**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to ensure the residents received medication as ordered in accordance with professional standards of practice for 1 (Resident #1) of 3 residents reviewed. Findings include: Review of Resident #1's clinical record showed the resident was admitted on [DATE] with diagnoses that included Stage 3 chronic kidney disease, and malignant neoplasm of prostate. Review of Resident #1's physician order dated 9/19/2024 read, Bisacodyl Rectal Suppository 10 MG [milligrams] (Bisacodyl), Insert 1 suppository rectally at bedtime for constipation. Review of Resident #1's Medication Administration Record (MAR) for October 2024 revealed no documentation on 10/2/2024 and 10/7/2024 for administration of Bisacodyl rectal suppository. During a telephonic interview on 11/6/2024 at 2:03 PM, Staff B, Licensed Practical Nurse (LPN), stated, I did not give the suppository because he had a bowel movement. I should have given the suppository routinely like the orders are written. I did not call the doctor. During a telephonic interview on 11/6/2025 at 5:08 PM, the Advance Practice Registered Nurse (APRN) stated, The physician orders needed to be followed unless the resident refuses and then the refusal should be documented and I should be notified. I was not notified that the medication was not given. During an interview on 11/6/2024 at 4:07 PM, the Director of Nursing stated, The suppository should have been given as ordered. If it is not given, then the physician needs to be notified. Review of the facility policy and procedure titled Administering Medications revised on 7/13/2015 read, Policy: Medications will be administered in a timely manner and as prescribed by the resident's attending physician or the facility's Medical Director in accordance with our established policies . Policy Interpretation and Implementation . 3. Medications must be administered in a timely manner and in accordance with the attending physician's written/verbal orders. 4. Should a dosage seem excessive considering the resident's age and medical condition, or a medication order seems to be unrelated to the resident's current diagnosis or medical condition, the person preparing/administering the medication shall contact the resident's attending physician or the facility's Medical Director for further instruction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide laboratory services to meet the needs for 1 (Resident #1) of 3 residents reviewed. Findings include: Review of Resident #1's clinical record showed the resident was admitted on [DATE] with diagnoses that included Stage 3 chronic kidney disease, and malignant neoplasm of prostate. Review of Resident #1's physician order dated 10/4/2024 read, CBC [Complete Blood Count]; CMP [Complete Metabolic Panel]; UA C&S [Urinalysis Culture and Sensitivity]. Review of Resident #1's UA C&S results read, Collection Date: 10/05/2024 00:00 [12:00 AM], Received date: 10/05/2024 10:05 [10:05 AM], Reported Date: 10/07/2024 13:15 [1:15 PM] . Source: Urine. Organism 1 > [more than] 100,000 CFU/ML [Colony Forming Units per Milliliter] Enterococcus faecalis. Sensitivity MIC ORG [microorganism] #5. Ampicillin <= [less than equals to] 2 S [Susceptible], Ciprofloxacin <=1 S, Nitrofurantoin <=32 S, Penicillin 2 S, Tetracycline >8 R [Resistant], Vancomycin 2 S. Review of Resident #1's clinical records revealed no lab results reported with reported to the physician. Review of the email sent from Infection Preventionist to the interdisciplinary team on 10/8/2024 at 10:21 AM read, [Resident #1's name] UA +[positive], needs ABT [antibiotic therapy]. During an interview on 11/6/2024 at 2:07 PM, the Infection Preventionist stated, I review cultures/urine results every morning. On 10/7/24, there were no result, the culture was still pending. I do not check the results again until the next day. The nurse assigned to the patient is supposed to follow up with abnormal labs during their shift. The next day [10/8/2024], I reviewed the results and [Resident #1's name] results were back. The urinalysis was positive and I sent an email to the IDT [Interdisciplinary team] directing that the resident needed antibiotics, but by that time the patient had already been sent to the hospital. During a telephonic interview on 11/6/2024 at 12:49 PM, Staff A, Licensed Practical Nurse (LPN), stated, I do not remember the patient. I do not know if the results were given to the providers or not. During a telephonic interview on 11/6/2024 at 5:08 PM, the Advance Practice Registered Nurse (APRN) stated, He [Resident #1] was confused on admission and had a history of UTIs. When the urinalysis was ordered, if he was symptomatic, I would have given him 3 days of IM [intramuscular] Rocephin. No Rocephin was ordered so he was not symptomatic, so I will wait for the sensitivity report. I was never informed of the urinalysis report. I do not feel harm was caused for him not being medicated on 10/7/2024 after sensitivity was received. During an interview on 11/6/2024 at 4:07 PM, the Director of Nursing confirmed the urinalysis and culture sensitivity report result received on 10/7/2024 at 1:15 PM was positive and not reported to the physician, and stated, The primary nurse is responsible to call the physician when the urinalysis is reported as abnormal. We receive the results via fax now. Review of the facility policy and procedure titled Test Results revised on 7/6/2010 read, Policy: The resident's attending physician shall be notified of the results of diagnostic tests. Policy Interpretation and Implementation . 2. Should the test results be provided to the facility, the attending physician ARNP [Advanced Registered Nurse Practitioner] shall be promptly notified of the results. 3. The Unit Manager or the nurse receiving the test results shall be responsible for notifying the physician of the test results. Noting the tests results by initially dating them. 4. Signed and dated reports of all diagnostic services shall be made a part of the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident records were complete and accurate for 1 (Resident #1) of 3 residents reviewed. Findings include: Review of Resident #1's clinical record showed the resident was admitted on [DATE] with diagnoses that included Stage 3 chronic kidney disease, and malignant neoplasm of prostate. Review of Resident #1's physician order dated 9/23/2024 read, Prostat AWC every shift for wounds. Review of Resident #1's physician orders dated 9/19/2024 read Senna S Oral tablet 8.6- 60 MG [milligrams], Give 1 tablet by mouth every 12 hours for constipation. Review of Resident #1's physician order dated 9/19/2024 read, Carbidopa-Levodopa Oral Tablet 10-100 MG, Give 2 tablet by mouth four times a day for Parkinson's. Review of Resident #1's Medication Administration Record (MAR) for October 2024 revealed no documentation on 10/7/2024 at night shift for administration of Prostat AWC, no documentation on 10/7/2024 at 9:00 PM for administration of Senna S and Carbidopa-Levodopa. During a telephonic interview on 11/6/2024 at 2:03 PM, Staff B, LPN, stated, I did not have many medications and I gave him his medications on 10/7/2024, but forgot to chart them. During an interview on 11/6/2024 at 4:07 PM, the Director of Nursing stated that the medication should be given as ordered and documented in the resident chart as given by the nurse. Review of the facility policy and procedure titled Administering Medications revised on 7/13/2015 read, Policy Interpretation and Implementation . 9. The individual administering the medication must initial the resident's MAR on the appropriate line and date for that specific day before administering the next resident's medication. Review of the facility policy and procedure titled Medical Record Documentation revised on 4/16/2023 read, Policy: All services provided to the resident, or any changes in the resident's condition, shall be recorded in the resident's medical record. Policy Interpretation and Implementation: 1. All treatments and medications shall be ordered by the physician and documented on the resident's MAR/TAR [Treatment Administration Record] . 11. Documentation in the resident's Medical Record and the Resident Care Plan is the responsibility of every nurse.

Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plans were implemented for 2 of 4 residents reviewed for positioning, Residents #73 and #74. Findings include: 1) During an observation on 9/23/2024 at 9:59 AM, Resident #74 was resting with her eyes closed. The resident's feet were not offloaded while in bed. There was a yellow pillow with white cover on top of the wheelchair. During an observation on 9/23/2024 at 12:14 PM, Resident #74 was lying in bed with her eyes closed. The resident's feet were not offloaded while in bed. During an observation on 9/23/2024 at 12:53 PM, Resident #74 was lying in bed with her eyes closed. The resident's feet were not offloaded while in bed. During an observation on 9/24/2024 at 7:45 AM, Resident #74 was lying in bed with her eyes closed. The resident's feet were not offloaded while in bed. There was a yellow pillow with white cover on top of the wheelchair. During an observation on 9/24/2024 at 8:40 AM, Resident #74 was sitting up in bed with breakfast tray in front of her. The resident's feet were not offloaded. There was a yellow pillow with white cover on top of the wheelchair. During an observation on 9/24/2024 at 11:06 AM, Resident #74 was resting with her eyes closed. The resident's feet were not offloaded while in bed. There was a yellow pillow with white cover on top of the wheelchair. Review of Resident #74's care plan dated 7/12/2024 showed it read, Approaches. Float heels when in bed. 2) During an observation on 9/23/2024 at 10:00 AM, Resident #73 was lying in bed, with the bed being at the lowest position. The resident's feet were not offloaded while lying in bed. During an observation on 9/23/2024 at 12:15 PM, Resident #73 was lying in bed, with the bed at being the lowest position. The resident's feet were not offloaded while lying in bed. During an observation on 9/24/2024 at 7:46 AM, Resident #73 was resting with her eyes closed. The resident's feet were not offloaded while in bed. There was a pillow on top of the chair in the room. During an observation on 9/24/2024 at 8:41 AM, Resident #73 was sitting up in bed. The resident's feet were not offloaded. There was a pillow on top of the chair in the room. During an observation on 9/24/2024 at 11:07 AM, Resident #73 was lying in bed with her eyes closed. The resident's feet were not offloaded. There was a pillow on top of the chair in the room. Review of Resident #73's care plan dated 4/16/2024 showed it read, Approaches. Float heels when in bed. During an interview on 9/24/2024 at 11:10 AM, Staff A, Licensed Practical Nurse (LPN), stated, I would have to look for [Resident #73's name and Resident #74's name] to see if they have orders to offload feet while in bed. During an observation on 9/24/2024 at 11:10 AM, Staff A, LPN, entered Resident #74's room and woke the resident up and asked her if she could place the pillow that was on the chair under her feet. Resident #73 stated, Sure, I do not care. Staff A placed the pillow under the resident's feet. Staff A returned to the medication cart and reviewed orders for Resident #73. During an interview on 9/24/2024 at 11:12 AM, Staff A, LPN, stated, [Resident #73's name] and [Resident #74's name] both have orders for floating heels. Both residents are hard to follow command. We have to provide a lot of education, and they are very confused and combative at times. You might do something and then not be there. During an interview on 9/25/2024 at 7:50 AM, the Director of Nursing stated, If a resident is care planned for offloading, it should be done. Review of the facility policy and procedure titled Care Plan- Comprehensive with the last review date of 7/19/2024 showed it read, Policy Interpretation and Implementation. 1. An interdisciplinary assessment team, in coordination with the resident and his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident.

Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. Findings include: 1) During an observation on 9/23/2024 at 9:44 AM, Resident #46 was sitting in her wheelchair in her room. There was a bottle of Biofreeze fast-acting menthol pain relief gel roll-on on top of the nightstand (Photographic evidence obtained). During an interview on 9/23/2024 at 9:44 AM, Resident #46 stated, I have arthritis and have the girls put it on at night for me. 2) During an observation on 9/23/2204 at 10:08 AM, Resident #2 was sitting up in her bed. On top of the resident's bedside table, there were one bottle of Biofreeze fast-acting menthol pain relief gel roll-on, one Voltaren cream, and one Lotrimin Clotrimazole cream. During an interview on 9/23/2024 at 10:08 AM, Resident #2 stated, I use the Biofreeze for my neck and the cream is a muscle relaxer that I use. During an observation on 9/24/2024 at 11:15 AM with Staff A, Licensed Practical Nurse (LPN), there were one bottle of Biofreeze, one Voltaren cream and one Lotrimin Clotrimazole cream on top of Resident #2's bedside table. During an interview on 9/24/2024 at 11:15 AM, Staff A, LPN, stated, Sometimes the family will bring in medication without us knowing. Medication should not be at the bedside. 3) During an observation on 9/23/2024 at 10:10 AM, Resident #41 was lying in bed. There were two bottles of eye drops in the resident's cabinet. During an interview on 9/23/2024 at 10:10 AM, Resident #41 stated, I cannot reach the eye drops. I am not sure what they are for. During an observation on 9/24/2024 at 8:40 AM, Resident #41 was lying in bed. There was one bottle of eye drops on top of the resident's cabinet (Photographic evidence obtained). During an interview on 9/24/2024 at 8:40 AM, Resident #41 stated, Yesterday, they took one of the eye drop bottles and only left that one. During an observation on 9/24/2024 at 11:18 AM with Staff A, LPN, there was one bottle of eye drops on top of the Resident #41's cabinet. There was no one in the resident's room. During an interview on 9/24/2024 at 11:18 AM, Staff A, LPN, stated, As far as I know, [Resident #41's name] does not have orders for eye drops. During an interview on 9/25/2024 at 7:48 AM, the Director of Nursing stated, Medication should not be left at the bedside. Review of the facility policy and procedure titled Storage of Medication with the last review date of 7/19/2024 showed it read, Policy: Medications and biologicals shall be stored in a safe, secure, and orderly manner. Policy Interpretation and Implementation . 6. Compartments containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended. (Compartments include, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.)

Based on record review and interview, the facility failed to ensure an accurate assessment reflective of a resident's status at the time of the assessment for 1 (Resident #84) of 3 residents reviewed for discharge. Findings include: Review of Resident #84's admission record documented, Date of Discharge 03/26/2023. Review of Resident #84's physician's order dated 3/25/23 read May DC [discharge] home when arrangements made. Review of Resident #84's Minimum Data Set (MDS), Resident Assessment and Care Screening titled Discharge Return not anticipated dated 3/26/2023 read, Summary Section A - Identification Information Target, the discharge date [Section A2000} read 3/26/2023 and the discharge status [Section A2100] read Acute hospital. During an interview on 5/31/23 at 1:35 PM Staff D, Case Manager stated, This resident [Resident #84] went home with home health care. He went home with his daughter. The MDS is incorrect. He did not go to the hospital. He went home. During an interview on 6/1/23 at 1:30 PM the Administrator stated, We do not have a policy and procedure for MDS assessments. We follow the RAI (Resident Assessment Instrument) manual.

Based on observation, interview, and record review the facility failed to ensure care and services for central venous access devices in accordance with professional standards of practice for 2 (Resident #237 and #238) of 2 residents reviewed with a central venous access devices. Findings include: 1). During an observation on 5/30/2023 at 11:45 AM Resident #237 was lying in bed with a single lumen midline with gauze under the transparent dressing. The dressing was dated 5/28/2023. During an observation on 5/31/2023 at 1:00 PM, Resident #237 was lying in bed with a single lumen midline with gauze under the transparent dressing. The dressing was dated 5/28/2023. During an observation on 6/01/2023 at 8:20 AM Resident #237 was lying in bed with single lumen midline with gauze under the transparent dressing. The dressing was dated 5/28/2023. During an interview on 6/1/2023 at 8:20 AM Staff C, License Practical Nurse (LPN), stated, [Resident #237's name] has a midline dressing dated 5/28/2023 with gauze under the transparent dressing. Normally IV [intravenous] dressings are changed weekly. I do not know if the dressing should be changed at a different time; dressings are done by the Registered Nurses. Review of Resident #237's admission record documented an admission date of 5/18/2023 with diagnoses that included osteomyelitis, severe sepsis with septic shock, peripheral vascular disease, and type 2 diabetes mellitus without complications. Review of Resident #237's physician's order dated 5/19/2023 read Heparin Sod (Pork) lock flush Intravenous Solution 10 unit/ml (milliliters) (Heparin Sodium (Porcine) Lock Flush) Use 1 dose intravenously one time a day for after midline flush at completion of IV antibiotic therapy. Review of Resident #237's physician's order dated 5/19/2023 read Normal Saline Flush Intravenous Solution 0.9% (Sodium Chloride Flush) Use 1 dose intravenously one time a day for Flush line before and after IV antibiotic therapy dose. Review of Resident #237's physician's order dated 5/27/2023 documented, Ertapenem Sodium Injection Sodium Reconstituted 1 GM (gram) (Ertapenem Sodium) Use 1 dose intravenously one time a day for Osteomyelitis until 06/30/2023. Review of Resident #237's physician's order revealed no dressing change orders for midline venous device. During an interview on 6/01/2023 at 8:36 AM the Director of Nursing stated, I would have to look up when a dressing should be changed when it has a gauze under the transparent dressing. I do not see any dressing orders for [Resident #237's name] for his midline. I would have to question the unit manager to see, I am not seeing any orders. 2). During an observation on 5/30/2023 at 11:20 AM Resident #238 was lying in bed, right hand single lumen midline noted. The transparent dressing had gauze under the dressing and was dated 5/28/2023. During an observation on 5/31/2023 at 1:10 PM Resident #238 was lying in bed, right hand single lumen midline noted. The transparent dressing had gauze under the dressing and was dated 5/28/2023. During an observation on 6/1/2023 at 8:10 AM with Staff C, LPN, Resident #238 was lying in bed, right hand single lumen midline noted. The transparent dressing had gauze under the dressing and was dated 5/28/2023. During an interview on 6/1/2023 at 8:11 AM with Staff C, LPN, stated, I am not sure if the dressing is dated 5/28/2023. I would have to look in the system to see when it was last changed. Normally midline dressings are changed weekly. Typically, LPNs do not do dressing changes it would be a Registered Nurse. Review of Resident #238's admission record documented an admission date of 5/27/2023 with diagnoses including transient cerebral ischemic attack, cellulitis of right upper limb, type 2 diabetes and chronic kidney disease stage 3. Review of Resident #238's physician's order dated 5/28/2023 read Change Right Midline catheter site dressing as needed for Midline IV (intravenous). Review of Resident #238's physician's order dated 5/28/2023 read Change Right Midline catheter site dressing one time a day every 7 day(s) for Midline IV. Review of Resident #238's physician's order dated 5/28/2023 read Normal Saline Flush Solution 0.9% (Sodium Chloride Flush) use 10 ml (milliliters) intravenously one time a day for Midline IV after medication administration. Review of Resident #238's physician's order dated 5/28/2023 read Normal Saline Flush Solution 0.9% (Sodium Chloride Flush) use 10 ml (milliliters) intravenously one time a day for Midline IV before medication administration. Review of the policy and procedure titled Midline Catheter Dressing Change,' revised date 2/2018, read Guidance. 2. When a transparent dressing is applied over a sterile gauze dressing it is considered a gauze dressing and is change: 2.2 Every two days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2). During an observation on 05/30/23 at 11:20 AM Resident #238 was lying in bed, nasal cannula wrapping on top of oxygen concentrator machine and tubing had no date. During an observation 05/31/2023 at 1:10 PM Resident #238 was lying in bed, nasal cannula wrapping on top of oxygen concentrator machine and tubing had no date. During an observation on 6/1/2023 at 8:10AM with Staff C, LPN, nasal cannula wrapping on top of oxygen concentrator machine and tubing had no date. During an interview on 6/1/2023 at 8:07AM with Staff C, LPN stated, Tubing should be dated and it should be bagged when not in used. Review of Resident #238 admission record documented Resident was admitted on [DATE] with diagnosis including transient cerebral ischemic attack, cellulitis of right upper limb, type 2 diabetes and chronic kidney disease stage 3. Review of Resident #238 physician order dated 5/27/2023 documented, Oxygen: 2 Liters via NC Q HS and weekly tubing change at bedtime and every night shift every Sun (Sunday) change tubing. 3). During an observation on 5/30/23 at 11:20 AM Resident #239 was lying in bed, passive nebulizer mask placed on top of nebulizer machine without a bag and tubing was observed with no date. During an observation 5/31/2023 at 9:00 AM Resident #239 was lying in bed, passive nebulizer mask placed on top of nebulizer machine without a bag and tubing was observed with no date. During an observation on 6/1/2023 at 8:06 AM with Staff C, LPN, passive nebulizer mask placed on top of nebulizer machine and tubing was dated with what appear to be 2/19/2023. During an interview on 6/1/2023 at 8:07 AM with Staff C, LPN stated I am not able to read the date on the tubing. The nebulizer mask should be bagged, and the tubing should be changed weekly on Sunday. Review of Resident #239's admission record documented resident was admitted on [DATE] with diagnoses including multiple subsegmental pulmonary emboli without acute cor pulmonale, dyspnea, and interstitial pulmonary disease. Review of Resident #239's physician's order dated 5/26/2023 read, Nebulizer: tubing change weekly Sunday 7p-7a every night shift Sun. Review of the policy and procedure titled, Administering Medications through a Small Volume (Handheld) Nebulizer last reviewed 1/20/2023 read, Steps in the Procedure. 27. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. 28. Change equipment and tubing every seven days, or according to the facility protocol. Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care services consistent with professional standards of practice for 3 of 6 residents (#71, #238, and #239) reviewed. Photographic Evidence Obtained Findings include: 1). During an observation on 5/30/2023 at 9:39 AM, Resident #71 was observed lying in bed and not wearing her nasal cannula which was observed to be wrapped around the right handrail of the bed. The nasal cannula was not bagged. During an observation on 6/1/2023 at 7:52 AM, Resident #71's nasal cannula was wrapped around the right handrail of the bed. The nasal cannula was not bagged. During an interview with Staff A, Licensed Practical Nurse (LPN) on 6/1/2023 at 8:11 AM, Her tubing was not bagged. During an interview with the Director of Nursing on 6/1/2023 at 9:23 AM, Ultimately, staff are expected to bag and date all oxygen tubing.

Based on observation, interview, and record review the facility failed to ensure the medication storage rooms were free from expired medications for two of two medication storage rooms. Findings include: During an observation on 5/31/23 at 10:12 AM of medication storage room one, there was one bottle of normal saline with an expiration of 12/4/21, four bottles of normal saline with an expiration date of 10/29/22, one bottle of normal saline with an expiration date of 1/17/23, two bottles of normal saline with an expiration date of 3/31/23, three bottles of normal saline with an expiration date of 3/25/22, and two bottles of unopened Sterile Water with expiration date of 3/15/23. During an observation on 5/31/23 at 10:30 AM of medication storage room two, there was two Irrigation Tray Piston Syringe containers with an expiration date of 5/22/22 and one Irrigation Tray Piston Syringe container with an expiration date of 1/11/22. During an interview on 5/31/23 at 11:00 AM the Director of Nursing stated, those items (one bottle of normal saline with an expiration of 12/4/21, four bottles of normal saline with an expiration date of 10/29/22, one bottle of normal saline with an expiration date of 1/17/23, two bottles of normal saline with an expiration date of 3/31/23, three bottles of normal saline with an expiration date of 3/25/2, two bottles of Sterile Water with expiration date of 3/15/23, two Irrigation Tray Piston Syringe containers with an expiration date of 5/22/22, one Irrigation Tray Piston Syringe container with an expiration date of 1/11/22) are expired. The Unit Managers try to do a monthly check. I don't know why those expired items were not discarded. During an interview on 5/31/23 at 11:05 AM Staff B, Unit Manager, stated, Central Supply goes through and spot checks the expiration dates. It is ultimately nursing's responsibility to ensure no expired medications are in the medication room. I do not know why there are expired items in the medication storage room. Review of the policy and procedure titled, Storage of Medication last reviewed 1/20/2023 read, Policy Interpretation and Implementation. 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinue, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on record review and interview the facility failed to ensure the arbitration agreements presented to 3 (Resident #66, Resident #237 and Resident #240) of 3 residents reviewed were given 30 days to rescind the arbitration agreement. Findings include: Review of the facility Arbitration Agreements presented to Resident #66 on 10/17/2021, presented to Resident #237 on 5/7/2023 and presented to Resident #240 on 5/21/2023, read, This agreement shall remain in full force and effect not withstanding the termination, cancellation or natural expiration of the Resident admission Agreement. If this Arbitration Agreement is not rescinded within three (3) business days of signing as provided for in the final paragraphs of this Agreement, this Agreement shall remain in effect for and shall be binding on the Facility and Resident for this and all of the Resident's other admission or re-admission to the Facility (if any) without any need for further renewal. During an interview on 6/1/2023 at 1:05 PM the Administrator stated, I spoke to the risk manager and we did have three days written in the arbitration agreement, but it should have been 30 days. Since we print documents via Docusign maybe it was a typo. In practice we don't hold Residents to that agreement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation on 1/24/2022 at 11:10 AM, Resident #362's oxygen delivery tubing was dated 1/16/2022 and the nebulizer tubing was dated 1/9/2022 (Photographic evidence obtained). Review of Resident #362's admission records revealed the resident was admitted on [DATE] with the diagnosis to include pneumonia. Review of Resident #362's Minimum Data Set (MDS) dated [DATE] read, Section O. Special Treatments, Procedures, and Programs: C. Oxygen 1. While Not a Resident: Yes, 2) While a Resident: Yes. Review of the physician orders for Resident #362 read, Order Summary: Nebulizer: tubing change weekly Sunday 7p-7a every night shift every Sun [Sunday] for PNA [Pneumonia]. Order Date: 01/06/2022. Order Summary: Oxygen: Change oxygen tubing every week as needed for O2 [oxygen] therapy. Order Date: 01/06/2022. Order Summary: Oxygen: Change oxygen tubing every week every night shift every Sun for O2 therapy. every night shift every Sun for O2 (oxygen) therapy. During an observation on 1/25/2022 at 1:44 PM, Resident #362's oxygen delivery tubing attached to the oxygen tank was dated 1/16/2022 and the nebulizer tubing was dated 1/9/2022 (Photographic evidence obtained). During an observation on 1/25/2022 at 2:53 PM, Resident #362's oxygen delivery tubing attached to the oxygen tank was dated 1/16/2022 and the nebulizer tubing was dated 1/9/2022 (Photographic evidence obtained). During an interview on 1/25/2022 at 2:53 PM, Staff D, LPN, Unit Manager, confirmed that the Resident #362's nebulizer tubing was dated 1/9/2022 and oxygen tubing was dated 1/16/2022. She stated, It is the facility expectation that oxygen tubing and nebulizer tubing is changed weekly on Sundays. Nebulizer tubing was due to be changed on 1/16/2022 and oxygen tubing was due to be changed on 1/23/2022. Based on observation, interview, and record review, the facility failed to ensure residents who needed respiratory care were provided such care consistent with professional standards of practice for 2 of 3 residents reviewed for respiratory care, Residents #44 and #362, in a total sample of 30 residents. Findings: 1. Review of the physician orders for Resident #44 read, Order Date: 1/30/2020. Order Summary: Oxygen: 2 liters via N/C [Nasal Canula] PRN [as needed] every shift and as needed. During an observation on 1/24/2022 at 10:27 AM, Resident #44 way lying in her bed receiving oxygen via nasal cannula. Resident #44's oxygen concentrator gauge showed she was receiving oxygen at 3 liters via nasal cannula. During an observation on 1/25/2022 at 8:47 AM, Resident #44 was lying in her bed receiving oxygen via nasal cannula. Resident #44's oxygen concentrator gauge showed she was receiving oxygen at 2.5 liters via nasal cannula. During an interview on 1/25/2022 at 8:47 AM, Resident #44 stated, I did not adjust the gauge on my oxygen concentrator. I let them do it. During an interview on 1/26/2022 at 7:54 AM, Staff A, Licensed Practical Nurse (LPN)/ Unit Manager, confirmed Resident #44's physician order was for oxygen to be administered at 2 liters via nasal cannula. During an observation on 1/26/2022 at 7:56 AM with Staff A, LPN, Unit Manager, Resident #44's oxygen concentrator gauge was adjusted between 2.5 and 3 liters. During an interview on 1/26/2022 at 7:56 AM, Staff A, LPN, Unit Manager, confirmed Resident #44's oxygen concentrator gauge showed a higher rate than the prescribed 2 liters via nasal cannula.