**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility's policy it was determined the facility failed to ensure residents were treated in a dignified manner for two (2) of sixty-nine (69) sampled residents (Residents #14 and #90). Interview and observations revealed Resident #14 was transferred from a room which he/she could enter a bathroom to a room in which the size of his/her wheelchair prohibited access to the bathroom. The sink and toilet were not accessible to Resident #14. The facility provided Resident #14 a bedside commode, placed near a window leaving the resident exposed to the outside. Resident #14 was still unable to wash his/her hands. In addition, observations revealed facility staff used baby talk when talking with Resident #90. Resident #90, was able to feed himself/herself. However, staff held the resident's hands or shoulders while other staff fed him/her to prevent interference from the resident's hands and arms. The findings include: Review of the facility's policy, Quality of Life-Dignity, revised August 2019, revealed staff would promote, maintain, and protect resident privacy and dignity,which included bodily privacy. Review of the facility's policy, Quality of Life - Accommodation of Needs, revised August 2009, revealed the resident's individual needs and preferences would be accommodated to the extent possible. Review of the facility's policy, Appointing a Resident Representative, revised December 2016, revealed a resident who had not been found to be incompetent had a right to appoint a representative who may exercise the resident's right to the extent provided by state law. The representative acted on behalf of the resident to support the resident's decisions. The facility treated the representative's decisions as the decision of the resident. 1. Review of Resident #14's clinical record revealed the facility admitted Resident #14, on 04/18/2019, with the diagnoses of Morbid Obesity, Major Depressive Disorder, and Parkinson's disease. Review of the Annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #14 with a Brief Interview for Mental Status (BIMS) score of fourteen (14) and determined he/she was interviewable. Continued review revealed the resident used a w/c for locomotion. Further review revealed the resident's bed status in the facility, on 02/12/2021, included the transfer of the resident from the C Unit room nine (9) to the B Unit room seven (7). Observations, on 03/12/2021 at 11:08 AM, revealed the facility transferred Resident #14 to room B-7. Observations revealed the resident transferred independently from the chair to an extra wide wheelchair (w/c); wheeled self to the bathroom door, and attempted unsuccessfully to enter the bathroom. Continued observations revealed the bathroom door opened against the wall, therefore it only opened at a forty-five (45) degree angle. A standard size beside commode sat against the wall by the opened windows with toilet paper on the windowsill. Interview with Resident #14, on 03/12/2021 at 11:08 AM, revealed the facility moved him/her to the room after notification of the facility's transition of room C-9 to a semi-private room. The resident stated his/her POA instructed the facility not to move him/her. The resident stated he/she was fearful the facility would discharge him/her if he/she did not move. The resident stated staff brought him/her to look at the room. However, he/she did not attempt to go into the bathroom. He/she stated one would think the facility assessed the bathroom door to ensure he/she could fit into the room with the oversized wheelchair. Resident #14 stated within one (1) hour of the move he/she attempted to toilet with the realization the w/c did not fit through the door. The resident stated he/she notified staff with requests to return to the original room. The resident stated on 02/13/2021, the therapist came to the new room, evaluated his/her ability to pass through the door in the w/c, and determined it was unsafe for the resident to attempt to take the several steps into the room to toilet and notified the Executive Director. Resident #14 stated, on 02/13/2021, the facility staff brought him/her a BSC for use. He/she stated because the facility did not bring the BSC, on 02/12/2021, he/she had to use the brief to toilet for the remainder of the day. Resident #14 stated he/she felt the facility did not care about his/her desire to use a real toilet. The resident stated he/she had to use the chair in an open room, staff had to now assist him/her with cleaning, and he/she felt afraid someone would see him/her exposed because of the windows. Furthermore, he/she stated the BSC was to small and she/he remained fearful of injury. Interview with Family Member (FM) #6, on, 03/13/2021 at 1:35 PM, revealed Resident #14 told her often he/she could not get into the bathroom to toilet or to wash his/her hands after toileting or before meals. The FM stated the resident stated they used a warm cloth or used bacterial gel for hand hygiene. Continued interview revealed the FM stated Resident #14 felt humiliated because he/she could not access the bathroom and wanted to remain independent. FM #6 stated the other room (he/she had moved from) had a wide entrance and the door fully opened. The FM stated the family voiced and wrote not to move the resident. FM #6 stated the resident expressed anger and fear of body exposure to the outside. Interview with FM #7, on 03/13/2021 at 1:59 PM, revealed the facility continually asked the resident to move and the FM told the Executive Director they attempted to bully the resident to move. The FM stated they informed the Executive Director through phone conversations and mail that as the POA (Power of Attorney) for Resident #14, the facility may not move Resident #14. FM #6 stated they were informed of the move when the resident called them about the move and said he/she could not get into the bathroom in the new room. The FM stated the resident reported the facility staff left the BSC full of waste and the entire room smelled of the waste often. He further stated, the Therapy Department informed the facility about the safety concerns for the resident's inability to get into the bathroom and the use of the BSC because it was too small. FM #6 stated the resident expressed fear of exposure due to the commode placement by the window. The FM further stated all conversations fell on deaf ears with the Executive Director. Review of FM #7's letter to the facility Executive Director, dated 02/03/2021, revealed FM #7 notified the Executive Director, as the representative for Resident #14. The FM requested the facility not move the resident to a new room without consent or input. Review of the Progress Notes, dated 02/12/2021 at 12: 08 PM, revealed the facility moved the resident to room B-7 around 11:00 AM. Further review of the clinical record revealed no documented evidence the facility notified the POA of the resident's room change. Record review revealed the facility admitted Resident #78 on 08/14/2020 with the diagnoses of Alzheimer's, Diabetes, and Anemia. Review of the resident's Quarterly MDS assessment, dated 02/12/2021, revealed the resident used a wheelchair for locomotion, and required minimal assist of one for toileting. Review of Resident #78's Progress Notes, dated 02/12/2021 at 1:10 PM, revealed the facility moved the resident to room C-9. Room C-9 was the room Resident #14 had resided before he/she was moved. Interview with Certified Nursing Aide (CNA) #18, on 03/14/2021 at 11:20 AM, revealed the CNA assisted the Resident #14 on both units. The CNA stated when Resident #14 lived on the C unit, the resident could transfer from the wheel chair, toilet independently, and take care of his/her cleansing after use of the toilet. The CNA stated when the resident remained in bed they required extensive help to clean and change the brief. CNA #18 stated Resident #14 was independent with minor assistance. However, the resident required help in the room on the B Wing. The CNA stated the resident could not reach to clean himself/herself, required assistance on and off the commode. The CNA stated Resident #14 wanted to remain independent. The CNA stated if they were moved to a room and had to use a commode after having a bathroom they would be very angry and may become more depressed. Interview with Licensed Practical Nurse (LPN) #2, on 03/20/2021 at 7:45 AM, revealed Resident #14 expressed the fear of exposure to other people in or outside of the facility. The LPN stated the resident could not pull the room curtain or shut the blinds to provide privacy when he/she toileted on the BSC. The LPN further stated it was a privacy issue and people liked to keep independent and private to the best of their ability. Interview with the Occupational Therapist (OT), on 03/15/2021 at 3:41 PM, revealed the OT worked with Resident #14 on the B and C Units. The OT stated he met Resident #14 in the new room in B-7 on 02/13/2021 for therapy. The OT stated the resident remarked the w/c could not fit into the bathroom. Further interview revealed the OT stated the resident told him he/she had used the briefs since transfer to the room for toileting. The OT stated the resident remarked he/she felt worthless because the facility would not listen to him/her about the bathroom. The OT stated they informed the Executive Director of Resident #14's comments and concern for the resident's safety if the resident attempted to go into the bathroom. The OT further stated when they returned to the resident the next day the resident stated the facility had provided a BSC and appeared very upset. He stated he would feel worthless if the facility provided a BSC when he could use a toilet. Interview with the Maintenance Director, 03/13/2021 at 3:30 PM, revealed he assisted the facility to move Resident #14 to room B-7. He stated the facility gave the resident a BSC because the bathroom door was too small for the resident's wheelchair. He stated the resident expressed that he/she was upset to have to use the BSC and that the facility did not care how he/she felt. He stated he would not feel good to use a BSC when the other room allowed the person to use a full bathroom. 2. Record review revealed the facility admitted Resident #90 on 02/12/2021 with the diagnoses of Severe Intellectual Disabilities, Seizures, and Dysphagia. Review of the Initial MDS assessment, dated 02/19/2021, revealed the resident required full assistance with all Activity of Daily Living (ADL) care. Further review revealed the resident required one assist with meals. Interview with Family Member (FM) #3, on 03/11/2021 at 11:54 AM, revealed the facility was provided full instruction by the family and care givers from the group home for the resident's care. The FM stated the resident fed himself/herself with required assistance to place the food onto the utensil. She stated the resident's meals were a messy event. However, they informed the facility to allow the resident to remain involved in order to not lose his/her skills. Observation, on 03/11/2021 at 12:40 PM, revealed CNA #3 assisted Resident #90 with lunch. The staff attempted to fully feed the resident who actively reached for the food on the tray. The resident did not have a personal protector in place to prevent spillage onto clothing. Personal Care Assistant (PCA) #1 entered the room and CNA #3 requested help to keep the resident's hands out of the way. The PCA placed their hands on top and forward onto the resident's shoulders and kept both of the resident's arms from reaching for the tray. The PCA continued until the CNA stated the resident did not want the meal. Further observation, on 03/12/2021 at 8:52 AM, revealed CNA #3 fed Resident #90 breakfast while conversing to with the resident. The resident constantly reached for the tray, which was placed on the opposite side of the CNA. The CNA called the resident boy-boy while the aide encouraged him/her to eat with other baby talk. In addition, observations revealed PCA #1 entered to assist the CNA. The PCA stood in front of the resident and held the resident's hands while the CNA continued feeding and encouraging the resident. The resident did not have a cloth protector with the meal. Interview with Personal Care Aide (PCA) #1, on 03/18/2021 at 3:52 PM, revealed the PCA worked to assist the CNA's in the facility. The PCA stated Resident #90's mind was like a baby, and he/she reached for everything. The PCA stated at times CNA #3 would ask to have the resident's hands held because the resident pushed the aides hands away or constantly reached for the tray. PCA #1 stated when an elder resident constantly reached or pushed away, the staff would not hold their hands in order to feed the resident. However, she stated the difference between an elder and Resident #90 was the resident's cognitive level was that of a two (2) year old. PCA #1 stated the facility educated staff on abuse and resident's rights. She stated staff was to ensure resident's rights were protected. However, the PCA stated she did not know if holding a resident's hands down or arms to prevent grabbing or reaching could be a dignity concern with the rights of a resident. Interview with CNA #3, on 03/19/2021 at 10:34 AM, revealed the facility trained staff on abuse, dignity and resident rights. The CNA stated staff needed assistance to keep Resident #90's hands out of the way when they fed him/her. CNA #3 stated the resident became agitated when she attempted to feed him/her. The CNA stated the resident was on a level of a toddler and she attempted to meet the needs of the resident's on his/her cognitive level. Interview with CNA #19, on 03/19/2021 at 11:18 AM, revealed the facility educated staff of resident rights, which included abuse and dignity. The CNA stated when they fed Resident #90 the resident could get agitated. However, the CNA stated they would stop attempting to feed the resident, distract the resident and retry to feed the resident. The CNA stated staff were not to hold Resident #90's hands or prevent his/her arms from reaching or pushing away the food. The CNA stated when staff spoke to the resident they should speak to him/her like you would any other adult. The aide stated baby talk and nick names were disrespectful to the resident. Interview with LPN #2, on 03/20/2021 at 7:45 AM, revealed the facility was to ensure all residents were treated as family. The LPN stated residents should be treated like family which included respect and dignity. The LPN stated all residents were to be spoken to as an adult. He stated Resident #90 followed normal talk, simple commands and did not require baby type language. He further stated the facility provided education to staff for abuse, resident rights, and how to treat residents with dignity. Interview with the DNS (Director of Nursing Services) on 03/20/20201 at 12:51 PM, revealed staff should treat all residents in the facility like family, therefore respect and dignity should occur at all times. He stated he was not in the facility when staff moved Resident #14 to the new room and the facility was attempting to find suitable arrangements for a new room. However, he stated the use of a BSC when someone could toilet would make someone feel more depressed. In addition, he stated he expected staff to meet Resident #90's needs in a professional manner. He stated this included speaking to residents like an adult. In addition, he stated as the new DNS, moving forward included providing good care to the residents at all times because the facility was there to provide care. Interview with the Executive Director (ED), on 04/031/21 at 2:00 PM, revealed the facility had not identified issues with dignity toward residents. She stated the facility had applied for the transition of single rooms to double occupancy. However, to date the State had not notified the facility of approval. She stated conversations with Resident #14's family included not to move the resident to a semi-private room. However, Resident #14 was cognitively intact to make his/her own decisions without his/her POA and approved the room move. The ED stated the OT notified her of the inability of Resident #14 to use the restroom and the facility provided a BSC because the facility attempted to ensure the resident remained in a private room as requested. Continued interview revealed she would not know what she would feel if she had to use a BSC in an open room with possible exposure of her body. The ED stated she expected staff to talk respectful to all residents at all times. She stated she would not want to be spoken to in a negative or derogatory manner by staff. In addition, she expected staff to use diversional activities if needed, when they assisted residents with a meal. The ED stated everyone was human and were to be treated with respect and dignity at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the clinical record revealed the facility admitted Resident #82 on 10/21/2019 with diagnoses to include Alzheimer's disease, Major depressive disorder, and Osteoarthritis. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #82 with a Brief Interview for Mental Status (BIMS) score of fifteen (15) and determined he/she was interviewable. Interview with Resident #82, on 03/09/2021 at 3:24 PM, revealed the bathroom sink would not drain and the resident was not able to wash his/her face or hands. The resident revealed there had been a problem with the drain since the facility moved him/her to the room in November and he/she reported the issue to Certified Nursing Assistants (CNAs), nurses, housekeeping, maintenance, and the Administrator. According to the resident, the facility provided him/her with aloe-cleaning cloths for hygiene. In addition, the resident stated the overhead light fixture had only one bulb and was dim. The resident revealed he/she could not see well and there was not enough light in the room to do personal paperwork. Observation of the bathroom sink, on 03/10/2021 at 1:18 PM, revealed approximately five (5) inches of gray water. Interview with the resident during observation revealed it took about seven (7) to ten (10) days to drain completely. Observation, on 03/12/2021 at 9:26 AM, revealed approximately one (1) inch of gray colored liquid standing in the bathroom sink. Resident #82 was seated at the window and requested the State SurVey Agency Surveyor come closer in order to see better in the light. Interview with the resident, during this observation, revealed the sink was full when he/she went to bed and a CNA dipped some of the water out. Continued interview revealed the resident could not understand why the facility would not do something about the light in the room. Observation on 03/13/2021 at 8:47 AM, revealed approximately one (1) inch of gray liquid standing in the resident's bathroom sink. Review of Work Orders, dated December 2020 through February 2021, revealed no work orders related to Resident #82's clogged sink or broken ceiling light. Interview with CNA #2, on 03/31/2021 at 3:02 PM, revealed she noticed the clogged sink before the facility moved Resident #82 to the room. She stated she dipped water out of the sink to try to clean it up and reported the issue to the nurse. She stated a clogged drain should be addressed immediately because it was not homelike for the resident. Interview with CNA #17, on 03/13/2021 at 9:07 AM, revealed she noticed Resident #82's clogged sink, but she did not report the issue to maintenance because she was so busy. CNA #17 stated staff was supposed to fill out a work order and put it in the maintenance basket. She stated water stood in the sink and it was an inconvenience because the resident could not wash their hands. The CNA stated she was not aware of an issue with the lighting in the room. Interview with CNA #18, on 03/13/2021 at 9:51 AM, revealed he was not sure where to locate a work order. CNA #18 stated he put a note under the door of the maintenance office when he noticed an issue. The CNA revealed it would be important to ensure adequate lighting to ensure residents could read and help prevent falls. Interview with CNA #4, on 03/13/2021 at 1:49 PM, revealed she reported maintenance issues to the nurse or told maintenance if she saw them. Interview with Licensed Practical Nurse (LPN) #4, on 03/16/2021 at 4:09 PM, revealed the C/D unit used a maintenance log to report issues. She stated Resident #82 reported the sink drain was backed up about a month ago and she reported the issue to the Maintenance Director. The LPN revealed the resident performed his/her own hygiene and the sink was the only place to wash up. She further revealed it was important for the resident to perform hand hygiene to prevent the spread of infection. She stated she was not aware of the issue with the light; however, it was important to ensure adequate lighting for safety reasons. Interview with the former Housekeeping Manager, on 03/13/2021 at 3:06 PM, revealed Resident #82's sink had been stopped up since the resident moved to the room and stated she bailed water from the sink in order to clean it. The Manager revealed she submitted work orders for the sink and reported the issue to the Maintenance Director. However, the issue was never resolved. In addition, the Housekeeping Manager revealed she submitted a work order for the light at the request of the resident. The Housekeeping Manager revealed the facility ordered a new ballast light for the resident's room, but Maintenance never installed it. The Manager revealed it was important to address the maintenance issues because the resident did a lot of reading and needed adequate light. She further revealed the resident needed a functioning sink to wash his/her hands after toileting. According to the Housekeeping Manager, the Administrator did not follow up on concerns unless her boss or the state survey agency (SSA) was in the building. Interview with the Maintenance Director, on 03/13/2021 at 3:54 PM, revealed he was aware of the issue with Resident #82's sink drain. He revealed he was not aware of any work orders related to the clogged sink and could not recall how long there had been an issue. In addition, he revealed the resident reported the broken light to him; however, he forgot about it. According to the Maintenance Director, the light had been broken for about a week and a half. He revealed staff reported maintenance issues by word of mouth or by text and he did more work without a work order than he did with a work order. He stated once work orders were resolved he wrote 'done' on the paper and put them in a drawer. The Maintenance Director revealed it would be important to ensure issues were resolved so the resident could wash his/her hands and read. Interview with the Administrator, on 04/02/2021 at 2:51 PM, revealed she was aware of the issue with Resident #82's sink and stated the facility worked on it several times. She further revealed she became aware of the lighting issue when the Maintenance Director changed the light. However, she was not aware how long the light had been broken. The Administrator revealed it was important to ensure residents had access to a working sink and adequate lighting. Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure reasonable accommodation of needs for five (5) of sixty-nine (69) sampled residents (Residents #14, #54, #56, #82, and #445). Interviews revealed the facility moved Resident #14 from a room with an accessible rest room to a room in which the rest room door did not accommodate the resident's wheel chair. Interviews revealed the resident reported to the facility on [DATE] he/she could not get into the bathroom immediately after the facility transferred him/her to a new room. However, the facility did not address the need to use the bathroom until 02/13/2021 when the facility provided Resident #14 with a bedside commode. Resident #14 had to use a brief when the facility did not respond for twenty-four (24) hours. Resident #14 stated he/she felt invisible and uncared for by the facility. Staff reported the resident appeared upset, sad, and angry when the facility provided the BSC instead of the use of a bathroom. Observation and interviews revealed the facility failed to provide translation services for communication with staff for Residents #54, #56, and #445, whose primary language was not English. Resident #445's primary language was Spanish and Residents #54's and #56's primary language was Russian. Observation and interviews revealed Resident #82 could not use the bathroom sink due to a backup of water and could not read due to inadequate lighting in the room. The resident revealed he/she liked to wash in the sink on a daily basis and wash his/her hands after toileting. However, the resident revealed he/she could not complete either and was afraid of getting an infection from his/her hands not being clean. The findings include: Review of the facility's policy, Quality of Life - Accommodation of Needs, revised August 2009, revealed the resident's individual needs and preferences would be accommodated to the extent possible, except when the health and safety of the individual or other resident would be endangered. The policy revealed in order to accommodate individual needs and preferences, adaptations may be made to the physical environment, including the resident's bedroom and bathroom, as well as the common areas in the facility. The policy revealed staff's attitudes and behaviors must be directed towards assisting the residents in maintaining independence, dignity, and well-being to the extent possible and in accordance with the residents' wishes. Review of the facility's policy Quality of Life - Homelike Environment, revised May 2017, revealed the facility's staff and management would maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics included: a clean, sanitary and orderly environment; and comfortable (minimum glare) yet adequate (suitable to the task) lighting. The policy revealed comfortable and adequate lighting was provided in all areas of the facility to promote a safe, comfortable, and homelike environment. The lighting design emphasizes: sufficient general lighting in resident-use areas; Task lighting as needed; Reduction in glare; even light levels; Maximum use of daylight; Night lighting to promote safety and independence; and dimming switches, where feasible. 1. Review of the clinical record revealed the facility admitted Resident #14, on 10/20/2019, with diagnoses to include Parkinson's disease, Major depressive disorder, and Morbid Obesity. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #14 with a Brief Interview for Mental Status (BIMS) score of fourteen (14) and determined he/she was interviewable. The facility assessed the resident's locomotion with use of a wheelchair (w/c). Review of the facility's notification letter, undated, revealed the facility planned to change the C Unit private rooms to semi-private rooms and would assist with transfer to another unit to continue use of a single room if desired. In addition, the facility would accommodate residents' needs as possible. The administrator signed the notification letter. Review of the bed status revealed the facility transferred Resident #14's, on 02/12/2021, from the C Unit room nine (C-9) to the B Unit room seven (B-7). Observations, on 03/12/2021 at 11:08 AM, revealed the facility room placement for Resident #14 was B-7. Observations revealed the resident transferred independently from the chair to an extra wide w/c, he/she went to the bathroom door, and attempted unsuccessfully to enter the bathroom because the width of the w/c. Observations revealed the bathroom door opened against the wall, therefore it only opened at a forty-five (45) degree angle. The bedside commode laid against the wall at the window and toilet paper sat on the windowsill. Interview with Resident #14, on 03/12/2021 at 11:08 AM, revealed the facility moved him/her to B-7 on 02/12/2021. The resident revealed the C-wing contained all single rooms. The resident stated the facility notified families of the intent to transition the C Unit rooms into double occupancy rooms. Resident #14 stated because of the size of his/her w/c it could not fit through a regular rest room door and the facility placed him/her in C-9 to allow him/her to maintain independence with toileting. Furthermore, the resident revealed his/her Power of Attorney (POA) notified the facility's administrator not to move the resident without consent or involvement. However, the resident revealed the administrator and upper management 'badgered him/her to move to another unit whereas he/she could remain in a single room and feared the facility would discharge him/her for continued refusal. The resident revealed he/she looked at the room prior to the move. However, the resident stated the facility did not ensure his/her w/c would fit in the rest room. The resident revealed he/she figured the facility reviewed the rest room door to accommodate the width of the w/c. Furthermore, the resident stated once in the room, he/she discovered the door to the rest room could not fit the w/c. Resident #14 stated he/she notified the administrator and POA with the request to return to C-9 until other arrangements could be made. The resident stated the facility did not respond on 03/12/2021 and he/she had to toilet in the brief from 02/12/2021 early afternoon to 02/13/2021 late morning when staff brought the BSC. Resident #14 revealed when staff brought the BSC on 03/13/2021 they remarked the resident would have to toilet in the BSC or use his/her brief. The resident stated he/she felt bad to be forced to use a brief or BSC. In addition, the resident remarked he/she felt like the facility did not care about what he/she needed to remain independent to the best of his/her ability and he/she felt invisible to the facility. Interview with Family Member (FM) #6, on, 03/13/2021 at 1:35 PM, revealed Resident #14 stated that he/she could not get into the bathroom to toilet or to wash his/her hands. The FM revealed the resident revealed he/she used a warm cloth or used bacterial gel for hand hygiene. The FM revealed the resident stated the w/c could not get through the rest room door. The FM revealed the other room had a wide entrance to the rest room and the door fully opened. The FM revealed Resident #14's POA requested the facility not to move the resident. The FM revealed the resident expressed anger because the facility would move him/her to a room that could accommodate the size of the w/c. Interview with FM #7, on 03/13/2021 at 1:59 PM, revealed they represented Resident #14 as his/her POA. The FM revealed they informed the administrator through phone conversations and mail that as the POA for Resident #14, the facility may not move Resident #14 without consent or input. The FM revealed Resident #14 informed the family after the move when the resident called and reported he/she could not get into the bathroom in the new room. The FM revealed they notified the administrator the facility moved the resident without the POA's consent and requested the resident either return the original room or a room which could accommodate the w/c. The FM revealed the administrator stated Resident #14 was cognitively intact and could make his/her own decisions and the resident gave consent after looking at the room and determined it accommodated his/her needs. The FM revealed the resident's therapist informed the facility the rest room could not accommodate the w/c and risked the resident's safety. The FM further revealed because the facility would not move the resident to accommodate the w/c, the facility provided a BSC in the open room for toileting. The FM revealed the facility did not accommodate the resident's toileting needs after numerous requests to remain independent to his/her ability. Review of FM #7's letter to the facility's Administrator, dated 02/03/2021, revealed as the representative for Resident #14, the FM requested the facility not move the resident to a new room without consent or input,. Review of Progress Notes, dated 02/12/2021 at 12: 08 PM, revealed the facility moved the resident to room B-7 around 11:00 AM. The facility failed to provide documentation of notification to the POA of the resident's room change. Observations with the Maintenance Director (MD), on 03/15/2021 at 11:00 AM, revealed the Director of Maintenance used the facility's tape to measure B-7 rest room door with the open angle of the door reported by the MD as less than ninety (90) degrees and the entry measured twenty-nine (29) inches. Further observation revealed the MD measurement for C-9's rest room included the door opened to one-hundred and eighty (180) degrees and the rest room door entry measured thirty-six (36) inches. In addition, the MD measured Resident #14's w/c width as 29 inches. Interview with the MD, on 03/15/2021 at 11:00 AM, revealed the facility did not request him to measure the rest room entry to B-7 before the facility moved Resident #14. He revealed plain visual sight could reveal the entry to B-7 could not accommodate the width of the w/c. He further revealed the facility knew the resident could not enter the rest room in B-7 when the administrator asked him to look at the entry the next day of the move. He revealed he notified the administrator even after he attempted to move the furniture around the room the resident still could not get into the rest room. He revealed facility administrator revealed she attempted to accommodate the resident with the move to a single room, the resident gave approval of the move, and therefore the resident decided the room worked for his/her needs with toileting. Furthermore, he revealed he felt the facility should move the resident to accommodate the resident to toilet in a restroom and not a BSC. Interview with the Occupational Therapist, on 03/15/2021 at 3:41 PM, revealed they assessed the resident's room for safety and accommodation for use of the rest room with the resident's w/c. He revealed the w/c could not fit through the rest room door. He revealed the resident's goal included to remain as independent as possible. He revealed he reported the use of the bathroom would be a risk to the resident's safety to the administrator. The OT stated the resident required a room with a larger entry to the rest room. However, the OT revealed the administrator remarked the resident made the decision to accept the room and the next time the OT went to complete therapy the room contained a BSC. The OT revealed Resident #14 expressed anger and dismay to be made to use a BSC and seemed more depressed after he/she was transferred to the new room. Furthermore, the OT revealed the facility provided a normal sized BSC and the equipment remained a safety concern for the resident's weight with the ability to sit and stand as the BSC caught the resident's hips. Interview with the admission Director (AD), on 03/20/2021 at 10:59 AM, revealed the facility's administration made the decision to move Resident #14 to the B Unit because the resident wanted to remain in a single room. The AD stated the facility did not inquire if the room could accommodate a large w/c. He stated the facility knew how upset Resident #14 was since he/she moved to the room and would not move the resident to a new room. Continued interview revealed the facility approached him on 3/19/2021 to locate a room which could a rest room could accommodate Resident #14's w/c. He revealed the facility responsibility included to ensure the rights of the residents, make the residents comfortable and live in a homelike environment to accommodate the resident to maintain independence. The AD revealed the use of a BSC could make Resident #14 depressed as it would anyone. Interview with CNA #1, on 03/17/2021 at 1:16 PM, revealed Resident #14 could self-transfer and toilet when he/she resided in C-9. However, the aide revealed the resident required moderate assistance now that the facility provided the resident with a BSC. The aide revealed the resident reported to staff he/she wanted to use the rest room and requested many time to move to a room which could accommodate the size of his/her w/c. The aide revealed the resident told the administrator he/she didn't like to use the BSC and needed different accommodations. However, the administrator would not move the resident. Furthermore, the aide revealed the resident appeared emotional upset and at times angry when he/she could use a bathroom and was made to use the BSC. Furthermore, the aide revealed the resident's risk of falls increased because the resident could not use the grab bars to steady or pull up off the BSC which further increased the dependency for staff. The aide further revealed the resident did not have any accommodations to ensure he/she lived in a homelike environment and the facility's responsibilities included to provide a place like the resident lived in at home. Interview with CNA #18, on 03/14/2021 at 11:20 AM, revealed the aide cared for Resident #14 on Unit A/B and previously on Unit C/D. The CNA revealed when Resident #14 could transfer from the wheel chair, toilet independently, and take care cleansing after use of the toilet with occasional minimal assistance. However, the resident required assistance with toileting in B-7. CNA #18 revealed the resident could not reach to clean himslf/herself and required assistance on and off the BSC. The CNA revealed Resident #14 wanted to remain independent. CNA #18 revealed the resident's rights included to have the facility accommodate needs of the residents. The CNA further revealed because the resident could not get into the rest room, the resident could not wash their hands. The aide further revealed the resident feared losing his/her independence. Interview with Medical Records Coordinator/LPN, on 03/14/2021 at 9:40 AM, revealed she took care of Resident #14 when she filled in as a nurse on the unit for staff. She revealed the resident's abilities while he/she resided in C-9 included to transfer independently, able to toilet with minor assist and fiercely independent. The LPN revealed the resident could enter and exit the rest room in C-9 and he/she could not in B-7. The LPN revealed the facility provided the resident a BSC in B-7. The LPN stated Resident #14 complained frequently to staff about the required use of a BSC when he/she could use the rest room in C-9. Interview with Licensed Practical Nurse (LPN) #2, on 03/20/2021 at 7:45 AM, revealed the facility knew the resident could not enter the rest room in B-7. He stated instead of moving the resident the facility accommodated his/her toileting needs with a BSC. LPN #2 stated he considered the BSC disgraceful, and the facility's treatment to the resident was indignant, and the resident voiced to the facility provider that it was undignified utilities for toileting. Interview with Social Services, on 03/19/2021 at 10:12 AM, revealed the any resident who could use a rest room and was made to use a BSC would be upset and uncomfortable with the situation. The SS stated if the situation occurred to him he would demand to know why this happened and demand a room change to use the rest room. Interview with the DNS, on 03/20/2021 at 12:51 PM, revealed the facility should provide accommodations in the facility to meet a resident's request or need to maintain his/her level of care. the DNS revealed the facility moved Resident #14 while out of the building. The DNS revealed the rest room in Resident #14's room was small and the resident could not use the rest room. The DNS further stated the focus of the facility should always be about what the resident needs, not what the facility decided the resident needed. Furthermore, he expected the facility to provide and accommodate resident's needs to remain at the level physically and mentally to the best of the facility and staff's ability. Interview with the Executive Director (ED), on 04/03/202021 at 2:00 PM, revealed the facility moved Resident #14 after the resident decided the room on the B Unit could accommodate his/her needs, including toileting. The ED revealed communications with the POA included only to not move the resident into a double occupancy room. The ED stated the facility moved the resident because the facility applied for the ability to increase census with double rooms. However, the ED revealed to date, the facility had not been notified of approval from the State. The ED revealed the facility utilized a program called magical moments where staff routinely met with the residents and document complaints or needs and as the ED, she signed off on the forms. The ED revealed staff notified her of Resident #14's concerns of the inability to access the rest room. She stated she spoke to the resident and discussed his/her desire to have a private room and the facility provided the private room as requested. She stated that in order to stay in a private room she would see if renovations could be done by maintenance to the door to allow access.The ED further revealed the facility's responsibilities included to provide residents with a quality of life which accommodated the resident's needs at all times. The ED revealed the failure to accommodate the resident's needs could cause an adverse effect to the resident. 2. Review of the facility's Quality of Life-Accommodation of Needs Policy, revised 08/2009, revealed the facility's goal was to provide an environment to maintain dignity and achieve the highest level of function and well-being for the residents. The policy revealed the facility would provide assistive devices for the physical environment and staff would communicate with the residents achieving the highest level of functioning while maintaining dignity. The facility did not provide a requested policy regarding translation for Residents with a language barrier or spoke a foreign language. Review of the clinical record revealed the facility admitted Resident #54 on 05/12/2020, with diagnoses that included Cognitive Communication Deficit, Dementia with Behavioral Disturbance, Acute on Chronic Congestive Heart Failure, and Type Two (2) Diabetes Mellitus. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of three (3) and resident usually comprehended and was understood by others. Review of Resident #54's care plan, initiated on 05/15/2020 with revisions on 02/10/2021, revealed interventions included difficulty with communication due to English as a second language and the goal to ensure communication of Resident #54's basic needs. The interventions included staff's anticipation of resident's needs, communication without distractions, use of simple words, and alternative tools as needed. Further care plan review revealed the provision of a communication board and therapy to screen quarterly and as needed. Review of the Social Services Progress Review for MDS Documentation, dated 01/29/2021, revealed Resident #54's speech was clear, was usually understood by staff, and understood communication provided by facility staff. Review of Speech Language Pathology Discharge summary, dated [DATE], revealed speech therapy identified Resident #54 had a moderate/expressive communication disorder and had difficulty understanding English, as his/her primary language was Russian. The speech therapy discharge summary revealed Resident #54 still required maximum cueing for communication with the use of simple yes/no questions, use of visual aides, and speaking slowly to increase understanding. Review of Psychiatry Progress Notes, dated 12/2020 through 02/2021, revealed Resident #54 had a mild comprehension impairment, was oriented to person, and English was not his/her primary language which affected communication with the resident. Observation of Resident #54, on 03/09/2021 at 11:28 AM, revealed Resident #54 lying in bed and just smiled when spoken to. When asked resident to verify his/her name, he/she repeated his/her last name back. Additional observation, on 03/18/2021 at 11:55 AM, revealed resident well groomed, dressed appropriately, and sitting in his/her wheelchair in the room. A communication board was not present. Interview with Certified Nurse Aide (CAN) #8, on 03/18/2021 at 10:58 AM, revealed she requested Resident #54 to speak English and the resident also had a communication board. Interview with CNA #21, on 03/13/2021 at 2:42 PM, revealed she used a translation application on her personal cellular phone to communicate with the residents with language barriers. Interview with CNA #17, on 03/13/2021 at 2:44 PM, revealed she used hand gestures to communicate with Resident #54 because the facility did not have translation services available. Interview with the Speech Language Pathologist (SLP), on 03/16/2021 at 2:14 PM, revealed assessments for residents with language barriers were completed on admission and quarterly. She stated she used a cellular phone translator application to communicate with non-English speaking residents. The SLP stated she communicated with facility staff to determine if the resident was having any difficulty with communication for the quarterly assessment. Interview with the Director of Social Services (SSD), on 03/17/2021 at 8:14 AM, revealed he did not use any tools to evaluate Resident #54 for a BIMS assessment for the MDS assessment. He stated he used video conference by telephone or utilized family members to translate for the residents with English as a second language with communication difficulties. He stated the facility did not have translation services available for staff to communicate with residents. The SSD stated Resident #54 did not have a communication board in his/her room. Interview with the Advanced Practice Nurse Practitioner (APRN), on 03/20/2021 at 3:40 PM, revealed her communication with non-English speaking residents and those with communication barriers was to motion to him/her what she was going to assess. She stated facility staff were also used to translate for non-English speaking residents. The APRN stated the facility did not have translation services available for staff use and therefore, she used her cellular phone at times to translate from English to another language. Interview with the Director of Nursing Services (DNS), on 03/21/2021 at 03/20/2021 4:17 PM, revealed the facility did not have any translation services available to staff to utilize. He stated there could be an inaccurate translation with the use of a translation application via cellular phone, which was not his preference. The DNS stated the facility was attempting to arrange for translation services for the facility. Interview with the Executive Director (ED), on 04/02/2021 at 2:30 PM, revealed the facility utilized visual translation boards, facility staff, and family members to translate for the residents who spoke a foreign language. She stated the facility had translation services via a telephone service, which was available to the ED, DNS, and SSD. She stated the contact information was not available to other facility staff members. She stated it could be frustrating for the residents not being able to communicate his/her needs. The ED stated the lack of awareness for translation services was an education opportunity. 3. Review of the clinical record revealed the facility admitted Resident #56, on 11/25/2016, with diagnoses of Aphasia, Hemiplegia, and Hemiparesis following a Cerebral Infarction Affecting the Left Non-Dominant Side. Review of the Physician Orders, dated 01/2021-03/2021, revealed no SLP services ordered. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed a BIMS score of fourteen (14), resident was sometimes understood by others and sometimes understood communication with others. The MDS revealed Resident #56 required one (1) person staff support for transfers, walking in room/hall, dressing, eating, toilet use, personal hygiene, locomotion on/off unit. The assessment revealed resident had impaired range of motion for upper and lower extremities and required the use of a wheelchair and walker for mobility. Bed mobility required the assistance of two (2) staff members. The MDS revealed Resident #56 was always incontinent of bowel and bladder. Review of Resident #56's care plan, initiated on 02/23/2020 and last revised on 02/13/2021, revealed difficulty with communication due to Russian being primary language with English as a second language. The goal was to ensure Resident #56 was able to make basic needs known on a daily basis. The care plan reveal[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure the Nurse Practitioner (NP) Care Services provided timely orders for one (1) of sixty nine (69) sampled residents (Resident #85). The facility received a critical lab value of a Blood Urea Nitrogen (BUN) level of 111 (above 20 is high) mg/dl (deciLiter) on 03/09/2021 at 1:00 AM. The facility notified the NP immediately. However, there was no documented evidence the NP addressed the critical lab until 4:14 PM (03/09/2021), roughly fifteen (15) hours later. In addition, the facility failed to provide adequate fluids per dietary recommendations after the NP ordered a reduction of fluid intake per Enteral Feeding. Furthermore, the NP failed to follow-up with pharmacy regarding insulin orders which were not initiated. The findings include: The State Survey Agency requested the facility's policy related to Reporting Critical Lab values. The facility presented its Change in Condition policy. Review of the Change in Condition policy dated October 2019 revealed an acute change in condition would be communicated to the physician and the responsible party. Review of the contract titled, Health Care Services Agreement (Medical Director Services), undated, revealed the agreement included services with a company owned and operated by an Advanced Practice Nurse Practitioner. The agreement revealed midlevel NP's provided services to the facility and residents for sudden needs of a resident. Further review revealed in an emergency the contractor availability on call included to advise the facility with resident concerns when the facility identified the medical provider as unavailable. However, the contracted NP failed to provide immediate services for Resident #85's critical lab and then provided services to the resident without documented consultation with the Pulmonary Medical Director (PMD). 1. Record review revealed Resident #85 was transferred to an acute care facility on 03/10/2021 and was not in the facility during the investigation. Review of Resident #85 clinical record revealed the facility initially admitted the resident on 04/10/2020 with diagnoses of Traumatic Brain Injury, Diabetes Mellitus, and Enteral Feed (tube feeding). Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview of Mental Status (BIMS) score of four (4). Review of Resident #85's Comprehensive Care Plan, initiated 05/01/2020, revealed a potential for nutritional risk related to reliance on therapeutic enteral feeding for nutrition, significant weight loss, altered skin integrity and diagnoses of anemia and diabetes. The goal stated the resident would not exhibit unplanned significant weight change thought the next review and the resident would receive adequate nutrition and hydration with a target date of 04/29/2021. Interventions included lab/diagnostic tests as ordered, report results to MD and follow up as indicated; provide tube feeding as ordered. Interview with Licensed Practical Nurse (LPN) #11 on 03/18/2021 at 3:18 PM revealed critical labs could be threatening to the resident. She indicated the lab would call to the floor and report the critical lab to a nurse. Per protocol, the nurse would then call the doctor/NP and the doctor/NP would give orders to intervene. LPN #11 further stated the outcome of untreated critical labs could be system failures. Review of the Lab Results Report for Resident #85, revealed the normal range for Blood Urea Nitrogen (BUN) was 7 mg/dL to 25 mg/dL. On 02/15/2021 Resident #85's BUN was 47 mg/dL. On 02/22/2021, Resident #85's BUN was 68 mg/dL. On 03/05/2021, Resident #85's BUN was 95 mg/dL. On 03/08/2021, Resident #85's BUN reached a critical level of 111 mg/dL. On 03/10/2021 Resident #85's BUN was again critical at 122 mg/dL. Interview with Certified Medication Technician (CMT), on 03/20/2021 at 11:11 AM, revealed she was new to the facility and assigned to the G Hall on 03/09/2021, the evening the critical lab value for Resident #85 was called into the facility. CMT indicated she always answered the phone, however the nurse on her hall was in a resident's room providing treatment, so she took the critical lab for Resident #85's BUN of 111 mg/dL. CMT further stated she immediately reported the critical lab to the nurse on the A- Hall, LPN #12. She revealed she did not remember time. However, indicated it was after midnight. Interview with LPN #12 on 03/20/2021 at 10:47 AM, revealed she was responsible for the A/B Unit and the C/D Unit on the night the critical lab for Resident #85 was reported. She stated she took over the C/D Unit at 11:00 PM. LPN #12 explained an unnamed staff member on the G-hall took the critical lab value. She stated she did not recall the time, but it was the middle of the night. She additionally stated she immediately notified the NP by phone of Resident #85's BUN of 111. The NP indicated she would address the critical lab when she made her morning rounds. Review of Physician/ Prescriber orders in Point Click Care (PCC) reflected the orders were placed into the system by Licensed Practical Nurse (LPN) #11, on 03/09/2021 at 4:14 PM, approximately 15 hours after the critical lab was called to the facility. Review of the Physician/ Prescriber Order written by the Nurse Practitioner, dated 03/09/2021 untimed, revealed orders were written to administer D5W (intravenous sugar solution to rehydrate) at 100 cc/hour continuous; Basic Metabolic Panel (BMP) in AM (morning). Review of Resident #85's Hospital records, revealed the resident was admitted to the hospital on [DATE] at 12:35 PM with a primary diagnosis of Dehydration with Hypernatremia secondary to Acute Kidney Injury. Review of the Hospital labs, dated 03/10/2021 at 12:56 PM, revealed a Blood Urea Nitrogen (BUN) lab value of 123 mg/dL (reference range 7-20 mg/deciliter (dL)), (The BUN test measures the level of nitrogen in the blood to assess the functions of the kidneys and liver) and Sodium of 155 mmol/L (reference range 137-145 mmol/L. Interview with the Medical Records Coordinator, on 03/18/2021 at 3:47 PM, revealed after the facility received a critical lab, the doctor or NP should be notified for guidance. She further stated, critical labs should be acted on immediately because the resident's condition could get worse. Interview with the Director of Nursing Services (DNS) on 03/19/2021 at 11:40 AM, revealed he did not know the official policy for reporting critical labs. He stated the nurse should immediately notify the doctor/ NP of the critical labs by phone call. The nurse should then document the call in the progress notes along with any orders. An additional interview with DNS on 03/21/2021 at 12:25 PM revealed Physician Services were to oversee care of the residents. He stated he was unaware of the fifteen (15) hour delay after the facility notified the NP of the critical labs. The DNS further stated, the provider should deal with critical labs immediately and indicated it would not be practical to wait. Additionally, the DNS stated there could be adverse outcome with a delay in treatment. Interview with the NP on 03/18/2021 at 10:50 AM revealed the cause of an elevated BUN was Chronic Kidney Disease, dehydration, and/or kidney failure. The NP further stated potential complication of BUN of 111 could be kidney failure and dysfunction. Further interview with NP on 03/20/2021 at 3:40 PM, revealed she did not remember when the first critical lab for Resident #85's BUN of 111 mg/dL was reported to her. She indicated she rounded in the facility and wrote orders for Resident #85 midmorning or early afternoon and added she could not remember the date. She explained sometimes the facility called or texted with critical labs at night, adding, they had the option to call other providers. However, if it was a critical lab they usually called her. However, she explained she would have given orders when notified of a critical lab BUN of 111 mg/dL. She added, usually she would see the critical labs before they were reported to facility. 2. Review of Physician/ Prescriber physical order sheet written by the NP, dated 02/22/2021 untimed, revealed a written order to increase free water to one thousand and five-hundred (1500) cc every twenty-four (24) hours or sixty-two (62) cc per hour. Review revealed the previous order included 300 cc of water every 4 hours. This resulted in a decrease of free water by 300 cc in a 24 hour period. Review of the Progress Notes- Nutrition/Dietary Notes written by the RD effective 01/19/2021 at 10:57 AM and on 02/24/2021 at 10:04 AM revealed the Nutrition at Risk (NAR) review. Review revealed the recommendations for free water/flushes of 300 cc every four (4) hours for a total of 1800 cc every day. However, the recommendation was not ordered after the NAR review on 02/24/2021. Review of Resident #85's Medication Administration Record (MAR) dated 01/01/2021- 03/01/2021, revealed the facility did not include on the MAR or Treatment Administration Record (TAR) an order for free water or flushes. Review of Resident #85's clinical record revealed the facility documented evidence did not include that staff provided the resident free water/flushes or monitored for hydration from 12/28/2020-03/10/2021. The facility sent Resident #85 to an acute facility for an evaluation on 03/10/2021 after review of lab results drawn on 03/10/2021 at 4:28 AM. Review of Resident #85's Lab Result, dated 03/10/2021 at 4:28 AM, revealed the resident's BUN was 122 mg/dL (reference range 7-25 mg/dL) and a sodium level of 158 mEq/L (reference range 135-145 mEq/L). The result of 122mg/dL was noted as a critical level. Review of admission hospital records, dated 03/10/2021, revealed the primary diagnosis to be dehydration with Hypernatremia. Interview with LPN #6 on 03/17/2021 at 10:57 AM revealed Resident #85 was ordered 1500 cc of free water every 24 hours. However, she was unsure if it appeared on the MAR to chart. She also stated the potential outcome for a resident not receiving enough fluids would be dehydration. Interview with LPN #11 on 03/18/2021 at 2:27 PM revealed there were no free water no orders on the MAR to administer free water to Resident #85. She stated she flushed with 60 cc of water when she changed Resident #85's feeding bag. However, did not give any additional water free to Resident #85. Interview with Registered Dietician (RD) on 03/18/2021 at 2:42 PM revealed she calculated tube feeds and free water needs and would give suggested orders. She stated sometimes the Advanced Practice Registered Nurse (APRN) would also give orders for free water. The RD additionally stated feeding pumps were discussed in clinical meeting. Dual pumps had pre-programmed amounts to ensure residents received free water to potentially prevent elevated labs or dehydration. She also indicated Resident #85 was last assessed as a Nutrition at Risk (NAR) resident on 02/24/2021 and was suggested him/her to receive 300 ml of free water every four (4) hours. RD assessed MAR/Treatment Administration Record (TAR) record on PCC during the interview and replied she did not see free water flushes on the MAR/TAR. However, stated free water flushes were ordered for February and March. She indicated she did not know how to ensure free water was given if it did not show up on the MAR/TAR and stated, That would be a DNS question. RD additionally stated the potential outcome for not receiving free water flushes could be elevated labs or dehydration. Interview with DNS on 03/19/2021 at 11:40 AM revealed free water was given via G-tube and calculated by dietician. He explained the RD made recommendations. However, the orders for free water would need to come from the doctor. He indicated the order for free water should show on the MAR and explained, if it's not on the MAR the nurse would not know to do give free water. In addition, he stated the potential outcome for not receiving hydration would be a clogged G -tube and potential for dehydration. Interview with NP on 03/20/2021 at 1:40 PM revealed free water is the extra water given to residents to accommodate their needs. NP was asked to clarify the free water order written by NP on 02/22/2021 increase free water to 1500 cc per 24 hours or 62 cc per hour. The previous free water order was 300 cc every 4 hours. The NP explained she could not give you definitive answer as to why free water was decreased. However, stated Resident #85 did have a history of Heart Failure or there were multiple orders for free water/flushes and may have been over looked. 3. Review of Physician order, dated 03/01/2021, revealed the NP ordered on, 03/01/202, to start Lantus 10 units subcutaneous twice a day. Review revealed this was an increase from the previous order which was to administer Lantus 10 units subcutaneous once a day. Review of Resident #85's March 2021 MAR/TAR revealed Pending Confirmation an order for Lantus Solostar 100 units/ml, inject 10 units subcutaneous twice a day for diabetes. The provider ordered the Lantus 10 unit one time a day, the previous order, to be discontinued on 03/14/2021. However, record review revealed the Lantus Solostar 10 units subcutaneous two times a day was not imitated as ordered. However, review revealed Resident #85 continued to receive the discontinued dose of Lantus 10 units once a day. Record review of Resident #85's Lab Result, dated 03/10/2021 at 4:28 AM, revealed a blood glucose level of four hundred and eighty-three (483) mg/dL. The normal range for glucose included 65-125 mg/dL. Further review of Resident #85 Weight and Vitals Summary, dated 03/10/2021, revealed documented blood sugars of three hundred and eighty-seven (387) mg/dL at 7:48 AM and three hundred and eighty-nine (389) mg/dL at 10:11 AM prior to Resident #85 being sent to the hospital. Record review of Resident #85's hospital admission records, dated 03/10/202, revealed the resident diagnoses included poor control of Type 2 Diabetes Mellitus. Interview with the Lead Pharmacist, on 03/20/2021 at 12:23 PM, revealed the facility entered an electronic order entered, on 03/01/2021 at 1:16 PM, for Solostar Lantus 10 units subcutaneous to be given twice a day. However, the order remained pending confirmation until discontinued on 03/14/2021 when Resident #85 was sent to the hospital. The Lead Pharmacist stated pending confirmation meant the doctor or NP would need to sign off on the order. He also stated pharmacy could not see PCC and explained they used a different system. He stated when the doctor/NP signed the order, it would be electronically submitted and the order would appear for staff on the MAR. He stated a new electronic order was received on 03/19/2021 for Lantus 10 units once a day instead of twice a day. Further interview with the NP, on 03/20/2021 at 3:40 PM, revealed she worked independently, without oversite from the Medical Directors or a Physician because after four (4) years of work as a NP, the state of Kentucky did not require someone to oversee her. She revealed she had seen orders with pending confirmation. However, she stated she was not sure what pending confirmation meant and was never instructed that she needed to make any changes to orders with pending confirmation. the NP stated she thought the nursing staff addressed those orders. She stated she could not verify every order she wrote was imitated and did not follow-up to ensure orders were entered into PCC. She stated the potential outcome for not receiving the updated order for insulin included uncontrolled blood sugar, a higher risk of infections, long-term eye nerve damage, kidney issues, heart issues, or stroke. Interview with the Pulmonary Medical Director (PMD), on 03/20/2021 at 9:30 AM, revealed the facility Nurse Practitioner (NP) rarely worked with the PMD. The PMD revealed he only worked with two NP's employed by his practice. Furthermore, the PMD revealed he did not provide supervision because the NP was contracted for services by the facility and not under his practice. Further interview on 04/02/2021 at 11:15 AM, revealed the contracted NP did not take call for emergency, on call services, or notifications for the PMD residents. The PMD revealed he expected the facility to call him or his NP's for all care needs related to residents under his services. However, the contracted NP should directly notified the PMD for any concerns with resident's which he may need to address. The PMD revealed the contracted NP notified him of resident needs because staff addressed issues with the contracted NP who made daily rounds while he made rounds twice a week. Interview with the Medical Director (MD), on 03/20/2021 at 12:01 PM, revealed he oversaw the medical aspect for the facility and the second medical director oversaw the residents with pulmonary diagnoses. The MD revealed the facility held an independent contract with the facility NP and he did not provide oversite or supervision. Further interview, on 04/02/2021 at 10:01 AM, revealed when the MD first became the director the contracted NP made changes to resident care without notification. The MD revealed he met with the contracted NP with specific instructions to consult him for resident needs which may require significant order changes. The MD revealed the contracted NP addressed care needs in the facility for low level management for urgent care response needs (I.E. a urinary tract infection). Otherwise, the MD revealed he expected the contracted NP to call and discuss any changes in care. Furthermore, the MD revealed the contracted NP worked for the facility and the facility was a single entity business and therefore not the supervisor for the contracted NP. The MD further revealed the PMD followed Resident #85 for care.