**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents by failing to ensure a fall mat was positioned appropriately for 1 (#42) of 2 (#42 and #68) residents reviewed for falls. Findings: Review of the record for resident #42 revealed an admission date of 11/14/2022 with diagnoses including type 2 diabetes mellitus, dementia, unsteadiness on feet, orthostatic hypotension, and age-related osteoporosis. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 5 which indicated that resident #42 was severely cognitively impaired for daily decision making. Further review revealed resident #42 required partial/moderate assistance with bed mobility, transfers, and meals. Resident #42 was frequently incontinent and dependent upon staff for toileting. Review of resident #42's current plan of care revealed, effective 07/01/2024, revealed fall mats were to be applied to both sides of bed. Review of resident #42's fall risk evaluation dated 03/26/2025 revealed a fall risk score of 15 which indicated resident #42 was at high risk for falls. On 04/01/2025 at 10:16 a.m., resident #42 was observed lying supine in the bed with head of bed elevated. Further observation of resident #42 revealed a fall mat was not in place on the right side of the bed. On 04/01/2025 at 1:47 p.m., resident #42 was observed lying in the bed. Further observation of resident #42 revealed a fall mat was not in place on the right side of the bed. On 04/01/2025 at 1:47 p.m., an interview with S5Certified Nursing Assistant (CNA) confirmed that a fall mat should be in place on the right side of resident #42's bed. On 04/01/2025 at 4:20 p.m., S2Director of Nursing (DON) was notified that the fall mat was not in place on the right side of resident #42's bed. On 04/02/2025 at 10:09 a.m., S1Administrator was notified that the fall mat was not in place on the right side of resident #42's bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #33 Review of the medical record revealed resident #33 was admitted to the facility on [DATE] and re-admitted after a hospitalization on 03/29/2025. Review of the medical record revealed the resident had diagnoses including COPD, morbid obesity, muscle weakness, lack of coordination, anxiety disorder, hypertension, congestive heart failure, and depression. Review of the quarterly MDS assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively aware and able to make daily decisions. Further review revealed the resident required maximal assistance from staff for activities of daily living. Review of the current physician's orders revealed an order for oxygen at 2 liters per nasal cannula dated 10/23/2024. Observation on 03/31/2025 at 1:29 p.m. revealed sampled resident #33 was lying in bed with oxygen per nasal cannula at 1.5 liters. Observation of the outside of the door revealed no sign that oxygen was being used. Observation on 04/01/2025 at 11:10 a.m. revealed sampled resident #33 was sitting up in the wheelchair with oxygen per nasal cannula at 1.5 liters and the resident's door revealed no signage in regards to oxygen being in use. Observation on 04/02/2025 at 8:10 a.m. revealed sampled resident #33 was sitting up in the bed with oxygen per nasal cannula at 2.5 liters and the resident's door revealed no signage in regards to oxygen being in use. Interview on 04/02/2025 at 1:10 p.m. with S1Administrator confirmed there should have been a sign in regards to oxygen in use on the outside of the resident's door and that the resident's oxygen should have been at 2 liters per nasal cannula as ordered by the physician. Based on observations, record reviews, and interviews, the facility failed to ensure that each resident received necessary respiratory care and services that is in accordance with physician's orders, professional standards of practice, and the resident's care plan by: 1.) not administering the prescribed amount of oxygen as ordered for 2 (#33, #57) of 2 residents and 2.) not having signage on the outside of the resident's door to indicate oxygen was in use for 1 (#33) of 2 (#33, #57) residents reviewed for respiratory care. Findings: Review of the facility's Oxygen Administration policy (undated) revealed the following, in part: Purpose The purpose of this procedure is to provide for safe oxygen administration. Preparation Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen. Review of the resident's care plan to assess for any special needs of the resident. Equipment and supplies No Smoking/Oxygen in Use signs. Steps in the Procedure Place an Oxygen in Use sign on the outside of the room entrance door. Resident #57 Review of the medical record for resident #57 revealed diagnoses including chronic obstructive pulmonary disease (COPD), generalized anxiety disorder, major depressive disorder, unsteadiness on feet, myopathy, muscle weakness, and epilepsy. Review of the March 2025 physician's orders revealed an order dated 11/21/2023 for oxygen at 2 liters (L) per nasal cannula continuous. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #57 had intact cognition for daily decision making and required assistance with activities of daily living. Review of the care plan revealed resident #57 received oxygen therapy related to COPD. Further review of the care plan also revealed that oxygen was to be administered at 2 liters per nasal cannula continuous. On 03/31/2025 at 9:50 a.m., 04/01/2025 at 2:40 p.m., and 04/02/2025 at 8:20 a.m. observations of resident #57's oxygen flow rate revealed that her oxygen flow rate was set at 3 liters. On 04/02/2025 at 8:30 a.m., S1Administrator was informed that resident #57's oxygen was not administered per the physician's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to implement policies and procedures for Enhanced Barrier Precautions (EBP) for 1 (#155) of 1 residents reviewed for EBP. Resident #155 had a wound that was being treated to her right ankle and there was not a sign on the outside of her door to indicate EBP needed to be implemented. Findings: Review of the facility's EBP policy revised on 04/2024 revealed the following, in part: EBP are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation 1. EBPs are used as an infection prevention and control intervention to reduce the spread of MDROs to residents. 11. Signs are posted on the door or wall outside the resident room indicating the type of precautions and personal protective equipment. Review of the medical record for resident #155 revealed an admission date of 03/07/2025 with diagnoses including chronic obstructive pulmonary disease, cognitive communication deficit, diabetes mellitus, dysphagia, muscle weakness, heart failure, and pulmonary fibrosis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident #155 was cognitively intact for daily decision making. Resident #155 required assistance with activities of daily living. Review of the March 2025 Physician's orders revealed an order dated 03/08/2025 for wound care to a diabetic ulcer to the right lateral malleolus to be done daily and as needed (prn) soilage or dislodgement. Cleanse with wound cleanser, pat dry with gauze, apply Medihoney to wound bed, cover with Calcium Alginate, and cover with a dry foam dressing. On 03/31/2025 at 9:55 a.m. and 04/01/2025 at 8:40 a.m., observations of the outside of resident #155's door revealed there was no signage to indicate the resident was on EBP. On 04/01/2025 at 10:30 a.m., an interview with S3Licensed Practical Nurse (LPN)/Wound Care Nurse (WCN) confirmed resident #155 currently received treatment to a diabetic ulcer to her right ankle. S3LPN/WCN further confirmed resident #155's door did not have signage on the outside to indicate EBP was required. On 04/01/2025 at 12:30 p.m., S2Director of Nursing (DON) was notified that there was no signage on the outside of resident #155's door to indicate the resident required EBP.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 40 Review of the medical record for resident #40 revealed an admission date of 11/07/2018 with diagnoses including Alzheimer's disease, cerebral infarction, heart disease, and seizures. Review of the quarterly MDS assessment dated [DATE] revealed the facility was unable to assess resident #40's BIMS score. Resident #40 required extensive assistance with bed mobility and was totally dependent on staff for transfers and toilet use. On 03/31/2025 at 1:05 p.m. and 04/01/2025 at 11:30 a.m., observations of resident #40 revealed he was lying in the bed with half bed rails raised on both sides of the bed. Review of the Physician's orders for resident #40 revealed no documented evidence of an order for bed rails. Review of the current care plan revealed resident #40 had limited physical mobility with an intervention for bedrails as needed or desired for increased mobility and transfers. Review of the Side Rail/Bed Mobility/Lift assessment dated [DATE] revealed right and left half rails were utilized. On 04/01/2025 at 1:00 p.m. interview with S2DON confirmed resident #40 did not have a physician's order for the bed rails. On 04/02/2025 at 8:10 a.m. S1Administrator was notified that resident #40 did not have a physician's order for bed rails as stated in the facility's Bed/Side Rail policy. Resident 155 Review of the medical record for resident #155 revealed an admission date of 03/07/2025 with diagnoses including chronic obstructive pulmonary disease, cognitive communication deficit, diabetes mellitus, dysphagia, muscle weakness, heart failure, and pulmonary fibrosis. Review of the MDS assessment dated [DATE] revealed resident #155 was cognitively intact for daily decision making. Resident #155 required extensive assistance with bed mobility, toilet use, and limited assistance with transfers. On 03/31/2025 at 9:55 a.m., 04/01/2025 at 8:40 a.m. and 10:00 a.m., observations of resident #155 revealed she was in the bed with half bed rails raised on both sides of the bed. Review of the Physician's orders for resident #155 revealed no documented evidence of an order for bed rails. Review of the Side Rail/Bed Mobility/Lift assessment dated [DATE] revealed right and left half rails were utilized. On 04/01/2025 at 2:40 p.m., S2Director of Nursing (DON) confirmed resident #155 did not have a physician's order for bed rails. On 04/02/2025 at 7:45 a.m. S1Administrator was notified that resident #155 did not have a physician's order for bed rails as stated in the facility's Bed/Side Rail policy. Based on observations, record reviews and interviews, the facility failed to ensure residents had an order for bed rails as stated in the facility's policy for 4 (#40, #52, #88 and #155) of 4 residents reviewed for bed rails. The facility failed to ensure that bed rails were maintained properly for 1 (#88) of 4 (#40, #52, #88 and #155) residents reviewed for bed rails. Findings: Review of the facility's Bed/Side Rail policy and procedure effective 11/28/2017 revealed the following, in part: 1.1 Purpose: To ensure a bed is appropriate for the resident and that if bed rails are required, they are utilized, installed, and maintained properly. 1.5 Policy Bed rails require a physician order and the order must state the reason for bed rail use. Resident #52 Review of the record for resident #52 revealed an admission date of 05/12/2022 with diagnoses including type 2 diabetes mellitus, polyneuropathy, pressure ulcer of sacral region stage 4, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 14 which indicated that resident #52 was cognitively intact for daily decision making. Further review revealed that resident #52 required partial/moderate assistance with bed mobility, and substantial/maximal assistance with transfers. Review of the March 2025 Physician's orders for resident #52 revealed no order for bed rails. Review of resident #52's current plan of care revealed that a bedrail was used as needed or desired for increased mobility and transfers due to limited mobility. Review of resident #52's Side Rail/Bed Mobility/Lift assessment dated [DATE] revealed that right and left half bed rails were initiated on 10/21/2024. Further review revealed that the bed rails were to be utilized while in bed for mobility and positioning. On 04/01/2025 at 10:23 a.m. resident #52 was observed in bed and both the right and left bed rails were raised. On 04/02/2025 at 8:11 a.m. resident #52 was observed sitting upright in bed with right and left bed rails raised. On 04/02/2025 at 10:09 a.m. S1Administrator was notified that resident #52 did not have a physician's order for bed rails as stated in the facility's Bed/Side Rail policy. Resident #88 Review of the record for resident #88 revealed an admission date of 01/09/2025 with diagnoses including chronic kidney disease, urinary retention, obstructive uropathy, constipation, and generalized muscle weakness. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 13 which indicated that resident #88 was cognitively intact for daily decision making. Further review revealed resident #88 required substantial/maximal assistance with bed mobility, and was dependent on staff for toileting and transfers. Review of the March 2025 Physician's orders for resident #88 revealed no order for bed rails. Review of resident #88's Side Rail/Bed Mobility/Lift assessment dated [DATE] revealed that right and left half bed rails were initiated on 02/21/2025. Further review revealed that the bed rails were to be utilized while in bed for mobility. On 03/31/2025 at 8:45 a.m., resident #88 was observed seated upright in the bed with the right and left bed rails raised and the right bed rail was loose. On 04/01/2025 at 10:08 a.m., observation of resident #88's bed revealed the right bed rail was loose. On 04/01/2025 at 10:29 a.m., observation of resident #88's bed rails with S6Maintenance Supervisor confirmed the right bed rail was loose and needed to be repaired. On 04/02/2025 at 10:09 a.m., S1Administrator was notified that resident #52 did not have a physician's order for bed rails as stated in the facility's Bed/Side Rail policy, and the right bed rail was loose.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Medication Storage Room On 03/31/2025 at 2:43 p.m., an observation of the facility's medication room revealed: 1 bottle of Aspirin 325 milligrams (mg), 100 tablets expired on 12/2024; 1 bottle of Famotidine 10 mg, 30 tablets expired on 02/2025; 1 Surecan Safety II needle expired on 09/11/2024; 1 Insyte Autoguard 24 gauge 0.75 inch needle, expired on 12/31/2023; and, 1 Miniloop with extended intravenous connector, expired on 10/21/2022. On 03/31/2025 at 2:50 p.m., an interview with S4LPN confirmed the medications and resident supplies were expired and available for resident use. On 03/31/2025 at 3:30 p.m., S2Director of Nursing (DON) was notified of the expired medications and resident supplies that were stored in the medication room and available for resident use. Based on observations, record review, and interviews, the facility failed to ensure 1) drugs and biologicals used in the facility were stored properly in a locked compartment by leaving a medication at resident's bedside for 1 (#57) of 1 residents reviewed for medication storage and 2) expired medications and resident supplies were not stored in the medication storage room and accessible for resident use. Findings: Review of the facility's Storage of Medications policy Revised November 2020 revealed the following, in part: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Resident #57 Review of medical records for resident #57 revealed diagnoses of chronic obstructive pulmonary disease (COPD), generalized anxiety disorder, major depressive disorder, unsteadiness on feet, myopathy, muscle weakness, and epilepsy. Review of the March 2025 Physician's orders revealed an order dated 01/28/2025 for Xopenex Hydrofluoroalkane (HFA) Inhalation Aerosol 45 micrograms/actuation (Levalbuterol Tartrate) 2 puff inhale orally every 6 hours as needed for COPD Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition for daily decision making and required assistance with activities of daily living. On 03/31/2025 at 9:50 a.m. a Xopenex inhaler was observed in resident #57's room on her bedside table. Interview with resident #57 revealed that she keeps the inhaler in her room and administers this medication herself. On 04/01/2025 at 2:20 p.m. record review revealed no order from physician to keep Xopenex inhaler at the bedside. On 04/01/2025 at 2:45 p.m., an interview with S7Licensed Practical Nurse (LPN) revealed that resident #57 has been keeping the Xopenex inhaler at her bedside for a while. S7LPN also stated that she could not find a physician's order for the medication to be kept in resident's room. On 04/02/2025 at 8:30 a.m. an interview with S1Administrator confirmed that resident #57 had been keeping her inhaler at her bedside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and interviews, the facility failed to ensure all allegations of physical abuse by staff was reported immediately to the state agency, but no later than 2 hours after the allegation was made to the administrator for 1 (#1) of 4 (#1, #2, #3, and #4) residents investigated for abuse. Findings: Review of the facility's policy titled Abuse Components Plan with an effective date of 10/24/2022 revealed: 1) An alleged violation involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of property/funds, and/or any other reportable incident will be reported immediately, but no later than: a) Two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury; or b) Twenty-four (24) hours if the alleged violation does not involve does not involve abuse, AND has not resulted in serious bodily injury. Results of alleged violations must be within 5 working days of the incident. Review of the medical record revealed that resident #1 was admitted to the facility on [DATE] with diagnoses including, a fracture of the left proximal humerus, schizophrenia, history of falling, generalized muscle weakness, unsteadiness on feet, cognitive communication deficit, and severe morbid obesity. Review of the Minimum Data Set (MDS) dated [DATE] revealed that resident #1 had a documented brief interview for mental status score of 13. A score of 13-15 indicated the resident was cognitively intact with daily decision making skills. Review of the care plan with an initiated date of 06/25/2024, revealed resident #1 had an Activities of Daily Living (ADL) self-care performance deficit. Further review revealed resident #1 required two staff for repositioning, turning, dressing, and toilet use. Review of the grievance report dated 08/01/2024 revealed that S1Administrator was notified on 08/01/2024 at approximately 2:45 p.m. by resident #1's family member, of an allegation involving S3CNA striking resident #1 in his face, scratching his testicles, and pulling resident #1's fractured arm, and rebreaking his arm. Further review of the grievance report revealed there was no documentation of a report to the state agency initiated. On 08/05/2024 at 10:30 a.m., an observation revealed resident #1 was in his room, lying in his bed. Further observation revealed the resident had a sling in place to his left arm. During an interview with resident #1, he revealed that a worker had pulled his left arm, pushed on him hard while turning him in the bed, wiped his testicles roughly when cleaning him, and she had hit resident #1 on the right side of his face. On 08/05/2024 at 12:42 p.m., an interview with S5Licensed Practical Nurse (LPN) revealed that last week (referring to the week of 07/29/2024 through 08/04/2024) resident #1 had reported to S5LPN that S3CNA had wiped him roughly during incontinent and pushed him hard when turning resident #1 on his side. S5LPN further revealed that she had notified S1Administrator and S6CNA Supervisor of the allegations reported to her (S5LPN) by resident #1. On 08/06/2024 at 9:35 a.m., an interview with S3CNA revealed that she had worked with resident #1 on 08/01/2024 from 6:00 a.m. to 2:00 p.m. She further revealed that resident #1 reported that she (S3CNA) wiped his testicles too hard. During an interview on 08/06/2024 at approximately 5:30 p.m. with S1Administrator and S2Director of Nursing, S1Administrator confirmed that she had not initiated a report to the state agency after becoming aware of an allegation of abuse on 08/01/2024, involving resident #1 and S3CNA.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs. The facility failed to ensure CNAs implemented the care plan for 1 (#1) of 4 (#1, #2, #3, and #4) residents reviewed for Activities of Daily Living (ADLs). Findings: Resident 1 Review of the medical record revealed that resident #1 was admitted to the facility on [DATE] with diagnoses including, left proximal humerus, schizophrenia, history of falling, generalized muscle weakness, unsteadiness on feet, cognitive communication deficit, and severe morbid obesity. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that resident #1 had a documented brief interview for mental status score of 13. A score of 13-15 indicated the resident was cognitively intact with daily decision making skills. Review of the care plan with an initiated date of 06/25/2024, revealed resident #1 had an Activities of Daily Living (ADL) self-care performance deficit. Further review revealed resident #1 required two staff for repositioning, turning, dressing, and toilet use. On 08/06/2024 at 9:35 a.m., an interview with S3Certified Nursing Assistant (CNA) revealed that she worked on 08/01/2024 from 6:00 a.m. - 2:00 p.m. with resident #1. S3CNA confirmed that she assisted resident #1 with turning and repositioning by herself. On 08/06/2024 at 4:30 p.m., S4Medicare Case Manager/Registered Nurse (RN) confirmed resident #1's care plan revealed he required 2 person assistance with bed mobility, toilet use, dressing and transfers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #80 Record review revealed resident #80 was admitted to the facility 11/15/2021 with diagnoses that included unspecified sequelae of cerebral infarction, hemiplegia and hemiplegia following cerebral infarction affecting right dominant side, generalized muscle weakness, aphasia following cerebral infarction, lack of coordination, unsteadiness on feet, and dysarthria following cerebral infarction. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score 00 which indicated resident #80 was severely cognitively impaired. Resident #80 had a range of motion impairment of the upper and lower extremity on one side. Further review of the MDS revealed resident #80 was dependent on staff for personal hygiene. Review of the active care plans revealed resident #80 had an Activities of Daily Living (ADL) self-care performance deficit related to hemiplegia/hemiparesis right side that affects ability to self-perform ADLs. Review of the approaches revealed resident #80 required total assistance by one staff with personal hygiene. On 03/18/2024 at 8:40 a.m., an observation of resident #80 revealed his fingernails on both hands were long with a brown grimy substance under nails. On 03/19/2024 at 7:51 a.m., an observation of resident #80 revealed his fingernails on both hands were long with a brown grimy substance under fingernails On 03/19/2024 at 9:50 a.m., an interview and observation with S2DON (Director of Nursing) in resident #80's room revealed resident #80's fingernails on both hands were long with a brown grimy substance under his fingernails. S2DON confirmed resident # 80's fingernails needed to be cleaned and trimmed. Based on observations and interviews, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming and personal hygiene for 3 (#70, #80 and #92) of 3 (#70, #80 and #92) sampled residents reviewed for activities of daily living (ADLs). Findings: Resident #70 Review of the medical record for resident #70 revealed diagnoses of heart disease, muscle weakness, reflux, edema, and anemia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognitive skills for daily decision making and required partial to moderate assistance with personal hygiene. Review of the care plan revealed the resident had an activities of daily living (ADL) self care performance deficit regarding bathing/showering. Further review of the care plan revealed resident #70 required limited assistance with 1 staff member for bathing/showering. On 03/18/2024 at 2:30 p.m. and on 03/19/2024 at 8:15 a.m., observation of resident #70's fingernails on both hands revealed a brown substance was observed under his fingernails and the fingernails needed trimming. On 03/19/2024 at 10:00 a.m., an observation of resident #70's fingernails with S2Director of Nursing (DON) revealed the DON confirmed the resident's fingernails needed to be cleaned and trimmed. Resident #92 Review of the medical record for resident #92 revealed diagnoses of cerebral infarction, hemiplegia and hemiparesis, depression, and diabetes mellitus. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition for daily decision making and required assistance with ADLs. Review of the care plan revealed the resident had an activity of daily living with self care performance deficit related to hemiplegia and hemiparesis. The resident required maximum assistance with one staff member for bathing/shower. On 03/18/2024 at 10:47 a.m., observation of resident #92 revealed his fingernails on his right hand were long and needed to be trimmed. On 03/19/2024 at 10:45 a.m., an observation of resident #92's fingernails with S2DON revealed the DON confirmed the resident's fingernails needed to be trimmed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the pharmacist failed to report any irregularities to the attending physician, facility's medical director, and director of nursing for 1 (#93) of 5 (#15, #55, #58, #71, & #93) sampled residents reviewed for unnecessary medications. The pharmacist failed to identify that the facility did not obtain a lipid panel for resident #93 as ordered by the physician. Findings: Review of the medical record for resident #93 revealed the resident was admitted on [DATE] with diagnoses including: congestive heart failure, diabetes, gout, obesity, bipolar disorder, kidney injury, hypertension, hyperlipidemia, depression, and reflux. Review of the physician orders revealed an order dated 10/20/22 for Rosuvastatin Calcium 20 milligrams (a statin drug used to reduce cholesterol), give 1 tablet by mouth every day. Further review revealed laboratory orders for a lipid panel (a blood test that checks cholesterol levels) every 3 months in February, November, August, and May. Review of the record revealed there was no documented evidence that a lipid panel was drawn in November 2023 or February 2024. Review of the pharmacist's Drug Regimen Review for 12/11/2023, 1/15/2024, and 2/14/2024 revealed there was no documented evidence that the pharmacist identified the missing lipid panel for resident #93 from November 2023. An interview with S2Director of Nursing on 03/20/2024 at 10:00 a.m. confirmed the pharmacist did not identify the missing lipid panel for resident #93 on his monthly drug regimen reviews.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 (#93) of 5 (#15, #55, #58, #71, & #93) sampled residents reviewed for unnecessary medications. The facility failed to obtain a lipid panel as ordered by the physician for resident #93. Findings: Review of the medical record for resident #93 revealed the resident was admitted on [DATE] with diagnoses including: congestive heart failure, diabetes, gout, obesity, bipolar disorder, kidney injury, hypertension, hyperlipidemia, depression, and reflux. Review of the physician orders revealed an order dated 10/20/2022 for Rosuvastatin Calcium 20 milligrams (a statin drug used to reduce cholesterol), give 1 tablet by mouth every day. Further review revealed laboratory orders for a lipid panel (a blood test that checks cholesterol levels) every 3 months in February, November, August, and May. Review of the record revealed there was no documented evidence that a lipid panel was drawn in November 2023 or February 2024. An interview with S2Director of Nursing on 03/20/2024 at 10:00 a.m. confirmed the lipid panel was not obtained for resident #93 in November 2023 or February 2024 as ordered by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #15 Record review revealed resident #15 was admitted to the facility 06/27/2022 with diagnoses that included heart failure, hypothyroidism, essential hypertension, iron deficiency anemia, hyperlipidemia, anxiety disorder, major depressive disorder, insomnia, bipolar disorder, and presence of cardiac pacemaker. Review of resident #15's active March 2024 physician orders included the following: Oxygen (O2) at 2 liters per minute (LPM)/nasal cannula (NC) as need for O2 saturation less than 92%. O2 saturation every shift. Follow O2 orders. Clean filter(s), change date and initial on tubing weekly one time a day on Sundays. On 03/18/2024 at 9:50 a.m., an observation of resident #15's room revealed an O2 nasal cannula that was dated 3/11/2024. The nasal cannula was uncovered and lying across the oxygen concentrator. Resident #15 reported she takes oxygen as needed for shortness of breath. On 03/19/2024 at 8:04 a.m., an observation of resident #15 room revealed the O2 nasal cannula was dated 3/11/2024. The nasal cannula was uncovered and lying across the oxygen concentrator. On 03/19/2024 at 10:00 a.m., an interview and observation with S2DON (Director of Nursing) in resident #15 room revealed resident #15's nasal cannula was dated 3/11/2024. The nasal cannula was uncovered and lying on the oxygen concentrator. S2DON confirmed resident #15's nasal cannula should be changed weekly on Sundays. S2DON further confirmed the nasal cannula should be stored in a plastic bag when not being used. Resident #43 Record review revealed resident #43 was admitted to the facility 04/21/2021 with diagnoses that included cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, seizures, chronic obstructive pulmonary disease, unspecified asthma with acute exacerbation, contact with and suspected exposure to asbestos, essential hypertension, old myocardial infarction, and sleep apnea. Review of resident #43's March 2024 physician orders included the following: Ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg (milligrams)/3 ml (milliliters) vial give one vial inhalation orally three times a day for shortness of breath. This order had a start date of 11/10/2023 and end date 03/08/2024. Ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml vial give 1 vial inhalation orally as needed for shortness of breath. This order had a start date of 03/08/2024 and end date of 03/19/2024. Ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml vial give 1 vial inhalation orally every 6 hours as needed for shortness of breath. This order had a start date 03/19/2024. On 03/18/2024 at 8:55 a.m., an observation of resident #43's room revealed a nebulizer machine sitting on the bedside dresser. The nebulizer tubing and face mask was not dated. The nebulizer tubing and face mask was uncovered and hanging from the nebulizer machine. Further observation revealed there was not a plastic bag available to store the nebulizer tubing and face mask. Resident #43 reported he could not recall the last time they changed his nebulizer face mask. On 03/19/2024 at 7:53 a.m., an observation of resident #43's room revealed the nebulizer tubing and face mask was not dated. The nebulizer face mask was uncovered and hanging from nebulizer machine. On 03/19/2024 at 9:55 a.m., an interview and observation with S2DON (Director of Nursing) in resident #43's room revealed the nebulizer tubing and face mask was not dated. The nebulizer face mask was uncovered and hanging from the nebulizer machine. S2DON confirmed resident #43's nebulizer tubing and face mask should be dated and changed weekly on Sundays. S2DON further confirmed the nebulizer tubing and face mask should be stored in a plastic bag when not being used. Resident #14 Review of the medical record for resident #14 revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, diabetes, heart failure, peripheral vascular disease, acute nasopharyngitis (common cold) and hypertension. Review of the physician orders for March 2024 revealed an order dated 03/07/2024 for Ipratropium - Albuterol 0.5 - 2.5 (3) mg/3 ml - one vial per nebulizer every 6 hours. On 03/18/2024 at 11:30 a.m. and 4:55 p.m., observations of the nebulizer mask revealed the mask was not in use and it was observed on the resident's bed not stored properly in a bag. Further observation of the nebulizer mask on 03/19/2024 at 7:55 a.m. revealed the mask was not in use and it was observed on the bedside table not stored properly in a bag. On 03/19/2024 at 10:10 a.m., an interview with S2 Director of Nursing (DON) confirmed the nebulizer treatment mask was not stored properly. Based on observations, record reviews and interviews, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 5 (#14, #15, #29, #43, and #68) of 6 (#14, #15, #29, #43, #68, and #77) sampled residents reviewed for respiratory care. The facility failed to ensure: 1) nebulizer tubing and face mask were changed weekly for resident #43 and 2) nebulizer masks were stored properly when not in use for residents #14, #29, #43, #68 and 3) the nasal cannula was stored properly when not in use for resident #15. Findings: Review of the facility's policy revised on November 2011 for Respiratory Therapy - Prevention of Infection revealed in part: Infection Control Considerations related to Medication Nebulizers/Continuous Aerosol: 7. Store the circuit in plastic bag, marked with date and resident's name, between uses. Resident #68 Review of the medical record for resident #68 revealed an admission date of 12/01/2020 with diagnoses including chronic obstructive pulmonary disease (COPD), anxiety, depression, chronic pain, anorexia, and heart disease. Review of the physician's orders revealed an order dated 09/09/2022 for Ipratropium-Albuterol Solution 0.5 - 2.5 (3) milligrams (mg)/3 milliliters (ml) administer 1 vial inhale orally every 4 hours. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition for daily decision making and the resident required assistance with activities of daily living. Review of the care plan revealed the resident had altered respiratory status/difficulty and breathing. On 03/18/2024 at 10:30 a.m., 2:01 p.m., 4:50 p.m., and on 03/19/2024 at 10:26 a.m. observations of the nebulizer mask revealed it was not in use and it was observed on the bedside table not stored properly in a bag. On 03/19/2024 at 10:26 a.m., an interview with S2 Director of Nursing (DON) confirmed the nebulizer treatment mask was not stored properly. Resident #29 Review of the medical record for resident #29 revealed an admission date of 08/22/2014 with diagnoses including chronic obstructive pulmonary disease, prosthetic heart valve, aortic stenosis, pneumonia, and sleep apnea. Review of the physician orders revealed an order dated 02/11/2023 for Ipratropium- Albuterol solution 0.5 - 2.5 (3) mg/3ml administer 1 vial inhale orally every 6 hours as needed for shortness of breath/wheezing. Review of the quarterly MDS assessment dated [DATE] revealed the resident had moderate impaired cognition for daily decision making, and required assistance with activities of daily living. Review of the care plan revealed the resident had asthma related to COPD and the resident was to have medications administered as ordered, and nebulizer treatments administered as ordered. On 03/18/2024 at 11:00 a.m., 12:54 p.m., 5:00 p.m., and on 03/19/2024 at 10:10 a.m. observations of the nebulizer mask revealed the mask was not in use, and was located on the over bed table not stored properly in a bag. On 03/19/2024 at 10:30 a.m., S2 Director of Nursing (DON) confirmed that the nebulizer treatment mask was not stored properly when not in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to immediately inform the resident's responsible party of a change in condition for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for medication administration. The facility failed to ensure resident #1's responsible party was notified of a new order for resident #1 to receive the antibiotic Doxycycline for a diagnosis of pneumonia. Findings: Review of the medical record revealed resident #1 was initially admitted to the facility on [DATE]. Further review revealed the resident's diagnoses included cognitive communication deficit, disease of the upper respiratory tract, and pneumonia. Review of resident #1's physician orders revealed an order dated 02/05/2024 for Doxycycline Hyclate oral tablet 100 milligrams; give 1 tablet by mouth two times a day for pneumonia, for 10 days. Review of the February 2024 medication administration record revealed documented entries on the medication administration record of resident #1 being administered the medication Doxycyline (Antibiotic) 100 milligrams, one tablet by mouth on 02/05/2024 at 8:00 p.m. and 02/05/2024 at 8:00 a.m. as per the scheduled dose times. Review of resident #1's medical record revealed there was no documented evidence of resident #1's responsible party being notified of the new medication order and prior to the resident receiving the initial dose of the Doxycycline as documented on the medication administration record. During an interview on 02/06/2024 at approximately 1:30 p.m., S3LPN (Licensed Practical Nurse), confirmed that she did not immediately notify resident #1's responsible party of the new order for resident #1 to receive the antibiotic Doxycycline Hyclate 100 mg, one tablet twice daily for a diagnosis of pneumonia. During an interview on 02/07/2024 at 12:20 p.m., S2DON (Director of Nursing) reported there was further documentation of resident #1 receiving the initial dose of the Doxycycline Hyclate on 02/05/2024 at 7:15 p.m. and a second dose on 02/06/2024 at 8:10 a.m. S2DON confirmed that resident #1's responsible party had not been notified of the new medication change prior to resident #1 receiving the first initial dose of the medication on the date of 02/05/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure Resident #54 was properly transferred using the Vander-Lift by two person assist according their policy and procedure for 1 (#54) of 4 (#46, #49, #52, #312) sampled residents reviewed for accidents. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be Past Noncompliance citation. Findings: Review of the Transfer and Lift Policy dated 11/01/2016 revealed in part: Two persons are always required for standup lifts (Vera) and bed lifts ([NAME]), and the ceiling lift (GoLift Portable 450). Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. The resident's diagnoses included but not limited to the following: pressure ulcer of sacral region stage 4, peripheral vascular disease, type 2 diabetes mellitus with hyperglycemia, unspecified sequelae of cerebral infarction, chronic obstructive pulmonary disease, major depressive disorder, morbid (severe) obesity, acute embolism and thrombosis of right internal jugular, hallucinations unspecified, unsteadiness on feet, muscle wasting and atrophy multiple sites, idiopathic peripheral autonomic neuropathy, acquired absence of right leg below knee, essential hypertension, pleural effusion, atherosclerosis of native arteries of extremities with intermittent claudication bilateral legs, and nicotine dependence. Review of Resident #54's quarterly MDS (Minimum Data Set) data dated 11/23/2022 revealed a BIMS (Brief Interview Mental Status) score of 13. A score of 13-15 indicated the resident was cognitively intact with daily decision making. Further review revealed she was totaly dependent on two person physical assistance with transfers. Review of Resident #54's care plan revealed an ADL (Activities of Daily Living) self-care deficit. Interventions included: extensive assistance by 2 staff with bathing/showering, bed mobility, repositioning, and toileting. Further review revealed the resident required mechanical lift ([NAME]) using brown sling with 2 staff assistance for transfers. Review of Morse Fall Scale dated 08/21/2022 revealed Resident #54 had a score of 60 and was at high risk for falls. Review of accident/incident report date 11/23/2022 at 11:15 a.m. revealed Resident #54 was being transferred from her bed to a geri chair by S11 CNA (Certified Nursing Assistant) using the Vander-Lift by herself. S11 CNA reported that during the transfer while resident was on the lift, the lift started to tilt and she lowered the resident to the floor with that being the nearest surface. S11 CNA notified the nurse. Resident #54 was assessed for injuries. Head to toe assessment revealed no bruising or bleeding. Range of motion performed with no complaints. No apparent injuries at time of the incident. Resident #54 was transferred to local emergency room via ambulance for further evaluation and treatment related to pain to the right rib area and back. Review of documentation of resident #54's emergency room visit on 11/23/2022 revealed the following: Patient sent from Nursing Home with complaint of fall while staff were trying to use the lift to transfer patient. Patient reports back pain and that she hit her head on the floor, denies any loss of consciousness. Patient takes Eliquis. Triage vital signs: Temp 36.9 C, pulse 98, Resp 20, O2 sat 97%, B/P 159/72, pain intensity 10. Patient complained of pain in her head, neck, thoracic spine, and right ribs after the fall during attempts to move her at the nursing home using the lift this morning. No associated loss of consciousness, shortness of breath nausea vomiting. Patient appears bed ridden has a right leg amputation. Rates pain server aching worse with movement. Physical exam: No apparent distress, well appearing Skin: warm dry no jaundice, hives or petechie Neck: non tender and supple full range of motion. HENT: right occipital tenderness Musculoskeletal: thoracic spine right rib tenderness status post right leg amputation. No edema, redness, or swelling. Psychiatric: anxious Lab CBC and CMP done XRAYS done: CT (Computerized Tomography) scan cervical spine without contrast, CT scan head/brain without contrast, CT scan thoracic spine without contrast Xray right ribs done. Report: No acute displaced fractures or other acute abnormality. Lungs trace left pleural effusion and atelectasis, No pneumothorax. Medical decision making narrative: 11/23/2022 17:26 Nursing notes, vital sign reviewed. Radiology reports reviewed head neck and thoracic spine shows a slight T1 compression fracture. Patient reports having had problems in the past in that area before, suspect this is old. Lab including CBC, chemistry panel unremarkable. Discharge Clinical Impression: Rib contusion, Thoracic compression fracture Discharge back to nursing home. New prescription hydrocodone-acetaminophen 10-325 mg tablet take one po q 6 hours prn pain. 3 day quantity # 12. On 01/30/2023 at 2:00 p.m. an interview with Resident #54 revealed a couple of months ago she was being transferred from her bed to the geri chair by only one CNA. Resident #54 reported that S11 CNA used the Vander-Lift to transfer her by herself. Resident #54 revealed during the transfer she missed the geri chair and fell to the floor. Resident #54 reported she was sent to the emergency room. Resident #54 reported that she broke 2 ribs on her right side. Resident #53 reported that she has had chronic back pain for years but currently denies any rib pain. On 01/31/2023 at 10:15 a.m. an interview with Resident #54 revealed she was not experiencing any pain. Resident #54 reported since the incident on 11/23/2023, there have been two aides present and assisting while transferring her using the Vander-Lift. On 01/31/2023 at 11:45 AM an interview conducted with S14 CNA reported that Resident #54 was a two person assist with all transfers using the Vander-Lift. S14 CNA confirmed that she has received training on how to properly use the Vander-Lift for resident transfers On 01/31/2023 at 1:30 p.m. an interview with S1 Administrator revealed S11 CNA was removed from patient care and moved to ward clerk duties at the desk pending the investigation into the incident that occurred on 11/23/2022 while S11 CNA was transferring resident # 54 using the Vander-Lift. S1 Administrator reported Resident #54 was sent to the emergency room on [DATE] after the incident for evaluation and treatment. Resident #54 returned to the facility the same day. S1 Administrator reported there were no broken ribs noted on the xray report. S1 Administrator reported Resident #54 was diagnosed with right rib contusion and an old T1 compression fracture. S1 Administrator revealed that their investigation revealed that S11 CNA did not follow the facilities policy by not having two person present to assist with all transfers using the Vander-Lift resulting in Resident #54 fall. S1 Administrator confirmed S11 CNA was transferring Resident #54 by herself using the Vander-Lift at the time of the incident on 11/23/2022. S1 Administrator reported that S11 CNA had previously received training on the facilities policy and procedure related to resident transfers using the Vander-Lift prior to 11/23/2022. S1 Administrator reported that S11 CNA was written up and was counseled on 11/23/2022. S1 Administrator further revealed S11 CNA received in-service training on the facilities transfer policy and procedure personally by S2 DON (Director of Nursing) on 11/23/2023. Review of hand written statement by S11 CNA dated 11/23/2022 revealed the following: On 11/13/2022 I attempted to transfer Resident #54 with the [NAME]'s lift while assisting her I notice it began to lean so to keep from falling I lowered it to down to my right side to keep from hurting the resident. I'm aware that lift is two assist at the time no one was around to assist me and the resident was crying to get up. I take full responsibility for my poor actions and judgement. On 01/31/2023 at 3:00 p.m. an interview with S2 DON confirmed that S11 CNA did not follow the facilities policy and procedure when transferring Resident #54 by herself on 11/23/2022. S2 DON confirmed that she conducted a formal write up and counseled S11 CNA for not following the facilities transfer policy and procedures on 11/23/2022. S2 DON further revealed she provided personalized in-service training with S11 CNA on facilities transfer and lift policy and procedures on 11/23/2023. S2 DON reported that S11 CNA had been trained on the facilities transfer and lift policy and procedure prior to this incident. S2 DON further confirmed that S11 CNA was aware that Resident #54 was a two person assist with all transfers using the Vander-Lift. S2 DON further reported that all CNA' s and Nurses on each shift received in-service training on the facilities transfer and lift policy and procedure that started on 11/23/2022 at 5:30PM. S2 DON reported that they added this to their Quality Improvement Corrective Action Plan. S2 DON confirmed that they have not had any other incidents with resident transfers using the Vander-Lift since incident involving Resident #54 on 11/23/2022. On 02/01/23 07:45a.m. an interview with S11 CNA revealed she had received training on how to properly transfer residents with the Vander-Lift prior to the incident with Resident #54 on 11/23/2023. S11 CNA reported that she was providing care for Resident #54 on 11/23/2022. She revealed Resident #54 was crying and wanted to get up to go smoke. S11 CNA reported that she knew that Resident #54 was a two person assist with all transfers using the Vander-Lift. S11 CNA reported that around 11:00 a.m. the other CNA's were busy so she went ahead and transported Resident #54 by herself using the Vander-Lift. S11 CNA reported that while she transferring her from her bed to the geri chair the lift started to tilt and she lowered Resident #54 to the ground to prevent her from being injured. S11 CNA reported that she immediately went and got the nurse, DON and Administrator and informed them of what happened. S11 CNA reported that she knew she should have asked for help, but the other CNA's were busy, and she did not think to ask the nurse for help. S11 CNA reported Resident #54 really did not complain about any pain at the time of the incident. S11 CNA confirmed that she was removed from patient care and assigned ward clerk duty while Administration did their investigation. S11 CNA reported that she was counseled and written up for not following policy and procedure of using 2 person assist with the Vander-Lift while transferring Resident #54. S11 CNA confirmed she received in-service training by S2 DON on the facilities transfer and lift policy and procedure. S11 CNA further confirmed she took computerized training of resident transfers. S2 DON reported that S12 Unit Manager has been monitoring the CNA's randomly several times a week to make sure they are following the facilities transfer and lift policy and procedure and safely transferring the resident that require the Vander-Lift for transfers. On 02/01/2023 at 09:35 a.m. interview with S10 RN (Registered Nurse) Wound Care Nurse revealed she assessed Resident #54 on 11/23/2022 immediately after the incident. She revealed Resident #54 was laying on the floor and did not complain of any pain and had to be encouraged to go to the emergency room to get evaluated. Head to toe assessment revealed no bruising or open skin area. S10 RN Wound Care Nurse reported Resident #54 did not start reporting any pain or discomfort until about a week or two after the incident. Review of Residnet#54's repeat chest Xray done on 12/12/2022 report revealed normal mineralization of the visualized osseous structures. There was no evidence of any rib fracture. On 02/01/2023 at 09:10 a.m. an observation of S13 CNA and S14 CNA transfer Resident #54 from her bed to ger chair using the Vander-Lift revealed no issues noted with the transfer. S13 CNA and S 14 CNA both revealed they have had several in service training on the facilities transfer and lift policy and procedure. On 02/01/2023 at 09:30 a.m. an interview with S12 Unit Manager revealed she has been conducting random monitoring of resident's that required the Vander-Lift to make sure CNA's used the proper lift, the proper lift pad, the proper transfer assist, the correct technique. S12 Unit Manager reported that she has been conducting the monitoring several times a week since the incident on11/23/2022. S12 Unit Manager reported that she has not observed any issues during any of the observations. Review revealed the nursing facility addressed and implemented the following area regarding resident being transferred safely according to the facilities transfer and lift policy and procedure: Review of In-Service training done prior to the incident dated 04/13/2022 by S12 Unit Manger on Lift policy. The expectation is that appropriate techniques are utilized for lifting, transferring, moving and repositioning residents in order to protect the wellbeing and safety of residents and staff. Color coded stickers are placed at the head of the resident's bed and/or on the kiosk. Check the patient's weight and physical condition. All staff are responsible for using the required number of assistants for transfers/lifts per residents. Review of the sign in sheet revealed S11 CNA was one of 27 signatures that signed. Review of In-Service training done prior to the incident dated 09/13/2022 on Bed Mobility/Transfers are a normal part of daily activities, They are used to improve or maintain the resident's self-performance in moving between surfaces/positions. Utilizing assisted devices as needed and proper techniques. Review any precautions with resident. Always make sure that bed is in lowest position. Failure to do so affects resident care and will result in disciplinary action. Review of the sign in sheet revealed S11 CNA was one of 37 CNA signatures that signed. S1 Administrator removed S11 CNA from resident care immediately after the incident pending outcome of the investigation. Reviewed documentation of S11 CNA formal write up and counselling for no following facilities transfer and lift policy and procedure. CNA did not follow lift policy of using 2 people assist when operating the lift which resulted in lift tilting and having to ease resident to the floor. CNA will always have at least two staff operating the lift. Next action if expected improvement or standard is not met: suspension and or termination. This form was signed by S11 CNA and S2 DON on 11/23/2022. Reviewed documentation of S11 CNA in service training dated 11/23/2022 by S2 DON on the facilities transfer lift policy and procedure. Reviewed S11 CNA training transcript revealed documentation of completion of Safe transfers dated 11/28/2022. Reviewed documentation of the in service training on transfer and lift policy and procedure dated 11/23/2022 with start time 5:30 p.m. the sign in sheet revealed the signature of 40 staff members that included CNAs LPNs(Licensed Practical Nurse) and word clerks. Reviewed of the monitoring Audit Tool revealed documentation S12 Unit Manager observed random residents on different halls who required the Vander-Lift for transfers. The Audit tool checked to make sure the right lift used, the right lift pad used, proper transfer assistance used, correct technique used, and the date and name the of the resident and CNAs who transferred the resident. The documentation revealed the monitoring occurred several times a week since 11/22/2022 through 1/30/2023. Review of the Quality Improvement Corrective Action Plan revealed: 11/23/2022 Identifiable problem- CNA improper lift usage causing lift to tilt and having to lower resident to floor. S2 DON followed up weekly to determine if there was a recurring problem. Review of the weekly documentation revealed no problems noted. The correction date will be 11/28/2022; since all investigations, training, and monitoring had been put into place by this date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the assessment must accurately reflect the resident's status for 1 (#55) of 6 (#2, #22, #55, #67, #306, #309) residents who received dialysis services according to the CMS-672 Resident Census and Conditions of Residents form, by failing to ensure resident #55's assessment accurately reflected the resident's current dialysis access status. Findings: Review of the medical record revealed resident #55 was admitted to the facility on [DATE] with diagnoses including end stage renal disease. Review of the January 2023 MAR (Medication Administration Record) included the following physician orders: 06/24/2022-Assess tunnel catheter right chest for redness, warmth, pain or bleeding every day shift; 06/24/2022-Post Dialysis: Assess tunnel catheter daily for pain, bleeding, redness, or warmth every day q shift; and, 06/24/2022-Assess tunnel catheter right chest q shift ensuring it is clamped and capped. Further review of the January 2023 MAR revealed a check mark with S9LPN's initials documented in the designated section on the MAR, indicating that she had assessed the tunnel catheter every shift on the date of 01/31/2023. On 01/31/2023 at 8:56 a. m., an interview with resident #55 revealed she received dialysis treatments (hemodialysis) at a local dialysis center three days a week on Monday, Wednesday, and Friday. Resident #55 reported she currently had a left arm dialysis access. She further reported that she had previously had a dialysis access to her upper right chest area, but she no longer had the dialysis catheter as it had recently been removed. Resident #55 could not recall the exact date the access had been removed. On 02/01/2023 at 11:54 a. m., S9LPN (Licensed Practical Nurse) reported that a couple of weeks ago, resident #55 had her right upper chest dialysis catheter removed. After completing a review of the January 2023 MAR with S9LPN, she confirmed that she had initialed the MAR on 01/31/2023 indicating that she had assessed the resident's right chest tunnel catheter on the date of 01/31/2023. S9LPN further confirmed that resident #55 had the right upper chest dialysis catheter removed prior to the date of 01/31/2023 and that she had recorded an inaccurate assessment. On 02/01/2023 at 12:27 p. m., S2DON (Director of Nursing) confirmed S9LPN's assessment was inaccurate, because the access had already been removed.

Based on observations and interviews, the facility failed to maintain all mechanical, electric, and patient care equipment in safe operating condition, by failing to ensure the kitchen's deep fryer, flooring, and grout was free of grease build up. Findings: On 01/31/2023 at 12:50 p. m., an observation of the kitchen revealed a deep fryer with a lower compartment. Observation of the inside of the fryer's lower compartment revealed a built up of grease that was covering the internal components of the fryer. Further observation of the kitchen revealed grease stained build up on the floor that was located behind and underneath the deep fryer and also an unsolidified grease build up that was observed in the tile grout. S3Dietary Manager was notified of the findings. After completing an observation of the lower compartment of the deep fryer, flooring, and grout, S4Dietary Manager reported she was unaware of the last time the deep fryer's lower compartment had been cleaned. She confirmed the deep fryer was not in safe working condition at that time and the floor and grout needed to be cleaned. On 01/31/2023 at 1:30 p. m., S1Administrator and S4 Maintenance Supervisor were notified of the findings regarding the observations of a grease build up on the inside the lower compartment of the deep fryer that coverer the internal components. They were further notified of the observations of grease stained build up on the floor and the unsolidified grease build up observed in tile grout behind and underneath the deep fryer. After the observation of the deep fryer, floor, and grout, with S1Administrator and 4Maintenance Supervisor was completed, they both confirmed the deep fryer was not in safe working condition and the lower compartment of deep fryer, kitchen floor, and tile grout needed to be cleaned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure resident #1's seatbelt was properly secured prior to being transported in the facility's van for 1 (#1) of 6 sampled residents (#1, #2, #3, #4, #5, #6) reviewed for accidents. Findings: Review of the Vehicle and Driver Policy dated 11/29/2019 revealed in part: Driver Safety Rules: All drivers and passengers operating or riding in a company vehicle must wear seat belts and wheelchairs/scooters must be properly secured with the securement equipment. In addition, the V-006-Driver In-service Checklist shall be completely by the facility administrator or designee for each driver, on each vehicle the driver is authorized to operate, to demonstrate proficiency in use of the vehicle, lift system, and securement system. Review of the medical record revealed resident #1 was admitted to the nursing facility on 02/02/2021. The resident's diagnoses included Type 2 diabetes mellitus with diabetic chronic kidney disease and hypertensive chronic kidney disease with Stage 5 chronic kidney or end stage renal disease. Review of the physician orders dated 11/18/2022 revealed: admit to (the name of the dialysis was noted in the order) at 12:30 on Monday, Wednesday, and Friday. Further review revealed dialysis may change schedule to suit their needs. Review of the annual Minimum Data Set, dated [DATE] revealed resident #1 had a brief interview for mental status score of 15. A score of 13-15 indicated the resident was cognitively intact with daily decision making. Further review revealed he needed limited assistance with transfer with one person physical assistance. Review of Morse Fall Scale revealed resident #1 had score of 75 and at high risk for falls. Further review of the Morse Fall Scoring, high risk was a score of 45 or higher. Review of the incident note dated 11/21/2022 at 7:35 a.m., CNA (Certified Nursing Assistant) called this nurse to resident room around 4:00AM resident stated he was in pain left leg from top knee to toe. Unable to move perform body assessment. Resident was reporting pain to knee. Appears to be swollen. Scant amount bleeding to toe area. Provided pillow to elevate and pain med given. Resident stated he was getting on the van for dialysis and was given the belts to lock, but was unable to lock. During transport, driver hit on brakes really hard and he flew out the chair and landed on floor. Transported back to center for assistance in getting off the floor. Nurse assisted back in w/c and headed back to dialysis in pain and no one looked at this hurt leg. Came back to center transported back to bed and pain pill given. This nurse informed resident (Referring to resident #1) that I will report his statement to proper supervisor. The note was signed per S3LPN (Licensed Practical Nurse). On 12/27/2022 at 9:45 a.m., an observation revealed resident #1 sitting up in his wheelchair, in the hallway. The resident was asked for an interview. He agreed and self-propelled himself to his room. Further observation revealed the resident's right leg was amputated above the knee. During the interview, resident #1 reported he did have an incident in the van in November 2022, when S5CNA (Previous transport/van driver) did not make sure his seatbelt was secured. Resident #1 further reported the van driver put him in the van, S5CNA secured the wheelchair in place, and threw the seatbelt shoulder strap across the resident #1. He further reported that he could not catch the strap, he forgot it was not secured, and the van driver (S5CNA) had not checked to make sure the strap had been secured after throwing it to the resident. Further interview revealed, as they neared the dialysis center, a vehicle pulled out in front of the van and 5CNA had to throw on her brakes. Resident #1 reported this caused him to fall out of his wheelchair and land on his left knee with the leg underneath him and touching the floor of the van. He further reported the S5CNA pulled over and tried to lift him up and back into his wheelchair, but the he (Resident #1) was too heavy. Resident #1 reported he remained on the floor of the van until the S5CNA returned to the nursing home facility where his nurse (did not recall her name) had assessed him. Resident #1 denied any complaints of pain and injury at the time of the fall. He did report that he reported that he had pain to the left knee the following day (Referring to 11/21/2022). Resident #1 further reported that he notified S1Administrator when she had come to his room to check on him. He reported x-rays were taken of his left knee. On 12/27/2022 at 11:38 a.m., an interview with S1Administrator revealed on 11/20/2022 at approximately 10:00 a.m. resident #1 had slid out of his wheelchair and onto the floor of the facility's van, when in route to his dialysis appointment. She reported the incident was due to the van driver S5CNA not making sure resident #1's seatbelt was locked when in route, the resident's wheelchair was locked at the time of the incident. S1Administrator further reported the resident had fallen on his knee, she was notified the next morning, and x-rays were taken of the knee with no negative findings. S1Administrator reported the van driver, who was also serving in the capacity of a ward clerk, had been removed as a van driver and placed solely in the position of a ward clerk. On 12/27/2022 at 1:53 p.m., an interview with S5CNA (previous transport/van driver) revealed that on 11/20/2022, she was the van driver at the time of resident #1's incident. She reported that she was transporting the resident to his dialysis center for his treatment, when the road light changed and she had to put on her brakes quickly, but not hard. She reported resident #1's wheelchair was secured, but the upper seatbelt straps were not secured. S5CNA further reported when the resident was first assisted into the van, she had secured the wheelchair and handed the resident the upper straps (referring to the van's seatbelts) as he usually fastened the straps. She reported she thought the resident had snapped it, but he did not. She confirmed resident #1 had not secured/locked the straps in position and she (S5CNA) had not checked to make sure they were locked after she had handed them to resident #1. Further interview revealed at the time, S5CNA had stopped abruptly, resident #1 slid out of his wheelchair onto his left knee, and onto the floor of the van. S5CNA reported she then assisted resident #1 to a sitting position only, as she reported he was too heavy for her to left back into the wheelchair. S5CNA then returned the resident to the nursing facility where S4LPN assessed the resident. Further interview revealed resident #1 did not report any complaints of pain and /or any other type of injuries at that time. S5CNA reported she then transported resident #1 to the dialysis center. S5CNA reported she had received in-service training regarding safety precautions, the securing and locking of wheelchairs, and safety precautions including those from a checklist. S5CNA further reported she had been removed from the van driver duties, and placed on ward clerk and CNA floor duties since the incident on 11/20/2022. On 01/03/2023 at 2:13 p.m., a telephone interview with S4LPN revealed she did recall an incident in November 2022 when resident #1 had a fall in the van while going to the dialysis center for treatment. She reported that resident #1 and the transport/van driver (Referring to S5CNA) both had informed her (S4LPN) that S5CNA was driving the van and had to quickly brake causing resident #1 to fall from his wheelchair and onto the floor, as the resident had unlocked his wheelchair. Further interview revealed S4LPN assessed resident #1 and found no injuries nor complaints from the resident. S4LPN reported resident #1 returned to the dialysis center for his treatment. S4LPN further reported she had not notified S2DON of the fall, because the fall incident caused no major injuries. On 01/03/2023 at 3:22 an interview with S2DON (Director of Nursing) revealed she became aware on 11/21/2022 that resident #1 had slid out of his wheelchair during transport to the dialysis center on 11/20/2022 per S3LPN. S2DON reported that she (S2DON) assessed resident #1 and observed some puffiness, wrapping on the toe, with a little drainage, but not a lot edema. S2DON reported that she not seen any bruising and abrasions on resident #1's knee of the left leg at the time of her assessment. On 01/06/2023 at 4:40 p.m., an interview with S1 Administrator confirmed there was nothing in the current vehicle and driver policy to address resident incidents occurring in the van, it only addressed accidents in a motor vehicle. Review of this policy also revealed that it included that all drivers and passengers operating or riding in a company vehicle must wear seat belts, and wheelchairs/scooter must be properly secured with the securement equipment. S1Administator reported at this time that S5CNA had transported the resident back to the facility after the wheelchair incident in the van as safely as possible. The facility was unable to provide a policy / procedure that addressed resident related incidents that could occur during transport.