Based on record review, observations, and interviews, the facility failed to obtain informed consent for side rail use and failed to assess resident for the risk of entrapment from side rails quarterly for 1(#3) of 3(#1, #2, and #3) sampled residents. Findings: Review of the facility's Proper Use of Side Rails policy (revised August 2024) revealed in part: Purpose The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. Definition Physical restraints are defined by the Centers for Medicare and Medicaid Services (CMS) as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. (Note: The definition of restraints is based on the functional status of the resident and not on the device, therefore any device that has the effect on the resident of restricting freedom of movement or normal access to one's body could be considered a restraint.) General Guidelines 1. Side rails are considered a restraint when they are used to limit the resident's freedom of movement (Prevent the resident from leaving his/her bed). (Note: the side rails may have the effect of restraining one individual but not another, depending on the individual resident's condition and circumstances) 2. Side rails are only permissible if they are used to treat a resident's medical symptoms and/or to assist with mobility and transfer of residents. 3. Upon admission, readmission, with routine quarterly or significant change MDS (Minimum Date Set) and PRN(As Needed), therapy nursing designee will complete the Side Rail Utilization Assessment, or equivalent form to determine the resident's symptoms, risk of entrapment and rationales for using side rails prior to implementation. When used for mobility or transfer, the assessment will include a review of the resident's: a. Bed mobility. b. Ability to change positions, transfer to side of bed and from bed or chair, and to stand and toilet, c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. 4. Consent for use of side rail will be obtained from the resident or legal representative, after presenting potential benefits and risks. Review of Resident #3's medical record revealed an admission date of 05/19/2023 with diagnoses included, in part: muscle wasting and atrophy, not elsewhere classified, left shoulder, chronic pain, unspecified osteoarthritis, and morbid obesity due to excess calories. Review of Resident #3's physician orders revealed: 09/10/2024 may have (bilateral) assist rails to promote independence and bed mobility. Check for placement and functioning every shift; every shift related to muscle wasting and atrophy, not elsewhere classified, multiple sites. Review of Resident #3's 04/25/2025 Annual MDS revealed Resident #3 had a BIMS (Brief Interview Mental Status) Score of 15, which indicated intact cognition. Review of Resident #3's care plan dated 02/29/2024 revealed in part, Resident #3 may have bilateral assist rails to promote independence in bed mobility; provide supportive care. Review of Resident #3's medical record failed to reveal a Side Rail Utilization Assessment had been conducted quarterly as per policy. Observation on 06/30/2025 at 3:15 p.m. revealed Resident #3 resting in bed with bilateral hand assist rails in use. Observation on 07/01/2025 at 8:50 a.m. revealed Resident #3 resting in bed with bilateral hand assist rails in use. During an interview on 06/30/2025 at 3:15 p.m. Resident #3 reported he used the hand assist rails to adjust and sit on the bedside. During an interview on 07/01/2025 at 3:20 p.m. S1DON (Director of Nursing) confirmed the Side Rail Utilization Assessment contained both assessment and consent. S1DON reported a Side Rail Utilization Assessment should have been completed quarterly per policy and had not been completed for Resident #3.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure an alleged violation involving abuse was reported to the State Survey and Certification Agency for 1 (#1) of 3 (#1, #2, #3) sampled residents reviewed for abuse. Findings: Review of Facility's Abuse and Neglect Policy (revised October 15, 2022) revealed: Policy Statement - The facility will ensure that each resident has the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility will provide a sage resident environment and protect residents from abuse. Staff to resident abuse of any type: The facility assumes the responsibility upon admission of ensuring safety and well-being of the resident. Staff are expected to be in control of their behavior and behave professionally .Treatment/Management: 2. The management and staff, with physician support, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies. Review of Resident #1's medical records revealed an admit date of 11/05/2020 with the following diagnoses, including in part: persistent mood (affective) disorder/unspecified, other specified mental disorders due to known physiological condition, insomnia/unspecified, neurocognitive disorder with Lewy Bodies, dementia in other diseases classified elsewhere/ unspecified severity with agitation, history of falling, cognitive communication deficit, pseudobulbar affect, anxiety disorder/unspecified, age-related physical debility and major depressive disorder/recurrent/unspecified. Review of Resident #1's MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) of 03 (severely impaired cognition). Review of Facility's State Survey and Certification Agency Reports since last survey failed to reveal an incident of alleged abuse for Resident #1. Review of Facility's investigation of Resident #1's alleged abuse reported on 12/25/2024 revealed interviews with the staff reporting the abuse and the staff accused of abuse. Further review revealed witness written statements, body audits completed on residents residing in the memory care unit and an in-service conducted on reporting abuse. During an interview on 01/07/2025 at 2:40 p.m. S1 DON (Director of Nursing) confirmed she was notified on 12/25/2024 by S1 CNA (Certified Nursing Assistant) S2 CNA kicked resident when she stepped over him and cursed at Resident #1. S1 DON acknowledged the incident involving Resident #1's alleged abuse was investigated but the facility failed to notify the State Agency and should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility's video footage review, and interviews the facility failed to ensure a comprehensive, person-centered care plan had been developed and implemented for 1 (#4) of 4 (#1, #2, #3, #4) sampled residents. The facility failed to ensure, Resident #4 was checked every two hours for incontinence. Findings: Review of Resident #4's medical record revealed an admit date of 07/17/2020 and reentry date of 05/28/2024 with diagnoses including, but not limited to, schizoaffective disorder bipolar type, Alzheimer's disease, history of falls, and osteoarthritis. Review of Resident #4's MDS (Minimum Data Set) dated 08/26/2024 revealed a BIMS (brief interview for mental status) score of 2 indicating severely impaired cognition. Review of Resident #4's comprehensive care plan revealed, in part, the problem of frequent bowel incontinence with intervention including, but not limited to, check resident every two hours. On 10/28/2024 at 2:00 p.m., review of facility's video footage from 10/21/2024 at 11:00 p.m. to 10/22/2024 at 7:15 a.m. revealed in part, S3 CNA (Certified Nursing Assistant) entered Resident #4's room on 10/21/2024 at 11:08 p.m. and exited Resident #4's room [ROOM NUMBER] seconds later. Further review of facility's video footage from 10/21/2024 at 11:00 p.m. to 10/22/2024 at 7:15 a.m. revealed no staff member entered Resident #4's room again until 10/22/2024 at 6:25 a.m. During an interview on 10/28/2024 at 2:30 p.m. S1 Administrator confirmed, after reviewing facility video surveillance, S3 CNA entered Resident #4's room on 10/21/24 at 11:08 p.m. and did not enter Resident #4's room again until 10/22/24 at 6:25 p.m. S1 Administrator also confirmed no other staff entered Resident #4's room between 10/21/24 at 11:08 p.m. and 10/22/24 at 6:25 p.m. During an interview on 10/29/2024 at 10:30 a.m., S2 DON (Director of Nursing) confirmed Resident #4's current comprehensive care plan included an intervention to check on Resident #4 every two hours related to incontinence. During an interview on 10/29/2024 at 10:30 a.m., S1 Administrator confirmed, based on facility's video footage from 10/21/2024 at 11:00 p.m. to 10/22/2024 at 6:25 a.m., staff did not check on Resident #4 every two hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to ensure a resident received ADL (Activities of Daily Living) care for 1 (Resident #3) out 4 (Residents #1, #2, #3, #4) residents reviewed. Findings: Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included, in part a primary diagnosis of muscle wasting and atrophy. Other diagnoses included COPD (Chronic Obstructive Pulmonary Disease), bronchitis, cough, anxiety, dysphagia, bipolar disorder, insomnia, hypertension, pain, and osteoporosis. Review of Resident #3's minimum data sheet dated 09/10/2024 revealed a BIMS (Brief Interview of Mental Status) of 15 which would indicate the resident was cognitively intact. Review of Resident #3's comprehensive care plan revealed a care plan with a focus indicating the resident has an ADL self-care performance deficit related to decreased vision, impaired balance. Interventions included personal hygiene: resident requires assistance with personal hygiene. Observation on 10/28/2024 at 8:15 a.m. revealed Resident #3's finger nails to left and right hands were long and dirty. During an interview on 10/28/2024 at 8:15 a.m. Resident #3 was asked if he wanted to have long fingernails and Resident #3 indicated he did not and the nails needed to be cut. Resident #3 also indicated he had asked for his nails to be trimmed a week ago. On 10/28/2024 at 8:25 a.m. S2 DON (Director of Nursing) observed Resident #3's fingernails and S2 DON confirmed Resident #3's fingernails to right and left hands were dirty and needed to be trimmed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure residents were treated with dignity and respect. The facility failed to address 1 resident (#1) out of 3 (#1, #2, #3) residents in a dignified and respectful manner. Findings: Review of Facility's Resident Rights Policy (revised October 4, 2022) revealed: Employees shall treat all residents with kindness, respect, and dignity .These rights include the resident's right to: a. a dignified existence; and c. be treated with respect, kindness, and dignity . Review of Resident #1's medical records revealed an admit date of 08/29/2024 and a discharge date of 08/31/2024 with the following diagnoses, including in part: Chronic Obstructive Pulmonary Disease (COPD)/unspecified, centrilobular emphysema, chronic respiratory failure with hypoxia, unspecified diastolic (congestive) heart failure, pneumonia/unspecified organism and pulmonary hypertension/unspecified. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating cognitively intact. Further review revealed Resident #1 was receiving oxygen therapy and hospice. During a telephone interview on 10/08/2024 at 10:00 a.m. S5 Complainant confirmed after the incident with the administrator Resident #1 became fearful, felt threatened and didn't want to be left alone. During an interview on 10/08/2024 at 2:35 p.m. S3 Licensed Practical Nurse (LPN) reported Resident #1 told her he was leaving the facility because of the way the administrator spoke to him, how he was rude. S3 LPN further reported Resident #1 was oriented and indicated he was actively dying. During an interview on 1/08/2024 at 2:45 p.m. S4 Certified Nursing Assistant (CNA) reported she took care of the resident. S4 CNA reported the resident told her he was leaving the facility because he didn't like the way he was treated. During an interview on 10/09/2024 at 8:50 a.m. S2 Business Office Manager reported she asked S1 Administrator to join the meeting in an attempt to help Resident #1 and his son understand the payment process. S2 Business Office Manager confirmed S1 Administrator told Resident #1 if his funds were not used to pay his bill at the facility Adult Protective Services (APS) would be notified and he could be arrested. S2 Business Office Manager confirmed Resident #1 was visibly shaken by what S1 Administrator said about notifying APS. S2 Business Office Manager confirmed Resident #1 was adamant about leaving the facility and not feeling safe after the conversation with S1 Administrator regarding APS notification. During an interview on 10/09/2024 at 10:45 a.m. S1 Administrator acknowledged he told Resident #1 if he didn't pay on the day of admission he would call APS.

Based on observations and interview the facility failed to accommodate the needs of 1 (#78) of 26 sampled residents. The facility failed to ensure Resident #78's call light was within reach. Findings: Review of Resident #78's medical record revealed an admit date of 04/03/2024 with diagnoses that included, in part, parkinsonism, unspecified dementia with psychotic disturbance, type 2 diabetes mellitus, pain unspecified, restlessness and agitation, and insomnia. Review of Resident #78's 06/06/2024 Quarterly MDS (Minimum Data Set) revealed Resident #78 had a Brief Interview Mental Status (BIMS) of 03 which indicated a severe cognitive impairment and required extensive assistance with bed mobility, transfer, and toilet use. Observation on 08/19/2024 at 8:20 a.m. revealed Resident #78's call light was on the bedside table where Resident #78 could not reach it. During an interview on 08/19/2024 at 8:20 a.m. this surveyor asked Resident #78 if he could reach his call light and Resident #78 was observed feeling around on his bed and answered no. Observation on 08/19/2024 at 8:56 a.m. revealed Resident #78 calling help repeatedly as this surveyor approached Resident #78's room. Call light was observed on Resident #78's bedside table and out of Resident #78's reach. During an interview on 08/19/2024 at 8:59 a.m. S4 CNA (Certified Nursing Assistant) observed Resident #78's call light on Resident #78's bedside table and reported the call light was out of Resident #78's reach and should not be.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure residents have a right to be free from any physical restraint not required to treat the resident's medical symptoms for 1 (Resident #360) out of 17 (#3, #17, #23, #39, #41, #66, #68, #72, #75, #78, #80, #87, #88, #96, #358, #360 and #361) residents investigated for physical restraints. The facility failed to ensure: 1.) a side rail utilization assessment was completed, 2.) a consent for the use of side rails was obtained, and 3.) a physician's order was in place for the use of bedrails for Resident #360. Review of facility's Use of Restraints policy with a revision date of April 2017 revealed in part: Policy Statement: Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms(s) and never for discipline of staff convenience or for the prevention of falls. Policy Interpretation and Implementation: 1. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. 2. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e. side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint. 4. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: a. Using bedrails to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility while in bed . 6. Prior to placing a resident in restraints, there shall be a Restraint Necessity/Positioning Device Assessment Form and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions . 9. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. the specific reason for the restraint (as it relates to the resident's medical symptom); b. how the restraint will be used to benefit the resident's medical symptom; and c. the type of restraint. Review of Resident #360's medical record revealed an admission date of 08/14/2024 with diagnoses including heart failure, essential hypertension, and muscle wasting and atrophy. Review of Resident #360's Brief Interview for Mental Status (BIMS) Evaluation dated 08/14/2024 revealed Resident #360 had a BIMS score of 00, indicating severe cognitive impairment. Review of Resident #360's Nursing admission Assessment dated 08/14/2024 revealed in part, Resident #360 was totally dependent on staff for bed mobility, transfers and locomotion. Review of Resident #360's admission Fall Risk assessment dated [DATE] revealed Resident #360 was at high risk for falls. Review of Resident #360's physician's orders failed to reveal a physician's order for the use of side rails. Review of Resident #360's medical record failed to reveal an admission Side Rail Utilization Assessment had been completed on 08/14/2024. Further review of the medical record also failed to reveal a consent for the use of side rails from Resident #360 or the Responsible Party (RP). Review of Resident #360's admission Side Rail Utilization Assessment dated 08/20/2024 at 11:00 a.m. revealed in part, Resident #360 had a history of falls, an alteration in safety awareness and displayed poor bed mobility or difficulty moving to a sitting position on the side of the bed. Further review revealed Resident #360 was not currently using the side rails for positioning or support and side rails were not indicated for mobility assistance. Review of Resident #360's interdisciplinary notes revealed nursing note entries by S8ADON (Assistant Director of Nursing) which read in part: 08/19/2024 at 9:45 a.m. Resident #360 pulling to left side and continues to put arm in side rail. Pillow placed on left side for protection. 08/19/2024 at 2:33 p.m. Resident #360 continues to pull to left side and put left arm in rail. An observation on 08/19/2024 at 8:30 a.m. revealed Resident #360 was asleep in bed with bilateral upper side rails in use. An observation on 08/19/2024 at 12:30 p.m. revealed Resident #360 was asleep on left side and positioned close to the upper left side rail with legs partially hanging out of bed. Resident #360 appeared restless and was reaching at left side rail. An observation on 08/20/2024 at 8:20 a.m. revealed Resident #360 was asleep on left side and positioned near the raised upper left side rail. During an interview on 08/21/2024 at 4:20 p.m., S3Corporate Nurse acknowledged Resident #360 had bed rails in use without a physician's order, side rail assessment or consent. S3Corporate Nurse acknowledged Resident #360 would not be able to use an assist rail for mobility and side rails were used as a restraint. During an interview on 08/22/2024 at 9:00 a.m., S9Physical Therapist acknowledged Resident #360's admission side rail assessment failed to reveal side rails were indicated for mobility assistance. S9Physical Therapist acknowledged Resident #360 had bilateral upper side rails in use without a completed admission side rail assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and interviews, the facility failed to ensure correct use and maintenance of bed rails. The facility failed to assess residents for use of bed rails (side rails), obtain an informed consent from resident or resident representative prior to installation of bed rails, and/or obtain physician order for bed rails for 11 (#3, #17, #23, #41, #66, #68, #72, #78, #80, #88, #96) out of 17 (#3, #17, #23, #39, #41, #66, #68, #72, #75, #78, #80, #87, #88, #96, #358, #360 and #361) residents investigated for physical restraints. Findings: Review of the facility's Proper Use of Side Rails policy with a revision date of January 16, 2024 revealed in part: Purpose: The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of the side rails as restraints unless necessary to treat a resident's medical symptoms. Definition Physical restraints are defined by the Centers for Medicare and Medicaid Services (CMS) as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. (Note: The definition of restraints is based on the functional status of the resident and not on the device, therefore any device that has the effect on the resident of restricting freedom of movement or normal access to one's body could be considered a restraint. General Guidelines 1. Side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed). (Note: the side rails may have the effect of restraining one individual but not another, depending on the individual resident's condition and circumstances.) 2. Side rails are only permissible if they are used to treat a resident's medical symptoms and/or assist with mobility and transfer of residents. 3. Upon admission, readmission, with routine quarterly or significant change MDS and PRN, therapy/designee will complete the Side Rail Utilization Assessment or equivalent form to determine the resident's symptoms, risk of entrapment and rationales for using side rails prior to implementation. When used for mobility or transfer, the assessment will include a review of the resident's: a. bed mobility b. ability to change positions, transfer to side of bed and from bed to chair, and to stand and toilet; c. risk of entrapment from the use of side rails and d. that the bed's dimensions are appropriate for the resident's size and weight. 4. Consent for use of side rail will be obtained if used as a restraint, from the resident or legal representative after presenting the potential benefits and risk using the Informed Consent for Use of Bed Rails. 10. The resident will be checked at least every shift for safety and proper functioning of the side rail use Resident #3 Review of Resident #3's medical record revealed an admit date of 11/17/2023 with the following diagnoses, including but not limited to: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, hypertension, hypothyroidism, pain, other seizures, hereditary and idiopathic neuropathy unspecified, schizophrenia, and chronic obstructive pulmonary disease unspecified. Review of Resident #3's physician orders revealed an order dated 02/02/2024 that read: May have (Right/Left/Bilateral) assist rails to promote independence in bed mobility. Check for placement and functioning every shift. Review of Resident #3's medical record failed to reveal a side rail assessment had been conducted. Review of Resident #3's medical record failed to reveal a consent for side rails had been obtained. Observation on 08/19/2024 at 1:30 p.m. revealed Resident #3 was lying in bed with head of bed elevated and side rails were raised to each side of upper bed. Observation on 08/21/2024 at 8:25 a.m. revealed Resident #3 had a side rail raised on the left side of the upper bed. During an interview on 08/22/2024 at 1:10 p.m. S3 Corporate Nurse reviewed Resident #3's medical record and reported Resident #3 did not have an assessment or consent for side rails. Resident #17 Review of Resident #17's medical record revealed an admit date of 08/19/2022 with the following diagnoses, including but not limited to: Alzheimer's disease, spinal stenosis, and history of falling. Review of Resident #17's physician orders revealed an order dated 01/31/2024 that read: May have (Right/Left/Bilateral) assist rails to promote independence in bed mobility. Check for placement and functioning every shift. Review of Resident #17's August 2024 MAR (Medication Administration Record) failed to reveal check for placement and functioning of side/assist rails had been conducted. Review of Resident #17's medical records failed to reveal a consent for side rails. Observation on 08/19/2024 at 9:30 a.m. revealed Resident #17's side rails were raised on each side of upper bed. Observation on 08/19/2024 at 3:45 p.m. revealed Resident #17's side rails were raised on each side of upper bed. Observation on 08/21/2024 at 10:30 a.m. revealed Resident #17's side rails were raised on each side of upper bed. Observation on 08/22/2024 at 8:15 a.m. revealed Resident #17's side rails were raised on each side of upper bed. During an interview on 08/21/2024 at 11:30 a.m. S3 Corporate Nurse confirmed that there was no consent for bed rails for resident #17. S3 Corporate Nurse also confirmed that medical records for resident #17 failed to reveal any checks completed for placement or function of bilateral assist rails. Resident #23 Review of Resident #23's medical record revealed an admit date of 11/21/2023 with the following diagnoses, including but not limited to: schizoaffective disorder bipolar type, repeated falls, restlessness and agitation, other seizure, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of Resident #23's physician orders revealed an order dated 08/20/2024 that read: May have (bilateral) assist rails to promote independence in bed mobility. Check for placement and functioning every shift. Directions: every shift for promote independence. Further review of Resident #23's physician orders revealed failed to reveal an order for side rails prior to 08/20/2024. Review of Resident #23's medical record failed to reveal a consent for side rails prior to 08/20/2024. Observation on 08/19/2024 at 09:10 a.m. revealed Resident #23's right upper side rail was raised while lying on back in bed. Observation on 08/20/24 at 08:45 a.m. revealed Resident #23's side rails were raised on each side of upper bed. Observation on 08/20/2024 at 3:06 p.m. revealed Resident #23 was resting quietly in bed with side rails were raised on each side of upper bed. During an interview on 08/22/2024 at 1:10 p.m. S3 Corporate Nurse reviewed Resident #23's medical record and reported Resident #23 did not have a side rail assessment, consent for side rails, or physician order for side rails prior to 08/20/2024. Resident #41 Review of Resident # 41's medical record revealed an initial admit date of 08/25/2020 and a re-entry admission date of 02/02/2023 with the following diagnoses, including but not limited to: idiopathic progressive neuropathy, overactive bladder, history of falling, unspecified dementia, and lack of coordination. Review of Resident #41's physician orders failed to reveal an order for side rails. Review of Resident #41's current medical record failed to reveal a quarterly side rail utilization assessment had been done after the initial assessment was done on 05/31/2022. Observation on 08/20/24 at 10:09 a.m. revealed Resident # 41 was in bed resting with eyes closed. Further observation revealed side rails were raised on each side of upper bed. Observation on 08/21/2024 at 12:30 p.m. revealed Resident #41 was in room sitting up in wheel chair. Further observation revealed side rails were raised on each side of upper bed. Observation on 08/21/2024 at 8:10 a.m. revealed Resident #41 in bed eating breakfast. Further observation revealed side rails were raised on each side of upper bed. During an interview on 08/22/2024 at 1:30 p.m. S3 Corporate Nurse reviewed Resident # 41's current medical record and confirmed a quarterly side rail assessment had not been done. During an interview on 08/22/2024 at 1:40 p.m. S3 Corporate Nurse reviewed medical record and confirmed Resident #41 did not have a physician order for side rails. Resident #66 Review of Resident #66's medical record revealed an admit date of 07/28/2022 with the following diagnoses, including but not limited to: hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, dysphagia and depression. Review of Resident #66's physician orders revealed an order dated 01/30/2024 that read: May have bilateral assist rails to promote independence in bed mobility. Check for placement and functioning every shift. Review of Resident #66's medical record failed to reveal a consent for side rail use had been obtained. Review of Resident #66's medical record failed to reveal a quarterly side rail utilization assessment had been done after the initial assessment was done on 07/29/2022. Observation on 08/19/2024 at 10:30 a.m. revealed Resident #66's side rails were raised on each side of upper bed. Observation on 08/20/2024 at 8:30 a.m. revealed Resident #66 was in the bed with side rails raised on each side of upper bed. Observation on 08/21/2024 at 8:20 a.m. revealed Resident #66 was asleep in bed with side rails raised on each side of upper bed. During an interview on 08/21/2024 at 4:20 p.m., S3 Corporate Nurse acknowledged a consent for side rail use had not been obtained and ongoing quarterly assessments had not been completed on Resident #66 and should have been. Resident #68 Review of Resident #68's medical record revealed an initial admit date [DATE] and an admission (re-entry) date of 08/06/2024 with the following diagnoses, including but not limited to: pressure ulcer of sacral region, stage 4 and pressure ulcer of sacral region, stage 3, cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, and muscle wasting and atrophy, multiple sites. Review of Resident #68's physician orders failed to reveal an order for side rails. Observation on 08/20/2024 at 10:01 a.m. revealed Resident #68 was resting with eyes closed with side rails raised on each side of upper bed. Observation on 08/20/2024 12:05 p.m. revealed Resident #68 was resting with eyes closed with side rails raised on each side of upper bed. Observation on 08/21/2024 at 8:00 a.m. revealed Resident # 68 was resting with eyes closed with side rails raised on each side of upper bed. During an interview on 08/22/2024 at 1:50 p.m. S3 Corporate Nurse reviewed medical record and confirmed Resident #68 did not have physician orders for side rails. Resident #72 Review of Resident #72's medical record revealed an admit date of 09/09/2021 with the following diagnoses, including but not limited to: cerebral vascular accident, hemiplegia and hemiparesis on right side and lack of coordination. Review of Resident #72's physician orders revealed an order dated 01/31/2024 that read: May have bilateral assist rails to promote independence in bed mobility. Check for placement and functioning every shift. Review of Resident #72's August 2024 MAR (Medication Administration Record) failed to reveal any monitoring for placement and functioning had been conducted. Review of Resident #72's medical record failed to reveal a consent for side rails or quarterly assessments for side rail utilization. Observation on 08/19/2024 at 9:30 a.m. revealed Resident #72 had side rails raised on each side of upper bed. Observation on 08/19/2024 at 3:45 p.m. revealed Resident #72 had side rails raised on each side of upper bed. Observation on 08/21/2024 at 10:30 a.m. revealed Resident #72 had side rails raised on each side of upper bed. Observation on 08/22/2024 at 8:10 a.m. revealed Resident #72 had side rails raised on each side of upper bed. During an interview on 08/21/2024 at 11:30 a.m. S3 Corporate Nurse confirmed that there was no consent for bed rails for resident #72. S3 Corporate Nurse also confirmed that medical records for resident #72 failed to reveal any monitoring had been completed for placement or function of bilateral assist rails. During an interview on 08/22/2024 at 1:25 p.m., S3 Corporate Nurse confirmed that there are no quarterly assessment for side rail utilization assessment for resident #72. Resident #78 Review of Resident #78's medical record revealed an admit date of 04/03/2024 with the following diagnoses, including but not limited to: Parkinsonism, pain unspecified, restlessness and agitation, pure hypercholesterolemia unspecified, dementia, type 2 diabetes mellitus without complications. Review of Resident #78's physician orders failed to reveal an order for the use of side rails. Review of Resident #78's August 2024 MAR failed to reveal any monitoring had been conducted in regard to Resident #78's side rails. Observation on 08/19/2024 at 9:10 a.m. revealed Resident #78's side rails were up on each side of upper bed. Observation on 08/21/2024 at 8:10 a.m. revealed Resident #78's side rails were up on each side of upper bed. During an interview on 08/22/2024 at 1:15 p.m., S3 Corporate Nurse reviewed Resident #78's medical record and reported Resident #78 did not have an order for side rails and monitoring had not been conducted for Resident #78 who used side rails. Resident #80 Review of Resident #80's medical record revealed an admit date of 10/31/2023 with following diagnoses, but not limited to: muscle wasting and atrophy, multiple sites, type 2 DM, muscle weakness (generalized), primary generalized (osteo) arthritis, aphasia, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and lack of coordination. Review of Resident #80's physician orders failed to reveal an order for the use of side rails. Observation on 08/20/2024 at 9:09 a.m. revealed Resident #80 was in bed watching television with side rails raised on each side of upper bed. Observation on 08/21/2021 at 8:10 a.m. revealed Resident #80 was in bed eating breakfast with side rails raised on each side of upper bed. During an interview on 08/22/2024 at 1:40 p.m., S3 Corporate Nurse reviewed Resident #80's medical record and confirmed Resident #80 did not have a physician order for side rails. Resident #88 Review of Resident #88's medical record revealed an initial admission date of 05/30/2023 and a re-entry date of 03/06/2024 with the following diagnoses, including but not limited to: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, type 2 diabetes mellitus, abnormalities of gait and mobility, lack of coordination, muscle wasting and atrophy. Review of Resident #88's physician orders failed to reveal an order for the use of side rails. Observation on 08/20/24 at 9:09 a.m. revealed Resident #88 was in bed watching television with side rails raised on each side of upper bed. During an interview on 08/22/2024 at 1:40 p.m. S3 Corporate Nurse reported Resident #88 did not have a physician order for bed rails. Resident #96 Review of Resident #96's medical record revealed an admit date of 12/06/2023 with the following diagnoses, including but not limited to: rhabdomyolysis, lack of coordination and rheumatoid arthritis. Review of Resident #96's physician orders failed to reveal an order for the use of side rails. Review of Resident #96's medical record failed to reveal a side rail utilization assessment consents. Observation on 08/20/24 at 9:40 a.m. revealed Resident # 96 was in bed with side rails raised on each side of upper bed. Observation on 08/20/2024 at 12:20 p.m. revealed Resident # 96 was in bed watching television with side rails raised on each side of upper bed. Observation on 8/21/2024 at 8:10 a.m. revealed #96 in bed eating breakfast with side rails raised on each side of upper bed. During an interview on 08/22/2024 at 1:40 p.m. S3 Corporate Nurse reported an initial side rail assessment and consent had not been completed for Resident #96. S3 Corporate Nurse further reported Resident #96 did not have a physician order for side rails.

Based on observation of the medication pass, review of current physician orders, and interviews, the facility failed to ensure that it is free from medication error rate of 5% or greater by committing 2 errors (#19, #93) out of 29 opportunities for an error rate of 6.9%. Findings: Resident #19 Observation during medication pass on 08/20/2024 at 8:20 a.m. revealed S6 LPN (Licensed Practical Nurse) administered Fluticasone Propionate and Salmeterol 250mcg (microgram) /50mcg by oral inhalation to Resident #19. Review of Resident #19's current physician orders revealed a 07/16/2024 order for Breo Ellipta Inhalation Aerosol Powder Breath Activated 100-25 mcg/act (actuation) (Fluticasone Furoate-Vilanterol) 1 puff inhale orally one time a day related to chronic obstructive pulmonary disease. During an interview on 08/20/2024 at 2:30 p.m. S6 LPN reviewed Resident #19's medication container from medication cart which read Fluticasone Propionate and Salmeterol 250mcg/50mcg and reviewed Resident #19's physician order and reported the medication was not administered as per the physician order and should have been. Resident #93 Observation of the medication pass on 08/20/2024 at 7:37 a.m. revealed S6 LPN administered one-half tablet of Metoprolol Succ (Succinate) ER (Extended Release) 25mg (milligram) by mouth to Resident #93. Review of Resident #93's current physician orders revealed a 03/13/2024 order for Metoprolol Succinate ER Tablet Extended Release 24 hour 25mg - give 1 tablet by mouth one time a day related to essential hypertension. During an interview on 08/20/2024 at 2:35 p.m. S6 LPN reviewed Resident #93's medication card from the medication cart which contained half tablets equaling 12.5mg in each blister and read Metoprolol Succ ER 25mg tab (Toprol XL 25mg) - give one-half tablet by mouth once daily and reviewed Resident #93's physician order and reported the medication was not administered as per the physician order and should have been. During an interview on 08/20/2024 at 2:37 p.m. S7 NP (Nurse Practitioner) reviewed the order for Resident #93's Metoprolol Succinate ER 25mg tablet and confirmed Resident #93 should have received a full tablet. During an interview on 08/20/2024 at 3:50 p.m. S2 DON (Director of Nursing) observed Resident #19's medication container for Fluticasone Propionate and Salmeterol 250mcg/50mcg and Resident #93's medication card for Metoprolol Succinate and agreed the medications did not match the physician orders.

Based on record review and interviews, the facility failed to electronically submit accurate payroll information for direct care staffing as required. Findings: Review of PBJ (Payroll Based Journal) [NAME] Report 1705D for the fiscal year 2024, 2nd quarter (January 1-March 31) revealed excessively low weekend staffing was triggered. During an interview on 08/22/2024 at 10:10 a.m S1 Administrator reported S5 Human Resources submits the agency staffing information to corporate and corporate submits PBJ report quarterly to CMS (Centers for Medicare & Medicaid Services). S1 Administrator reported the facility had adequate staff. S1 Administrator reported an agency invoice may have been missed or corporate may not have had the agency invoice at the time of reporting. During an interview on 08/22/2024 at 10:25 a.m. S5 Human Resources reported the PBJ staffing report is completed by the corporate office. S5 Human Resources reported when staffing agencies send staffing hours to the facility late, the staffing hours reported to corporate office will show that the facility did not have enough staff. S5 Human Resources reported when staffing agency hours are late to the facility and corporate sends the information into the PBJ system, the staffing numbers do not show the agency staff hours and it appears the facility did not have adequate staffing.

Based on record review and interviews the facility failed to ensure provision of services in compliance with all applicable Federal, State, and local laws, regulations and codes by failing to investigate an incident involving resident to staff violence for 1 (Resident #1) of 3 (Residents #1, #2, and #3) sampled residents. The facility failed to follow the facility's policy by failing to investigate a resident to staff verbal exchange that progressed to a physical exchange between Resident #1 and S6 LPN (Licensed Practical Nurse). Findings: Review of Workplace Aggression/Violence Policy revised April 2023 Policy Statement It is the policy of this facility that all employees, residents, family members, visitors, contractors, vendors, etc., enjoy a positive, respectful, productive and safe environment while on our premises. Policy Interpretation and Implementation 1. Workplace violence is defined as violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty. Violent acts include, but are not limited to: a. Verbal or physical harassment; b. Verbal or physical threats; c. Assaults or other violence made directly or indirectly by words, gestures, or symbols; d. Any other behavior that causes others to feel unsafe (e.g., bullying, sexual harassment); and/or . 2. This facility has implemented a Workplace Corporate Compliance Program. The goal of this program is to promote an environment free of behavior, actions, or language causing or contributing to workplace violence, harassment or bullying. . 5. It is the responsibility of all employees to notify the appropriate supervisor or HR (Human Resources) Director of any threats which they have witnessed, received, or been told that another person has witnessed or received. . Review of Resident #1's medical record revealed an initial admission date of 11/16/2023 with diagnoses that included, in part, bipolar disorder current episode depressed moderate 05/07/2024, anxiety disorder 11/16/2023, and violent behavior 05/22/2024. Review of Resident #1's 06/12/2024 admission MDS (Minimum Data Set) revealed Resident #1 had a BIMs score of 15 which indicated Resident #1 was cognitively intact. Review of Resident #1's Progress Notes revealed a 05/21/2024 at 22:42 Nurses Note by S6 LPN which read in part: 12am: . resident was rolling down hallways yelling, screaming and using profanity . Writer entered resident room and observed resident sitting in wheelchair by door. Writer informed resident to not yell down hallways while others are sleeping. resident rolled next to writer . writer then asked resident . to move back away from writer and resident then stood up and pushed writer out of resident room and slammed door . Writer then . went to front nurses station and notified DON (Director of Nursing). Resident then came to front nurses station yelling at staff and saying to writer just wait until I finish with you, you _(profanity)__, you won't have a job. Writer informed resident to please leave nurses station and go back to room. Resident then left nurses' station. Review of undated witness statement documentation revealed the following: To whom it may concern, On May 21st on the 11-7pm shift I witnessed Resident #1 push the nurse, S6 LPN and slammed the door. Sincerely, S7 CNA (Certified Nursing Assistant) Review of the facility's Incident Log failed to reveal an incident report with investigation had been completed in regard to the 05/21/2024 incident between Resident #1 and S6 LPN. During an interview on 06/26/2024 at 3:03 p.m. S7 CNA reported she had been seated in the dining room near the hall entrance and in sight of Resident #1's door, and heard Resident #1 yelling and cussing and got up to see what was going on and saw Resident #1 push S6 LPN, who had been standing in Resident #1's doorway, toward the hallway and slam the door. During an interview on 06/25/2024 at 11:29 a.m. S5 DON reported an incident report had not been completed for the 05/21/2024 incident between staff and Resident #1 as she saw the progress note entered in Resident #1's medical record and did not think it was necessary to write an incident report for it. During an interview on 06/25/2024 at 10:22 p.m. S4 Administrator reported an incident report had not been completed for what occurred between Resident #1 and S6 LPN on 05/21/2024, he had not viewed the camera recording from the 05/21/2024 incident, and the recording of the incident was no longer available. During an interview on 06/25/2024 at 2:35 p.m. S9 NP (Nurse Practitioner) reported Resident #1 had a history of running into people with his wheelchair, would roll over their feet, would throw trays, would scream and yell, had charged a nurse, would fly off the handle when he did not get his way and always denied any accusations. S9 NP further reported she had been made aware of the incident that occurred between Resident #1 and staff member the night of 5/21/2024 and she had visited with Resident #1 on the morning of 05/22/2024 and found Resident #1 to be more aggressive than normal and was unable to calm Resident #1 down. The decision was made to PEC (Physician's Emergency Certificate) Resident #1 and after Resident #1's refusal to go, police were called and assisted with transfer to Behavioral hospital. During a phone interview on 06/27/2024 at 10:11 a.m. S8 NP reported he had been consulted by S9 NP the morning of 05/22/2024 regarding Resident #1's current behavior of agitation and pushing of a staff member the night before. S8 NP further concurred the behavior was notably above Resident #1's baseline, it was reasonable Resident #1 could be aggressive again, and was in need of an inpatient treatment. During an interview on 06/27/2024 at 9:05 a.m. S1 Regional Vice-President reported, if notified of a workplace violence issue, that issue would be reported to the facility's Corporate Compliance Officer. S1 Regional Vice-President further reported the facility had not considered the 05/21/2024 occurrence between Resident #1 and a staff member an incident, but a behavior and it was not investigated nor was it reported to the facility's Corporate Compliance Officer. S2 Corporate Nurse was present during the interview and confirmed.

Based on observations, record reviews and interview, the facility failed to ensure 1 (Resident #3) of 3 (Resident #1, #2, #3) sampled residents was free of accidents and hazards. Findings: Review of Resident #3's medical records revealed admit date of 12/07/2023 with the following diagnoses, in part: muscle wasting and atrophy/multiples sites, other abnormalities of gait and mobility, other lack of coordination, anxiety disorder/unspecified, shortness of breath, Type 2 diabetes mellitus without complications, pain/unspecified, heart failure/unspecified, and pulmonary fibrosis/unspecified. Review of Resident #3's Comprehensive Care Plan revealed: risk for falls r/t (related to) gait/balance problems, Psychoactive drug use - fall mats x 2, keep bed in low position Be sure the resident's call light is within reach . Review of Resident #3's Physician's Orders revealed an order dated 04/09/2024 - patient to have low bed and fall mats. Observation on 04/15/2024 at 10:10 a.m. revealed Resident #3 lying in bed with call bell hanging off side of bed out of reach. Bed in high position. Observation on 04/15/2024 at 4:00 p.m. revealed Resident #3 lying in bed asleep. Bed in high position. Call bell wrapped around assist rail and hanging down out of reach. Observation on 04/16/2024 at 8:10 a.m. Resident #3 lying in bed with bed in high position and call bell on floor. Observation on 04/16/2024 at 10:25 a.m. revealed Resident #3's call bell on floor and bed in high position. During an interview on 04/16/2024 at 10:25 a.m. S1 Restorative Aide acknowledged the bed should be lowered and the call bell should not be on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a physician's order was entered correctly for one resident (#2) of four residents (#1, #2, #3, #4) that were sampled. Findings: Record review of Resident #2's physician telephone orders dated 08/03/2023 revealed, in part, an order for blood glucose checks daily in the a.m. and as needed. Record review of Resident #2's physician orders for August, September, October, and November 2023 revealed the following order, in part: An order with start date of 08/03/2023, Accucheck daily and as needed (blood sugar check). Humalog 100unit/milliliter subcutaneous solution inject subcutaneous per sliding scale finger stick before meals and hour of sleep (four times a day). Time code was for 6 a.m. Parameters, 0-60 hypoglycemic protocol; 61-199=0units; 200-250=2units; 251-300=4units; 301-350=6units; 351-400=9units; [PHONE NUMBER]=12units, recheck in one hour; if greater than 400 call MD (medical doctor). These orders should have read as, blood glucose checks daily in a.m. and as needed, instead of before meals and hour of sleep. During an interview on 11/07/2023 at 12:30 p.m., S1DON (director of nursing) verified S2LPN (licensed practical nurse) did not enter the new order for Resident #2's blood sugar check on 08/03/2023 correctly. The LPN should have changed the order to be done in the morning and as needed instead of before meals and hour of sleep.

Based on interviews and record review the facility failed to ensure grievance were addressed and investigated for 1(#2) of 5 (#1, #2, #3, #4, #5) sample residents. The facility failed to follow their policy/procedures that was presented by the DON (Director of Nursing) for reporting and investigating grievances. Findings: Review of the facility Resident Grievances/Complaints policy - Staff Responsibility revealed the following: Policy Statement Staff members are encouraged to guide residents about where and how to file a grievance and/or complaint when the resident believes that his/her rights have been violated. Policy Interpretation and Implementation 1. Should a staff member overhear or be the recipient of a complaint voiced by a resident, a resident's representative (sponsor), or another interested family member of a resident concerning the resident's medical care, treatment, food, clothing, or behavior of other resident, etc. the staff member is encouraged to guide the resident, or person acting on the resident's behalf, as to how to file a written complaint with the facility. 2. Staff members will inform the resident or the person acting on the resident's behalf that he or she may file a grievance or complaint with the Grievance Officer, Administrator, or other government agencies as noted on the resident's bulletin board, without fear of threat or any other form of reprisal. 3. Staff members will inform the resident or the person acting on the resident behalf as to where to obtain a Resident Grievance Complaint Form and where to locate the procedures for filing a grievance or complaint (e.g. posted on a bulletin board). 4. All alleged abuse, mistreatment, neglect, injuries of unknown source, and misappropriation of property will be reported to the Administrator. Review of resident #2's clinical records revealed diagnoses that include ataxia, type 2 diabetes mellitus, generalized anxiety disorder, depression and constipation. Review of resident #2's face sheet revealed responsible party is her daughter. During an interview on 08/21/21023 at 10:00 a.m. responsible party reported she had spoken to the Administrator and the DON several times regarding the lack of care her mother was receiving. She reported when she spoke with the Administrator about her mother not receiving a bath in 14 days, she was told maybe Hospice need to do a better job. She reported she visits as much as possible but other family members, (aunts, and siblings) visit also and have found the same thing. Review of resident #2's most recent Quarterly MDS (Minimum Data Set) with ARD (assessment reference date) 08/09/2023 revealed - Section C - Cognitive Pattern BIMS (Brief Interview for Mental Status) Summary Score 11 indicating moderately cognitively intact. Section G - Functional Status Resident requires one person assist with bed mobility and transfers. Physical assist with part of bathing. Always incontinent of bladder and bowel. Review of resident #2's Comprehensive Plan of Care revealed a need for total assistance for all activity of daily livings times 1 to 2 staff and a need to be fed by staff. Some of the interventions are staff will provide assistance with transfers, bed mobility and toileting. Resident have chosen to receive Hospice Care. During an interview on 08/21/2023 at 3:00 p.m. S2 Social Service Director reported once a Grievances is made they are usually given to her and she keeps them in a binder. She confirmed she did not have a Grievance for resident #2. During an interview on 08/21/2023 at 3:40 p.m. S1 DON (Director of Nursing) reported after reviewing the Grievance binder confirmed she did not have a Grievance report for resident #2.

Based on record reviews, observation, and interviews the facility failed to accommodate the needs and preferences of 3 (#4, R1, R2) of 7 (#1, #2, #3, #4, #5, R1, R2) residents who required needed assistance with ADL (Activities of Daily Living) that included transfers, toileting, bed mobility and eating. Findings: Review of the facility's Resident Call Light System Policy revealed, in part: Purpose: The purpose of this procedure is to respond to the resident's request and needs. Policy Implementation: A call light system (audible and visual) is in place and operative in the facility. This system allows individual residents to access a system that notifies nursing that the resident has a need. Residents can communicate with the Nurse's Station from their room and/or bathing and toileting facilities. Purpose: The call light system is activated in the resident's room, the light outside the door is checked and the panel light and volume are checked at the nurse's station to ensure it is working properly. Review of resident #4 clinical record revealed an admit date of 10/07/2023 with diagnoses of but not limited to Osteoarthritis, Gout unspecified, abnormalities of gait, and lack of coordination. Review of resident #4's MDS (minimum data set) dated 06/02/2023 revealed resident #4 was assessed to have a BIMS (brief mental status interview) of 11, indicating moderately impaired cognition. Function status assessment indicated resident #4 required one person physical assist with bed mobility and transfers. Review of resident #4's Comprehensive Plan of Care revealed the need for assistance with ADL (actvity of daily living) requiring limited assistance with transfers, bed mobility and toileting. Some of the intervenntions are staff will provide assistance with transfers, bed mobility, and toileting needs as needed. Resident #4 is at risk for falls. Some of the intervention is to assist resident with standing by for all ambulation. Keep walker within reach. Some interventions are assist me with stand by assist for all ambulation. Keep walker within my reach at all times. Resident has episodes of incontinence of bowel and bladder. Some of the interventions listed are keep call light in reach. Assist to toilet when indicated, assist with incontinent care as needed prompt incontinent care. Observation on 08/21/2023 at 9:20 a.m. revealed resident #4 called surveyor to her room from the hallway. Surveyor entered resident #4's room to see what she needed and she said she needed help to go to the bathroom. She reported a CNA (certified nursing assistant) had just picked up her breakfast tray and she had asked for help to the bathroom and she did not. Resident #4 reported she needed help quickly, she really needed to go. Surveyor pushed the call light, no one answered and someone turned the call light off. Surveyor push the call light for help again and 2 CNAs entered the room. S3 CNA stated, I thought someone was on the floor. S3 CNA asked resident #4 what do you need, you can go to the bathroom by yourself. S3 CNA speaking loud and demeaning. Surveyor asked S3 CNA to lower her voice. Surveyor asked, S3 CNA how do you know resident #4 can go to the bathroom by herself. S3 CNA reported she works with resident #4 every day and resident #4 knows she can get up to the bathroom by herself. Surveyor observed resident #4 struggling attempting to get out of bed on her own. S3 CNA was just standing there in the room. Observed resident #4 having difficulty grabbing the arm of the wheelchair that the CNA finally placed alone the side of the bed. Resident R1 Review of resident R1's clinical records revealed an admit date d 08/02/2023with diagnoses of but not limited to Rhabdomyolysis, systemic lupus erythematous organ system involve, morbid obesity due to excess calories, other lack of coordination, history of falls and diabetes type 2. During an interview on 08/22/2023 at 9:45 a.m. resident R1 reported that she has had problems with getting assistance when she put her call light on. Resident R1 reported while sitting up in the wheelchair after 2 hours of sitting the back of her leg starts to hurt and she is ready to be assisted back to bed. Resident R1 reported she waited so long last evening for assistance to the bathroom until she had to go without assistance. Resident R1 reported no one ever came when she turned her call light on. Resident R1 report she had reported this to the night nurse. Review of resident R1's 5 day MDS with ARD (assessment reference date) 08/09/2023 revealed BIMS of 14 indicating cognitive intact. Functional Status revealed resident R1 need ADL support provided by two+ person's physical assist with bed mobility, and transfers. Toilet use resident R1 requires one person physical assist. Review of resident R1's Comprehensive Plan of Care revealed a need for assistance time's 1-2 staff with ADL's. Extensive assistance with transfers, assistance with bed mobility and assistance with toileting. Interventions are staff will provide assistance with transfers, bed mobility and toileting as needed. Resident R2 During an interview on 08/21/2023 at 9:40 a.m. resident R2 reported you all need to do something about theses call light. Resident R2 reported she pushed her call light this morning and no one ever came. Resident R2 reported she is not to get up by herself, she is to have help to the bathroom. Resident R2 reported she waiting and no one ever came to help her. Resident R2 reported so she got up to the bathroom by herself. She reported once she got in the bathroom she turned on the light in the bathroom. Resident R2 reported a young lady came in her room and said she had to turn out theses lights. She reported the young lady turned out the lights. She reported she told the young lady she needed help. Resident R2 reported the young lady just shrug her shoulders and left the room without helping her. She reported she did not know the young ladies name and she hadn't reported it. Diagnoses include type 2 diabetes mellitus without complications, morbid (severe) obesity due to excess calories, Muscle wasting and atrophy, hypertension. Review of resident R2's admission MDS with ARD 08/18/2023 revealed Section C Cognitive Patterns a BIMS of 14 indicating cognitive intact. Review of resident R2's admission Care Plan reveal limited assistance is required with ambulation/transfers. Fall, safety risk and elopement risk are to encourage use of call light. Bath/Hygiene Amount of Assistance is limited, extensive, support of one person.

Based on observations and interviews, the facility failed to accommodate the needs of 2 (#73, #101) of 25 sampled residents observed for accommodation of needs. The facility failed to ensure the call light devices were in a position where they could be activated. Findings: Review of facility's Resident Call Light System with a revision date of June 2023 revealed in part: Purpose: The purpose of this procedure is to respond to the resident's requests and needs. General guidelines: 4. Ensure that the call light is easily reachable by the resident Resident #73 Observation on 07/24/23 at 8:45 a.m. revealed Resident #73's call light lying on Resident #73's floor. During an interview on 07/24/2023, 8:45 a.m. Resident #73 reported she knew how to use the call light but could not reach it. Resident #101 Observation on 07/24/2023 at 9:00 a.m. revealed call light device lying on Resident #101's floor. During an interview on 07/24/2023 at 9:00 a.m., Resident #101 reported she knew how to use the call light but could not reach the device. During an interview on 07/24/2023 at 9:00 a.m., S2 ADON (Assistant Director of Nursing) acknowledged Resident #73's and Resident #101's call light devices were lying on floors, out of the residents' reach. S2 ADON further acknowledged Resident #73 and Resident #101 were capable of using their call light devices and should have been within reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the provider failed to complete an investigation for 1(Resident #68) of 1(Resident #68) residents after Resident #68 had an injury from an unknown origin. Findings: Review of the facility's policy for investigating injuries with a revision date of December 2016 revealed: Policy statement- The Administrator will ensure that all injuries are investigated. Policy interpretation and implementation revealed, in part: 1. The DON (director of nursing) or a designee will assess all injuries and document clinical findings in the clinical record. 2. If an incident/accident is suspected, a nurse or nurse supervisor will complete a facility approved accident/incident form. The form will be disseminated to the appropriate individuals, for example the Administrator and Director of Nursing Services. Review of the facility's Falls-Clinical Protocol with a revision date of March 2018 revealed the following, in part: Assessment and Recognition 2. The nurse shall assess and document/report the following b. Recent injury, especially fracture or head injury Monitoring and Follow-up 1. The Nursing Staff will follow up on any fall associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. The Charge Nurse will complete an assessment every shift for seventy-two hours post incident. Record review of Resident #68's diagnosis revealed the resident was diagnosed with with a fracture of her left patella dated 06/16/2023. Resident #68 also had a diagnosis of dementia. Record review of Resident #68's Physician orders for July 2023 included: 1. Keep immobilizer in place to LLE (left lower extremity) at all times, start date 06/16/2023, discontinued 07/03/2023. 2. Long leg immobilizer may remove when in bed, activity as tolerated. Start date 07/04/2023, discontinued 07/24/2023. Record review of Resident #68's comprehensive care plan included: Problem- risk for pain, fracture right thumb from fall; 06/16/223 resident has fracture to left patella, LLE immobilizer in place. Interventions- monitor for pain, staff to attempt to keep immobilizer devices in place . Record review of Resident #68's Minimum Data Set, dated [DATE] included: 1. Section C showed a BIMS (Brief Interview for Mental Status) of 99 (unable to complete interview) Record review of Resident #68's Nurse's Notes included: 1. 06/15/2023 11:19 a.m.- writer notified by CNA (certified nursing assistant) resident is having a hard time standing. Resident complained of pain and has some swelling and bruising to left knee. Notified NP (nurse practitioner) and will have x-ray of left leg. 2. 06/15/2023 4:39 p.m.- writer received x-ray results showed a patella fracture. Notified NP (Nurse Practitioner) and she stated to send resident to ER (emergency room). 3. 06/16/2023 at 4:01 p.m.- 3:46 p.m. resident returned to facility via facility transport .immobilizer in place to LLE .addendum 4:20 p.m.- keep immobilizer in place to LLE at all times until follow-up appointment. Record review of the facility's incident log failed to reveal an entry was made on 06/15/2023 after Resident #68's left patella fracture was found. During an interview on 07/26/2023 at 8:45 a.m., S1 DON indicated she should have completed in incident report for Resident #68 after the patella fracture was found on 06/15/2023. During an interview on 07/26/23 at 9:20 a.m., S2 ADON (assistant director of nursing) indicated she completed a head to toe assessment on Resident #68 after an unwitnessed fall on 06/08/2023 and the Resident #68's knees did not have any bruising or swelling. During a telephone interview on 07/26/23 at 12:15 p.m., S3 CNA indicated she and another CNA was transferring Resident #68 from bed to wheelchair on 06/15/2023 and when Resident #68 was in standing position the resident complained of pain to her knee and they put the resident back in bed and notified the S2 ADON. During an interview on 07/26/2023 at 1:50 p.m., S8 Corporate Nurse indicated an incident report should have been completed when Resident #68 was found to have a patella fracture on 06/15/2023. During an interview on 07/26/2023 at 3:20 p.m., S8 Corporate Nurse indicated staff should have completed an investigation after Resident #68 was confirmed to have a patella fracture on 6/15/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to ensure resident's personal dietary choices were met for 1 (#92) out of 3 (#34, #209, #92) sampled residents reviewed for food. The facility served Resident #92's dislikes. Review of Resident #92's Medical Record revealed admit date [DATE]. Review of Resident #92's MDS (Minimum Data Set) assessment dated [DATE] revealed: Section C: Cognitive Patterns - BIMS (Brief Interview for Mental Status) 15 - intact cognition. During an interview on 07/24/2023 at 8:30 a.m. Resident #92 reported he filled out his dislikes and likes for the kitchen but they keep sending him squash and beets. Resident #92 further reported his dislikes, squash and beets, are on his dietary ticket but the kitchen doesn't pay attention and sends it anyway. Observation on 07/24/2023 at 12:15 p.m. revealed Resident #92's lunch tray contained squash in a bowl. Further observation revealed Resident #92's dietary ticket with dislikes as squash and beets. During an interview on 07/24/2023 at 12:30 p.m. S9 Dietary Manager acknowledged Resident #92's dislike of squash should not have been on his tray and staff need to pay more attention to the dietary ticket.

Based on record reviews and interviews the facility failed to inform and provide written information to residents or resident's representative concerning the right to formulate an advance directive for 4 (#2, #7, #18, #71) of 32 residents reviewed for advance directives. Findings: Review of facility's Advance Directives policy with a revision date of 05/31/2023 revealed in part: 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 8. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. Resident #2 Review of Resident #2's Medical Records failed to reveal and Advanced Directive. During an interview on 07/25/2023 at 11:15 a.m. S8 Corporate Nurse reported the facility is unable to produce documentation of Advanced Directive information provided to Resident #2. Resident #7 Record review of Resident # 7's medical record failed to reveal an Advanced Directive was completed. During an interview on 07/25/2023 at 11:15 a.m., S8 Corporate Nurse indicated and Advanced Directive was not found for Resident # 7. Resident #18 Review of Resident #18's medical record failed to reveal an Advance Directive Acknowledgement. During an interview on 07/25/2023 at 10:55 a.m. S8 Corporate Nurse, acknowledged Resident #18 had not been issued an Advance Directive and should have. Resident #71 Review of Resident #71's medical failed to reveal an Advanced Directive had been issued. During an interview on 07/25/2023 at 10:15 a.m. S7 Hospital Liaison, reported she was unable to produce a copy of Resident #71's Advance Directive Acknowledgement. During an interview on 07/25/2023 at 10:30 a.m. S8 Corporate Nurse, acknowledged Resident #71 had not been issued a written Advance Directive from facility and should have been.

Based on record review and an interview the facility failed to ensure resident's plan of care was reviewed and revised for 1 (#13) out of a total of 25 sampled residents reviewed for plan of care. The facility failed to revise the plan of care for Resident #13 to include refusal of house supplements. Findings: Review of Resident #13's medical record revealed a significant weight loss of 14.17 % in a six-month period. Review of Resident #13's current physician's orders revealed an order dated 04/18/2023 which read house supplement, give 90 mls. (milliliter) by mouth four times a day. Review of Resident #13's May 2023 - July 2023 Medicine Administration Records revealed Resident #13 refused house supplements on the following dates and times: 05/16/2023 at 8:00 p.m. 05/19/2023 at 8:00 a.m., 12:00 p.m. and 4:00 p.m. 05/20/2023 at 8:00 a.m., 12:00 p.m. and 4:00 p.m. 05/21/2023 at 8:00 a.m., 12:00 p.m. and 4:00 p.m. 05/25/2023 at 8:00 a.m., 12:00 p.m. and 4:00 p.m. 06/09/2023 at 8:00 a.m., 12:00 p.m. and 4:00 p.m. 06/21/2023 at 4:00 p.m. 06/24/2023 at 8:00 a.m., 12:00 p.m. and 4:00 p.m. 06/28/2023 at 8:00 a.m., 12:00 p.m. and 4:00 p.m. 07/09/2023 at 8:00 a.m., 12:00 p.m. and 4:00 p.m. 07/16/2023 at 8:00 a.m., 12:00 p.m. and 4:00 p.m. 07/22/2023 at 8:00 a.m., 12:00 p.m. and 4:00 p.m. 07/23/2023 at 12:00 p.m. and 4:00 p.m. Review of Resident #13's comprehensive care plan (initiated 01/31/2023) revealed the problem of altered nutrition with an approach to give house supplement 90 mls. by mouth, four times daily. Further review of Resident #13's comprehensive care plan failed to reveal a care plan revision to reflect refusal of care. During an interview on 07/26/2023 at 9:15 a.m., S6 Nurse Practitioner reported she had not been made aware Resident #13 had been refusing house supplements. During an interview on 07/26/2023 at 10:00 a.m. S1 DON (Director of Nursing) reviewed Resident's #13's comprehensive care plan and acknowledged Resident #13's care plan had not been revised to reflect refusal of house supplements and should have been. During an interview on 07/26/2023 at 10:15 a.m., S2 ADON (Assistant Director of Nursing) reported Resident #13 had refused house supplements at times. S2 ADON acknowledged Resident #13's care plan had not been revised to reflect refusal of house supplements and should have been.

Based on observations, record review, and interviews, the facility failed to ensure a resident who required assist with activities of daily living (adl) received the necessary services to maintain grooming and hygiene for 1 (#86) of 3 residents reviewed for activities of daily living. The facility failed to ensure Resident #86 received a shower in a timely manner. Findings: Review of facility's Shower/Tub Bath policy with a revision date of October 2010 revealed in part: The purpose of the procedures are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Review of Resident #86's MDS (Minimum Data Set) dated 06/26/2023 revealed Resident #86 required a one person assist for personal hygiene. Review of Resident #86's Bath Day Roster revealed Resident #86's shower record: 07/21/2023 at 11:20 a.m. - Friday - Shower (S11 CNA) 07/22/2023 at 2:23 p.m. - Saturday - Not scheduled bath day (S11 CNA) 07/23/2023 at 11:11 a.m. - Sunday - Not scheduled bath day (S11 CNA) 07/24/2023 at 1:32 p.m. - Monday - Not scheduled bath day (S10 CNA) 07/25/2023 at 10:43 p.m. - Tuesday - Not a scheduled bath day (S11 CNA) An observation on 07/24/23 9:30 a.m. revealed Resident #86's hair appeared disheveled and greasy in appearance. During an interview on 07/24/2023 at 9:30 a.m. Resident #86 reported she had not had a shower since last week. Observation on 07/25/2023 at 11:30 a.m. revealed Resident #86's hair appeared greasy and disheveled. During an interview on 07/25/2023 at 11:30 a.m. Resident #86 reported she still had not had a shower. During an interview on 07/25/2023 at 11:40 a.m. S10 CNA (certified nurse assistant) reviewed Resident #86's bath day roster and reported not a scheduled bath day is the code used when a shower had not been given. During an interview on 07/25/2023 at 11:45 a.m. S11 CNA reported when a scheduled shower is not provided, she documents not a scheduled bath day. S11 CNA acknowledged Resident #86 had not been given a shower over the weekend. During an interview on 07/26/2023 at 2:15 p.m., S1 DON (Director of Nursing) reviewed Resident #86's shower record and acknowledged Resident #86's last shower had been given five days ago.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure there was sufficient staff with appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to ensure that resident calls for help were answered timely and resident needs were met. Findings: Observation on 07/24/2023 9:30 a.m. revealed resident #18 called for assistance with the use of the call button, the light over resident #18's door came on. An audible call was overhead stating, room [ROOM NUMBER] needs assistance, at 9:35 a.m., 9:45 a.m., and 9:49 a.m., with no response. Further observation failed to reveal any visible staff on the hallway of resident #18's room at the time of resident #18's call for assistance and resident #18's light over the door remained on until 9:55 a.m., when a staff member entered resident #18's room. During an interview on 07/24/2023 at 8:45 a.m. S12 Licensed Practical Nurse (LPN) reported resident #18's hall was short one CNA (certified nursing assistant) due to a call-in. S12 LPN reported the replacement CNA had not arrived at the facility yet. During resident council meeting on 07/24/2023 at 1:00 p.m. resident #259 reported, staffing is a problem and sometimes there are only 3 nurses in the facility. During an interview on 07/24/2023 at 8:30 a.m. resident #2 reported there was only one CNA assigned to his hall and she won't pull him up, turn him or get him up in his chair because she's pregnant, so he can't get up unless therapy gets him up. Review of resident #2's MDS (minimum data set) dated 07/14/2023, revealed resident #2 had a BIMS (brief interview mental status) score of 15, indicating intact cognition and required total assistance with bed mobility, transfers and toileting. During an interview on 07/25/2023 at 2:00 p.m. S13 CNA reported she was the only one on the hall and resident #2 required a Hoyer Lift to get out of bed with 2-3 people assisting. S13 CNA further reported she would have to go find someone on another hall to come help her if resident #13 wanted to get up. During an interview on 07/25/2023 at 8:30 a.m. resident #209 reported, We only have one CNA on the hall and either the she works herself to death or don't do anything at all and we don't get the help we need, we have waited at least an hour to get help. During an interview on 07/25/2023 at 10:30 a.m. S10 CNA reported she was unable to shower Resident #71 on 07/24/2023. S10 confirmed 07/24/23 was a scheduled shower day for Resident #71. S10 CNA reported the facility was short staffed on 07/24/2023 so she was unable to get resident #71 to the shower. Review of the facility's Resident Council Meeting Minutes revealed the following reported staffing issues: May 30, 2023- missing showers because no CNAs are available to assist, slow to get help getting in and out of bed. March 28, 2023- Slow response to call light on weekends. During an interview on 07/26/2023 at 3:00 p.m. S14 Administrator and S1 DON (Director of Nursing) reported the facility does their best to staff appropriately and confirmed staffing was an issue in the facility that was being monitored.

Based on observations and interviews the facility failed to provide a safe, functional environment. The facility failed to ensure: 1. Toilets were securely attached to the floor in resident #209's, and resident #7's bathrooms. 2. Resident #24's faucet was attached securely to the bathroom sink 3. Clean out receptacle on 200 hall was warped, uneven and unleveled. Findings: Observation on 07/24/2023 at 8:00 a.m. revealed resident #209's toilet was not secured to the floor and moved around. During an interview on 07/26/2023 at 9:00 a.m. resident #209 reported her toilet was loose and shook when she sat on it. Observation on 07/24/2023 at 8:15 a.m. revealed resident #7's toilet was not secured to the floor and moved around. Observation on 07/24/2023 at 8:20 a.m. revealed resident #24's bathroom faucet was loose and moved around. Observation on 07/26/2023 at 9:10 a.m. with S4 Maintenance Supervisor revealed resident #209's and resident #7's toilets were not secured to the floor and moved around. Observation on 07/26/2023 at 9:15 a.m. with S4 Maintenance Supervisor revealed the clean out receptacle on the 200 hall was warped, uneven and unleveled. During an interview on 07/26/2023 at 9:30 a.m. S4 Maintenance Supervisor confirmed resident #209's, resident #7's toilets, and resident #24's bathroom faucet should have been repaired. S4 Maintenance Supervisor also confirmed the clean out receptacle on the 200 hall should have been repaired.

Based on observations and interviews, the facility failed to provide a safe, sanitary, and comfortable environment by failing to ensure: 1. The dispensing area of the ice machine located on Hall A was clean; 2. The microwaves used for heating resident food items on Hall A, Hall B, and Hall C was clean; 3. The in-room air conditioning/heating units in 42 rooms (Rooms A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, P, Q, R, S, T, U, V, W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG, HH, II, JJ, KK, LL, MM, NN, OO, PP) were clean. There were 111 residents residing in the facility according to the facility provided census sheet. Findings: 1. Observation during the initial tour of the facility beginning on 04/24/2023 at 9:00 a.m. revealed the ice machine located on Hall A had a black slimy substance up inside and outside of the ice dispensing area. Observation on 04/25/2023 beginning at 9:53 a.m. revealed the ice machine located on Hall A had a black slimy substance up inside and outside of the ice dispensing area. During observation and Interview on 04/25/2023 beginning at 1:00 p.m., S1 Administrator observed the ice machine on Hall A, and agreed it was dirty and needed to be cleaned. S1 Administrator further indicated maintenance was responsible for keeping the ice machines clean. During an interview on 04/25/2023 at 1:41 p.m. S3 Maintenance Director, indicated housekeeping should wipe down the exterior surfaces of the ice machines, and maintenance was responsible for the internal components and surfaces. S3 Maintenance Director further indicated he must have missed cleaning the machine on the Hall A. During an interview on 04/26/2023 at 9:00 a.m. S4 Corporate Director of Physical Plant indicated housekeeping cleaned the outside surfaces of the machines, and maintenance was responsible for cleaning the inside components of the machine including the inside surfaces of the dispenser component. During an interview on 04/26/2023 at 9:13 a.m. S5 Assistant Dietary Manager indicated there was no ice machine in the kitchen. S5 Assistant Dietary Manager further indicated dietary staff did not clean the ice machines, but housekeeping was supposed to clean the exterior surfaces and maintenance was supposed to clean the internal components. 2. Observations during the initial tour of the facility beginning on 04/24/2023 at 9:00 a.m. revealed the microwaves for resident use located on the East end of Hall A, the East end of Hall B, and the [NAME] end of Hall C had food particles covering the inside top and sides. Observations in the building on 04/25/2023 beginning at 9:53 a.m. revealed the microwaves for resident use located on the East end of Hall A, the East end of Hall B, and the [NAME] end of Hall C had food particles covering the inside top and sides. During observations and interview on 04/25/2023 beginning at 1:00 p.m., S1 Administrator indicated housekeeping was responsible for cleaning microwaves for patient use in the hallways. S1 Administrator observed the microwaves for resident use on the hallways and agreed they were dirty with food buildup and needed to be cleaned. During an interview on 4/25/23 at 1:30pm S2 Housekeeping Supervisor reported the microwaves on the hallways that are used for heating residents' food items should be cleaned by housekeeping staff every morning and then again around 2:00 pm before they leave. 3. Observation on 04/24/2023 at 4:48 p.m. revealed the in-room air unit in Resident #3's room (Rm MM) had a thick buildup of a black slimy substance covering the air outflow area. Further observation revealed a thick dry flaky gray substance covering the air intake grates. During an interview on 04/24/2023 at 4:49 p.m. resident #3 reported she had never seen anyone clean the air unit in the room. Observations in the building on 04/25/2023 beginning at 9:53 a.m. revealed the following concerns: Rooms A, B, C, D, E and F in-room air units had black spotted areas and dark brown particles on the outflow areas; Rooms G, H, I, J, and O in-room air units had black moldy looking spots; Rooms K, L, M, N, P and Q had moderate to large amounts of fluffy gray particles on the air filters; Rooms R, S, T, U, V, W, X, Y, Z, AA, BB, CC, DD, PP, FF, GG, and KK in-room air units had a thick buildup of a black slimy substance covering the air outflow areas; Rooms EE, HH, JJ, LL, MM, NN, and OO had a thick buildup of a black slimy substance covering the air outflow areas and a thick dry flaky gray substance covering the air intake grates and the pull-out filters; Rm II had a thick buildup of a black slimy substance covering the air outflow area and a thick dry flaky gray substance covering the air intake grates. Further observation revealed the space for the pull-out filter was empty with no filter present. During Observations and Interview on 04/25/2023 beginning at 1:00 p.m., S1 Administrator indicated housekeeping was responsible for keeping the in-room air units clean. S1 Administrator observed the in-room air units and agreed the air outflow areas, air intake areas, and filters were dirty and needed to be cleaned. During an interview on 04/25/2023 at 1:29 p.m. S2 Housekeeping Supervisor indicated maintenance was supposed change the filters, but housekeeping was supposed to dust and clean the other surfaces of the in-room air units every day, and check the filter twice a week. S2 Housekeeping Supervisor further agreed housekeeping staff had not cleaned all of the units the way they should. During an interview on 04/25/2023 at 1:41 p.m. S3 Maintenance Director, indicated housekeeping should wipe down the surfaces of the in room air units, and maintenance was supposed to take out and clean the filters every 2 weeks and as needed. S3 Maintenance Director agreed the filters were dirty and needed to be cleaned and/or replaced.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to immediately consult with the resident's Physician and immediately notify a resident's responsible party when there was an accident involving the resident which resulted in injury for 1(#1) of 5(#1, #2, #3, #4, #5) residents sampled. Findings: Review of the facility's Change in a Resident's Condition or Status policy revealed the following: Policy statement Our facility shall promptly notify the resident, his or her Attending Physician or Nurse Practitioner and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) Policy Interpretation and Implementation 1. The nurse will notify the resident's Attending Physician, Nurse Practitioner or physician on call when there has been a(an): a. accident or incident involving the resident; b.discovery of injuries of an unknown source; . Record review of Resident #1's EHR (electronic health record) revealed the resident was admitted on [DATE]. The resident was discharged to an acute hospital on [DATE]. The resident returned to the facility on [DATE] on hospice care. The resident expired on [DATE]. Record review of Resident #1's diagnoses revealed the resident had an admitting diagnosis of dementia. Other diagnoses included, Alzheimer's disease, dependence on wheelchair, atrial fibrillation, long term use of anticoagulants, occlusion and stenosis of bilateral carotid arteries, psychotic disorder with delusions, history of venous thrombus and emboli, acquired absence of right leg above knee amputation, artherosclerosis of coronary artery bypass graft, history of transient ishaemic attach, and abnormalities of gait and mobility. Record review of Resident #1's comprehensive care plans revealed the resident was at risk for falls related to Alzheimer's dementia. Interventions included keep call bell in reach, place fall mat at bedside for safety, etc. Update to the care plan showed the resident was found on floor next to bed with laceration to forehead and was sent to emergency room for evaluation on [DATE]. Record review of Resident #1's Minimum Data Set, dated [DATE] showed the resident had a BIMS (brief interview for mental status) score of 99 indicating the resident interview was not successful. Record review of Resident #1's nurse notes revealed on [DATE] multiple notes from 10:40 a.m.-5:48 p.m. by S3 LPN (licensed practical nurse) that indicated S3 LPN was called to Resident #1's room when S4 CNA (certified nursing assistant) called out at 10:40 a.m. S3 LPN found resident lying on his right side close to his bed with a pool of blood noted on the floor, large open area to forehead measuring 5-6 millimeters, resident was alert but some confusion was noted at that time. It appeared that resident may have been attempting to transfer from wheelchair to bed. S3 LPN spoke with charge nurse at an acute hospital and informed her Resident #1 was in need of further evaluation after a fall and they said to send the resident at 10:50 a.m. At 10:55 a.m. S3 LPN contacted an ambulance service for transport. Ambulance arrived and received Resident #1 at 11:25 a.m. Resident #1's spouse is here, informed her of fall/transfer to acute hospital at 12:55 p.m. Record review of Resident #1's hospital records revealed an emergency department note indicating [AGE] year old male presented to emergency with chief complaint of head injury just prior to arrival. Head laceration coming from nursing home from an unwitnessed fall .CT (computerized tomography) scan on [DATE] showed large scalp hematoma overlying the right forehead with punctate areas of intraparenchymal hemorrhage involving right frontal lobe and left frontal lobe. An additional small focus of subarachnoid hemorrhage is present in the left parietal region. In the setting of obvious recent trauma to the head, the above described areas of intraparenchymal or subarachnoid hemorrhage could certainly be posttraumatic in nature. However, a follow-up MRI (magnetic resonance imaging) without and with IV (intravenous) contrast is recommended after acute symptoms resolve to assess the possibility of underlying metastatic disease to the brain. Discharge summary diagnosis included Wafarin induced coagulopathy, altered mental status, hemorrhage intracerebral, facial laceration, fall, dementia, and pleural effusion on left. During an interview on [DATE] at 1:15 p.m., Son of Resident #1 indicated his father had a fall with head laceration on [DATE]. Resident #1's RP (responsible party) was not called after the fall and the RP only found out about the fall and transport to hospital when she went to the facility to visit Resident #1. During an interview on [DATE] at 4:40 p.m. S2 DON (director of nursing) indicated S3 LPN was Resident #1's staff nurse on [DATE]. S4 CNA was the staff member that found Resident #1 on the floor in his room. When S2 DON talked to S4 CNA after the resident had fallen on [DATE], S4 CNA indicated that she had just passed Resident #1's room taking linens to the room past his and he was sitting in his wheelchair, after approximately 3-4 minutes S4 CNA walked back by Resident #1's room and saw him lying on the floor and she called out for S3 LPN to come to room. During a telephone interview on [DATE] at 12:10 p.m. S3 LPN indicated she was called to Resident #1's room by S4 CNA. The resident was on the floor with laceration on his forehead and she cleansed the laceration and applied gauze to the site with tape securing the dressing. Resident was alert but seemed confused. S3 LPN called an acute hospital to see if they could send the resident for further evaluation and the hospital indicated they would. S3 LPN then called an ambulance service for transport. S3 LPN indicated she did not call the Resident #1's RP to notify her about the incident, the RP showed up to the nursing home to visit Resident #1 and S3 LPN apologized to the RP for not calling her to let her know about the incident. She told the RP what happened and the name of the acute hospital. S3 LPN indicated she texted the NP (nurse practitioner) about the incident. S3 LPN texted S2 DON a screen shot of the text to the NP. S2 DON showed the text to surveyor and it was time stamped 5:04 p.m. on [DATE], and revealed S3 LPN informed the NP of two different resident falls and one was Resident #1 and was described as Resident #1 had an unwitnessed fall around 10:00 a.m. Hit his head and should require sutures. Resident has not come back as of yet. During an interview on [DATE] at 12:20 p.m. S2 DON confirmed the NP was not notified of Resident #1's fall until 5:04 p.m. on [DATE] via a text message from S3 LPN. S2 DON also confirmed Resident #1's RP was notified of the of Resident #1's fall with head laceration and transport to the hospital after the RP's arrival to visit Resident #1 at 12:55 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure care and service were provided in accordance with professional standards by not following physician orders for 6 (#1, #2, #3, #4, #5, #6) of 6 residents reviewed for quality of care. Findings: Review of the facility's Administering Medications policy with revision date of April 2019 revealed in part: Medications are administered in a safe and timely manner, and as prescribed .Medications are administered in accordance with prescriber orders, including any required time frame .Medications are administered within one (1) hour of their prescribed time, unless otherwise specified .If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall note on the MAR/EMAR (Medication Administration Record/Electronic Medication Administration Record) and sign or initial the reason for that drug and dose not given. The Physician will be notified for any drugs that are held or refused so that orders can be reviewed as necessary . Review of the facility's Charting and Documentation policy with revision date of July 2017 revealed in part: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .Documentation of procedures and treatments will include care-specific details, including: .Whether the resident refused the procedure/treatment . Resident #1 Review of Resident #1's record revealed an admit date of 04/29/2021 and diagnoses including but not limited to Peripheral Vascular Disease, unspecified sleep disorder, Heart failure, Vascular wounds to toes, restlessness and agitation. Review of Resident #1's January 2023 physician orders revealed orders including: 01/18/2023-Monitor for target behaviors every shift for use of psychotropic medication 01/18/2023-monitor for side effects of antidepressant medication every shift 12/21/2022-Trazodone 50 mg once daily at bedtime 11/28/2022-obtain a complete set of vital signs every shift 11/08/2022-Lasix (a diuretic) 40 mg (milligrams) twice a day 10/14/2022-Metolazone (a diuretic) 2.5 mg every day prior to morning Lasix dose 09/23/2022-Norco 50-325 tab give one tablet every 6 hours as needed for left toe pain 09/13/2022-Nifedipine ER (Extended Release) 30 mg every day, Hold if < (less than) 110/60 or heart rate <60 09/13/2022-Metoprolol ER 100 mg twice a day Hold if <110/60 or HR <60 04/22/2022-Eliquis (a blood thinner) 5 mg twice a day 12/03/2021-Monitor for edema related to diuretic therapy every shift; 0=no edema, 1=+1, 2=+2, 3=+3, notify MD (Medical Doctor) of +3 06/07/2021-observe for signs and symptoms of bleeding or bruising due to anticoagulant treatment-see nurses notes and notify physician 04/29/2021-assess pain every shift using a verbal/non-verbal scale Review of Resident #1's January 2023 MAR revealed the following were documented with a red N as not being administered/completed: Monitoring for target behaviors was not done for the p.m. shift by S3 LPN (Licensed Practical Nurse) on 01/19/2023 to 01/22/2023; Observation for signs and symptoms of bleeding or bruising due to anticoagulant therapy was marked as not done by S3 LPN for the p.m. shift on 01/01/2023 to 01/07/2023, 01/09/2023 to 01/16/2023 and 01/18/2023 to 01/25/2023; Monitoring for edema related to diuretic therapy was marked as not done for the p.m. shift by S3 LPN on 01/01/2023 to 01/07/2023, 01/09/2023 to 01/16/2023, and 01/18/2023 to 01/25/2023; Monitoring for side effects of antidepressant medication was marked as not done for the p.m. shift by S3 LPN on 01/19/2023 to 01/22/2023; Assessment for pain was marked as not done for the p.m. shift by S3 LPN on 01/01/2023 to 01/07/2023, 01/09/2023 to 01/16/2023, and 01/18/2023 to 01/25/2023; A complete set of vital signs was marked as not done for the p.m. shift by S3 LPN on 01/01/2023 to 01/07/2023, 01/09/2023 to 01/16/2023, and 01/18/2023 to 01/25/2023, and was not done by S4 LPN on 01/17/2023; Review of the January 2023 MAR Administration Notes failed to reveal a documented reason monitoring and medication administration was not done as ordered. Resident #2 Review of Resident #2's medical record revealed and admission date of 07/30/2021 with diagnoses that included, in part, chronic pain syndrome and uncomplicated opioid dependence, Neuromuscular dysfunction of bladder, essential hypertension, pressure ulcer of sacral region Stage 4, anxiety disorder unspecified, bipolar disorder unspecified, major depressive disorder, insomnia unspecified, unspecified psychosis not due to a substance or known physiological condition, and paraplegia unspecified. Review of Resident #2's January 2023 physician orders revealed: 01/17/2023 Trazodone (antidepressant) 100mg tablet-give 2 tablets=200mg by mouth at bedtime daily for insomnia 05/31/2022 Cymbalta (antidepressant) 60mg capsule - give one capsule by mouth daily. 02/28/2022 Monitor for side effects of antidepressant medication every shift. 06/30/2022 Monitor for target behaviors every shift for use of psychotropic medication 05/31/2022 Furosemide 40mg tablet give one tablet by mouth daily. 02/28/2022 Monitor for edema related to diuretic therapy every shift: 0=no edema, 1=+1, 2=+2, 3=+3, Notify MD of +3. 09/8/2022 Percocet 10-325mg tablet-one tablet by mouth every six hours as needed for pain. 02/28/2022 Assess pain every shift using a verbal/non-verbal scale 03/7/2022 Cat: May have indwelling foley catheter in place every shift DX (Diagnosis): Stage IV sacral wound, Size 20FR (French), Balloon: 30ml (milliliters) 06/20/2022 Cat: Monitor urine consistency every shift 1=clear, 2=cloudy, 3=mucus if negative findings notify MD. 02/28/2022 Cat: Monitor urine color every shift 1=yellow, 2=bloody, 3=dark If negative findings notify MD. Review of Resident #2's January 2023 MAR revealed the following were documented with a red N as not being administered/completed: -Monitoring for edema was marked as not done on the p.m. shift by S3 LPN for days 01/01/2023 to 01/07/2023, 01/09/2023 to 01/16/2023, and 01/18/2023 to 01/25/2023. -Monitoring for Target behaviors for use of psychotropic medication was marked as not done on the p.m. shift by S3 LPN for days 01/01/2023 to 01/07/2023, 01/09/2023 to 01/16/2023, and 01/18/2023 to 01/25/2023. -Monitoring for side effects of antidepressant medication was marked as not done on the p.m. shift by S3 LPN for days 01/01/2023 to 01/07/2023, 01/09/2023 to 01/16/2023, and 01/18/2023 to 01/25/2023. -Assessment for pain using a verbal/non-verbal scale was marked as not done on the p.m. shift by S3 LPN for days 01/01/2023 to 01/07/2023, 01/09/2023 to 01/16/2023, and 01/18/2023 to 01/25/2023. -Monitoring for urine color and monitoring for urine consistency was marked as not done on the p.m. shift by S3 LPN for days 01/01/2023 to 01/07/2023, 01/09/2023 to 01/16/2023, and 01/18/2023 to 01/25/2023. Review of the Resident #2's January 2023 MAR Administration Notes failed to reveal a documented reason monitoring and medication administration was not done as ordered Resident #3 Review of Resident #3's medical record revealed Resident #3 was admitted to the facility on [DATE] and had diagnoses that included, in part, Hemiplegia following cerebral infarction affecting left nondominant side, aphasia following unspecified cerebrovascular disease, cognitive communication deficit, COPD, encephalopathy, cerebral infarction, anxiety disorder, pseudobulbar affect, pain unspecified, essential hypertension, and bipolar disorder. Review of Resident #3's January 2023 physician orders revealed: 08/08/2022 Cymbalta 30mg capsule give one capsule by mouth daily. 05/31/2022 Monitor for side effects of antidepressant medication every shift. 04/24/2022 Monitor for target behaviors every shift for use of psychotropic medication 06/20/2022 Norco 10-325 tablet-give one tablet by mouth every 6 hours. 05/31/2022 Assess pain every shift using a verbal/non-verbal scale 03/30/2020 Check temperature every shift. 06/01/2020 Check O2 (oxygen) sat (saturation) every shift Review of Resident #3's January 2023 MAR revealed the following were documented with a red N as not being administered/completed: -Monitoring for target behaviors for use of psychotropic medication was marked as not done on the p.m. shift by S3 LPN for days 01/01/2023 to 01/07/2023, 01/09/20213 to 01/16/2023 and 01/18/2023 to 01/25/2023. -Monitoring for side effects of antidepressant medication was marked as not done on the p.m. shift by S3LPN from 01/01/2023 to 01/07/2023, 01/09/2023 to 01/16/2023, and 01/18/2023 to 01/25/2023 for the PM shift. -Assessment of pain was marked as not done on the p.m. shift by S3 LPN from 01/01/2023 to 01/07/2023, 01/9/2023 to 01/16/2023, and 01/18/2023 to 01/25/2023. -Temperature check was marked as not done by S5 LPN on the p.m. shift on 01/08/2023; Temperature checks was marked as not done by S3 LPN on the p.m.shift on 01/01/2023 to 01/07/2023, 01/9/2023 to 01/16/2023, and 01/18/2023 to 01/25/2023; and Temperature check was marked as not done by S4 LPN on the p.m. shift on 01/17/2023. -O2 (Oxygen) saturation check was marked as not done by S5 LPN on the p.m. shift on 01/08/2023; O2 saturation checks were marked as not done by S3 LPN on the p.m. shift on 01/01/2023 to 01/07/2023, 01/09/2023 to 01/16/2023, and 01/18/2023 to 01/25/2023; and O2 saturation check was marked as not done by S4 LPN on the p.m. shift on 01/17/2023. Review of the January 2023 MAR Administration Notes failed to reveal a documented reason monitoring and medication administration was not done as ordered. Resident #4 Review of Resident #4's medical record revealed Resident #4 was admitted to the facility on [DATE] and had diagnoses that included, in part, other specified depressive episodes, pain, encounter for attention to colostomy, pain unspecified, other primary disorders of muscles, essential hypertension, quadriplegia unspecified, autonomic dysreflexia, weakness, retention of urine unspecified, and neuromuscular dysfunction of bladder unspecified. Review of Resident #4's December 2023 physician orders revealed the following orders: 02/23/2022 Cat: May have suprapubic catheter in place every shift, Dx: Neuromuscular dysfunction of bladder, unspecified Size: 18FR, Balloon: 10cc 02/23/2022 Cat (catheter): Monitor urine color every shift 1=yellow, 2=bloody, 3=dark, If negative findings notify MD 02/23/2022 Cat: Monitor urine consistency every shift 1=clear, 2=cloudy, 3=mucus, if negative findings notify MD. 02/23/2022 Colostomy care every shift-Observe for periosteal irritation. Changes in Stoma Color, change in stoma drainage, stoma protrusion and/or edema, etc.-Report to NP (Nurse Practitioner)/MD if indicated. 02/23/2022 Hydrocodone 10mg-Acetaminophen 325mg tablet give one tablet by mouth twice daily as needed for pain. 02/23/2022 Assess pain every shift using a verbal/non-verbal scale. 02/23/2022 Check oxygen saturation every shift 02/23/3033 Check temperature every shift Review of Resident #4's January 2023 MAR revealed the following were documented with a red N as not being administered/completed: -Monitoring for urine color and monitoring for urine consistency was marked as not done on the p.m. shift by S3 LPN for 01/01/2023 to 01/07/2023, 01/09/2023 to 01/14/2023, 01/16/2023 and 01/18/2023 to 01/25/2023. -Assessment for pain was marked as not done by S3 LPN for the p.m. shift on days 01/01/2023 to 01/07/2023, 01/09/2023 to 01/14/2023, 01/16/2023 and 01/18/2023 to 01/25/2023. -Colostomy Care was marked as not done by S3 LPN for the p.m. shift for 01/01/2023 to 01/07/2023, 01/09/2023 to 01/14/2023, 01/16/2023, and 01/18/2023 to 01/25/2023. -Oxygen saturation was marked as not done by S5 LPN for the a.m. shift on 01/08/2023; Oxygen saturation was marked as not done by S3 LPN for the p.m. shift on days 01/01/2023 to 01/07/2023, 01/09/2023 to 01/14/2023, 01/16/2023 and 01/18/22023 to 01/25/2023; Oxygen saturation was marked as not done by S4 LPN for the p.m. shift on 01/17/2023. -Temperature check was marked as not done by S5 LPN for the a.m. shift on 01/08/2023; Temperature check was marked as not done by S3 LPN for the p.m. shift on days 01/01/2023 to 01/07/2023, 01/09/2023 to 01/14/2023, 01/16/2023, and 01/18/2023 to 01/25/2023; Temperature check was marked as not done by S4 LPN for the p.m. shift on 01/17/2023. Review of the January 2023 MAR Administration Notes failed to reveal a documented reason monitoring and medication administration was not done as ordered. Resident #5 Review of Resident #5's record revealed an admit date of 03/23/2022and diagnoses including but not limited to: unspecified fracture to shaft of humerus, left arm, Type 2 diabetes mellitus with hyperglycemia. Review of Resident #5's January 2023 Physician orders revealed orders including: 08/25/2022-monitor for side effects of pain medications every shift 06/27/2022-Levemir U-100 unit/ml (milliliter) give 45 units subcutaneous daily at bedtime, accucheck at bedtime 05/30/2022-accucheck before meals and at bedtime 03/23/2022-assess pain every shift using a verbal/non-verbal scale 03/23/2022-hydrocodone 5 mg-acetaminophen 325 mg every 8 hours as needed for moderate to severe pain Review of Resident #5's January 2023 MAR revealed the following were documented with a red N as not being administered/completed: 6:00 a.m. accucheck was marked as not done by S3 LPN on 01/04/2023, 01/05/2023, 01/10/2023, 01/14/2023, 01/16/2023, 01/18/2023, or 01/29/2023; 8:00 p.m. (bedtime) accucheck was marked as not done by S3 LPN on 01/02/2023 to 01/06/2023, 01/08/2023 to 01/15/2023, 01/17/2023 to 01/22/2023, and 01/24/2023; Levemir U-100 unit/ml 45 Units subcutaneous at bedtime was marked as not administered by S3 LPN on 01/02/2023 to 01/06/2023, 01/08/2023 to 01/15/2023, 01/17/2023 to 01/22/2023, and 01/24/2023; Assessment for pain on the p.m. shift was marked as not done by S3 LPN on 01/01/2023 to 01/07/2023, 01/09/2023 to 01/16/2023, and 01/18/2023 to 01/25/2023. Review of the January 2023 MAR Administration Notes failed to reveal a documented reason monitoring and medication administration was not done as ordered. During an interview on 01/25/2023 at 12:05 p.m. Resident #5 indicated the nurse did not always do her bedtime accucheck or give her bedtime dose of insulin. Resident #6 Review of resident #6's record revealed an admit date of 11/17/2022 and diagnoses including but not limited to: diabetes with diabetic neuropathy, chronic venous insufficiency, Depression, Edema, Mood disorder due to known physiologic condition with depressive features, unspecified psychosis not due to a substance or known physiologic condition, history of pulmonary embolism, generalized anxiety disorder. Review of Resident #6's January 2023 physician orders revealed orders including: 01/23/2023-monitor for adverse reactions related to antibiotic therapy every shift 01/23/2023-terbinafine 250 mg every day for seven days 01/06/2023-Risperdal 0.5 mg three times a day 01/06/2023-Lexapro 10 mg every day 12/26/2022-monitor for side effects of antidepressant medication every shift 12/19/2022-Klonopin 0.5 mg twice a day as needed for anxiety 12/12/2022-Monitor for target behaviors every shift for use of psychotropic medication 12/12/2022-monitor for side effects of antipsychotic medication every shift 11/22/2022-Coreg 3.125 mg twice a day, Hold for SBP <100 HR <60 11/18/2022 Glipizide (oral medication for blood sugar) 5 mg every day 11/17/2022-obtain a full set of vital signs q shift 11/17/2022-Xarelto (a blood thinner) 10 mg every day 11/17/2022-Novolog 100 u/ml vial (a fast acting insulin) inject subcutaneously per sliding scale before meals and at bedtime 11/17/2022-Lantus U-100 insulin 100 Unit/ml (a long acting insulin) give 50 units subcutaneous twice daily 11/17//2022-Percocet 10-325mg three times a day for chronic pain Review of Resident #6's January 2023 MAR revealed the following were documented with a red N as not being administered/completed: 6:00 a.m. Accuchecks were not done and sliding scale insulin was not administered by S3 LPN on 01/05/2023, 01/06/2023, 01/10/2023, 01/13/2023, 01/15/2023, 01/18/2023, and 01/22/2023; 8:00 p.m. Accuchecks were not done and sliding scale insulin was not administered by S3 LPN on 01/01/2023 to 01/06/2023, 01/08/2023 to 01/10/2023, 01/12/2023 to 01/15/2023, 01/17/2023, 01/18/2023, 01/21/2023, and 01/22/2023; 8:00 p.m. Lantus Insulin (long acting insulin) was not administered on 01/01/2023 to 01/06/2023, 01/08/2023 to 01/15/2023, 01/17/2023, 01/18/2023, and 01/20/2023 to 01/22/2023; Percocet scheduled for 6:00 a.m. for chronic pain was not administered by S3 LPN on 01/06/2023, 01/10/2023, 01/13/2023, 01/15/2023, 01/18/2023, and 01/22/2023; Percocet scheduled for 10:00 p.m. for chronic pain was not administered by S3 LPN on 01/02/2023, 01/05/2023, 01/12/2023, 01/14/2023, 01/17/2023 to 01/21/2023, and 01/24/2023; Coreg 3.125 mg scheduled for 8:00 p.m. was not administered by S3 LPN on 01/01/2023 to 01/06/2023, 01/08/2023 to 01/15/2023, 01/17/2023, 01/19/2023 to 01/23/2023, and was not administered by S4 LPN on 01/16/2023; Observation for signs and symptoms of bleeding or bruising due to anticoagulant therapy, monitoring for side effects of antipsychotic medication, monitoring for side effects of antidepressant medication, and assessment for pain were not done for the p.m. shift by S3 LPN on 01/01/2023 to 01/07/2023, 01/09/2023 to 01/16/2023, and 01/19/2023 to 01/25/2023. A full set of vital signs was not obtained for the p.m. shift by S3 LPN on 01/01/2023 to 01/07/2023, 01/09/2023 to 01/16/2023, and 01/18/2023 to 01/25/23, and was not done on by S4 LPN on 01/17/2023. Review of the January 2023 MAR Administration Notes failed to reveal a documented reason monitoring and medication administration was not done as ordered. During an interview on 01/25/2023 at 12:00 p.m. Resident #6 indicated S3 LPN came in her room during the night shift, but did not always check her glucose or give her bedtime insulin. Further review of Resident #1, #2, #3, #4, #5, and #6's January 2023 MARs revealed a legend at the top of each page of the MARs: * Not scheduled, Administered, N Not Administered ?See Details Report for SR Details During a telephone interview on 1/25/2023 at 9:30 a.m. S3 LPN reported a red N on the MAR indicated medication was not administered or a task was not completed. S3 LPN further indicated any time she documented an N on Residents #1, #2, #3, #4, #5, #6's MAR for monitoring, assessments, or vital signs it was because the residents had either refused or were asleep and she wasn't going to wake them up. An interview was conducted with S2 DON (Director of Nursing) on 01/25/2023 at 4:55 p.m. with S1 Administrator present. S2 DON reviewed the January 2023 MARs for Resident's #1, #2, #3, #4, #5, #6 and confirmed monitoring was not done as ordered, vital signs were not done as ordered, and accuchecks and insulin administration was not done as ordered and should have been. S2 DON further indicated if nursing staff had a reason for not completing care as ordered, it should be documented in the MAR administration notes and was not. During a telephone interview on 01/25/2023 at 10:33 p.m. S3 LPN confirmed she did not check Resident #5 and Resident #6's accucheck blood sugar or administer residents their insulin as ordered on days the MAR was marked with an N because the residents refused. S3 LPN further confirmed the MAR administration notes should indicate the residents' refusals and did not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews the facility failed to ensure residents were free from accident hazards for 1 resident (Resident #3) out of a total sample of 6 residents. The facility failed to ensure Resident #3 had fall mats in place as per physician order. Findings: Review of Resident #3's medical revealed Resident #3 was admitted to the facility on [DATE] and had diagnoses that included, in part, hemiplegia following cerebral infarction affecting left non-dominant side, other abnormalities of gait, cognitive communication deficit, contracture of muscle left upper arm, contracture left hand, contracture of left knee, other lack of coordination, muscle wasting and atrophy of left and right upper arm, encephalopathy, cerebral infarction, repeated falls, pain unspecified, and essential hypertension. Review of physician orders revealed an 11/28/2022 order for Bilateral floor mats in place while in bed. Review of care plan revealed Resident #3 was a Fall risk related to CVA (cerebrovascular accident) left sided weakness and a history of falls with interventions that included, in part, bilateral floor mats in place while in bed. Observation on 01/23/2023 at 7:57 a.m. revealed Resident #3 was lying in bed with head of bed elevated being assisted by CNA (Certified Nursing Assistant) with breakfast meal. No fall mats were in place. Observation on 01/24/2023 at 8:42 a.m. revealed Resident #3 was lying bed and no fall mats were present. Observation on 01/25/2023 at 8:05 a.m. revealed Resident #3 was asleep in bed and no fall mats were present. During an interview on 01/25/2023 at 2:11 p.m. S6 LPN (Licensed Practical Nurse) observed Resident #3's room and agreed there was no fall mats in Resident #3's room and there should be. During an interview on 01/25/2023 at 2:25 p.m. S7 CNA reported she had worked with Resident #3 for about a year and she had never seen fall mats in Resident #3's room.