feeding equipment was conducted. Wen the surveyor asked Staff H, LPN what is the facility's protocol for labeling tube feeding equipment. Staff H, LPN replied, The overnight shift is responsible for labeling the equipment because they hang it up. When I come on shift I do rounds but did not notice the syringe bag was not labeled. At 10:00 AM, I flushed the tube and reconnected at 2:00 PM, I flushed the PEG (Percutaneous Endoscopic Gastrostomy) tube this morning at 10:00 AM and administered medications. The purpose for labeling the syringe and all equipment is to ensure its a new one used each shift because it can be old. This morning the syringe was hanging, and I opened it so that it signified to me that it was new. 2) On 9/23/24 at 10:27 AM Resident #101 observed in bed. An Intravenous (IV) site observed on the left upper extremity dated 9/23/24. No Enhanced Barrier Precaution (EBP) sign noted on the door or next to Resident's name (photo evidence). Record review of the demographic sheet for Resident #101 revealed an admission date of 8/22/2024 with diagnosis that included: Osteomyelitis of Vertebra of the Lumbar Region. Record review of an admission Minimum MDS dated [DATE] Section C (Cognitive Status) revealed a Brief Interview of Mental Status score of 15 indicating the resident is cognitively intact, Section GG (Functional Status) revealed Resident#101 was independent for eating, set up clean for oral hygiene and dependent for toileting and transfer. Section I (Active Diagnosis) revealed Resident #101 had no Multidrug-Resistant Organism (MDRO) and Section O (Special Treatments) revealed Resident#101 received IV Medications. Record review of a Care Plan initiated on 8/22/2024 revealed Resident #101 was on IV antibiotic therapy related to Osteomyelitis to Lumbar area with a goal of receiving ordered IV antibiotic therapy without complications through next review date and interventions included: Administer Antibiotic medications as ordered by physician, Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of medications as indicated. Record review of Physician's order sheet revealed orders dated 9/16/24 for Enhanced Barrier Precautions: Encourage and assist resident to maintain enhanced barrier precautions for PICC (Peripherally Inserted Central Catheter) line every shift, 8/23/24 for Vancomycin Hydrochloride (HCL) Intravenous Solution 500 Milligrams(mg) per 100 Mil liters(mL) directions: Use one mg intravenously one time a day every Monday, Wednesday, Friday after dialysis for 51 Days, 9/6/24 Cefepime HCl Intravenous Solution one gram per 50 mL directions: Use one gram intravenously one time a day every Monday, Wednesday, Friday for Infection On 9/26/24 at 11:04 AM, the Infection Preventionist stated, Once a resident is identified as requiring Enhanced Barrier Precaution (EBP) for TF (Tube Feeding), tracheostomy, indwelling catheters, wounds that are draining, IV lines, I get an order for EBP and place a red sticker next to their name on the door. Staff are aware of the precaution, interventions and the appropriate Personal Protective Equipment required for EBP. Staff need to wear disposable gowns and gloves while providing care. Record review of the facility's policy entitled, Enhanced Barrier Precautions Revised: 4/1/2024 Policy: it is the policy of this facility that Enhanced Barrier Precautions, in addition to Standard and Contact Precautions will be implemented during high-contact resident care activities when caring for resident that have an increased risk for acquiring a multidrug-resistant organism (MDRO) such as a resident with wounds, indwelling medical devices or resident with infection or colonization with an MDRO. Procedures: Enhanced Barrier Precautions (EBP) consists of the use of gowns and gloves for high-contact care activities which include but may not be limited to: Dressing, Bathing/Showering.

Based on observation, interviews, and record review, the facility failed to ensure infection control practices related to hand hygiene was implemented during dining observations. As evidenced by staff failure to sanitize hands between the passing of meal trays. This deficient practice has the potential to cause cross contamination and affect all residents in the facility. There were 106 residents residing in the facility at the time of this survey. Findings included: On 06/19/23 at 12:05 PM, during the lunch observation on the second floor, Staff C, Certified Nursing Assistant (CNA), was observed getting food trays from Staff B, Registered Nurse (RN), and went to serve meals to rooms # 203, 204, and 202. Staff C did not wash her hands in between serving the meals to the residents. Observation on 06/20/23 at 11:50 AM, during lunch time on the second floor revealed Staff C brought a female resident in a wheelchair to the dining room. Staff C left and brought a male resident in a wheelchair to the dining room. Staff C then went to the food cart and touched the food trays without washing or sanitizing her hands. Further observation on 06/20/23 at 11:58 AM revealed Staff D (a CNA) set the food on the table for Resident #36. Staff D then went to push the food cart to the hallway without washing or sanitizing her hands. Staff D then took food trays to rooms # 209 and 208W without washing or sanitizing her hands. On 06/22/2023 at 10:39 AM, during an interview with Staff C regarding procedures during dining, Staff C stated that they always wash their hands when serving food. She stated that they wear gloves only when necessary. Staff C also stated that she washes her hands before passing trays to the residents that are independent with eating, and that she doesn't wash her hands in between passing the trays. She stated that she would wash her hands again when she is going to assist the residents who need assistance with eating. During an interview with Staff D on 06/22/2023 at 10:49 AM regarding handwashing procedures, Staff D stated, Before the nurse give me the tray, I wash my hands. After coming out of the room, I wash my hands again to take the next tray because they are different patients. You don't want to contaminate them. Before I transfer the resident, there is a sink in the resident's room, so I wash my hands. After I transfer the resident in the wheelchair to the table, I always wash my hands in the sink right here. Then I'll take the tray and serve the resident. When Staff D was asked about the observation of her going to the rooms and not washing her hands on 06/20/2023, Staff D stated, I don't remember that. I don't use sanitizer because I'm allergic to the soap and the sanitizer, but I always wash my hands. Further interview with Staff C on 06/22/2023 at 11:25 AM, regarding the observation of her not washing her hands during dining, Staff C stated, Like I said earlier, when I pass the trays, I only wash my hands one time. I only wash my hands before I pass the trays. I wash my hands again before I assist a resident with anything including feeding. When transferring the residents from their room to the dining room, I wash my hands before I start assisting the resident. I don't wash my hands when I'm transferring the residents. Before the nurse gives the tray to me to put on the resident's table, I wash my hands. Before assisting the resident with feeding, I wash my hands again. I don't remember, but I always wash my hands. If it happened my bad. Interview with Staff E, (Registered Nurse, RN), on 06/22/2023 at 11:51 AM regarding handwashing procedures, Staff E stated, Before we (RN) check the trays, we use hand sanitizer. For each tray, we do hand sanitizer. When I come I wash my hands. Between each tray, I wash my hands. That goes for all staff. In the hallway, the (CNAs) have to do the same thing. Because when they go inside the patient room, they have to set up the tray for the patient. When they come out of the patient room, they have to wash their hands before handling the next tray. We only have a few residents who don't need help with setting up the trays. Almost every resident needs help to set up their trays. After each tray, they're supposed to wash their hands. If a nurse doesn't see the CNA wash their hands after entering the room, they should ask them if they washed their hands. At least I will ask if they wash their hands if I don't see them wash their hands. On 06/22/2023 at 12:32 PM, during an interview with Staff B, RN regarding handwashing procedures during dining, Staff B stated, When the trays arrive, we're supposed to wash our hands before handling the trays. The nurses check trays and passing the trays to the CNAs. They know they have to wash their hands, but if we don't see them washing their hands, we have to ask them. I was passing trays in the hallway last Monday. There is a sink in the hallway and in the residents' room. They're supposed to wash their hands before handling each tray. Like after they take a tray and give it to the resident. A couple of times I didn't see the CNA who was working with me wash her hands, I asked her. Her last name [Staff C]. I didn't see when she washed her hands, I asked her and she said, yes she washed her hands. We're all supposed to wash our hands between each resident. A review of the facility's policy and procedures of handwashing and hand hygiene which were reviewed in January 2022 and revised in January 2023 revealed: All personnel shall be trained and regularly in-serviced on the Importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Hand hygiene products and supplies (sink, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: *Before and after direct contact with the residents; *before and after eating or handling food, *before and after assisting a resident with meals. A review of the facility's handwashing procedure revealed: Washing hands *Wet hands first with water, then apply and amount of product recommended by the manufacturer to hands; *Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. Using alcohol-based hand rubs * Apply generous amount of product to palm of hand and rub hands together; *cover all surfaces of hands and fingers until hands are dry; *follow manufacturer's directions for volume of product to use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS) was accurate for 2 out of 33 sampled residents (Resident #11 and #56). This deficiency has the potential to affect all 106 residents in the facility. The findings included: 1. Resident #11 was observed on 05/15/22 at 09:40 AM, the resident was in a special bed and he motioned with his hands, that he couldn't talk. The resident had a mattress on the floor next to his bed. On 05/16/22 at 08:42 AM, the resident was observed in bed asleep on his side, the resident was laying across the bed, and the residents legs appeared contracted. A mattress was on the floor next to the bed. On 05/17/22 at 10:04 AM, the resident was observed in the bed asleep, the resident woke up and said he was okay. The bed sheet was partially on the mattress and there was no pillow case on his pillow. On 05/18/22 at 08:20 AM, the resident was observed in bed asleep, the pillowcase was off the pillow and on the bed. A mattress pad was on the left side of bed today, and this was not present during other observations. The mattress was on the floor on the right side of the bed. On 05/18/22 at 11:41 AM, the resident was observed to be in a recliner chair, awake, and had a splint to the left hand. On 05/18/22 at 12:45 PM, Staff R, Certified Nursing Assistant (C N A) was observed feeding the resident for lunch. The resident had eaten approximately 99% of his pureed lunch. The resident was sitting in recliner, the splint wasn't on the right hand and was observed on the residents bed. The resident was reaching out with his left hand. During an interview on 05/18/2022 at 3:55PM with Staff K, a Registered Dietitian (RD), about the residents nutritional status, Staff K showed the her notes where the resident had been refusing to be weighed since January 2022 During the review of the residents medical record it was noted the resident was admitted to the facility on [DATE]. The residents diagnoses included but were not limited to Cerebral Infarction, Hemiplegia, Hemiparesis, Anxiety Disorder and other recurrent Depressive Disorder. The residents Quarterly MDS dated [DATE] documented in Section K - Swallowing/Nutritional Status, K200 had a weight of 104 pounds(lbs) and height 67 inches. The resident had not been assessed for weight gain or weight loss. The resident medical record documented the residents last weight was on 01/06/2022 and the resident weighed 104 lbs. The 02/15/2022 Quarterly MDS documented in Section E - Behavior, E800 Rejection of Care - Presence & Frequency - Did the resident reject evaluation or care that is necessary to achieve the residents goals for health and well being? The code was entered as (0), Behavior Not Exhibited. During interview on 05/18/2022 at 4:15PM with Staff L, Registered Nurse (RN) MDS Coordinator, about the reason the MDS did not document the resident was rejecting care. She reported, this wasn't documented because the behavior was not present in the 7 days prior to the completion of Assessment Reference Date (ARD). During record review it was noted the ARD was noted to be 02/15/2022 in Section A-Identification Information, Section A2300. In Section Z-Assessment Administration - Z0500, was dated 02/21/2022, this is the date the RN Assessment Coordinator signed the assessment as complete. During the review of Staff K's, Nutrition/Dietary Note dated 2/15/2022 at 2038 (8:38PM), the note documented the resident had refused his February weight, will continue to encourage to be weighed, January wt(weight) used to calculated EEN (Exclusive Enteral Nutrition). The residents current diet order was NAS (No Added Salt), CCHO (Consistent Carbohydrate), Pureed Texture, thin consistency, Glucerna TID (Three times per day), Snack TID, Prostat BID (Twice per day), NCS (No Concentrated Sweets) milkshake BID. During interview on 05/19/2022 at 11:15AM with Staff L, RN MDS Coordinator, to discuss Section E, Rejection of Care. Staff L was asked how long she has to make a correction to the MDS and she reported, 2 years. Staff L reported they were able to get the resident weighed today and Resident #11 weighed 107 lbs. On 05/19/2022 at approximately 1:00PM, Staff L brought a CMS (Centers for Medicare and Medicaid Services) Submission Report to document Resident #11's MDS had been modified for Rejection of Care. 2. On 5/15/22 at 9:25AM, Resident #56 was observed in his room, Staff R, C N A, was providing morning care. On 05/16/22 at 08:36 AM, Resident #56 was observed sitting up in a recliner, the resident shook his head to say he was okay. On 05/17/22 at 09:52 AM, the resident was observed in bed awake, he appeared to be shaved, and reports he's okay. He was asked about dialysis and he said tomorrow. On 05/18/22 at 12:26 PM, Resident #56 was observed sitting up in a recliner eating his lunch independently. During medical record review it was noted, the resident was admitted to the facility on [DATE]. The residents diagnoses included but were not limited to Type 2 Diabetes Mellitus, Stage 5 Chronic Kidney Disease and End Stage Renal Disease. During the review of the residents Quarterly MDS dated [DATE], it was noted in Section N-Medications, N300- 0, to document the resident didn't receive any injections. During the review of the residents physician orders it was noted the resident had an order for: Epoetin Alfa-epbx Solution 2000 UNIT/ML, Inject 4 milliliter subcutaneously one time a day every Mon, Wed, Fri for Anemia related to ANEMIA IN CHRONIC KIDNEY DISEASE Administered At Dialysis Pharmacy Active 4/1/2022 09:00 REVISION DATE- 5/7/2022. During interview on 05/19/2022 at 11:15AM with Staff L, RN MDS Coordinator, it was brought to her attention about Resident #56's Section N being inaccurate for injections since the resident was receiving Dialysis and had a physician order for Epoetin. On 05/19/2022 at approximately 1:00PM, Staff L brought a CMS (Centers for Medicare and Medicaid Services) Submission Report to document Resident #56's MDS had been modified for Injections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to implement a written care plan related to 1) Providing oxygen for one resident (Resident #27) out of four residents reviewed for oxygen treatment and 2) Smoking for one resident (Resident #7) out of one sampled resident for smoking safely. This has the potential to affect 106 residents residing in the facility at the time of this survey. The findings included: 1) Record review of the Oxygen Administration Policy and Procedure (revised October 2010) documented the following: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1) Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. General Guidelines: 1) Oxygen therapy is administered by way of an oxygen mask, nasal cannula and/or nasal catheter. Observation of Resident #27 on 5/15/22 at 8:08 AM revealed the resident sitting up in bed, wearing glasses and watching TV, preparing to eat breakfast. The Resident was not wearing oxygen by nasal cannula. Multiple observations were made throughout the survey process 5/15/22 to 5/19/22 and resident #27 was never observed receiving oxygen treatment and wearing a nasal cannula. Review of the Demographic Face Sheet for Resident #27 documented the resident was admitted to the facility on [DATE] with diagnoses to include hypertensive heart and chronic kidney disease, diabetes mellitus, morbid obesity, congestive heart failure, acute and chronic respiratory failure, end stage renal disease, dependence on renal dialysis and Atrial fibrillation. Review of the Minimum Data Set (MDS) admission Assessment for Resident #27 dated 2/23/22 documented the resident's Mental Status (BIMS-Brief Interview for Mental Status) Summary Score had a BIMS Summary Score of 14 out of 15 indicating no cognitive impairment and the resident was able to make her needs known. The resident required extensive to total dependence assistance with two+ persons physical assist for ADLs (Activities of Daily Living) and section O was coded for oxygen therapy use. Review of the Physician's Orders (POS) dated April 2022 and May 2022 for Resident #27 documented O2 (oxygen) at 2L (liters)/min (minute) via nasal cannula continuously every shift for sob (shortness of breath), (Start date 2/17/22). Observations revealed resident #27 was not wearing a nasal cannula. Review of the EMAR (electronic medical administration record) dated April 2022 and May 2022 for Resident #27 documented the resident received O2 at 2L/min via nasal cannula continuously from 2/17/22 to 5/17/22. Review of Resident's #27's care plan dated 4/18/2022 documented the resident is at risk for altered respiratory status/Difficulty Breathing r/t (related to) diagnosis of respiratory failure, CHF (congestive heart failure), ESRD (end stage renal disease); Goal: Resident will have no s/sx (signs/symptoms) of poor oxygen absorption through next review date; Interventions: Provide oxygen as ordered. Second care plan documented: Resident has altered cardiovascular status r/t CHF, Hypertension and Hyperlipidemia; Goal: Resident will be free from s/sx of complications of cardiac problems through next review date; Interventions: Give oxygen as ordered by the physician. Follow oxygen protocol and precautions. Review of the Physician's Orders (POS) dated May 2022 for Resident #27 documented Oxygen 2L via NC (nasal cannula) PRN (as needed) for sob every 1 hours as needed for sob (Start date 5/17/22 14:55, Revision date 5/17/22; Created by Corporate Director of Nursing) (DON). Copies of the medical record documentation was requested on 5/17/22 at 12:56 PM and the copies of the documentation were received from the facility DON on 5/17/22 at 3:27 PM. The oxygen administration documentation was changed during the time the documentation was requested. On 5/17/22 at 7:28 AM, resident #27 revealed that she does not receive oxygen via a nasal cannula continuously. On 5/18/22 at 2:34 PM, Staff E Registered Nurse (RN) stated, She was not getting the oxygen continuously. The order says PRN. I don't know about the order being changed. On 5/18/22 at 3:56 PM, the DON stated, The resident had an order for oxygen at 2L/min via nasal cannula continuously, every shift for sob for April 2022 to May 17, 2022. The order was changed on 5/17/22 at 14:55 to Oxygen at 2L/min via nasal cannula PRN. Oxygen 2L via NC PRN for sob every 1 hours as needed for sob (Start date 5/17/22 14:55, Revision date 5/17/22; Created by the DON, which is a Corporate Nurse. I don't know why she (Corporate Nurse) changed the order. 2) Record review of the Smoking Policy and Procedure (no written date available) documented: Storage and Distribution of Cigarettes: 1) Cigarettes and lighters for ALL smokers, will be kept in the nursing station and 2) Cigarettes will be monitored and distributed to residents by staff. Observation and Interview of Resident #7 on 5/16/22 at 8:18 AM revealed the resident sitting up in bed, watching TV and eating breakfast. The pack of cigarettes and lighter were on the resident's night stand. Photographic evidence submitted. The resident stated, I go to smoke usually after lunch. I keep my cigarettes and lighter on my night stand. I keep my own stuff. Review of the Demographic Face Sheet for Resident #7 documented, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to diabetes mellitus, hypertension and Hyperlipidemia. Review of the Minimum Data Set (MDS) Admission, dated 11/09/21 for Resident #7 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 14 out of 15 indicating no cognitive impairment and the resident was able to make his needs known. The resident required supervision to extensive assistance with one person physical assist for ADLs (Activities of Daily Living) and section J was coded yes for current tobacco use. Review of Resident's #7 Smoking care plan dated 11/11/21 documented the resident is at risk for injury such as burns from cigarette related to unsafe smoking practice; Goal: Resident will be free from injury thru next review date. Will be compliant of smoking policy and only smokes on designated area; Interventions: Educate resident on harmful effects of smoking and inform of smoking policy of the facility; Evaluate resident at intervals regarding smoking safety; Keep resident's smoking supply at the nurses' station; Provide resident with cigarettes in smoking areas only; Provide smoking apron as needed; Resident will not be allowed to keep his/her own cigarettes and lighting materials as deemed necessary by the staff and Supervise as needed and monitor for unsafe actions while smoking and intervene promptly. On 5/18/22 at 1:27 PM, the Activities Director stated, He smokes. He doesn't go out very often to smoke, maybe once or twice a day. The lighter and the cigarettes are kept at the nurses' station. The nurse or the clerk will hand him his cigarettes when he wants to go outside to smoke. Nursing does the smoking assessment. He requires supervision but he is able to light his cigarette without assistance. Smoking times are 8:30am, 1:00pm and 6:30 pm. If they want to smoke at other times, we will call the activities assistant or nursing to go down and supervise. I didn't know he kept his cigarettes and his lighter. He has been educated on the smoking policy. On 5/18/22 at 2:31 PM, Staff E Registered Nurse (RN) stated, I never seen him request for cigarettes and lighters. The resident is not to keep their cigarettes and their lighters. When they go down to smoke they are to ask for the cigarettes and the lighter. On 5/18/22 at 4:59 PM, the Social Services Assistant stated, I did not know he has both the cigarettes and lighter with him. He is not supposed to have the cigarettes and the lighter. We have a drawer at the nurses' station that houses the cigarettes and lighter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to 1) Provide adequate supervision to prevent accidents for one (resident #7) out of one sampled resident for smoking safely. This deficient practice enabled resident #7 to keep his cigarettes and lighter on his bedside table. There were 4 residents identified as smokers. 2) The facility failed to place an electric fans cord away from a bathroom water faucet and sink in Resident #45's room. This allowed resident #45's roommate, Resident #41 with the potential for an electrical shock due to the placement of the fan's cord. This deficient practice affected 2 out of 33 sampled residents. There were 106 residents residing in the facility at the time of the survey. The findings included: 1. Record review of the Smoking Policy and Procedure (no written date available) documented: Storage and Distribution of Cigarettes: 1) Cigarettes and lighters for ALL smokers, will be kept in the nursing station and 2) Cigarettes will be monitored and distributed to residents by staff. Observation and Interview of Resident #7 on 5/16/22 at 8:18 AM revealed the resident sitting up in bed, watching TV and eating breakfast. The pack of cigarettes and lighter were on the resident's night stand. Photographic evidence submitted. The resident stated, I go to smoke usually after lunch. I keep my cigarettes and lighter on my night stand. I keep my own stuff. Review of the Demographic Face Sheet for Resident #7 documented, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to diabetes mellitus, hypertension and Hyperlipidemia. Review of the Minimum Data Set (MDS) Admission, dated 11/09/21 for Resident #7 documented the resident's Mental Status (BIMS- Brief Interview for Mental Status) Summary Score had a BIMS Summary Score of 14 out of 15 indicating no cognitive impairment and the resident was able to make his needs known. The resident required supervision to extensive assistance with one person physical assist for ADLs (Activities of Daily Living) and section J was coded yes for current tobacco use. Review of the Smoking Nicotine Devices assessment dated [DATE] for resident #7 documented the following: Total Score 1=No Supervision; Resident smokes 1 time/day; Prefers smoking morning and afternoon; Resident was educated on the importance to follow smoking policy/safety precautions. Review of Resident's #7 Smoking care plan dated 11/11/21 documented the resident is at risk for injury such as burns from cigarette related to unsafe smoking practice; Goal: Resident will be free from injury thru next review date. Will be compliant of smoking policy and only smokes on designated area; Interventions: Educate resident on harmful effects of smoking and inform of smoking policy of the facility; Evaluate resident at intervals regarding smoking safety; Keep resident's smoking supply at the nurses' station; Provide resident with cigarettes in smoking areas only; Provide smoking apron as needed; Resident will not be allowed to keep his/her own cigarettes and lighting materials as deemed necessary by the staff and Supervise as needed and monitor for unsafe actions while smoking and intervene promptly. On 5/18/22 at 1:27 PM, the Activities Director stated, He smokes. He doesn't go out very often to smoke, maybe once or twice a day. The lighter and the cigarettes are kept at the nurses' station. The nurse or the clerk will hand him his cigarettes when he wants to go outside to smoke. Nursing does the smoking assessment. He requires supervision but he is able to light his cigarette without assistance. Smoking times are 8:30am, 1:00pm and 6:30 pm. If they want to smoke at other times, we will call the activities assistant or nursing to go down and supervise. I didn't know he kept his cigarettes and his lighter. He has been educated on the smoking policy. On 5/18/22 at 2:31 PM, Staff E Registered Nurse (RN) stated, I never seen him request for cigarettes and lighters. The resident is not to keep their cigarettes and their lighters. When they go down to smoke they are to ask for the cigarettes and the lighter. On 5/18/22 at 4:59 PM, the Social Services Assistant stated, I did not know he has both the cigarettes and lighter with him. He is not supposed to have the cigarettes and the lighter. We have a drawer at the nurses' station that houses the cigarettes and lighter. 2. On 05/15/22 08:45 AM, Resident #45 was observed in the bed located next to the window. The resident was verbally unresponsive and appeared to be unable to move without the total assistance of staff. The resident was observed to have a Tracheostomy, his left and right arms were contracted. The resident had Nutren 2.0 infusing at 65cc/hr, with a water flush at 40cc (Cubic Centimeter)/hr (hour). A square medium sized electrical fan was in a chair in the room and was on. The residents legs were contracted. The residents oxygen/O2 was on at 3 liters/minute and was connected to the tracheostomy. The fans cord was plugged into the electrical socket about the sink that was inside the residents room. A photo was obtained. Record review revealed Resident #45 was admitted to the facility on [DATE]. The residents diagnoses included but were not limited to Anoxic Brain Damage. On 05/16/22 at 08:24 AM, Resident #45 was observed in bed. The residents fan cord was next to the bathroom sink that resident #45's roommate was using. Resident #45's roommate was Resident #41 and he was observed to be alert, ambulatory and to use the bathroom sink. Record review revealed Resident #41 was admitted to the facility on [DATE]. On 05/17/22 at 10:55 AM, a wound care observation was completed with Staff Q, Licensed Practical Nurse (LPN) and Wound Care Nurse. The residents fan was on and the cord was over the bathroom faucet and sink. On 05/18/22 at 12:29 PM, Resident #45 was observed in bed and the fan was on and the fans cord was observed to be near the bathroom sink. Picture obtained. On 05/18/22 at 12:35 PM, Staff M, Registered Nurse for Resident #41 and #45 was interviewed about the reason for the fan, she said its to help the resident with ventilation. Staff M was asked about the safety for the resident since the electrical cord is across the sink and Staff M reported, the cord was usually under the sink. Staff M was informed the cord was across the sink and Resident #41 was ambulatory and uses the sink. Staff M reported, the cord shouldn't be across the sink. Staff M was asked to please check the location of the fans cord. On 05/18/22 at 01:43 PM, Staff C, Registered Nurse Supervisor was asked about resident #45's fan cord being over the sink. Staff C reported, the cord should be under the sink. Staff C reported, perhaps a staff member moved it. The facility's safety policy was requested. Staff C was shown the pictures where the cord was located on 05/17/22 and 05/18/22. I explained the residents roommate uses the sink and this is an accident hazard. On 05/19/22 at 08:47 AM, Resident #45 was observed in bed asleep. The electrical fan was no longer in the residents room. Review of the facility's Safety - Prevention of Accidents with a revision date of July 2021 documented, a Policy Statement of: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The Policy and Implementation section included: 4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On [DATE] at 9:30am Resident #35 was observed sitting up in bed with 2 liters of oxygen (O2) via nasal cannula. Resident #35 reported that he is feeling alright, and breakfast was alright. Resident #35 was in no respiratory distress and respirations were even and unlabored On [DATE] at 8:41am Resident #35 was observed on his bed and with 2 liters of oxygen via nasal cannula. Resident #35 was not observed to be in respiratory distress, respiration were even and unlabored. Record review of Resident #35s medical record revealed resident #35 was admitted to the facility on [DATE] with medical diagnosis included but not limited to Chronic Obstructive Pulmonary Disease with (Acute Exacerbation), Muscle Weakness (Generalized), Cognitive communication deficit, Dysphagia, Major Depressive disorder, Cataract, Primary Hypertension, and Dementia. Record review of the Physician Orders revealed that resident #35 was started on O2 at 2 L/min via nasal cannula as needed for Shortness of Breath as needed on [DATE] and the O2 was discontinued on [DATE]. Record review of Physician Orders dated on [DATE] revealed that Resident #35 also had orders for Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 1 inhalation inhale orally every 4 hours related to chronic obstructive pulmonary disease with (acute exacerbation). Record review of Resident #35 Comprehensive Minimum Data Set (MDS) dated [DATE] revealed: Section B Adequate Hearing, No Speech, and Vision Impaired. Section C Cognitive Patterns- Brief Interview of Mental Status (BIMS) Score 2 out of 15, which indicated severely impaired cognition. Section O (Special Treatment, Procedures, and Programs) did not code the resident for using oxygen as a part of his routine care. Record review of the Progress note dated from [DATE] revealed no documentation stating Resident #35 was receiving oxygen therapy as part of his care. Progress notes dated on [DATE] documented Resident #35 was receiving oxygen therapy for respiratory distress until the facility transferred the resident to the hospital. Review of the Physician orders for [DATE], revealed physician ordered to restart Resident #35 on oxygen. The Physician Orders: Respiratory- oxygen: nasal cannula/ mask continuous 02 @ 15 via non rebreathing mask continuously for shortness of breath. Record review of Resident #35's Care plan dated [DATE] revealed Resident #35 was cared planned for having a diagnosis of COPD and is at risk for complication. Goal: Resident will display optimal breathing pattern (Dyspnea) on exertion. Intervention: Remind resident not to push beyond and endure. Resident #35s Care Plans, did not document an approach for long term continuous oxygen therapy at 2 liters. Interview on [DATE] at 01:35pm with Staff C, Registered Nurse Supervisor, Staff C was asked about resident #35 who has been using continuous oxygen therapy since the beginning of this survey on [DATE], without a standing order provided for the resident. The Nurse Supervisor stated he was not sure why the order was discontinued. Staff C, briefly explained what had happened on [DATE] about the residents respiratory distress and the resident needed oxygen, because of 02 saturation was 88%. Record review of the facility's Oxygen Administration, Revised [DATE] revealed, Physicians will prescribe ancillary treatment as indicated, for example supplemental oxygen, diuretics, and antibiotics. Oxygen therapy during exercise may help increase walking distance and endurance. Supplemental oxygen has been demonstrated to be helpful in treating hypoxia associated with COPD and related conditions. Oxygen may be administered as long-term continuous therapy, during exercise, or to relieve acute dyspnea. A nurse may administer up to 2L of oxygen via Nasal Cannula as a standard order in an emergency. 4. On [DATE] at 11:00 AM, Resident # 3 was in bed awake, the resident had a tracheostomy, Percutaneous Gastrostomy (PEG) tube feeding running at 70 milliliters per hour (ml/hr.), air mattress, O2 at 2LPM via trach collar, humidifier present, suction equipment at THE bedside, AND bilateral heel protectors on. On [DATE] at 09:37 AM, the resident was in bed asleep, PEG tube feeding was on, the O2 at 2LPM via trach collar was infusing, the humidifier was present, supplies at bedside. On [DATE] at 11:01 AM, the resident was in bed asleep, PEG tube feeding was on, the O2 at 3 LPM via trach collar was infusing, the humidifier was present. Review of Resident # 3 's clinical record documented an initial admission to the facility on [DATE] with diagnoses including Acute and Chronic Respiratory Failure and Encounter for Attention to Tracheostomy. Record review of the physician order sheet revealed Resident #3 had orders up to and including: Effective Date-[DATE]-Oxygen 2-3 Liters at 28% Humidifier via Tracheostomy Continuous Care every shift related to Acute and Chronic Respiratory Failure and Hypoxia. Discontinue Date-[DATE]-Oxygen 5 Liters at 28% Humidifier via Tracheostomy Continuous Care and Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML. Record review of Resident #3 Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C-for cognitive patterns Brief Interview of Mental Status score (BIMS) was unable to be determined. Section G for functional status-Total dependence for activities of daily living. Section H for Bladder and Bowel-always incontinent. Section K for Swallowing/Nutritional status-no unknown weight loss/Tube Feeding. Section O for special treatments and procedures-received oxygen, suctioning, and tracheostomy care in the last fourteen days. Record review of Resident #3 Care Plans Reference Date-[DATE] revealed: The resident has a tracheostomy related to impaired breathing mechanics and diagnosis of respiratory failure. Goal: The resident will have clear and equal breath sounds bilaterally through the review date. The resident will have no sign and symptoms (s/sx) of infection through the review date. The resident will have no abnormal drainage around trach site through the review date. The resident will have temp within normal limits through review date and the resident will have white blood cell (WBC) count within normal limits through review date. Interventions: Keep call bell within easy reach, Monitor and document respiratory rate, depth and quality. Check and document q shift as ordered, monitor level of consciousness, mental status and lethargy as needed (PRN), Monitor/document restlessness, agitation, confusion increased heart rate (tachycardia) and bradycardia, O2 @ 5LPM continuous, provide good oral care daily and PRN, provide means of communication and procedural information, Reassure that help is available immediately. Resident has tracheotomy. Ensure that tracheostomy ties are secured at all times, Suction as necessary and Trach care q (every) shift. Focus: The resident has altered respiratory status/Difficulty Breathing r/t Respiratory failure. Goal: The resident will have no s/sx of poor oxygen absorption through the review date. The resident will maintain normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern through the review date. The resident will have no complications related to shortness of breath (SOB) through the review date. Interventions: Administer medication/puffers as ordered. Monitor for effectiveness and side effects. Assist resident/family/ caregiver in learning signs of respiratory compromise. Monitor /document changes in orientation, increased restlessness, anxiety, and air hunger. Monitor for s/sx of respiratory distress and report to Physician (MD) PRN: Increased Respirations; Decreased Pulse oximetry; Increased heart rate (Tachycardia); Restlessness; Diaphoresis; Headaches; Lethargy; Confusion; Hemoptysis; Cough; Pleuritic pain; Accessory muscle usage; Skin color changes to blue/grey. Monitor/document/report abnormal breathing patterns to MD (Medical Doctor): increased rate, decreased rate, periods of apnea, prolonged inhalation, prolonged exhalation, prolonged shallow breathing, prolonged deep breathing, use of accessory muscles, pursed-lip breathing, nasal flaring. Position resident with proper body alignment for optimal breathing pattern. Provide oxygen as ordered. Tracheostomy care as ordered. Use pain management as appropriate. Monitor/document side effects and effectiveness. I have requested that CPR (Cardio-pulmonary Resuscitation) measures ARE to be performed. Record review of the Nurses' progress notes revealed: [DATE] at 10:00am, Resident #3, MD: give new order O2 To 2L or 3LPM and Discontinue (D/C) O2 to 5LPM. Continue monitoring. SPO2(Oxygen Saturation): 98%, now. On [DATE] at 04:11pm, Nurse's Note documents, Resident is in the bed resting quietly, no acute distress noted, oxygen via tracheostomy is in place, head of bed is elevated, medication via peg tube tolerated well, tracheostomy care provided and inner cannula is in place, suctioned as needed, trach collar changed, nebulizer treatment tolerated well, assisted to comfort level, maintained clean and dry status, safety measures are in place with side rails in place. On [DATE] at 09:45 AM, (Staff C), Registered Nurse Supervisor accompanied the surveyor to Resident #3's room and he was shown the resident's oxygen level at 3LPM on the concentrator. Staff C was asked to check the resident's physician order and the resident's order stated, O2 at 5 LPM at 28% humidifier via tracheostomy continuous care, Staff C stated, he believed the concentrator is broken and cannot go up any higher than 3 LPM, Staff C left the room to go get a new concentrator and thanked surveyor for bringing the concern to his attention. On [DATE] at 9:47AM Staff C returned to Resident #3's room with a new oxygen concentrator, turned it to 5LPM with the humidifier. The oxygen level on the concentrator had dropped to 2 LPM, the humidifier was removed and the oxygen level on the concentrator rose to 3LPM. Staff C checked the resident, and no distress noted. The humidifier was reconnected to the oxygen, and the O2 level was observed at 3LPM. Staff C stated, he would call Resident # 3's Physician (MD) to make aware of the situation. On [DATE] at 09:50 AM, (Staff D), the Unit 3 Floor Nurse was present with Staff C in the room with the surveyor to observe the resident's oxygen level at 3 LPM. Staff D went to the computer to check the resident's orders with Staff C and observed the orders on the Electronic Medication Record (EMAR) revealed -02 @ 5LPM at 28% humidifier via Tracheostomy continuous care. On [DATE] at 10:03 AM, Staff C stated he spoke with Resident #3's MD, the MD changed the order to Oxygen 2-3 Liters at 28% humidifier via tracheostomy continuous care, he will be writing a note in the EMAR and nurses' notes about this change. On [DATE] at 07:45 AM, the Director of Nursing (DON) after being told about the surveyor's findings with Resident #3's oxygen not being administered as prescribed stated, that she will be conducting education in services with the nurses and will be having the company that is responsible for maintenance of the 02 concentrators, come to the facility and do a thorough inspection of all 02 concentrators in the building. Review of the facility's Policy and procedure titled, Oxygen Administration, revised [DATE] states: Step 9 in oxygen procedure-Check the mask, tank, humidifier, jar etc. to be sure they are in good working order and are securely fastened. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated. 3. Observation of resident #60 on [DATE] at 09:10 AM revealed the Resident was observed on her bed watching television. The Resident was observed receiving oxygen therapy. The Oxygen concentrator level was set at 2.5 Liters per Minute (LPM). The Resident reported, she had the oxygen all of the time. She had a nasal cannula on her nose. No distress or anxiety was noted. Record review of the admission Record revealed the resident was admitted to the facility on [DATE]. Record review of the residents Medical Diagnoses revealed the resident's diagnoses included, but were not limited to, Metabolic Encephalopathy; Chronic Obstructive Pulmonary Disease, Unspecified; Type 2 Diabetes Mellitus; Morbid (Severe) Obesity due to Excess Calories; Depression, Unspecified; Respiratory Failure, and Unspecified with Hypercapnia. Record review of the Care Plan initiated on [DATE] and next review date will be [DATE] revealed the resident had altered cardiovascular status related to Hypertension and Paroxysmal Atrial Fibrillation. Goal: Resident will be free from complications of cardiac problems through the review date. Interventions: Administer medications per medical doctor's (MD) order. Administer Oxygen per MD orders. Cardiology consult and follow up as indicated. Diet consult as necessary. Encourage low fat, low salt intake. Monitor vital signs as ordered. Notify MD of significant abnormalities. Resident/family/caregiver teaching to include: nature of the disease, risk factors such as high cholesterol, hypertension, and cigarette smoking, sedentary life style, obesity and stress. Record review of Physician Orders dated [DATE] revealed the resident was receiving Ipratropium-Albuterol Solution 0.5-2.5 (3) milligrams (mg)/3 milliliters (ml). 3 ml inhale orally via nebulizer four times a day related to Chronic Obstructive Pulmonary Disease (COPD). Record review of Physician Orders dated [DATE] revealed the resident had an order for Oxygen set at 2 liters (L) via nasal cannula as needed related to Respiratory Failure, Unspecified with Hypercapnia. Record review of the admission 5 days Minimum Data Set (MDS) Section C dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) Summary Score was 15, indicating the resident did not have impaired cognition. Record review of admission 5 days MDS section G dated [DATE] revealed the resident needed total dependence with one-person physical assistance for bed mobility, transfer, walk in room and corridor, locomotion on/off unit, dressing, toilet use and personal hygiene. The resident needed extensive assistance with one-person assistance for eating. Interview with Staff A, Certified Nursing Assistant (CNA) on [DATE] at 11:43 AM, she stated the resident was nice but she did not want to get out of the bed, she did not participate in activities. The resident was receiving Physical Therapy but she sometimes refused to go to therapy. She stated, if she noted the resident with distress or anxious she had to report it to the nurse. The resident refused to be changed when the nursing assistant went to change her diaper and told her to come back later. Interview with Staff B, Registered Nurse (RN) on [DATE] at 12:18 PM . She stated the doctor's order for oxygen was as needed, but the resident wanted to use it all the time. The Resident has a diagnosis of bipolar disorder and she believes she needed the oxygen all the time. Her saturation was 96% or higher all the time. Her oxygen order was 2 LPM. She reported, if the oxygen was at 2.5 LPM, it could be that therapy when they reconnected it maybe they moved the oxygen concentrator. Interview with Staff L, the MDS Coordinator on [DATE] at 03:53 PM. She stated, the process for MDS is as follows: the resident was admitted , we checked the medical record, we assessed the resident, completed the MDS. We did the cause and created the Care Plan. Resident #60s care plan was created due to the resident's cardiovascular disease related to Hypertension and Paroxysmal Atrial Fibrillation. Oxygen therapy was part of the interventions. Based on observations, interviews and record review, the facility failed to: 1) Ensure oxygen (O2) therapy for two (Resident#3 and Resident #60) was delivered at the prescribed order rate, 2) Failure to provide a standard order for continuous oxygen therapy at two liters per minute via Nasal Cannula (NC) for one (Resident #35) who has a diagnosis of Chronic Obstructive Pulmonary Disorder (COPD), failed to ensure one (Resident #27) received continuous oxygen treatments out of four residents reviewed for respiratory care. The facility had of 25 Residents receiving oxygen therapy at the time of the survey and this has the potential to affect 106 residents residing in the facility at the time of this survey. The findings included: 1. Record review of the Oxygen Administration Policy and Procedure (revised [DATE]) documented the following: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1) Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. General Guidelines: 1) Oxygen therapy is administered by way of an oxygen mask, nasal cannula and/or nasal catheter. Observation of Resident #27 on [DATE] at 8:08 AM revealed the resident sitting up in bed, wearing glasses and watching TV, preparing to eat breakfast. The Resident was not wearing oxygen by nasal cannula. Multiple observations were made throughout the survey process [DATE] to [DATE] and resident #27 was never observed receiving oxygen treatment and wearing a nasal cannula. Review of the Demographic Face Sheet for Resident #27 documented the resident was admitted to the facility on [DATE] with diagnoses to include hypertensive heart and chronic kidney disease, diabetes mellitus, morbid obesity, congestive heart failure, acute and chronic respiratory failure, end stage renal disease, dependence on renal dialysis and Atrial fibrillation. Review of the Minimum Data Set (MDS) admission Assessment for Resident #27 dated [DATE] documented the resident's Mental Status (BIMS-Brief Interview for Mental Status) Summary Score had a BIMS Summary Score of 14 out of 15 indicating no cognitive impairment and the resident was able to make her needs known. The resident required extensive to total dependence assistance with two+ persons physical assist for ADLs (Activities of Daily Living) and section O was coded for oxygen therapy use. Review of the Physician's Orders (POS) dated [DATE] and [DATE] for Resident #27 documented O2 (oxygen) at 2L (liters)/min (minute) via nasal cannula continuously every shift for sob (shortness of breath), (Start date [DATE]). Observations revealed resident #27 was not wearing a nasal cannula. Review of the EMAR (electronic medical administration record) dated [DATE] and [DATE] for Resident #27 documented the resident received O2 at 2L/min via nasal cannula continuously from [DATE] to [DATE]. Review of Resident's #27's care plan dated [DATE] documented the resident is at risk for altered respiratory status/Difficulty Breathing r/t (related to) diagnosis of respiratory failure, CHF (congestive heart failure), ESRD (end stage renal disease); Goal: Resident will have no s/sx (signs/symptoms) of poor oxygen absorption through next review date; Interventions: Provide oxygen as ordered. Second care plan documented: Resident has altered cardiovascular status r/t CHF, Hypertension and Hyperlipidemia; Goal: Resident will be free from s/sx of complications of cardiac problems through next review date; Interventions: Give oxygen as ordered by the physician. Follow oxygen protocol and precautions. Review of the Physician's Orders (POS) dated [DATE] for Resident #27 documented Oxygen 2L via NC (nasal cannula) PRN (as needed) for sob every 1 hours as needed for sob (Start date [DATE] 14:55, Revision date [DATE]; Created by Corporate Director of Nursing) (DON). Copies of the medical record documentation was requested on [DATE] at 12:56 PM and the copies of the documentation were received from the facility DON on [DATE] at 3:27 PM. The oxygen administration documentation was changed during the time the documentation was requested. On [DATE] at 7:28 AM, resident #27 revealed that she does not receive oxygen via a nasal cannula continuously. On [DATE] at 2:34 PM, Staff E Registered Nurse (RN) stated, She was not getting the oxygen continuously. The order says PRN. I don't know about the order being changed. On [DATE] at 3:56 PM, the DON stated, The resident had an order for oxygen at 2L/min via nasal cannula continuously, every shift for sob for [DATE] to [DATE]. The order was changed on [DATE] at 14:55 to Oxygen at 2L/min via nasal cannula PRN. Oxygen 2L via NC PRN for sob every 1 hours as needed for sob (Start date [DATE] 14:55, Revision date [DATE]; Created by the DON, which is a Corporate Nurse. I don't know why she (Corporate Nurse) changed the order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure its medication error rate was five percent or below, as evidenced by an error rate of 9.09% percent during medication administration observation. Three (3) medication errors were identified while observing a total of 33 opportunities, affecting Resident # 68 and # 76. These were 3 omission errors. The Findings Included: 1. 0n 5/17/22 at 8:39 AM during medication administration observation with Registered Nurse (Staff B). Staff B did not have on her medication cart and was unable to administer one prescribed medication (Sertraline 75MG (1) tablet) for Resident # 68. Review of Resident # 68 's clinical record documented an initial admission to the facility on [DATE] with diagnoses including major Depressive Disorder Review of Resident #68's physician orders for May 2022 revealed Sertraline 75 Milligram (MG), 1 tablet by mouth one time a day for depression related to major depression disorder Record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C of the assessment included a Brief Interview for Mental Status Score (BIMS) of 12 which indicated the resident has moderate cognitive impairment. On 5/17/22 at 8:39 AM, Interview with the Unit 3 Registered Nurse (Staff B) about the medications that was not given to resident #68, Sertraline 75 MG (1) Tablet, Staff B stated, I will call the pharmacy to reorder the medication, it was requested and we have not received it as yet, I will write the medication on the reorder sheet again to send to the pharmacy and I will follow up with a call to the pharmacy. On 05/17/22 at 03:33 PM, the Facility Corporate Nurse, Facility Pharmacist, stated Resident #68's medication Sertraline 75MG was reordered, the physician and psychologist were notified, and an order was received to give the medication immediately (STAT) upon arrival from pharmacy, the medication will be delivered today 5/17/22. On 05/18/22 at 08:10 AM, the Director of Nursing (DON) when told about the resident who had a missing medication during medication administration observation stated that she would be providing education and inservices to the nurses involved on reordering medications and medication administration procedures. Review of the facility's Policy and procedure titled Administering Medications, revised April 2022 states: Medications are administered in a safe and timely manner. Medications are administered in accordance with prescriber orders, including any required time frame. Review of the facility's Policy and procedure titled, Medication and Treatment Orders, revised July 2020 states: Drugs and Biologicals that are required to be refilled must be reordered from the reissuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available. Review of facility policy titled, Physician Order revised July 2020 states: If a medication is not available in medication cart, nurse may obtain medication from e-kit. If medication is not available in emergency kit, nurse may call physician to obtain new instructions. Pharmacy will be notified immediately. 2. During the medication administration observation on 5/17/2022 at 8:32AM with Staff N, Registered Nurse, Resident #76 had a physician order for Refresh Tears Solution (Carboxymethylcellulose Sodium), Instill 1 drop in right eye two times a day for Ectropion To right lower lid continuous Pharmacy Start Date-1/17/2022 21:00. Staff N, reported the Eye drops weren't available and she would reorder the Eye Drops. The medication was not administered during the 9:00AM medication administration observation. On 05/17/2022 the Medication discontinued. 3. During the medication administration observation on 5/17/2022 at 8:32AM with Staff N, Resident #76 had a physician order for VITAMIN C CHW (Chewable) 500MG, Give 1 tablet orally one time a day for vitamin, Pharmacy Start Date-11/1/2021. Staff N reported the medication was not available and she would notify the pharmacy. The medication was not given during the 9:00AM medication administration observation. On 05/17/2022 the Medication discontinued. On 5/17/2022 at 3:02pm, the facililty's Pharmacy Consultant reported the medication was changed to PO (By mouth) and the Vitamin C was administered. The revised physician order on 5/17/22 was changed to Ascorbic Acid Tablet 500 MG Give 1 tablet by mouth one time a day for Prophylaxis;Supplement Pharmacy Active 5/18/2022 09:00 5/17/2022-Order modified

Based on observations, interviews, and record review, the facility failed to demonstrate an effective plan of action was implemented to correct identified quality deficiencies in problem-prone areas, related to (F 689)- Free of Accident Hazards as evidenced by repeated deficient practice found during consecutive annual surveys. The findings included: Reviewed the CMS-2567 from the last recertification survey revealed that F 689 tag was cited in the previous survey on 12/12/2019. (Accident Hazard was a concern investigated during this survey with findings). Record review of the facility's policies and procedures revised April 2021, revealed the Quality Assurance and Performance Improvement (QAPI) Program is in place. It noted: Policy Interpretation and Implementation: The primary purpose of the Quality Assurance and Performance Improvement Program(QAPI) is to establish data-driven, facility-wide processes that improve the quality of care, quality of life and clinical outcomes of our residents. . QAPI Action Steps The following steps are employed or will be employed to support and enhance the facility QAPI programs: 20. Taking systematic action targeted at the root causes of identified problems. This encompasses the utilization of corrective actions that provide significant and meaningful steps to improve processes and do not depend on staff to simply do the right thing. Interview on 05/19/22 at 12:54 PM with the Nursing Home Administrator (NHA) revealed the facility has a QAPI/QAA Committee and they meet monthly. The NHA stated, the facility has a Performance Improvement Plan (PIP) for identified problems that have been identified and she mentioned different areas where they have ongoing PIPs are ongoing. Once the NHA finished with the explanation of the PIPs, the surveyor asked if there were any other area where the facility has a Performance Improvement Plan and NHA stated the ones mentioned are the only ones the facility have in place at this time. At 01:55 PM and after discussing the findings with the team, the NHA stated she forgot to show the surveyor the facilitys PIP for safety and stated she was bringing documentation to the team. At 02:15 pm on 05/19/2022, the NHA brought the PIP for Safety and for Physician orders. Record review of the PIP dated 03/01/2022 revealed a performance improvement plan (PIP) on safety hazards for duration of 3 months reviewed on 03/01/2022. This PIP revealed no identification of accident hazard identified by the team, and consequently no action plan for improvement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. This deficient practice has the potential to affect 106 residents residing in the facility at the time of this survey. The findings included: Observation of the 4th floor posted nursing staff on 5/15/22 at 6:26 AM, 11 PM-7 AM shift revealed the following: The staffing board was dated 5/13/22. 4th floor: Census-36; 2 Nurses and 4 Certified Nursing Assistants (CNA). The Staffing board was not updated to reflect the correct staffing and census. Photographic evidence submitted. Observation of the 4th floor actual staff working on 5/15/22 at 6:29 AM revealed, 1 nurse (Staff H) and 2 CNAs (Staff G and Staff I). The actual staff working on the 11-7 shift names were not on the staffing board and the actual census was 37 residents. On 5/15/22 at 6:37 AM, Staff G stated, The board is from Saturday staffing. The nurse was supposed to change the board. She didn't. Usually there are two nurses but there is only one nurse today. Only two C N As today, usually three. On 5/15/22 at 6:39 AM, Staff H stated, I didn't change the board, because I was waiting on the third C N A to come, but she didn't. I was the only nurse and it is hard when I have to pass meds, do trach (tracheostomy) care and everything else. We don't know if the other person is not going to show until we get here. On 5/15/22 at 6:43 AM, Staff I stated, Usually there are three C N As but only two CNAs work today. We need more C N As. On 5/15/22 at 8:10 AM Resident #27 stated, They are short staff here. Sometimes it takes a while for them to answer the call light. Review of the Demographic Face Sheet for Resident #27 documented the resident was admitted to the facility on [DATE] with diagnoses to include hypertensive heart and chronic kidney disease, diabetes mellitus, morbid obesity, congestive heart failure, acute and chronic respiratory failure, end stage renal disease, dependence on renal dialysis and atrial fibrillation. Review of the Minimum Data Set (MDS) admission Assessment for Resident #27 dated 2/23/22 documented the resident's Mental Status (BIMS-Brief Interview of Mental Status) Summary Score had a BIMS Summary Score of 14 out of 15 indicating no cognitive impairment and the resident was able to make her needs known. On 5/15/22 at 8:25 AM Resident #59 stated, Sometimes they take a long time to come and help me. Review of the Demographic Face Sheet for Resident #59 documented the resident was admitted to the facility on [DATE] with diagnoses to include end stage renal disease, dependence on renal dialysis, chronic atrial fibrillation and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) Annual Assessment for Resident #59 dated 12/27/21 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 15 out of 15 indicating no cognitive impairment and the resident was able to make her needs known. Observation of the 4th floor posted nursing staff on 5/15/22 at 8:53 AM, 7 AM-3 PM shift revealed the following: The staffing board was dated 5/15/22, Census-36; 1 Nurse and 4 CNAs. Staffing board did not reflect the wound care nurse, the correct staffing. Photographic evidence submitted. Observation of the 4th floor actual staff working on 5/15/22 at 8:54 AM revealed, 2 nurses and 4 CNAs. The wound care nurse was directed to fill in and work the medication cart on the floor. The actual staff working on the 11-7 shift names were not on the staffing board and the actual census was 37 residents. Observation of the posted nursing staff on 5/15/22 at 11:14 AM, 7 AM-3 PM shift revealed the following: On the 3rd floor: Census-37; 2 Nurses and 4 CNAs. On the 2nd floor: Census-32; 2 Nurses and 5 CNAs. On 5/15/22 at 12:23 PM, Resident #504 revealed that most days they have enough staff but on the weekends, staff is very light. They need more staff on the weekends. Review of the Demographic Face Sheet for Resident #504 documented the resident was admitted to the facility on [DATE] with diagnoses to include end stage renal disease, peripheral vascular disease, acute respiratory failure and hypertension. Review of the Minimum Data Set (MDS) admission Assessment for Resident #504 dated 5/12/22 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 14 out of 15 indicating no cognitive impairment and the resident was able to make his needs known. Observation of the posted nursing staff on 5/16/22 at 7:38 AM, 7 AM-3 PM shift revealed the following: On the 4th floor: Census-37; 2 Nurses and 5 CNAs. On the 3rd floor: Census-37; 2 Nurses and 6 CNAs. On the 2nd floor: Census-33; 2 Nurses and 5 CNAs. On 5/16/22 at 8:20 AM, Resident #7 revealed that the facility needs more staff here. He stated, There is not enough staff. Review of the Demographic Face Sheet for Resident #7 documented, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to diabetes mellitus, hypertension and hyperlipidemia. Review of the Minimum Data Set (MDS) Admission, dated 11/09/21 for Resident #7 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 14 out of 15 indicating no cognitive impairment and the resident was able to make his needs known. Observation of the posted nursing staff on 5/17/22 at 7:26 AM, 7 AM-3 PM shift revealed the following: On the 4th floor: Census-37; 2 Nurses and 5 CNAs. On the 3rd floor: Census-37; 2 Nurses and 5 CNAs. On the 2nd floor: Census-33; 2 Nurses and 5 CNAs. Observation of the posted nursing staff on 5/18/22 at 7:38 AM, 7 AM-3 PM shift revealed the following: On the 4th floor: Census-36; 2 Nurses and 5 CNAs. On the 3rd floor: Census-37; 2 Nurses and 5 CNAs. On the 2nd floor: Census-32; 2 Nurses and 5 CNAs. Observation of the posted nursing staff on 5/19/22 at 7:27 AM, 7 AM-3 PM shift revealed the following: On the 4th floor: Census-35; 2 Nurses and 5 CNAs. On the 3rd floor: Census-37; 2 Nurses and 5 CNAs. On the 2nd floor: Census-32; 2 Nurses and 4 CNAs. Review of the Calculating Staffing for Long Term Care Facilities for May 1-May 19, 2022, documented the weekly average for licensed nursing were 1.39, weekly average for C N As (certified nursing assistants) and PCAs (personal care assistants) were 2.52 and the combined weekly average for nursing, C N As and PCAs were 4.17. However, the direct care staff (nurses and cnas) consistently had staff calling out. Review of 18 months of Staffing from November 2020 to May 2022 revealed, the facility maintained 18 months of staffing, and that staffing documentation had staff signatures missing on the staffing sheets for all shifts. Review of the facility's assessment tool dated 08/18/2018 (updated 4/01/22) documented general staffing plan as the following: 1st Shift (11:00 PM-7:00 AM): 2nd Floor (Nurse-1; CNAs-3), 3rd Floor (Nurses-2; CNAs-4), 4th Floor (Nurses-2; CNAs-4); 2nd Shift (7:00 AM-3:00 PM): House Supervisor-1 Nurse; 2nd Floor (Nurses-2; CNAs-2-3, Restorative CNA-1), 3rd Floor (Nurses-2; CNAs-2-3, Restorative CNA-1), 4th Floor (Nurses-2; CNAs-4); 3rd Shift (3:00 PM-11:00 PM): House RN Supervisor-1 Nurse; 2nd Floor (Nurses-2; CNAs-3-4), 3rd Floor (Nurses-2; CNAs-4), 4th Floor (Nurses-2; CNAs-4). Review of the facility's current list of staffing with position titles and hire dates documented 53 RNs, 12 LPNs, 80 CNAs and 1 PCA. Review of the resident's acuity are documented as the following: Transfer with one to 2 persons assist: 2nd floor-12 residents, 3rd floor-14 residents, 4th floor-19 residents; Transfer Dependent: 2nd floor-8 residents, 3rd floor-22 residents, 4th floor-16 residents; Toilet use with one to 2 persons assist: 2nd residents floor-12 residents, 3rd floor-12 residents, 4th floor-16 residents; Toilet use Dependent: 2nd floor-10 residents, 3rd floor-25 residents and 4th floor-19 residents. On 5/18/22 at 4:30 PM, the Director of Nursing/Staffing Coordinator stated, We schedule each floor 2 nurses, except 11-7 shift 1 nurse, sometimes 2. Depends on the acuity of the resident and census. CNAs 5 on each floor for the shift, 2 on the 2nd floor and 3 C N As on the 3rd and 4th floor for the 11-7 shift. We use agency staff. Each nurse and C N A has a master schedule that projects for the months a minimum of 2 weeks. The projection is always posted before I leave for the day. They call the Staff Coordinator or me or the Administrator if they are going to call out. The staffing coordinator is new and still in training. I contact nurses to come in to fill in for the called out staff. We also use agency staffing. We don't have any problems providing staff on the weekends. When the nurse or the supervisor comes in, they are supposed to change the staffing on the board and it is supposed to be accurate. If someone calls out and the agency cannot send someone, myself, the ADON, MDS will come in and take a cart. On 5/19/22 at 8:36 AM, Staff J, stated, I usually work the 7-3 shift but they ask me to work a double shift on the 3-11 shift. They don't have enough staff here and they have a lot of staff who call out. Then they call the agency. They say they will come and then they don't show up. They ask me to work a lot of doubles. Sometimes I say yes and sometimes I say no.