**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of the facility's policy titled, Abuse, Neglect and Exploitation, the facility failed to ensure timely reporting of an allegation of physical abuse for one of 11 Residents (R) (R1) reviewed for abuse. This failure caused R1 to experience psychosocial harm and created the potential for this resident and other residents to experience further abuse. Findings include:Review of the facility's policy titled, Abuse, Neglect and Exploitation dated 3/1/2023 indicated, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of property; and Reporting/Response: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Review of R1's admission Record in the Electronic Medical Record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The residents' diagnoses included dementia and heart disease. Review of R1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/15/2025 in the EMR under the MDS tab indicated a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated the resident was moderately cognitively impaired.Review of R1's Progress Notes dated 7/11/2025 at 10:48 am in the EMR under the Notes tab, revealed Approx. (approximately) 7:30 am. Nurse entered room. Resident attempted to get out of bed without assistance. Bed was set in lowest position. Nurse encouraged resident to stay in bed and not to get up without assistance. At 7:40 am, nurse was asked by staff to come to room. Resident had placed himself in floor. No injuries noted. Staff then assisted resident back into bed to assist with dressing and resident was then placed into w/c (wheelchair). Resident became increasingly agitated and combative. Preceded to call staff derogatory names and racial slurs. Resident then yelled, I'll get my time with yall. Resident was put in w/c and placed near nursing station. Resident has also refused morning medications.Review of the facility's investigation revealed the alleged allegation of abuse occurred at approximately on 7/11/2025 at 7:30 am and was directly observed by three staff members (Certified Nurse Aide (CNA)2, CNA3 and Licensed Practical Nurse (LPN)1) who were in the R1's room with CNA1. However, the incident was not reported by any of the three staff members who observed the incident to administration. The investigation revealed the Administration became aware of the allegation of abuse of R1 by CNA1 when the incident was reported to management by R1's family member (F)1 via the facility's grievance process on the afternoon of 7/11/2025. The incident was then reported to the Administrator, who was the facility's Abuse Coordinator on 7/11/2025 at approximately 4:30 PM. The incident was reported to the State Agency (SA), the local police department, the resident's physician, and the local Ombudsman. The incident was reported to the SA on 7/11/2025 at 6:50 pm (more than 11 hours after the incident occurred). During an interview on 08/26/25 at 10:05 AM, CNA2 confirmed she was present on 7/11/2025 when the allegation of abuse of R1 by CNA1 occurred and confirmed she did not report the abuse to anyone in facility Administration. CNA2 stated she thought LPN1 would report the incident since she was present when the incident occurred. During an interview on 8/26/2025 at 5:02 pm, CNA3 confirmed she was present on 7/11/2025 when the allegation of abuse of R1 by CNA1 occurred and confirmed she did not report the abuse to anyone in facility Administration. CNA3 stated she got busy with her duties after the incident and did not report the event.During an interview on 8/26/2025 at 1:55 pm, LPN1 confirmed she was summoned to R1's room on 7/11/2025 at 7:30 am by CNA3. When she arrived in the resident's room, she observed CNA1 preparing to flick R1 in the face. LPN1 confirmed she did not report the abuse to facility's Administration and stated she should have reported the abuse immediately to the Administrator or the nurse in charge on the day of the incident.During an interview on 8/26/2025 at 1:30 pm, Registered Nurse (RN1) confirmed she was the charge nurse in the building on the day of the alleged abuse of R1 by CNA1. RN1 confirmed the abuse had not been reported to her until R1's family member reported the incident on the afternoon of 7/11/2025. RN1 confirmed CNA2, CNA3, and LPN1 had not reported the incident of abuse to her after the event occurred and stated the incident should have been reported to her, or someone in Administration, immediately after the event occurred. During an interview on 8/26/2025 at 3:00 pm, the Administrator confirmed the abuse of R1 by CNA1 on 7/11/2025 had not been reported to her timely. She stated she did not become aware of the allegation of abuse until 7/11/2025 at about 4:30 pm or 5:00 pm when the allegation was reported to her by RN1. The Administrator confirmed CNA2, CNA3 and LPN1 had not reported the allegation abuse to anyone in administration and confirmed she learned of the abuse after it was reported by R1's F1 several hours after the incident occurred. The Administrator confirmed the alleged abuse was, in turn, not reported to the SA, local police department, or the ombudsman within the required two-hour time frame. She stated her expectation was all allegations of potential abuse were to be reported to Administration immediately and allegations of abuse were expected to be reported to the SA, local police department, and the ombudsman within the required two-hour time frame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, resident and staff interviews, and review of the facility policy titled, Promoting Maintaining Resident Dignity, the facility failed to promote care in a manner that maintained or enhanced each resident's dignity, respect, and individuality for two of eight sampled residents (R) (R8 and R S). Specifically, staff were standing while feeding a resident. In addition, staff members did not knock or identify themselves before entering residents' rooms. Findings include: Review of the facility policy titled Promoting Maintaining Resident Dignity revised date 4/1/2024 revealed under Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Under Compliance Guidelines: .10. Respect the residents' living space. Maintain resident privacy. Review of the admission Record for R8 revealed he was admitted to the facility with a diagnosis of but not limited to dyskinesia (uncontrollable and involuntary movements) of esophagus. Review of R8's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score was assessed as eight which indicated cognition was moderately impaired. Section K (Swallowing and Nutritional Status) revealed R8 was assessed as having no swallowing disorder and no signs and symptoms of swallowing problems. Nutritional status triggered as an area of concern on the Care Area Assessment Summary. Review of the care plan initiated 5/16/2025 revealed that R8 is at risk for nutritional need related to a mechanical soft diet. Intervention to be implemented included setting up each meal tray and assisting R8 as needed. Observation on 6/11/2025 at 12:43 pm revealed Certified Nursing Assistant (CNA) GG feeding R8 lunch. The resident was leaning to the left side slouched down in the bed. CNA GG was standing feeding R8. Observation on 6/11/2025 at 12:52 pm revealed Licensed Practical Nurse (LPN) HH walking into room [ROOM NUMBER] without knocking or identifying herself before entering the resident room. Observation on 6/11/2025 at 12:54 pm revealed LPN HH walking into room [ROOM NUMBER] without knocking or identifying herself before entering the resident room. Observation on 6/18/2025 at 9:02 am revealed Staffing Coordinator II walking into room [ROOM NUMBER] without knocking or identifying herself before entering the resident room. Observation on 6/11/2025 at 12:50 pm of the Treatment Nurse (TN) JJ and CNA GG repositioning R8. TN JJ or CNA GG did not pull the curtain or shut the door to provide R8 with privacy from the visitor in the room or the surveyor in the hall. Interview on 6/11/2025 with CNA GG, she stated R8 was not her assigned resident for the day, and she was helping with feeding the residents. CNA GG was asked if she always stood up to feed the residents and CNA GG answered Yes. Interview on 6/11/2025 at 12:54 pm with LPN HH revealed she did not knock when the residents' door was open. She stated, I just walk in. Interview on 6/18/2025 at 9:32 am with the Staffing Coordinator II revealed she was aware that she should knock before entering a resident's room. She stated that this was the resident's home and she should knock and announce herself before entering. Interview on 6/18/2025 at 12:28 pm with R S revealed the staff would enter the room without knocking or announcing themselves. An interview on 6/18/2025 at 5:53 pm with the Director of Nursing (DON) revealed the staff were educated on a regular basis on resident rights that included knocking on the residents' doors, announcing themselves before entering the room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and family interviews, and review of the facility policies titled, Baseline Care Plan and Care Planning-Resident Participation, the facility failed to ensure that one of two Residents (R) (R1) reviewed for participation in care plan meetings were invited to and participated in a scheduled 72-hour care plan meeting. In addition, the family representative for R1was not invited to ensure that the care plan was individualized and met R1's personal goals and preferences. Findings include: Review of the facility policy titled Baseline Care Plan revised date 3/1/2025 revealed under Policy: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Under Policy Explanation and Compliance Guidelines: . 4. A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand. 5. A supervising nurse or MDS nurse/designee is responsible for providing the written summary of the baseline care plan to the resident and representative. This will be provided by completion of the comprehensive care plan. 7. If the summary was provided via telephone, the nurse shall indicate the discussion, sign the summary document, and make a copy of the written summary before mailing the summary to the resident/ representative. Review of the facility policy titled Care Planning-Resident Participation revised date 3/1/2025 revealed under Policy Explanation and Compliance Guidelines: The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes. The facility will make an effort to schedule the conference at the best time of the day for the resident/resident's representative. The facility will obtain a signature from the resident and/or resident representative after discussion or viewing of the care plan. Review of the admission Record for R1 revealed she was admitted to the facility with diagnoses of but not limited to dysphagia and gastro-esophageal reflux disease. Review of R1's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score was assessed as 15, which indicated cognition was intact. Review of R1's electronic medical record (EMR) attached under the Miscellaneous Documents tab revealed a document titled Care Plan Meeting Sign Sheet dated 1/7/2025 revealed there was no indication that the resident or family were invited or attended the care plan meeting. A phone interview on 6/6/2025 at 9:35 am with R1's family revealed the family stated there was never an invitation to a care plan meeting or any type of meeting with the facility until she inquired on 1/7/2025. She stated she received a phone call from the facility on 1/7/2025 informing her that R1's therapy would be discontinued. The family stated she told the caller she had not received any phone calls about her mom (R1) or if she was progressing with therapy. The family member revaled the caller told her she was under the impression she had spoken with someone and told the family member someone would call her back. She revealed on 1/9/2025 there was a conference call with the physical therapist, occupational therapist, and speech therapist. The family member stated there were no other disciplines to her knowledge present during the telephone conference. An interview on 6/11/2025 at 1:00 pm with Resident Assessment Coordinator EE revealed the department was responsible for the resident assessment and care plans. She stated a care plan meeting should be conducted 72 hours after the resident was admitted to the facility and 14 days after a comprehensive and quarterly MDS assessment was completed. She stated the residents were invited by a visit to the residents' room. The family/responsible party were called and invited. She stated the Discharge Planner was responsible for documenting the care plan meetings. The Resident Assessment Coordinator confirmed that R1 did not have a 72-hour care plan meeting or a care plan meeting 14 days after the admission MDS assessment was completed. An interview on 6/17/2025 at 2:23 pm with the Speech-Language Pathology (SLP) revealed she did not remember having a specific care plan meeting for R1. The SLP stated she remembered discussing with the family advancing R1's diet. The SLP was asked if the information was discussed in a care plan meeting, and the SLP responded and asked the surveyor, Did the facility even hold a care plan meeting?

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, it was determined that the facility failed to ensure quality care and services in accordance with professional standards for one Resident (R) (R1). Specifically, the facility failed to provide timely assistance to one resident (R1) who was in respiratory distress. Findings include: Review of the admission Record for R1 revealed she was admitted to the facility with diagnoses of but not limited to dysphagia and gastro-esophageal reflux disease. Review of the resident's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score was assessed as 15, which indicated cognition was intact. Section K (Swallowing and Nutritional Status) revealed R1 was assessed as having no swallowing disorder and no signs and symptoms of swallowing problems. Nutritional status triggered as an area of concern on the Care Area Assessment Summary. Review of the care plan initiated 12/17/2024 revealed that R1 is at risk for nutritional need related to a therapeutic diet. Intervention to be implemented included observe R1 for signs of dysphagia (difficulty swallowing): not limited to coughing, choking, and refusing to eat during meals. Review of the hospital Discharge summary dated [DATE] revealed the second day of hospital admission the patient (R1) had an episode of aspiration (inhaling into airway/lungs) of scrambled eggs on 12/5/2024 and required intubation (placement of a breathing tube). The patient had a diagnostic bronchoscopy and bronchoalveolar lavage (a medical procedure where a bronchoscope is used to wash the airways and collect a fluid sample from the lungs for diagnostic purposes) from right lower lobe on 12/5/2024 that revealed a remnants in the distal trachea and right lower lobe which were suctioned. The patient was extubated (breathing tube removed) on 12/6/2024 but had another aspiration event that same day and required re-intubation on 12/6/2024. The patient was able to be weaned off the ventilator on 12/8/2024. The patient after extubating had problems with swallowing. The resident (R1) was discharged from the hospital to __ facility. Review of the Medication Review Report (physician order) dated 12/16/2024 revealed: full code and Regular diet, Pureed texture, Honey consistency. Review of the Medication Review Report (physician order) dated 12/18/2024 revealed: occupational therapy (OT) clarification Order: Skilled OT 5 times a week for 30 days may include: therapeutic exercise, therapeutic activities, neuromuscular reeducation, manual therapy, self-care retraining, wheelchair management training, Orthotic (devices worn in shoes to relieve symptoms related to various foot and ankle conditions) fitting and training, Skilled instruction to resident, caregivers and staff. Review of the Medication Review Report (physician order) dated 12/26/2024 revealed Regular diet, Mechanical Soft texture, Regular/Thin consistency. Review of the Medication Review Report (physician order) dated 12/27/2024 revealed: Late entry for 12/17/2024 Clarification Orders: skilled speech therapy (ST) 5 times a week times 4 weeks for treatment of swallowing dysfunction and/or oral function for feeding, caregiver education for Dysphagia unspecified diagnosis code R13.10. Review of the Occupational Therapy (OT) note dated 1/17/2025 revealed: Self feeding TD (treatment dependent) plus: patient coughed-wet cough then was breathing through her mouth and appeared to be ready to throw up, attained basin for her to throw it up and she did not then tried to get a reading on the pulse ox (oximeter-device to measure oxygen level), unable, notified her nurse and nurse took over. Review of Nurses Note dated 1/20/2025 revealed: 1:00 pm Nurse entered room. Resident found in bed sitting upright with eyes opened and unresponsive. Nurse notified supervisor. Emergency services called. Resident transferred to __ Hospital. The family was notified at 1:15 pm. Review of R1's __ Death Certificate revealed R1 was pronounced dead on 1/17/2025. The immediate cause (final disease or condition resulting in death) hypoxic (inadequate levels of oxygen in the tissues and cells of the body) respiratory failure and aspiration of food. A phone interview on 6/6/2025 at 9:35 am with R1's family revealed the facility called on 1/17/2025 around 1:00 pm. The family was informed that mom (R1) was found unresponsive. The facility also informed the family, We worked on her and could not get her back. The family asked the caller what happened. The family was informed that R1 choked while eating lunch and was unresponsive afterwards. The family could not identify the caller but stated it was not the nurse. An interview on 6/6/2025 at 11:33 am with Licensed Practical Nurse (LPN) BB revealed around 1:00 pm Occupational Therapist AA came to the nursing station and requested that she come to R1's room because the resident wasn't looking too well. LPN BB revealed upon arriving at the room, the resident was not responding and had no pulse. LPN BB stated she left the room and went to find the Unit Manager (UM). She stated when she returned with the UM, R1 was placed in a supine (lying on one's back with face upward) position and chest compressions and ventilation were started with an Ambu bag (medical device that forces air into the lungs of patients who are not breathing or struggling to breathe) on R1. An interview on 6/6/2025 at 12:57 pm with LPN BB confirmed that she did not document the events that took place on 1/17/2025 in R1's EMR. She stated she was so overwhelmed that day and left work without charting the incident. She also revealed she spoke with the Nurse Practitioner (NP) on the phone and failed to write an order for R1 to be transferred to the hospital. An interview on 6/17/2025 at 3:05 pm, OT AA stated R1 was treated on 1/17/2025. The OT was assisting R1 with getting food from the plate to the mouth with her hand on R1's hand in a guiding motion as part of R1's therapy. She stated during the therapy session R1 began to cough (wet cough) and mouth breathing. The OT stated she attempted to get a pulse oximeter reading and was unsuccessful. The OT stated she did not stay with R1. The OT stated she left the room to get LPN BB. An interview on 6/18/2025 12:51 pm with Certified Nursing Assistant (CNA) CC revealed she has been educated on resident mealtimes and what to do if you find a resident unresponsive. She stated during mealtimes all residents' doors must remain open. She stated the reason for leaving the doors open was to listen out for residents' that may start coughing while eating. She stated if a resident became unresponsive, the staff could not leave but call out for help. She revealed that R1 was one of her assigned residents. CNA CC stated R1 did not have a suction machine in her room. An interview on 6/18/2025 1:32 pm with CNA DD revealed she has been educated by the facility on what to do if a resident became unresponsive. She stated she was educated never to leave the resident but call out for help. An interview on 6/18/2025 at 5:53 pm with the Director of Nursing (DON) revealed she was unaware that the OT was providing therapy services to R1 on 1/17/2025 when the resident became unresponsive. The DON stated the expectation of the staff was if a resident became unresponsive, the staff was educated to call out for help and not leave the room. The DON stated a staff person should always be with the resident.

Based on record review and staff interview, and review of the facility policy titled, MDS (Minimum Data Set) 3.0 Completion, the facility failed to accurately assess one of 35 sampled residents (R) (R34). The deficient practice had the potential for R34 to be at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: Review of the facility policy titled MDS 3.0 Completion revised 1/1/2024 revealed under Policy Explanation and Compliance Guidelines: According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's function capacity, using the RAI (Resident Assessment Instrument) specified by the State. Review of the electronic medical record (EMR) revealed that R34 was admitted to the facility with but not limited to diagnoses of chronic obstructive pulmonary disease (COPD) and malignant neoplasm of upper lobe, left bronchus or lung. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 7/10/2024 revealed in Section O-Special Treatments, Procedures, and Programs that Oxygen (O2) Therapy was not marked as Performed while a resident of this facility and within the last 14 days. Review of R34's care plan initiated 9/14/2023 revealed the following problem: resident has COPD. Interventions included oxygen settings: O2 via nasal cannula (NC) as ordered. Review of the EMR tab Orders revealed an order dated 1/24/2024 for O2 @ 2L/NC (2 liters via cannula), PRN (as needed) as tolerated. Interview with the MDS Resident Assessment Coordinator on 8/1/2024 at 4:05 pm confirmed that resident was receiving O2 therapy, and section O (Special Treatments, Procedures, and Programs) of the MDS where question related to oxygen should be marked as yes. She stated that this MDS section was marked incorrectly as no.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews, and review of the facility policy titled, Activities, the facility failed to ensure residents received activities to meet resident-centered and personal preferences for bed bound and dependent care residents for two of 35 sampled residents (R) (R49 and R36). Specifically, R49 and R36 were not provided with person-centered activities that would meet their individual needs. Findings Include: Review of the facility policy titled Activities last reviewed 3/1/2024 revealed under Policy: It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community. Under Policy Explanation and Compliance Guidelines .13. The facility will consider accommodations in schedules, supplies and timing in order to optimize a resident's ability to participate in an activity of choice. Review of R49's admission Minimum Data Set (MDS) documented the resident had been admitted to the facility with diagnoses of but not limited to end stage renal disease, dependence on renal dialysis, low back pain, type 2 diabetes, mellitus with hyperglycemia, hypertension, unspecified atrial fibrillation, hyperlipidemia, heart failure, chronic obstructive pulmonary disease, unspecified asthma, uncomplicated, gastro-esophageal reflux disease without esophagitis, benign, prostatic hyperplasia without lower urinary tract symptoms, anemia in other chronic diseases, atherosclerotic heart disease of native coronary artery without angina pectoris, gastroparesis, other intervertebral disc degeneration, lumbar region other cervical disc, degeneration, unspecified cervical region, muscle weakness, dysphagia, difficulty in walking. R49's quarterly MDS dated [DATE] revealed that R49 was assessed with a Brief Interview for Mental Status (BIMS) assessment of 12, indicating the resident has moderate cognitive deficit. Review of R49 baseline care plan dated 5/23/2024 revealed R49 prefers independent activities or spending time with my family rather than doing things in groups. The facility goal for R49 will continue participating in independent activities or things with their friends and family. R49's intervention was to assist resident in participating in their favorite activities at their highest level and invite resident to sit in during activity programs, letting them join in at their own comfort level. Observation on 7/31/2024 at 12:00 pm, R49 was observed to be asleep. Interview and observation on 7/30/2024 at 12:39 pm with R49 confirmed he would like to participate in some activities. He was observed watching television and eating lunch. Interview on 7/31/2024 at 12:39 pm with the Activities Director (AD) revealed she planned and performed activities and completed computer assessments to figure out what residents like and/or dislike. The AD confirmed she performed assessments at admission and quarterly. The AD shared she received help from the Certified Nursing Assistants (CNAs) to bring residents down to activities who were unable to ambulate. The AD confirmed she informed residents of activities by using the intercom, notifying residents by walking to rooms, or received assistance from the CNA's to help notify residents. The AD revealed today's afternoon scheduled activity was changed to bingo. The AD shared she notified residents of the change before the activity. The AD stated for residents who do not come into the activities room she would randomly do one-on-one activities. The AD confirmed she does not have a schedule for one-on-one activities with residents. The AD reviewed R49's quarterly review that revealed R49 would like to participate in bingo and musical entertainment. The AD reviewed the one-on-one log and revealed no forms were completed for the last three months for resident R49. The AD confirmed R49 had not been in any group activities in the last three months. The AD mentioned R49 had not been in activities because he was gone to dialysis or had family visits. Interview on 8/1/2024 at 2:37 pm with the Director of Nursing (DON), Administrator, and Regional Coordinator. The Administrator confirmed the role of the AD included planning and doing activities, resident council, assessment, and completing certain portion of the MDS. The Administrator confirmed for residents who were unable to enter activities were given one-on-one if they preferred, and she knew a log was done and confirmed that it was not located in the EMS but with the AD. The Administrator confirmed the MDS was completed at admission and annually. Review of R36 admission Minimum Data Set (MDS) documented the resident had been admitted to the facility with but not limited to diagnoses of fusion of spine, thoracolumbar region, spinal stenosis, thoracolumbar region, discitis, thoracolumbar region, paraplegia, incomplete, muscle weakness, paroxysmal atrial, fibrillation, benign neoplasm of pituitary gland, chronic diastolic (congestive) heart failure, essential (primary) hypertension, unspecified severe protein-calorie malnutrition, hyperlipidemia, dysphagia, unsteadiness on feet, difficulty in walking, major depressive disorder, recurrent, other lack of coordination, other malaise, chronic atrophic gastritis without bleeding, anemia, anxiety disorder, other chronic pain, polyneuropathy, unspecified osteoarthritis, insomnia, constipation, gastro-esophageal reflux disease without esophagitis, chronic kidney disease, stage, unspecified psychosis not due to a substance or known, physiological condition, acute upper respiratory infection, weakness, Parkinson's disease, without dyskinesia, without mention of fluctuations. R36 was assessed with BIMS assessment score of 10, indicating the resident has moderate cognitive deficit. Section F (Customary Routine) revealed Very Important for Activity preference. Review of R36 baseline care plan dated 10/28/2019 revealed R36 is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t [related to] Physical Limitations. The facility goal for R36 was to maintain involvement in cognitive stimulation and social activities as desired through review date. R36 intervention all staff to converse with resident while providing care. Invite the resident to scheduled activities. Provide with activities calendar. Notify resident of any changes to the calendar of activities. Thank resident for attendance at activity function. The resident needs one-on-one bedside/in-room visits and activities if unable to attend out of room events. The resident needs assistance/escort to activity functions. Observation and interview on 7/30/2024 at 12:20 pm with R 6 revealed she was not able to participate in any group activities because she cannot walk. R36 confirmed she would like to participate in activities. Interview on 7/31/2024 at 12:39 pm with the Activities Director (AD) revealed the AD reviewed R36's preference and confirmed none were offered during one-on-one activities. The AD revealed the one-on-one log she completed for R36 consisted of three dates in July; 7/4/2024, 7/11/2024, and 7/17/2024; each date activity included only conversation but on 7/4/2024 watermelon was consumed during conversation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interview, and the review of the facility policy titled, Oxygen (O2) Administration, the facility failed to ensure that O2 therapy was administered in accordance with the physician orders for two of 23 residents (R) (R34 and R14) receiving O2 therapy. The deficient practice had the potential to place R34 and R14 at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: Review of the undated policy titled Oxygen Administration dated 1/10/204 revealed under Policy: Oxygen is administered under orders of a physician, except in the case of an emergency. Review of the electronic medical record (EMR) for R34 revealed she was admitted to the facility with diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), malignant neoplasm of upper lobe, left bronchus or lung The resident's most recent Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score was coded as 15, which suggests that cognition is intact. Review of Physician orders for R34 revealed Oxygen Therapy-Nasal Cannula at rate of two liters, initiated 1/24/2024. Review of the care plan initiated on 9/14/2023 and revised on 9/14/2023 revealed that R34 has diagnosis of COPD with potential for respiratory infection/exacerbation of chronic obstructive pulmonary disease (COPD). Further interventions indicate OXYGEN SETTINGS: O2 via NASAL CANNULA (NC) AS ORDERED. Observation on 7/30/2024 at 12:30 pm revealed R34's O2 concentrator (machine to converts room air into O2) set on three liters per minute (LPN), being delivered via NC. Observation on 7/31/2024 at 9:20 am and 11:20 am revealed R34's O2 concentrator flow rate set at three LPM, being delivered via NC. Observation and interview on 7/31/2024 at 11:35 with Licensed Practical Nurse (LPN) AA on the A wing confirmed that R34's O2 tank setting was on almost three LPM. LPN AA checked R34's medical orders in the facility's EMR and confirmed that the physician order was for two LPM via NC. Review of the EMR for R14 revealed she was admitted to the facility with diagnoses including but not limited to acute and chronic respiratory failure with hypoxia, respiratory disorder, post COVID-19 condition. R14's most recent MDS dated [DATE] revealed a BIMS score was coded as 14, which suggests that cognition is intact. Review of R14's Physician orders revealed Oxygen therapy - two liters via nasal canula continuous as tolerated, dated 6/7/2024. Review of the care plan for R14 initiated on 5/15/2024 revealed that resident has oxygen therapy related to Ineffective gas exchange. Further interventions indicate OXYGEN SETTINGS: O2 via NASAL CANNULA (N/C) AS ORDERED. Observation on 7/30/2024 at 12:35 pm revealed R14's O2 concentrator flow rate set at three LPM, being delivered via NC. Observation on 7/31/2024 at 9:22 am and 11:22 am revealed R14's O2 concentrator flow rate set at three LPM, being delivered via NC. Observation and interview on 7/31/2024 at 11:37 am with LPN AA on A wing confirmed that R14's O2 tank setting was on almost three LPM. LPN AA checked R14's medical orders in the facility's electronic records and confirmed that the physician order was for two LPM.

Based on observations, staff interviews, record review, and review of the facility policy titled, Medication Administration, the facility failed to ensure that infection control practices were followed and adhered to by one of five nurses observed during medication administration. Findings Include: Review of the facility policy titled Medication Administration dated 6/1/2024 documented under Policy: Medications are administered by licensed nurses in accordance with professional standards of practice, in a manner to prevent contamination or infection. Under Policy Explanation and Compliance Guidelines, number 14 revealed: Remove medication from source, taking care not to touch medication with bare hand. Observation on 7/31/2024 at 8:32 am Licensed Practical Nurse (LPN) AA dropped a medication cup to the floor, bent over, picked up the cup, and placed it on a stack of clean unused medication cups. She then, with her bare hands, took medication out of a medication card and placed it in a medication cup to take to administer to a resident. Interview on 7/31/2024 at 8:48 am LPN AA verified and confirmed that she had dropped a medication cup to the floor, picked it up and placed it on a clean stack of cups. She stated she thought she had thrown it in the trash can but knew she should have thrown it out. LPN AA verified and confirmed that she had touched a medication with her bare hands and confirmed she should not have. LPN AA confirmed both were not appropriate infection control procedures. Interview on 7/31/2024 at 9:04 am the Director of Nursing (DON) confirmed that nurses should not touch any medications with bare hands. The DON confirmed that picking up a medication cup from the floor and placing it back on the clean stack was not an appropriate infection control procedure. She would expect an LPN to know the correct infection control protocols.