**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that all grievances were thoroughly investigated to include the pertinent findings or conclusions regarding the resident's concerns for 1 (#41) out of 39 sampled residents. Findings: Review of the facility's Grievance Policy and Procedure dated 05/23/2024 read in part: Purpose: To ensure each resident has the right to voice grievances with respect to treatment or care, that is, or fails to be furnished without discrimination or reprisal for voicing the grievances. To ensure each resident grievance will be followed up by prompt efforts to resolve grievance that the resident may have, including those with respect to the behavior of other residents. Policy: All grievances will be investigated thoroughly and appropriate corrective action taken . Resident #41. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Cerebral Infarction, Hemiplegia and Hemiparesis of Right Dominant Side. Review of the resident's quarterly MDS (Minimum Data Set) dated 09/03/2024 revealed the resident's BIMS (Brief Interview Mental Status) score was 15, which meant the resident was cognitively intact. Review of the resident's grievance dated 09/25/2024 at 11:00 a.m. revealed, Concerned that CNAs (Certified Nursing Assistants) are not responding to call bell quick enough and bringing her to restroom. She does not want to use a brief when she can go to restroom . On 10/08/2024 at 11:35 a.m., an interview was conducted with S1DON (Director of Nursing). S1DON stated she spoke to the resident concerning the staff answering the call bells. S1DON stated she does not recall if she asked the resident who the CNA was and which shift the CNA worked that told her to use a brief. S1DON confirmed the resident can call for assistance when she needs to go to the restroom. S1DON stated S7LPN (Licensed Practical Nurse) further investigated the grievance but did not provide evidence of her investigation. On 10/08/2024 at 12:13 p.m., an interview was conducted with S7LPN. S7LPN stated she spoke to the resident concerning her grievance and confirmed that she could not provide evidence of the investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately code the resident's Minimum Data Set (MDS) for anticoagulant use for 1 (Resident #9) out of 2 (Resident #9 and #38) residents reviewed for resident assessment discrepancy for anticoagulants. Findings: Review of Resident #9's electronic revealed she was admitted to the facility on [DATE]. Review of the resident's admission MDS dated [DATE] Section N - Medications revealed the box for taking Anticoagulants was selected. Review of Resident #9's August 2024 physician orders failed to reveal an order for an anticoagulant. On 10/09/2024 at 1:34 p.m., an interview was conducted with S12MDS. She confirmed that the resident had not received any anticoagulant medication and that she had made an error in coding the resident for anticoagulant use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to develop a comprehensive person-centered care plan that included orders for an AFO (Ankle Foot Orthosis) brace for 1 (#41) out of 2 (#41, #64) residents investigated for positioning and mobility out of a total sample of 39 residents. Findings: Resident #41. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Cerebral Infarction and Hemiplegia and Hemiparesis of Right Dominant Side. Review of Resident #41's quarterly MDS (Minimum Data Set) dated 09/03/2024 revealed the resident was coded for impairment on one side. On 10/08/2024 at 8:20 a.m., Resident #41 was observed sitting up in a wheelchair in her room. During this observation, an AFO brace was observed in place to resident's right lower leg. S9CNA (Certified Nursing Assistant) stated she applied the brace to the resident's right lower leg. Review of Resident #41's physician's orders revealed there was no order for an AFO brace to right lower leg. On 10/08/2024 at 10:00 a.m., an interview was conducted with S10PT (Physical Therapist). S10PT stated the therapy department did not give an order for the AFO brace. On 10/08/2024 at 10:03 a.m., an interview was conducted with S7LPN (Licensed Practical Nurse). She stated that she did not know if the resident had an order for the AFO brace. On 10/08/2024 at 10:05 a.m., an interview was conducted with S11LPN. S11LPN reviewed the resident's physician's orders and confirmed there were no orders for the AFO brace. She stated that if the brace was being applied by staff then there should have been an order for it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to revise the care plan to include an appropriate fall intervention after a resident fell for 1 (#89) of 3 (#9, #75 and #89) residents investigated for accidents. Findings: On 10/09/2024, a review of the facility's policy titled Care Plan Policy and Procedure, with a last review date of 03/19/2024, revealed in part: Purpose: To provide a comprehensive person-centered plan of care addressing resident's needs, strengths, goals, and approaches; Policy: Each resident's care plan will remain current and inform staff of resident's needs, strengths, goals and approaches; Procedure: The Resident's care plan will be updated quarterly and as needed. Review of Resident #89's medical record revealed he was admitted to the facility on [DATE]. Resident #89 had diagnoses that included in part . Other Specified Disorders of Muscle, Difficulty in Walking, Unspecified Lack of Coordination, Myopathy, and Cerebrovascular Disease. Review of Resident #89's Admit MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 07/25/2024, revealed a Brief Interview for Mental Status (BIMS) score of 9, which indicated moderately impaired cognition. Further review revealed Resident #89 used a wheelchair or walker for mobility. Review of Resident #89's current comprehensive care plan, revealed on 08/13/2024 the resident was at risk for falls related to unsteadiness with transitions, gait, and use of antidepressant and antipsychotic medication; Goals included in part: I will not experience any injuries related to falls; Interventions: Anti rollbacks to my w/c. Urinal provided; I need a pathway free from clutter in my room; I need my bed lock and in low position; I need my call light within reach; Refer me for therapy screen as appropriate; Remind me to ask for assist for all ambulation/transfers. Review of Resident #89's Incident Report dated 08/13/2024 at 8:45 p.m., completed by S16LPN (Licensed Practical Nurse) read in part . Resident heard call out for help. Entered resident room, resident noted to be lying in supine position on floor. Resident states he was trying to transfer from bed to wheelchair to go to the restroom when his socks caused him to slip down onto buttocks at side of bed then resident preceded to lie down on back.; No injuries observed at the time of incident; Oriented to person, place, situation, and time; Predisposing Situation Factors- Improper Footwear; Other info: Resident not wearing non-skid socks during transfer. Review of Resident #89's health records revealed a progress note dated 08/13/2024, completed by S16LPN which read in part Entered resident room, resident noted to be lying in supine position on floor. Resident states he was transferring from bed to wheelchair when his socks caused him to slip onto buttocks as side of bed. Applied non-skid socks to resident and reeducated on use of call light for staff assistance in transfers. On 10/07/24 at 12:29 p.m., an interview and observation was conducted with Resident #89. The resident was oriented to person, place, time and situation. He was sitting in his wheelchair with no shoes and regular socks on. Resident #89 stated that he had a recent fall because he did not have nonskid socks on. On 10/08/2024 at 11:35 a.m., a second interview was conducted with Resident #89. Resident #89 stated that his nonskid socks were in the laundry and he currently had no clean nonskid socks. On 10/09/2024 at 1:45 p.m., a third interview and observation was conducted with Resident #89. Resident #89 stated that his nonskid socks were in the laundry and he currently had no clean nonskid socks. Resident #89 opened his drawer to reveal that he had no nonskid socks. On 10/09/24 at 1:45 p.m. an interview was conducted with S2CORPRN (Corporate Nurse). S2CORPRN confirmed that Resident #89's Incident and Accident Report on 08/13/2024 acknowledged Resident #89 having improper footwear associated with his fall. S2CORPRN confirmed that the care plan should have been updated to include the use of nonskid socks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that a resident received services consistent with accepted professional standards and the resident's comprehensive person-centered care plan by the nursing staff failing to document that a resident's dialysis site was assessed and monitored daily for 1 (#107) out of 1 (#107) resident investigated for dialysis. Findings: On 10/09/2024, a review of the facility's policy titled, Dialysis Residents Care Policy and Procedure, with an unknown last reviewed date, revealed in part .Procedure .5. Assess and monitor dialysis site for bleeding or abnormalities as ordered by physician. Review of Resident #107's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Chronic Kidney Disease, End Stage Renal Disease and Dependence on Renal Dialysis. Review of Resident #107's care plan read in part .I receive dialysis 3x/wk (three times per week) r/t (related to) CKD4/ESRD (Chronic Kidney Disease, Stage 4/End Stage Renal Disease) .08/01/2024 double lumen tunneled HD (hemodialysis) cath (catheter) placement to right upper chest wall. Interventions included: Monitor my tunnel cath site (dressing maintained by dialysis). Review of Resident #107's October 2024's eMAR (Electronic Medication Administration Record) failed to reveal evidence that the resident's dialysis access site was assessed and monitored. On 10/09/2023 at 10:52 a.m., an interview and record review was conducted with S14LPN (Licensed Practical Nurse). S14LPN was asked how often the nurses documented they assess the resident's dialysis access site and where they documented their assessment in the chart. She stated the resident's dialysis access site was assessed only on return from the dialysis center on Monday, Wednesday and Friday and was documented on the dialysis communication form. S14LPN stated that they did not assess or monitor Resident #107's dialysis access site or document on it daily. On 10/09/2024 11:16 a.m., an interview and record review was conducted with S1DON (Director of Nursing). She stated that as part of the nurse's assessment, the nurses should have assessed and monitored the resident's dialysis access site. S1DON reviewed Resident #107's electronic medical record and confirmed that there was no documented evidence that the nurses had assessed or monitored the resident's dialysis access site every shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility's nursing staff failed to demonstrate appropriate competency and skills as evidenced by failing to assess and report bruises for 1 (#41) out of 3 (#12, #41, #56) residents investigated for skin conditions out of a total sample of 39 residents. Findings: Resident #41. On 10/07/2024 at 11:24 a.m., the resident was observed sitting up in a wheelchair in her room. The resident's right forearm was observed to have a large purple colored bruise. The resident stated the bruise was caused by the CNAs (Certified Nursing Assistants) as a result of them pulling on her arm while in the shower. Review of Resident #41's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Cerebral Infarction and Hemiplegia and Hemiparesis of Right Dominant Side. Review of Resident #41's quarterly MDS (Minimum Data Set) dated 09/03/2024 revealed the resident's BIMS (Brief Interview Mental Status) score was 15, which meant the resident was cognitively intact. On 10/08/2024 at 9:05 a.m., a telephone interview was conducted with S8LPN (Licensed Practical Nurse). S8LPN stated she did observe the bruise to Resident #41's right forearm. S8LPN stated the resident told her the bruise occurred when the CNAs were bathing her in the shower. S8LPN stated the resident told her the CNA pulled on her arm to move it out of the way during the shower. S8LPN stated she did not document an assessment or report the bruise because she thought the CNAs were just trying to transfer or reposition the resident. On 10/08/2024 at 1:30 p.m., an interview was conducted with S1DON. S1DON stated that there were no incident/accident reports for Resident #41. S1DON stated that she was not aware of the bruise on the resident's right forearm. S1DON and the surveyor went to inspect the resident's arm. S1DON observed the resident had a large purple colored bruise to her right forearm. The resident stated that the bruise occurred 3 to 4 days ago while in the shower. The resident stated that the CNA pulled on her arm while bathing her. S1DON stated that the nurse should have documented an assessment of the bruise in the notes and the incident should have been reported.

Based on observation, interviews, and record review, the facility failed to provide an assistive device at meal times for 1 (#13) of 5 residents who used assistive devices at mealtimes. Findings: On 10/9/2024, a review of the facility's policy titled Adaptive Eating Devices Policy and Procedure, with a last review date of 04/24/2024, read in part, Policy: Adaptive eating devices are available for those who need them. Procedure: 3. Adaptive devices are noted on each individual's meal identification (ID) card/ticket and medical record. 4. The food service department is responsible for ensuring that each individual receives the appropriate feeding devices for each meal. Review of Resident #13's clinical record revealed an admit date of 03/29/2022 with diagnoses which included: Aphasia, Cognitive Communication Deficit, Unspecified Protein-Calorie Malnutrition, Dysphagia, Hemiplegia and Hemiparesis Following Cerebral Infarction, and Parkinson's Disease. Review of Resident #13's Quarterly MDS with an ARD of 06/26/2024 revealed he had a BIMS (Brief Interview for Mental Status) score of 6, (indicating severe impaired cognition). Review of Resident #13's diet card revealed in part, Special Notes: Divided Plate or bowls. A review of Resident #13's Care Plan read in part, I am at risk for weight fluctuations, malnutrition related to altered diet, History of Dysphagia; Protein Calorie Malnutrition, therapeutic diet, episodes of refusing to allow staff to assist with meals. I do not like my food to touch; Goal: I will experience minimal weight fluctuation/nutrition related complications; Interventions- I require use of divided high sided plate/bowl as ordered. On 10/07/2024 at 11:45 a.m., and observation of Resident #13 was made in the dining room eating her lunch meal. Resident #13 was feeding herself off a regular plate and was noted to have difficulty scooping the food from her plate. On 10/07/2024 at 12:00 p.m., an interview, review of Resident #13's Dietary Card, and observation of Resident #13's lunch plate, was conducted with S13LPN (Licensed Practical Nurse) who was assigned to Resident #13's care. S13LPN confirmed that Resident #13 should have been served her meal with a divided plate or bowl and had not been. On 10/08/24 at 3:08 p.m., an interview was conducted with S3DM (Dietary Manager). She confirmed that dietary staff were responsible for serving residents appropriate adaptive eating devices. She also confirmed that Resident #13 should have been served with a divided plate or bowl.

Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to ensure refrigerated food items that were opened were cleaned and labeled with the date they were opened before storing. This deficient practice had the potential to affect the 115 residents who consumed food prepared in the kitchen. Findings: On 10/07/2024 at 8:28 a.m., an observation of the walk in cooler in the kitchen and an interview was conducted with S3DM (Dietary Manager). The following items were opened, used, and were not labeled with a date: A container of sweet and sour sauce with sticky residue drippings on the outside, a container of Italian dressing, a container of sour cream, two plastic bottles of nectar thick liquid, and a container of ham base. S3DM confirmed the above findings and stated all opened food items should have been cleaned and labeled with an open date, but had not been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure that staff and resident wore the appropriate PPE (personal protective equipment) for a resident on contact transmission based precautions (TBP) for 1 (#9) of 1 (#9) resident in the facility on TBP. This deficient practice had the potential to affect 115 residents who resided in the facility. Findings: On 10/08/2024, a review of the facility's policy titled Isolation Policy and Procedure, with a revision date of 04/08/2024, revealed in part . contact Isolation. a. these infections are transmitted via contact or indirect contact with the resident or the resident's environment example: MDRO (Multi Drug Resistant Organism) with the presence of acute diarrhea, draining wounds, or other sites of secretion's or excretions that are unable to be covered or contained. b. gown and gloves are to be utilized for all interactions that may involve contact with the resident or potentially contaminated areas in resident's environment. Review of Resident #9's medical record revealed she was admitted to the facility on [DATE] with diagnoses which included but were not limited to: Extended Spectrum Beta Lactamase (ESBL) Resistance, and Urinary Tract Infection (UTI). Review of Resident #9's MDS (Minimum Data Set) dated 08/24/2024 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 9, indicating she had moderate cognitive impairment. Further review of the MDS revealed in Section H Bowel and Bladder that the resident was occasionally incontinent. Review of Resident #9's care plan revealed the following in part : I have an infection: I have an ESBL UTI. I require Contact Precautions. Intervention: Follow Contact Precautions; Review of Resident #9's final microbiology report result on 10/06/2024 revealed: > (greater than) 100,000 colonies/ml (milliliter) escherichia coli (ESBL). Review of Resident #9's physician's orders revealed an order written on 10/06/2024 at 11:35 a.m., which read, new order per nurse practitioner contact precautions x (times) 7 days r/t (related to) ESBL. Staff in-serviced. RP (responsible party) and resident made aware. Further review revealed an order written on 10/07/2024 at 21:00 (9:00 p.m.) which read, Ciprofloxacin Oral Tablet 500mg (milligrams)- give 1 tablet by mouth twice a day. On 10/07/2024 at 9:54 a.m., an observation was made of Resident #9's room. Signage was posted outside the room which indicated the resident was on Contact Precautions, and PPE was observed outside the door. Resident #9 was observed in the hall using the hand rail along the wall to propel her wheelchair to her room. On 10/07/2024 at 11:09 a.m., a second observation was made of Resident #9 propelling herself in her wheelchair down the hall using the hall hand rails. The resident propelled herself to the dining hall and sat at a table with another resident. In an interview with Resident #9 she stated the sign outside of her door was because she fell at the facility. On 10/08/2024 at 8:11 a.m., another observation was made of Resident #9's room and the Contact Precautions sign remained in place. On 10/08/2024 at 8:13 a.m., Resident #9 was observed in the therapy gym working with therapy equipment. The resident had no PPE on, and other residents and staff were in the therapy room. S6OT (Occupational Therapist) stated she was working with Resident #9 on completing Occupational Therapy exercises. On 10/08/2024 at 8:16 a.m., a joint interview was conducted with S4IP (Infection Preventionist) and S5IP. S5IP stated she started working at the facility about a month ago and was currently training with S4IP. S4IP was asked if a resident on contact precautions should have therapy limited to his or her room. She stated when a resident was on Contact Precautions, therapy should take place in their room and the Resident should stay in her room. S4IP proceeded to confirm Resident #9 was on contact precautions for ESBL in her urine. S4IP and S5IP then walked to the therapy gym and confirmed Resident #9 was in the therapy gym with other residents and without PPE on. S5IP stated the Resident should have had therapy in her room and not in the therapy gym. In an interview with S6OT, she stated she was not aware the resident was on contact precautions. S6OT stated the therapy department followed the facility's policy and procedures for Contact Precautions which was to conduct therapy in the residents' rooms. On 10/08/2024 at 8:28 a.m., S4IP, S5IP, and S2CORPRN (Corporate Registered Nurse) walked to Resident #9's room and confirmed the resident's room had a sign indicating Contact Precautions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to conduct regular inspections of beds for proper mattress fit for the bed's frame for 1 (Resident #9) out of 3 (Resident #9, #75 and #89) residents investigated for accidents. Findings: Review of the EHR (Electronic Health Record) for Resident #9 revealed she was admitted to the facility on [DATE] with diagnoses that included Insomnia, Atrial fibrillation, History of falling, Displaced intertrochanteric fracture of right femur (healing), Muscle weakness and Fatigue. Further review revealed that the resident was receiving physical therapy to improve her functional status. Review of the resident's admission MDS (Minimum Data Set) dated 08/28/2024 revealed she had a BIMS (Brief Interview for Mental Status) of 9, indicating moderate cognitive impairment. The resident's function abilities included no impairment to upper extremities and impairment to one side of lower extremities. She utilized a wheelchair for mobility. Resident #9 required substantial/maximal assistance for the following: roll left and right; sit to lying; sit to stand; and chair/bed-to-chair transfer. On 10/07/2024 at 10:58 a.m., an observation of Resident #9's bed, currently unoccupied by the resident, revealed an approximate 6 inch gap between the mattress and the assist bar on both sides of the bed. The assist bars were firmly attached to both sides of the bed. The mattress did not slide easily on the bed frame and was approximately 35 inches in width. The bed's frame extended approximately 6 inches past the mattress visible on each side of the bed. On 10/08/2024 at 2:20 p.m., an observation of the resident's bed with S2CORPRN and S15ADM was conducted during which they both confirmed the 6 inch gap between the mattress and assist bars. Both S2CORP and S15ADM confirmed that the mattress was too small for the bed frame. S15ADM stated that this particular model of bed can be converted from a regular bed to a bariatric bed by sliding out the bed's frame and can covert from 39 inches to 42 inches in width. He reported that there must have been a bariatric sized mattress previously on the bed that had been changed at some point to a regular sized (36 inches) mattress. He added that the bed frame had not been reduced after the mattress was changed and this resulted in the frame extending past the mattress and gaps between the mattress and assist bars. S14ADM stated that the facility had about 7 of these bed models (Drive Primecare P703) and did not have any process in place to assess beds for mattress incompatibility. Review of owner's manual for Drive Primecare P703 Long Term Bed dated [DATE]st, 2017 revealed the following: Warning labels - Incompatible mattresses can create hazards Entrapment Warning - Incompatible mattress and assist rails/bars can create hazards .make sure mattress is the correct size for bed frame and assist bars secured to frame to decrease risk of entrapment. Mattress specifications warning - Possible entrapment hazard may occur if you do not use the recommended specification mattress. It is recommended that a 36, 39 or 42 wide mattress .is used. Accessories and options - 39 - 42 integrated width extension Width extension - this will expand the bed from 36 inches to 39 inches and 42 inches. Entrapment warning - accurate assessment of the resident and monitoring of equipment use are required to prevent entrapment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to coordinate hospice care services for 4 (#1, #2, #3, and #R1) out of 4 (#1, #2, #3, and #R1) residents reviewed for hospice care. The facility failed to: 1. allow Residents #1, #2, #R1 and or their RP (Responsible Party) the choice of hospice provider. 2. obtain the initial certification and or most recent recertification of terminal illness and most recent hospice POC (plan of care) for Residents #1, #2, #3, and #R1, and 3. immediately notify the hospice agency when there was an incident of alleged abuse towards Resident #R1. Findings: On [DATE], a review of the facility's policy titled Hospice Care Policy and Procedure with a revision date of [DATE], read in part, Purpose to assure all disciplines are working together to provide quality care to the resident. Procedure 3. Hospice will maintain all documentation in the clinical record . On [DATE], a review of the facility's agreement with the contracted hospice agency dated [DATE], read in part, . 3.6 Abuse and Bereavement Hospice shall report all alleged violations involving mistreatment, neglect or verbal, mental, sexual and physical abuse, including injuries of unknown source .within 24 hours of Hospice's actual notice of such alleged violations. V. Records (a) Nursing facility . shall prepare and maintain complete and detailed clinicals records . Each clinical record shall completely, promptly and accurately documents all services provided to, and events concerning each Residential Hospice Patient . Resident #1 Review of Resident #1's EHR (Electronic Health Record) revealed she was admitted to the facility on [DATE] with diagnoses including, but not limited to, Alzheimer 's Disease, and Anxiety Disorder. Review of Resident #1's February 2024 physician's orders revealed an order dated [DATE] that read in part: Admit to . hospice dx (diagnosis): terminal e/s (end stage) Alzheimer's Disease. Review of Resident #1's Quarterly MDS (Minimum Data Set) dated [DATE], revealed the Brief Interview for Mental Status (BIMS) of 1, indicating her cognition was severely impaired. Under Section O: Special Treatments, the resident was admitted to hospice. Further review of Resident #1's EHR failed to reveal a recent hospice care conference summary report (hospice plan of care), and the most recent recertification of terminal illness. Resident #2 Review of Resident #2's EHR revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Hemiplegia Following Cerebral Infarction, Other Speech/Language Deficits Following Cerebral Infarction and Unspecified Dementia Review of Resident #2's Quarterly MDS dated [DATE] revealed the BIMS of 4, indicating her cognition was severely impaired. Under Section O: Special Treatments the resident was admitted to hospice. Review of Resident #2's physician's orders revealed an order entry with a start date of [DATE] which read in part, Admit to Contracted Hospice for dx: End Stage Cerebral Infarction. Resident #3 Review of Resident #3's EHR revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Chronic Systolic (Congestive) Heart Failure and Shortness of Breath Review of Resident #3's physician's orders revealed an order entry with a start date of [DATE] which read in part, Admit to Contracted Hospice . dx: CHF (Congestive Heart Failure). Review of Resident #3's person-centered plan of care, revealed in part, a focus of I have chosen to receive hospice care with Contracted Hospice dx CHF. Review of Resident #3's hospice documents in the EHR revealed no evidence of an initial certification and or recertification of terminal illness and no hospice POC's. Resident #R1 Review of Resident #R1's EHR revealed he was admitted to the facility on [DATE] with diagnoses including, but not limited to, Cervical Disc Disorder with Myelopathy. Review of Resident #R1's [DATE] physician's orders revealed an order dated [DATE] which read in part: Admit to . hospice for terminal dx (diagnosis) of Cervical Disc Disorder with Myelopathy. Review of Resident #R1's Quarterly MDS dated [DATE] revealed the Brief Interview for Mental Status of 10, indicating his cognition was moderately impaired. Under Section O: Special Treatments, the resident was admitted to hospice. Review of Resident #R1's nurse's notes dated [DATE] revealed the following entry: Resident #R1 reported that his roommate punched him early this morning while he was in bed. I know I holler in my sleep sometimes, but I'm only human! He can't just beat me up. Resident #R1 stated he was punched on the arm, light bruising noted to left elbow. ROM (Range of Motion) to left arm WNL (Within Normal Limits). No other injuries noted. Afterward, staff assured that Resident #R1 and his roommate remain separated while investigation took place. Notified RP, DON (Director of Nursing) and Doctor. Further review of Resident #R1's EHR failed to reveal a recent hospice care conference summary report, most recent recertification of terminal illness, hospice initial visit, and hospice initial certification. On [DATE] at 9:21 a.m., the S2DON brought in a list of residents on hospice services along with the hospice contracts. S2DON stated the Contracted Facility was their primary hospice preferred provider. On [DATE] at 12:25 p.m., a phone interview was conducted with Resident #1's RP. She stated she did not pick the hospice company nor was she given a list in person or verbally with choices of different hospice companies of who the facility was contracted with. Resident #1's RP stated she was contacted by the Hospice Company directly and then met with them at the nursing home to sign the paperwork. On [DATE] at 2:00 p.m., a phone interview was conducted with Resident #R1'S RP. She stated the facility told them they work with Contracted Hospice, and that the Contracted Hospice is their preferred provider. Resident #R1's RP stated she was not informed of any other hospice companies the facility was in contract with. On [DATE] at 2:13 p.m., a phone interview was conducted with Resident #2's RP who confirmed that Resident #2 was receiving hospice services for a decline in her health. He stated while Resident #2 was admitted to the hospital, the facility reached out to the RP to inquire about hospice services for Resident #2. RP stated he agreed to hospice services for Resident #2. He further stated I did not receive a list of different hospice companies or different hospice pamphlets, I went with the contracted Hospice because that's what the facility told me they use. On [DATE] at 4:27 p.m. an interview and review of Resident #1, #2 #3 and #R1's hospice documents was conducted with S3ADON (Assistant Director of Nursing). S3ADON confirmed she was the designated team member for ensuring all hospice documents were current and scanned into the EHR. She stated the hospice documents are were only in the EHR and not in hospice binders or anywhere else. S3ADON, confirmed the last case conference summary for Resident #1 was done on [DATE] and stated it should have been done weekly, also and also confirmed the last recertification was expired on [DATE] and she did not have a current one in the chart. She confirmed Resident #2's last certification period that was scanned into the EHR was from [DATE] through [DATE] and the POC was from [DATE] through [DATE]. She was unable to verify a recertification or recent POC in the EHR. She confirmed Resident #3 did not have a certification, recertification or POC in the EHR. S3ADON confirmed there were no current certification and or recertification statements or hospice POC's for Residents #1, #2 #3, and #R1 and stated there should have been a current and updated certification and or recertification statement and POC's obtained from the residents' hospice agency and scanned into each resident's EHR. S3ADON stated she checked her emails and was unable to locate current certifications or recertifications and POC's for Residents #1, #2, #3, and #R1. On [DATE] at 9:53 a.m., a joint interview was conducted with S1ADM (Administrator), S2DON, and S3ADON. S1ADM stated the facility had two different hospice companies that they were in contract with. S2DON reviewed Resident #R1's EHR and stated the alleged abuse happened on [DATE] and could not locate documentation of Residents #R1's hospice company being notified. S1ADM, S2DON, and S3ADON, confirmed that the hospice company should have been notified of the alleged abuse incident with Resident #R1and were not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's policy and procedure, and interviews the facility's staff failed to immediately report an incident of alleged abuse to the Administrator/ DON (Director of Nursing) for 2 (#1 and #2) of 4 (#1, #2, #3, and #4) residents reviewed for abuse. Findings: Review of the facility's policy, Abuse and Neglect Policy and Procedure revealed, in part, the following: 2. Training . Staff should immediately report their knowledge related to abuse allegation to the Administrator or DON . Resident #1: Review of Resident #1's record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Chronic Obstructive Pulmonary Disease, Anxiety Disorder, Anemia, and, Heart Failure. Review of Resident #1's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 11indicating her cognition was moderately impaired. Resident #2: Review of Resident #2's record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Unspecified Dementia, Major Depressive Disorder, and Generalized Anxiety Disorder. Review of Resident #2's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 12 indicating her cognition was moderately impaired. Review of Resident #2's comprehensive care plan, dated 01/07/2024, revealed, in part, I display behavior r/t my yelling out at others, pushing items towards others, combativeness towards staff and rudeness to roommate. Review of S3CNA (Certified Nursing Assistant) handwritten statement read in part Date: 1- 2024, Time: 9:30 p.m. she (Resident #2) did not want anyone in the room she went on Resident #1 side and pushed the table by her . On 01/22/2024 at 10:21 a.m., a phone interview was conducted with S3CNA. S3CNA stated on 01/07/2024 at approximately 9:00 p.m. she was across the hall and heard Resident #2 yelling at Resident #1. She went in the room and saw Resident #2 walking around the room towards Resident #1's side of the room. S3CNA stated she observed Resident #2 push the bedside table towards Resident #1 and it hit Resident #1's thighs. S3CNA confirmed that she immediately told S2RN (Registered Nurse) that Resident #2 struck Resident #1 with the bedside table. S3CNA confirmed she did not tell S1DON about this incident between Resident #1 and Resident #2. Three attempts were made to contact S2RN via phone on 01/22/2024 at 10:27 a.m., at 10:50 a.m., and at 11:41 a.m. S2RN failed to return any phone calls and was unable to be interviewed. On 01/22/2024 at 10:51 a.m., an interview was conducted with S1DON. S1DON stated she was called at approximately 9:30 p.m. on 01/07/2024 by S2RN. S2RN told her that Resident #2 was being aggressive/combative towards staff, refused her medications, and wanted a new roommate. S1DON stated S2RN did not inform her that Resident #2 had pushed the bedside table and hit Resident #1's thighs. S1DON stated she was unaware of the incident until Resident #1's responsible party brought it to her attention on 01/10/2024 at approximately 5:00 p.m. She confirmed S2RN and S3CNA should have reported the abuse to her immediately and they did not.

Based on record review, review of the facility's policy, and interviews the facility's staff failed to ensure an allegation of abuse was thoroughly investigated for 2 (#1 and #2) out of 4 (#1, #2, #3, and #4) residents reviewed for abuse. Findings: Review of the facility's policy titled, Abuse and Neglect Policy and Procedure read in part, 5. Investigation: Administrator or designee will complete a thorough investigation. Interview employees who were working in resident's room during the time in question. Review of the investigation submitted for Statewide Incident Management System (SIMS) Incident ID: 160518 revealed, in part, Resident #1 was a victim involved in an allegation of physical abuse occurred on 01/07/2024. Further review revealed, S3CNA (Certified Nursing Assistant) was working with the Resident at the time of the alleged abuse and she was never interviewed by S1DON (Director of Nursing) as part of the investigation. On 01/22/2024 at 10:21 a.m., a phone interview was conducted with S3CNA. S3CNA stated she observed Resident #2 push the bedside table towards Resident #1 and it hit Resident #1's thighs. S3CNA confirmed she was in Resident #1's room during the incident. She confirmed that S1DON never interviewed her about the incident. On 01/22/2024 at 10:51 a.m., an interview conducted with S1DON. S1DON stated she was the designee employee to complete the investigation for Incident ID: 160518. She stated she did not interview S3CNA who was working in Resident #1's room during the time of the incident. S1DON confirmed in order to complete a thorough investigation S3CNA should have been interviewed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to provide reasonable accommodations of the resident's needs by failing to ensure the call light in the resident's room was in reach for 1 (#1) resident out of 3 sampled residents. Findings: Review of the facility's policy titled Following the Plan of Care read in part . Staff must follow the plan of care. This includes orders, treatments, and activities. Resident #1 was admitted to the facility on [DATE] with diagnoses in part: Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Type 2 Diabetes, and Repeated Falls. Review of Resident #1's plan of care read in part: I have had an acute ischemic CVA with resulting hemiparesis with an intervention to place call light within reach. Further review of Resident #1's plan of care revealed in part: I am at risk for falls r/t (related to) impaired mobility and cognition, generalized weakness, right hemiparesis, hx (history) of repeated falls. Requires recurrent repositioning, poor safety awareness with an intervention to place call light within reach. On 11/07/2023 at 9:30 a.m., an observation was made of Resident #1 in his room. Resident #1 was lying in bed. Further observation revealed the resident's call light on the floor near the night stand. The call light was not in the resident's reach. On 11/07/2023 at 09:50 a.m., a second observation was made of Resident #1 in his room. The resident's call light remained on the floor near the nightstand, and was not in the resident's reach. An observation and interview was then conducted with S4LPN (Licensed Practical Nurse) who confirmed that Resident #1's call light was on the floor, not in reach, and should have been in reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that nursing staff possess competencies and skill sets necessary to provide nursing services to meet the residents' needs safely by failing to ensure neurological checks were initiated and/or completed after unwitnessed falls for 2 (#1, #2) residents out of 3 sampled residents. Findings: Review of the facility's policy titled Incident and Accident Policy and Procedure read in part .8. Unwitnessed fall: .d. Obtain and document neurological observation Record vital signs and neurologic observations every 15 minute times four, then every thirty minutes times four, the every hour times five, then every shift for the remainder of the 72- hour Neurological Observation. Resident #1 was admitted to the facility on [DATE] with diagnoses in part: Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Repeated Falls, and Unspecified convulsions. Review of Resident #1's plan of care revealed the following in part: I am at risk for falls r/t (related to) impaired mobility and cognition, generalized weakness, right hemiparesis, hx (history) of repeated falls. Requires recurrent repositioning (repositions self once staff positions him in bed), poor safety awareness. Review of the facility's incident and accident logs for August 2023 to November 2023 revealed Resident #1 had unwitnessed falls on 08/31/2023, 10/13/2023, and 10/29/2023. Review of Resident #1's electronic medical record and hard chart failed to reveal neurological checks for the unwitnessed falls on 08/31/2023 and 10/13/2023. Resident #2 was admitted to the facility on [DATE] with diagnoses in part: Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Unspecified Lack of Coordination, and Aphasia. Review of Resident #2's plan of care revealed the following in part: I am at risk for falls r/t hx of falls, s/p (status post) right hip fx (fracture), CVA (Cerebrovascular Accident) with right hemiparesis. Review of the facility's incident and accident logs for August 2023 to November 2023 revealed Resident #2 had an unwitnessed fall on 09/06/2023. Review of Resident #2 electronic medical record and hard chart failed to reveal neurological checks for the unwitnessed fall on 09/06/2023. On 11/06/2023 at 3:45 p.m., S2DON (Director of Nursing) was asked to provide neurological checks for Resident #1's falls on 08/31/2023 and 10/13/2023 and Resident #2's fall on 09/06/2023. On 11/06/2023 at 3:50 p.m., a phone interview was conducted with S6LPN (Licensed Practical Nurse) who stated that she was Resident #2's nurse on the night of 09/06/2023. She stated the resident was found on the floor, and the fall was unwitnessed. SLPN stated that because it was an unwitnessed falls, she was required to initiate 72 hour neurological checks on the resident, but she did not remember if she initiated the neurological checks. On 11/06/2023 at 3: 55 p.m., S2DON was asked to provide neurological checks for the falls for Resident #1 and Resident #2. S2DON proceeded to look in the incident/accident report binder and there were no neurological checks in the binder for the falls on Resident #1's falls on 08/31/2023 and 10/13/2023. S2DON then provided partially completed neurological checks for Resident #2 and stated she had to find the rest. A review of the Neurological Observation Form dated 09/06/2023 for Resident #2 was reviewed with S2DON. There were observations documented from 7:45 p.m. to 8:30 p.m. S2DON stated that the neurological checks may not have been filed and may be at the nurses' stations or in medical records. S7ADON then looked for neurological checks for Resident #1 and Resident #2, but could not find the neurological checks.) On 11/06/2023 at 4:30 p.m., an interview was conducted with S2DON who stated that 72 hour neurological checks were to be completed on all residents who had unwitnessed falls. S2DON further stated that the nurse who completed the neurological checks after 72 hours, was to turn in the Neurological Observation Form to her, and the ward clerk scanned them into the resident's chart. S2DON confirmed that there were no documented and completed neurological checks for the unwitnessed falls for Resident #1 on 08/31/2023 and 10/13/2023 and Resident # 2 on 09/06/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide pharmaceutical services to meet the needs of each resident as evidence by failing to ensure there were specific indicators and parameters for Acetaminophen (Tylenol) for 1 (#3) resident out of 3 (#1, #2, #3) sampled residents. Findings: Review of facility's policy titled Medication Administration-General Guidelines read in part .4. Documentation .e. When PRN medications are administered, the following documentation is provided: .ii. Complaints or symptoms for which the medication was given. Resident #3 was admitted to the facility on [DATE] with diagnoses in part .History of falling, Polyarthritis, Pain, Mild cognitive impairment, Other speech and language deficits following other cerebrovascular disease, Unspecified lack of coordination, Other malaise, Muscle wasting and atrophy, Pain in left knee, Muscle weakness (generalized). Review of Resident #3's October 2023 physician orders revealed an order dated 07/18/2022 for Acetaminophen (Tylenol) 325mg (milligram) tab, give 2 tabs (650mg) by mouth every 4 hours PRN (as needed) for Pain/Elevated Temp (temperature). Review of Resident #3's October 2023 MAR (Medication Administration Record) revealed Acetaminophen 325mg tab, give 2 tabs (650mg) PO (by mouth) q4 (every four) hours PRN Pain/Elevated Temp was administered on 10/16/2023 at 10:35p.m. and 10/18/2023 at 4:40 a.m. Further review of the MAR failed to specify if the medication was administered for pain or administered for elevated temperature. Further review of Resident #3's MAR failed to reveal a parameter for elevated temperature or pain rating and follow up. Review of Resident #3's progress notes from 10/16/2023 to 10/18/2023 failed to indicate if the resident was administered Acetaminophen for elevated temperature or pain. On 11/07/2023 at 2:28 p.m., an interview and record review was conducted with S5LPN (Licensed Practical Nurse). A review of Resident #3's MAR was conducted and S5LPN confirmed parameters for Tylenol were not on the resident's physician's orders or MAR, and that although the medication's effectiveness could be assessed, there was no way to indicate why the medication was being administered. On 11/07/2023 at 3:17 p.m., a joint interview and record was conducted with S1CORPRN (Corporate Registered Nurse) and S2DON (Director of Nursing). S1CORPRN and S2DON reviewed Resident #3's electronic medical record. S1CORPN stated that the order for Acetaminophen should have been two separate orders, one for pain and one for elevated temperature. S1CORP and S2DON further confirmed the nurse failed to provide a documented indication for why the Acetaminophen was administered, there were no parameters for temperature, and there was no pain assessment completed prior to or after administering the Acetaminophen on 10/16/2023 and 10/18/2023 and should have.

Based on observations and interviews, the facility failed to maintain privacy and confidentiality of residents' medical records. The facility had a total census of 64 residents. Findings: Review of facility document titled Medication Administration-General Guidelines read in part .2. Administration p. in addition, privacy is maintained at all times for all resident information by closing Medication Administration book/covering the Medication Administration Record (MAR) sheet or computer screen when not in use. On 10/03/2023 at 1:20 p.m., an observation was conducted on Hall A revealed that the nurses' station a desktop computer was unattended. Further observation revealed that Resident #18's private medical information was visible on the desk top screen. On 10/03/2023 at 1:27 p.m., an interview was conducted with S6LPN (Licensed Practical Nurse). He confirmed that he should have initiated the privacy screen before he left off of Hall A to protect Resident #18's medical information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed, interviews, and observations, the facility failed to ensure the resident's care plan and physician's orders were followed for 1 (#59) of 40 sampled residents. This was evidenced when: 1. facility staff failed to apply left wrist splint while out of bed. 2. facility staff failed to apply right hand splint per physician order. Findings: Review of Resident #59's electronic clinical record revealed an admit date of 02/15/2022 with diagnoses that included Hemiplegia following cerebral infarction affecting right dominant side, and Muscle weakness. The resident resided on Hall A. Review of Resident #59's physician orders dated October 2023 revealed the following orders: Splint to left wrist when out of bed Apply right hand splint daily at noon for two hours. Review of the resident's care plan dated 05/03/2022 read in part, right hand splint to be worn as ordered . apply my splint to left wrist when out of bed as ordered. Review of Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 06, which indicated severe cognitive impairment. On 10/03/2023 at 12:00 p.m., an observation was conducted of Resident #59 during the lunch meal. The resident was seated at a table in the dining room. Further observation revealed that Resident #59's left wrist splint was not applied. On 10/03/2023 at 1:27 p.m., a second observation was conducted inside Resident #59's room, which revealed the resident sitting in her wheelchair. Further observation revealed that her left wrist splint was lying on the bed and her right hand splint had not been applied. On 10/03/2023 at 1:28 p.m., an interview was conducted with S4CNA (Certified Nursing Assistant) who was assigned to Hall A. S4CNA stated that she had not applied any splints to Resident #59's left or right wrist. On 10/03/2023 at 1:29 p.m., an interview was conducted with S5CNA who was also assigned to Hall A. She stated that she had not applied any splints to Resident #59's left or right wrist. S5CNA stated that the nurse was supposed to apply the splints. On 10/03/2023 at 1:30 p.m., an interview was conducted with S6LPN (Licensed Practical Nurse) who confirmed that he had not applied the left wrist splint while Resident #59 was out of bed, and that he had not applied the right hand splint at noon per physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a homelike environment for 1 (#52) out of 2 residents (#46 and #52) investigated for environment by failing to ensure that the resident's wheelchair and wheelchair pad were cleaned. This deficient practice had the potential to affect all residents in the facility who used a wheelchair. Findings: A review of the facility's policy titled Homelike Environment Policy and Procedure, read in part: It is our policy to provide a . homelike environment for our residents . Resident #52 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease and Anxiety Disorder. The resident had a BIMS (Basic Interview of mental Status) of 99, indicating the resident's cognition was severely impaired. On 10/02/2023 at 10:50 a.m., an observation was conducted of Resident #52 in her room. The resident was sitting on a pad in her wheelchair with the right side of the pad and wheelchair exposed. Old food was noted sticking to the pad and exposed portion of the wheelchair seat. On 10/03/2023 at 12:00 p.m., an interview and observation of Resident #52's wheelchair and pad was conducted with S2LPN (Licensed Practical Nurse). The resident was sitting in her wheelchair. S2LPN confirmed that both sides of the resident's wheelchair pad and wheelchair had old food sticking to it and should not have been. On 10/03/2023 at 12:46 p.m., an interview and observation was conducted with S7CNASup (Certified Nursing Assistant Supervisor). S7CNASup confirmed that the resident's wheelchair had old food sticking to it. She stated the residents living on the right side of the building are scheduled to get their wheelchairs cleaned every Monday, Wednesday, and Friday by the staff on the evening shift, and Resident #52's chair should have been cleaned last night.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide reasonable accommodations of the resident's needs by failing to ensure the resident's soft touch call bell in the room was in reach for 1 (#12) out of 23 sampled residents. Findings: Review of facility's policy and procedure titled Call Light, Use Of read in part, Purpose: .To assure call system is in proper working order .Procedure: . 7. When providing care to residents be sure to position the call light conveniently for the resident to use .10. Be sure all call lights are placed in reach .Equipment: Bedside call light in functioning order. Review of Resident #12's electronic health record revealed that the resident was admitted to the facility on [DATE] with the following pertinent diagnoses: Parkinson's Disease, Repeated Falls, Dysphagia, Muscle Wasting and Atrophy, Cognitive Communication Deficit, Difficulty Walking and Generalized Muscle Weakness. Review of Resident #12's Care Plan revealed that the resident was at risk for falls r/t (related to) weakness, impaired mobility and included the intervention of needing soft touch call light within reach. Further review of Resident #12's Care Plan revealed that the resident required staff assistance for ADLs (Activities of Daily Living) r/t Parkinson's, impaired mobility and cognition and included the intervention soft touch call bell. A random observation was conducted on 09/13/2022 at 2:10 p.m. of Resident #12 lying in bed with her soft touch call bell located out of reach and underneath the resident's pillow behind her head. On 09/13/2022 at 2:30 p.m., an observation was conducted with S5Maintenance of Resident #12's soft touch call bell observed underneath the resident's pillow. A phone interview was conducted with S3CNA on 09/13/2022 at 2:56 p.m. S3CNA confirmed she and S4CNA rounded on Resident #12 at the end of their shift. S3CNA reported she forgot to move the call bell from under the resident's pillow. On 09/13/2022 at 4:30 p.m., S6RN (Registered Nurse) confirmed the CNAs assigned to Resident #12 should have assured the resident's soft touch call bell was placed within the resident's reach before exiting the room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the physician was notified of blood sugar readings less than 69 as ordered by the physician for Resident #68. This deficient practice was identified for 1 (Resident #68) out of 23 final sampled residents. Findings: Review of the facility's policy titled Notification Requirement Policy and Procedure read in part . 1. Nursing services/designee shall be responsible for notifying the resident's physician and family when the following occurs: .b. There is a significant change in the resident's physical, mental, or emotional status .e. Laboratory and radiology results that fall outside of clinical reference ranges or as determined by physician Review of the facility's policy titled Blood glucose monitoring policy and procedure read in part . 9. Refer to physician orders for blood glucose parameters and physician/provider notification . Resident # 68 was admitted on [DATE] with diagnoses of Diabetes Mellitus Type 2, End Stage Renal Disease, and Atrial Fibrillation. Review of the resident's careplan revealed an intervention to monitor blood sugars as ordered. Review of the resident's physician's orders revealed an order for Accucheck AC&HS (With meals and hours of sleep) with Novolog (Insulin) Sliding Scale. For a reading of 0 to 69, give orange juice and recheck CBG (Capillary Blood Glucose) in 30 minutes and notify physician. Review of the resident's MAR (Medication Administration Record) from July 2022 to current revealed S2LPN documented the following blood sugar readings: 7/16/22- 65, 7/21/22-67, 7/23/22-65, 8/14/22-65, 8/15/22-62, 9/1/22-60, 9/11/22-69 and 9/12/22-56 Review of nursing progress notes from July 2022 to current revealed no documented evidence that the physician or nurse practitioner were notified when the resident's blood sugars were less than 69. On 9/12/22 at 1:06 PM, an interview was conducted with Resident #68. Resident #68 stated that her blood sugars have been low in the mornings. She stated when her blood sugar is low, she becomes lethargic and has difficulty speaking. On 9/14/22 at 11:50 AM, an interview was conducted with S1DON. The resident's physician's orders, nursing progress notes, and MAR from July 2022 to current were reviewed with S1DON. S1DON confirmed there was no documented evidence in the nursing progress notes and/or the resident's chart, from July 2022 to current, that the nurse practitioner or the physician were notified of Resident #68's blood sugars that were less than 69. S1DON confirmed the nurse should have notified the nurse practitioner or the physician of the resident's blood sugars when they were less than 69. On 9/14/22 at 1:45 PM, a phone interview was conducted with S2LPN. S2LPN confirmed she did not report Resident #68's blood sugars when they were less than 69 to the physician or nurse practitioner. S2LPN stated she thought she only had to report blood sugars that were less than 60. S2LPN confirmed she should have reported the blood sugars to the physician or nurse practitioner when they were less than 69.