Based on interview and record review, facility staff failed to accurately transcribe one resident's (Resident #18) eye drop medication orders from the hospital which resulted in the resident not receiving necessary medications during their stay at the facility. The facility census was 66. 1. Review of the facility's policy titled Reconciliation of Medications on Admission, revised July 2017, showed medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. Using an approved medication reconciliation form or other record, list all medications from the medication history, the discharge summary, the previous Medication Administration Record (MAR), and the admitting orders (sources). 2. Review of Resident #18's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 08/15/24, showed staff assessed the resident as: -Moderately cognitively impaired; -Vision moderately impaired; limited vision, not able to see newspaper headlines but can identify objects; -Diagnosis of Cataracts, Glaucoma or Macular Degeneration (an age-related eye disease that causes gradual loss in the center of the visual field). Review of the resident's medical record, dated October through November 2024, showed staff documented the resident has diagnoses of Primary open-angle glaucoma and Presence of intraocular lens (a clear, artificial lens that replaces the eye's natural lens to improve vision). Review of the resident's Physician Order Sheet (POS), dated 10/31/24, showed an order to admit to facility with hospital discharge orders. Review of the resident's hospital discharge orders, dated 10/31/24, showed orders for: -Atropine Ophthalmic 1% solution (used to relieve pain caused by swelling and inflammation of the eye), one drop in the right eye two times a day; -Brimonidine Ophthalmic 0.2% solution (used for lowering intraocular pressure (IOP) with open-angle glaucoma or ocular hypertension), one drop in the left two times a day; -Difluprednate Ophthalmic 0.05% Solution (used to treat eye pain, redness, and swelling caused by eye surgery. It is also used to treat an eye condition called endogenous anterior uveitis (eye inflammation), one drop in the right eye four times a day; -Latanoprost 0.005% Ophthalmic Solution (used to treat glaucoma), one drop in the left eye twice a day. Review of the resident's POS, dated October and November 2024, showed orders for: -Atropine Ophthalmic Solution 1%, instill one drop in right eye every 12 hours as needed for eye irritation; -Brimonidine Tartrate Ophthalmic Solution 0.2%, instill one drop in left eye every 12 hours as needed for eye irritation; -Difluprednate Ophthalmic Emulsion; instill one drop in right eye every 8 hours as needed for eye irritation; -Latanoprost Ophthalmic Solution, instill one drop in left eye every 12 hours as needed for eye irritation. Review of the resident's MAR, dated October and November 2024, showed staff did not document the resident received the eye medications as ordered on the hospital discharge orders. During an interview on 11/15/24 at 11:55 A.M., Pharmacist M said when a resident has a diagnosis of glaucoma eye drops are usually given as scheduled and not as needed. Pharmacist M said the facility orders should match the hospital discharge orders. During an interview on 11/15/24 at 12:09 P.M., Physician L said the orders received from the hospital should have been the orders followed by the facility. The physician said he/she did not know why the medication orders were not entered correctly. The physician said a resident with glaucoma could be harmed if eye drops are not given as ordered. During an interview on 11/15/24 at 2:11 P.M., Licensed Practical Nurse (LPN) J said when a resident is admitted , the charge nurse reviews the medication list, and enters the medications. The social worker reviews the list with the family, and another nurse will audit the orders. LPN J did not know why the medications were not administered according to the hospital discharge summary. LPN J said the resident's glaucoma could become worse if the eye drops were not administered correctly. During an interview on 11/15/24 at 2:41 P.M., the Director of Nursing (DON) said when a resident is admitted from the hospital a medication list is always provided. The list is double checked by multiple staff members. The DON did not know how these medications were entered incorrectly since it had been checked by multiple staff. MO00245028

Based on observation, interview, and record review, facility staff failed to maintain a medication administration error rate of less than 5% out of 38 opportunities observed, two errors occurred resulting in a 5.26%, which effected one residents (Resident #35) out of 21 sampled residents. The facility census was 66. 1. Review of the facility's policy titled Administering Medications, dated April 2019, showed the Director of Nursing (DON) supervises and directs all personnel who administer medications. Medications are administered in accordance with prescribe orders. The individual administering medications verifies the right resident, right medication, right dosage, right time, and right route before giving the medication. Review of the manufacturer's recommendations for insulin (a medication used to control blood sugars) pens, dated 09/11/15, showed prime the pen with two units (U) before each injection. Priming the pen removes the air from the needle and cartridge that may collect and ensures the pen is working correctly. If you do not prime the pen before each injection, you may get too much or too little insulin. 2. Review of Resident #35's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/10/24, showed staff documented the resident had a diagnosis of diabetes and received insulin injections. Review of the resident's Physician's Order Sheet (POS), dated November 2024, showed orders for: -Humalog Lispro Insulin 100 units U/milliliter (ml), give per sliding scale according to the resident's blood sugar, inject subcutaneously (SQ) with meals: -Glargine Insulin 100 U/ml, inject 10 units SQ once a day. Observation on 11/13/24 at 8:00 A.M., showed Registered Nurse (RN) A administered Humalog Insulin two units per the sliding scale orders but did not prime the insulin pen Observation showed the RN administered Glargine Insulin 10 units but did not prime the insulin pen. During an interview on 11/13/24 at 2:35 P.M., RN A said the proper way to administer insulin from a pen is to prime the pen with two units before giving each dose of insulin. RN A said he/she realized after he/she gave the insulin he/she failed to prime the pens and should have. RN A said the reason the pen should be primed before administering the insulin is to ensure an accurate dose is given as the pens can get air bubbles. RN A said not priming the pens is a medication error. 3. During an interview on 11/14/24 at 1:00 P.M., the Unit Manager N said the proper way to administer insulin using a pen is to prime the insulin pen with two units each time before setting the dose of insulin to give. This ensures the accuracy of the dose given as insulin pens can get air bubbles in them. If staff do not prime the pen each time it is considered a medication error. During an interview on 11/14/24 at 1:25, the DON said the nurses and CMT's are responsible to administer medications per the physician's orders accurately. The DON said the proper way to administer insulin using a pen is to prime the insulin pen with two units each time before setting the dose of insulin. The DON said this ensures the accuracy of the dose given as insulin pens can get air bubbles in them. The DON said if staff do not prime the pen each time this would be considered a medication error. During an interview on 11/14/24 at 2:22 P.M., the administrator said he/she expects staff to follow the standards of practice and facility policies regarding medication administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: [NAME], [NAME] Based on observation, interview, and record review, facility staff failed to review and revise the plan of care with changes in the residents' needs for seven residents (Resident's #5, #13, #14, #27, #29, #35, and #40) out of 25 sampled. The census was 66. 1. Review of the facility's policy Care Plans, Comprehensive Person Centered, dated March 2022, showed care plans are developed within seven days of completion of the required MDS (Minimum Data Set), a federally mandated assessment tool (Admission. Annual, or Significant Change of Status), and no more than 21 days after admission. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Assessments of residents is ongoing and care plans are revised as information about the resident and the residents' conditions change. 2. Review of Resident #5's admission MDS, dated [DATE], showed staff assessed the resident as moderately Cognitively Impaired and required an indwelling urinary catheter (tube placed directly in the bladder to drain urine). Review of the Physician Order Sheet (POS), dated November 2024, showed staff documented the resident's foley catheter had been discontinued on 11/03/24. Review of the care plan, dated 10/13/24, showed staff were directed to use enhanced barrier precautions due to the presence of an indwelling urinary catheter. 3. Review of Resident #13's admission MDS dated [DATE], showed staff assessed the resident as mild to moderately cognitively impaired, received anticoagulant (thins the blood) medication and required partial to moderate assist from staff for sitting on the side of the bed. Review of resident's medical record showed a signed consent, dated 10/1/24, for bed rail use to assist with mobility. Review of the POS, dated November 2024, showed an order for Eliquis (blood thinner) 5 milligrams (mg) daily and a bed enabler. Review of the resident's care plan, revised 11/11/24, showed it did not contain direction for staff in regard to the resident's use of an anticoagulant medication or the use of bed rails. Observation on 11/12/24 at 12:45 P.M., showed bed rails up on both sides of the resident's bed. During an interview on 11/12/24 at 12:45 P.M., the resident said the rails help him/her move around in bed. Observation on 11/13/24 at 02:36 P.M., showed bed rails up on both sides of the resident's bed. During an interview on 11/15/24 at 2:41 P.M., the Director of Nursing (DON) said blood thinners should be on the care plan due to the risk of bleeding. The DON said he/she did not know why blood thinners were not on the resident's care plan. During an interview on 11/15/24 at 3:33 P.M., the MDS Coordinator said blood thinners should be included on the care plan and he/she does not know why it is not on the resident's care plan. 4. Review of Resident #14's admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact and required partial/moderate assistance for bed mobility. Review of the resident's care plan, dated 10/03/24, showed it did not contain direction for staff in regard to bed rail or enabler use. Review of the POS, dated November 2024, showed an order for staff to assess the resident at admission for the use of a one-eighth type enabler on bed for positioning/transfer assistance, if indicated and/or with resident request. Observation on 11/12/24 at 1:38 P.M., showed the resident in bed with bed rails raised on both sides. Observation on 11/13/24 at 12:31 P.M., showed the resident in bed with bed rails raised on both sides. During an interview on 11/13/24 at 12:31 P.M., the resident said he/she utilized the bed rails to assist with mobility. 5. Review of Resident's #27's Quarterly MDS, dated [DATE], showed staff assessed the resident as moderate cognitive impairment, diarrhea, and frequently incontinent of bowel. Review of the resident's care plan, dated 7/4/24, showedteh care plan did not contain documentation of frequent bowel incontinence. Review of the resident's POS, dated November 2024, showed an order for Diphenoxylate-Atropine (a medication used to treat diarrhea) 2.5-0.024 mg, one tablet four times a day. Review of the resident's Bowel Incontinence log, dated 10/17/24 through 11/15/24 showed staff documented the resident has 15 episodes of bowel incontinence. 6. Review of Resident #29's admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact and required substantial/maximal assistance for bed mobility. Review of the resident's POS, dated November 2024, showed an order for staff to assess the resident at admission for use of one-eighth type of enabler on bed for positioning/transfer assistance, if indicated and/or with resident request. Review of the care plan, revised 11/08/24, showed it did not contain direction for staff in regard to bed rail or enabler use. Observation on 11/12/24 at 1:44 P.M., showed the resident in the room with both bed rails in the raised position. Observation on 11/13/24 at 12:16 P.M., showed the resident in the room with both bed rails in the raised position. During an interview on 11/13/24 at 12:16 P.M., the resident said he/she utilized the bed rails to assist with mobility. 7. Review of Resident #35's Quarterly MDS dated [DATE] showed staff assessed the resident as mild cognitive impairment, diagnosis of hemiplegia or hemiparalysis (partial or total paralysis of one side of the body), and required partial to moderate assistance for sitting on the side of the bed. Review of the medical record showed a bed rail consent, signed 8/11/23. Review of the POS showed an order, dated 8/16/24, for one-eighth type of enabler on bed for positioning/transfer assistance if indicated and /or with resident request. Review of the care plan, dated 10/25/24, showed it did not contain direction for staff in regard to the resident's bed rail use. 8. Review of Resident #40's admission MDS, dated [DATE], showed staff assessed the resident with moderate cognitive impairment and diagnosis of dementia. Review of the medical record, showed staff documented the resident had a diagnosis of dementia. Review of the care plan, dated 11/14/24, showed it did not contain direction for staff in regard to the resident's dementia. 9. During an interview on 11/15/24 at 2:05 P.M., Certified Nurse Aide (CNA) H said he/she knew where to find care plans but did not use them. CNA H said the basic care instructions for residents are on the white boards in the residents' rooms. During an interview on 11/15/24 at 2:11 P.M., Licensed Practical Nurse (LPN) J said care plans should include everything about a resident, however staff use the white boards in the residents' rooms in addition to report from therapy to be informed about the residents. During an interview on 11/15/24 at 2:15 P.M., LPN F said he/she has never been told about care plans and does not know how to access them. The LPN said nurses do not really work with care plans, and they are more for therapy. The LPN is is the responsibility of the case worker and social worker to update the care plans. During an interview on 11/15/24 at 2:36 P.M., CNA G said he/she knows how to care for residents by reviewing the hospital paperwork, and by using the white board at the nurses' station. During an interview on 11/15/24 at 2:41 P.M., the DON said chronic diarrhea should be on the care plan, as it poses a risk for skin breakdown. The DON said he/she did not know why it was not care planned for Resident #27. The DON said if a resident has bed enablers, it should be care planned. The DON said care plans are discussed at daily clinical meetings. The MDS Coordinator is responsible for developing the care plans. During an interview on 11/15/24 at 3:33 P.M., the MDS Coordinator said care plan changes can be made by anyone, but usually are not. Care plans are completed within 14 days of admission. The information is gathered from hospital records, staff, the chart, providers, family and the resident. The care plans should be updated when something changes. Chronic diarrhea and bed rails should be on the care plan and he/she does not know how diarrhea had been missed for Resident #13. The MDS Coordinator did not know why bed rails were missed for Residents #13, 14, #29 and #35. He/She said all staff know where to find care pans and should be using them to give the right care to residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to conduct regular entrapment assessments for seven (Resident #5, #13, #14, #17, #29, #35 and #40) out of seven sampled residents who used bed rails . The facility census was 66. 1. Review of the facility's Bed Safety and Bed Rails policy, dated August 2022, showed the use of bed rails is prohibited unless the criteria for use of bed rails have been met. Regardless of mattress, type, width, length and/or depth, the bed frame, bed rail and mattress will leave no gap wide enough to entrap a resident's head or body. Any gaps in the bed system are with the safety dimensions established by the Food and Drug Administration (FDA). Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including entrapment risks. The maintenance department provides a copy of inspection to the administrator. 2. Review of the maintenance department records showed it did not contain a completed entrapment assessment since June 2024. 3. Review of Resident #5's admission Minimum Data Set (MDS), a federally mandated assessment tool, showed staff assessed the resident as: -admitted on [DATE]; -Moderately Cognitively Impaired; -Required supervision or touch assistance for bed mobility. Review of the Physician Order Sheet (POS), dated November 2024, showed an order for staff to assess the resident at admission for the use of a one-eighth type of enabler on the bed for positioning/transfer assistance, if indicated and/or with resident request. Review of the medical record showed it did not contain an entrapment assessment. Observation on 11/12/24 at 1:21 P.M., showed the resident in bed with bed rails raised on both sides. Observation on 11/13/24 at 3:14 P.M., showed the resident in bed with bed rails raised on both sides. 4. Review of Resident #13's admission MDS, dated [DATE], show staff assessed the resident as: -admitted on [DATE]; -Mild to moderate cognitive impairment; -Partial to moderate assistance for lying to sitting side of bed. Review of the POS, dated November 2024, showed an order for staff to assess the resident at admission for use of a one-eighth type of enabler on bed for positioning/transfer assistance, if indicated and/or with resident request. Review of the care plan, dated 10/4/24, showed it did not contain documentaion of bed rail use. Review of the resident's medical record did not contain an entrapment assessment. Observation on 11/12/24 at 12:45 P.M., showed the resident in bed with bed rails raised on both sides. Observation on 11/13/24 at 2:36 P.M., showed the resident in bed with bed rails raised on both sides. 5. Review of Resident #14's admission MDS, dated [DATE], showed staff assessed the resident as: -admitted on [DATE]; -Cognitively intact; -Required partial/moderate assistance for bed mobility. Review of the resident's POS, dated November 2024, showed an order for staff to assess the resident at admission for use of one-eighth type of enabler on bed for positioning/transfer assistance, if indicated and/or with resident request. Review of resident's medical record did not contain an entrapment assessment. Observation on 11/12/24 at 1:38 P.M., showed the resident in bed with bed rails raised on both sides. Observation on 11/13/24 at 12:31 P.M., showed the resident in bed with bed rails raised on both sides. 6. Review of Resident #17's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -admitted on [DATE]; -Severely Cognitively Impaired; -Required substantial/maximal assistance for bed mobility. Review of the resident's (POS), dated November 2024, showed an order for staff to assess the resident at admission for use of one-eighth type of enabler on bed for positioning/transfer assistance, if indicated and/or with resident request. Review of the resident's medical record did not contain an entrapment assessment. Observation on 11/13/24 at 8:21 A.M., showed the resident in bed with bed rails raised on both sides. Observation on 11/14/24 at 2:01 P.M., showed the resident in bed with bed rails raised on both sides. 7. Review of Resident #29's admission MDS, dated [DATE], showed staff assessed the resident as: -admitted on [DATE]; -Cognitively intact; -Required substantial/maximal assistance for bed mobility. Review of the POS, dated November 2024, showed an order for staff to assess the resident at admission for use of one-eighth type of enabler on bed for positioning/transfer assistance, if indicated and/or with resident request. Review of the resident's medical record did not contain an entrapment assessment. Observation on 11/12/24 at 1:44 P.M., showed the resident's bed with bed rails raised. Observation on 11/13/24 at 12:16 P.M., showed the resident's bed with bed rails raised. 8. Review of Resident #35's Quarterly MDS dated [DATE], showed staff assessed the resident as: -Mild cognitive impairment; -Required partial/moderate assistance for bed mobility; -Diagnosis of hemiplegia (partial or total paralysis on one side of the body) or hemiparesis (weakness or inability to move one side of the body). Review of the care plan, dated 7/20/24, showed staff documented the resident used bed rails for mobility. Review of the POS, dated November 2024, showed an order dated 8/16/24 for staff to assess the resident at admission for use of one-eighth type enabler on bed for positioning/transfer assistance, if indicated and/or with resident request. Review of the resident's medical record did not contain an entrapment assessment. Observation on 11/12/24 12:15 P.M., showed the resident in bed with bed rails raised on both sides. Observation on 11/13/24 at 2:19 P.M., showed the resident in bed with bed rails raised on both sides. 9. Review of Resident #40's admission MDS, dated [DATE], showed staff assessed the resident as: -admitted on [DATE]; -Moderately Cognitively Impaired; -Required partial/moderate assistance for bed mobility. Review of the resident's POS, dated November 2024, showed it did not contain an order for bed rails. Review of the resident's medical record showed it did not contain an entrapment assessment. Observation on 11/13/24 at 9:00 A.M., showed the resident in bed with bed rails raised on both sides. Observation on 11/14/24 at 2:31 P.M., showed the resident in the room with bed rails in the raised position. 10. During an interview on 11/14/24 at 10:38 A.M., the administrator said the staff member who had been responsible for completing the entrapment assessments had been terminated in June of this year. The administrator said entrapment assessments had not been completed since June 2024. The administrator said the new maintenance director had been out and the assessments had not been completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to maintain a professional standard of care when staff did not follow manufacturer's guidelines to administer insulin using an insulin pen for one resident (Resident #22), failed to obtain specific orders for one resident's (Resident #1) tracheostomy (opening in neck to place a tube to allow air into the lungs) and to have a suction machine at the bedside side, failed to obtain an order and plan care for the use of a catheter (a tube to drain the bladder) for two residents (Resident #308 and #323), failed to discontinue an order for catheter use for one resident (Resident #26) who no longer used a catheter, failed to obtain an order and plan care for the use of a Continuous Positive Airway Pressure (CPAP - pressure to used to help keep airway open) machine for one resident (Resident #15), failed to obtain an order for dialysis and provide written communication between the facility and dialysis center for one resident (Resident #18), and failed to assess under the wound dressings on admission for one resident (Resident #308). The facility census was 64. 1. Review of the facility's Insulin Administration policy, dated September 2014, showed it did not contain direction or procedure for insulin pen use. Review of the Humalog Kwikpen Instructions for Use from www.humalog.com, dated April 2020, showed staff are directed to: -Wipe the rubber seal with an alcohol pad/swab; -Push the capped needle straight onto the pen and twist until tight; -Prime the pen (priming means removing the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly). Turn the Dose knob until a 2 is seen in the dose window. If you do not prime before each injection, you may get too little or too much insulin; -Hold the pen with the needle pointing up, tap the cartridge gently to collect air bubbles at the top, push the Dose knob until it stops and a 0 is seen in the dose window. Hold the dose knob in and count to 5 slowly. Insulin should be seen at the tip of the needle; -Turn the dose knob to select the number of units you need to inject; -Inject the insulin by cleansing the site with alcohol and let air dry, insert the needle into the skin, press the dose knob in and count to 5 slowly before removing the needle. Review of Resident #22's Physician Order Sheets (POS), dated 8/10/23 showed: -On 8/1/23, Humalog Solution 100 unit/ml, inject 8 units subcutaneously before meals; -On 8/1/23, Humalog Solution 100 unit/ml, inject 1 unit subcutaneously before meals for a blood sugar between 151-200. Observation on 8/10/23 at 10:44 A.M., showed Certified Medication Technician (CMT) F removed a Humalog insulin pen from the medication cart after he/she obtained a blood sugar of 160. He/She removed the cap, applied the needle, dialed the dose to 9, cleansed the resident's skin, inserted the needle into the resident's right abdomen, depressed the dose knob, and removed the needle. CMT F did not wipe the rubber seal, prime the pen or hold the pen against the skin for a slow count of 5 during administration. During an interview on 8/10/23 at 10:49 A.M., CMT F said he/she had not been instructed on administration of insulin by a pen but thought it should have been cleaned before attaching the needle to decrease risk of infections. CMT F did not know why to prime or how to prime the pen. During an interview on 8/11/23 at 9:30 A.M., Licensed Practical Nurse (LPN C) said staff should obtain an insulin pen, check and verify orders, apply a pen needle, prime the pen, and hold against the skin for a count of 5 during administration. He/she said he/she did not think it was necessary to cleanse the rubber seal before applying the pen needle and was not taught to. LPN C said staff should prime the pen and hold the needle in place during administration for a count of 5 to ensure the entire dose has been given. During an interview on 8/11/23 at 10:19 A.M., the Director of Nursing (DON) said staff are expected to gather supplies, cleanse the rubber seal (to decrease infection), prime with 2 units, verify dose, dial to correct dose, inject and hold the needle in place for 5 seconds to insure the correct dose is given. 2. Review of the facility's Tracheostomy Care policy, revised August 2013, showed staff are directed to do the following: -Check the physician's order; -Tracheostomy tubes should be changed as ordered and as needed (at least monthly); -Tracheostomy care should be provided as often as needed; -A replacement tracheostomy tube must be available at bedside at all times; -A suction machine, supply of suction catheters, exam and sterile gloves, and flush solutions, must be at the bedside at all times. Review of the facility's Medication Orders policy, revised November 2014, showed staff are directed to do the following: -A current list of orders must be maintained in the clinic record of each resident; -Medication orders: when recording orders for medications, specify the type, route, dosage, frequency, and strength of medication ordered; -Treatment orders: when recording treatment orders, specify the treatment, frequency, and duration of the treatment. Review of Resident #1's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 7/1/23, showed staff assessed the resident as follows: -Staff did not assess resident's cognition level; -Required supervision or set up assistance of one staff member for personal hygiene; -Resident had a tracheostomy; -Received tracheostomy care. Review of the resident's physician's orders, dated 8/10/23, showed the following: -Trach care two times a day (BID) (Do not throw away the reusable inner cannula); -Did not contain an order for trach inner cannula size, what to clean the trach site with and strength, what to clean the inner cannula with and strength, and suction as needed in an emergency. Observation on 8/8/23 at 10:56 A.M., showed the resident sat in his/her room with a tracheostomy in place. Further observation showed the resident's room did not contain a suction machine, at the bedside. Observation on 8/9/23 at 8:19 A.M., showed the resident in his/her room with a tracheostomy in place. Further observation showed the resident's room did not contain a suction machine at the bedside. Observation on 8/10/23 at 7:40 A.M., showed the resident sat in his/her chair in his/her room with a tracheostomy in place. Further observation showed the resident's room did not contain a suction machine at the bedside. Observation on 8/10/23 at 1:46 P.M., showed the resident was in his/her bed with his/her eyes closed with a tracheostomy in place. Further observation showed the resident's room did not contain a suction machine at the bedside. Observation on 8/11/23 at 8:35 A.M., showed the resident's room did not contain a suction machine at the bedside. During an interview on 8/10/23 at 1:46 P.M., LPN E said staff normally use a trach cleaning kit each time they provide care. He/She said they are pre-filled with what they use to clean with and he/she thinks they are all the same but not certain of that. During an interview on 8/11/23 at 10:06 A.M., LPN C said she would expect to have emergency equipment at bedside such as a suction machine, Ambu bag, and spare cannula for a resident with a tracheostomy. He/She said he/she would expect the tracheostomy orders to contain what to clean it with, how often to clean the tracheostomy and cannula, size of the cannula, how often to change the cannula, etc. He/She said he/she was not sure what size tracheostomy the resident had, but would expect to see it documented. He/She said he/she was not sure where to find that information. During an interview on 08/11/23 at 10:19 A.M., the Director of Nursing (DON) said he/she would treat residents with a tracheostomy accordingly. He/She said that if it was a new tracheostomy he/she would expect to have emergency equipment at bedside, but an old tracheostomy not necessarily. He/She said he/she would expect the orders to contain the size of the inner cannula, what to clean it with, how often to clean it, how often to change the inner cannula, etc. 3. Review of the facility's Catheter Care, Urinary policy, dated August 2022, showed: -To review the resident's care plan to assess for any special needs of the resident; -To review and document the clinical indications for catheter use prior to inserting; -Remove the catheter as soon as it is no longer needed; -Did not contain directions on what to include in the physician orders or when to obtain a physician order. 4. Review of Resident #308's Entry MDS, dated [DATE] showed the resident admitted on [DATE]. Review of the resident's POS, dated 8/10/23 showed it did not contain an order for the use of a catheter. Review of the resident's baseline care plan, dated 8/7/23 showed it did not contain direction for the use of a catheter. Observation on 8/8/23 at 10:56 A.M., showed the resident in bed and a catheter drainage bag hung from the bed frame. Observation on 8/9/23 at 9:01 A.M., showed the resident in bed with a catheter drainage bag hung to gravity. Observation on 8/9/23 at 10:26 A.M., showed the resident up in a wheelchair with a catheter drainage bag that hung from the bottom of the wheelchair. During an interview on 8/8/23 at 11:02 A.M., the resident's family said a catheter was placed in the hospital because the resident had a rash to the groin. He/She said the resident has a history of urinary tract infections. During an interview on 8/11/23 at 9:30 A.M., LPN C said residents with catheters should have orders for catheters. He/She said the orders should include replacement orders, catheter care, size of catheter, reason for catheter, size of balloon, and placement checking. LPN C did not know why the resident had a catheter but thought it was for urinary retention. During an interview on 8/11/23 at 10:19 A.M., the DON said the use of catheters should have orders in place that include size, balloon size, indication for use, and if any, indications for replacement. He/She was not sure why the resident had a catheter. 5. Review of Resident #323's Discharge, Return Anticipated MDS, dated [DATE], showed facility staff assessed the resident had an indwelling catheter. Review of the resident's POS, dated August 2023 showed an order dated 8/07/23 for Indwelling urinary catheter in privacy bag and catheter leg strap on at all times. Further review showed the POS did not contain a catheter order with the catheter size, balloon size or diagnosis. During an interview on 8/11/23 at 10:19 A.M., the DON said a resident with a catheter should have an order that included catheter size, balloon size, change as needed and diagnosis. 6. Review of Resident #26's Prospective Payment System (PPS) MDS dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Used a catheter; -Had diagnosis of tibia fracture (shin bone). Review of the resident's POS dated 8/10/23, showed: -On 7/21/23, Change catheter #16 french 10 cc bulb attached to gravity drainage bag every month on the 15th and as needed for leaking, plugged or dislodged; -On 7/21/23, May irrigate catheter with sterile water as needed if clogged as ordered by the physician; -On 7/21/23, Monitor catheter for proper placement, no kinking or compression that could obstruct urine flow to gravity bag during catheter care every shift. Observation on 8/8/23 at 3:12 P.M., showed the resident in his/her room in a wheelchair. Further observation showed he/she did not have a catheter. During an interview on 8/8/23 at 3:12 P.M., the resident said the catheter was removed at the facility but could not remember the date. He/she said staff helped him/her to the bathroom. During an interview on 8/11/23 at 9:30 A.M., LPN C said if a catheter was discontinued, there should be a physician order. He/She was not aware there was no order to discontinue the catheter for the resident and knew the resident did not have a catheter. During an interview on 8/11/23 at 10:19 A.M., the DON said when catheters were discontinued, there should be an order to do so. He/She was not aware the catheter was discontinued without an order for the resident. 7. Review of the facility's CPAP/BiPAP Support policy, revised March 2015, showed staff are instructed to review the physician's order to determine the oxygen concentration, flow and CPAP settings for the machine. Staff are also instructed to notify the physician if the resident refused the procedure. Review of Resident #15's admission MDS, dated [DATE], showed facility staff assessed the resident was not using BiPAP/CPAP while a resident or while not a resident. Review of the resident's POS, dated August 2023 showed it did not contain an order for CPAP. Review of the resident's care plan, revised 6/28/23, showed Resident was at risk for respiratory complications related to asthma, sleep apnea but did not include guidance on CPAP usage. Observation 8/08/23 at 11:03 A.M., showed a CPAP sat on the bedside table and the tubing and mask sat on the floor between the table and bed. During an interview on 8/11/23 at 10:19 A.M., the DON said if a resident came from home with CPAP there should be a doctor's order to reflect home settings and the CPAP use should be in the care plan. 8. Review of the facility's Care of a Resident with End-Stage Renal Disease (ESRD) policy, revised September 2010 showed: -Agreements between the facility and the contracted ESRD facility included all aspects of how the resident's care would be managed including how information would be exchanged between facilities. Review of the Memorandum of Agreement, dated 12/18/18, between the facility and the dialysis provider showed: -Facility staff will make an assessment of each patient's physical condition and determine whether the patient was stable enough to be dialized on an outpatient basis; -If it was determined that a patient was sufficiently stable, this assessment will be communicated to the facility's nurse manager or designee; -This assessment would and communication would occur prior to each and every transfer of a patient to dialysis facility for dialysis on an outpatient basis regardless of the number of times any particular patient may be transferred and dialized. Review of Resident #18's PPS 5-Day MDS, dated [DATE] showed facility staff assessed the resident as received dialysis while a resident and while not a resident. Review of the resident's POS dated, August 2023 showed the record did not contain a doctor's orders for dialysis. Review of the resident's care plan, revised 6/03/23, showed: - Resident required dialysis services related to renal failure; - Dialysis per order; - Collaborate care with dialysis center. Review of the resident's vital signs record showed the resident's blood pressure was charted as 199 systolic (squeezing) on 8/07/23. Further review showed the medical record did not contain a nurse note or documentation of provider notification. During an interview on 8/11/23 at 8:41 A.M., Registered Nurse (RN) U said a resident's dialysis was set up outside of the facility and he/she was not sure if there should be doctor's orders. RN U said when the resident returned from dialysis the nurse should assess the resident for pain, vital signs and any other issues. RN U said he/she was not aware of any documentation requirement and it was not facility policy to document assessments. RN U said there was no facility policy or paper assessments exchanged with dialysis providers and all communications were via phone. He/She added phone communications would be in nurses notes, dietician notes, etc. and no notes meant things were okay. During an interview on 8/11/23 at 10:19 A.M., the DON said a resident who went to dialysis should be assessed before or after dialysis. The DON said facility staff did not have written communication with the dialysis center. The DON also said the nurse notes should have the resident's assessment after dialysis and should include checking the dialysis site, how well the resident tolerated dialysis and vital signs. The DON also said the notes should include provider notification of abnormal vital signs and a systolic blood pressure of 199 would be abnormal. 9. Review of the facility's Skin Assessment policy, dated September 2022, showed: -Assessment of a resident's skin condition helps define prevention strategies; -Assessments should be completed upon admission, as soon as possible but no later than 8 hours from the time of admission to the facility each time there is a new stay. Review of Resident #308's Entry MDS, dated [DATE] showed the resident admitted to the facility on [DATE]. Review of the resident's admission assessment dated [DATE] showed staff documented the resident had a skin tear on the right arm from a transfer at the hospital and a skin tear on the right leg from the hospital. Observation on 8/8/23 at 10:56 A.M., showed the resident in bed with a foam dressing on his/her right forearm and right upper leg dated 8/6/23. Observation on 8/9/23 at 9:01 A.M., showed the resident in bed with a foam dressing on his/her right forearm and right upper leg dated 8/6/23. During an interview on 8/9/23 at 9:01 A.M., the resident's family said staff did not remove the dressings or change the dressings since admission. He/She said the dressings should have been changed. During an interview on 8/11/23 at 9:30 A.M., LPN C said on admission licensed nurses should remove all dressings and examine the skin, unless ordered by a physician otherwise. He/She said measurements are taken at that time depending on the type of wound. Additionally LPN C said there is no way to know if a wound is getting better or worse if it is not looked at upon admission or even what is under those bandages. He/She said the facility wound nurse will follow up on all wounds after admission. During an interview on 8/11/23 at 10:19 A.M., the DON said wound dressings should be removed on admission to the facility unless there is orders stating otherwise. He/She said staff should inspect what is underneath the bandage and report it to the DON and wound nurse. He/She was not aware the resident's dressings were not removed during admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review facility staff failed to assist five out of 16 sampled dependent residents (Resident #5, #12, #21, #33, and #313) with grooming and bathing. The facility census was 64. 1. Review of the facility's Activities of Daily Living (ADLs) policy, dated March 2018, showed staff were directed as follows: - Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs); - Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Review of the facility's Shaving the Resident policy, dated February 2018 showed staff are directed to review the resident's care plan for any special needs of the resident. Additional review of the policy showed it did not contain direction or guidance on when to offer or shave the residents. 2. Review of Resident #5's Quarterly MDS, dated [DATE], showed facility staff assessed the resident as follows: - Severe cognitive impairment; - Required extensive assistance from one person for transfers; - Personal hygiene extensive assistance one person; - Totally dependent on one person for bathing. Review of the resident's care plan, dated 4/3/23, showed staff were directed to assist the resident with bathing and grooming due to physical function deficit. Review of the resident's shower sheets, dated 6/5/23 through 8/7/23, showed staff documented the resident received a shower on 6/9/23, 6/12/23, 6/19/23, 6/26/23, 6/29/236, 7/10/23, 7/31/23, 8/3/23, and 8/7/23. Observation on 8/9/23 at 9:48 A.M., showed the resident had greasy, disheveled hair and a brown substance underneath his/her long, untrimmed finger nails. Observation on 8/11/23 at 10:00 A.M., showed the resident had unkempt hair and long finger nails with a brown substance under the finger nails. 3. Review of Resident #12's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 5/29/23, showed facility staff assessed the resident as: - Cognitively intact; - Required extensive assistance from one person for transfers; - Required extensive assistance from one person for personal hygiene; - Required physical help from one person for bathing. Review of the resident's care plan, dated 6/1/23, showed staff were directed to assist the resident with bathing and grooming due to physical function deficit. Observation on 8/8/23 at 2:00 P.M., showed the resident sat in a wheelchair with uncombed greasy appearing hair and unkempt facial hair. The resident's clothing had stains and food debris on them. Observation on 8/10/23 at 3:15 P.M., showed the resident was dressed in disheveled clothing and had greasy appearing hair. During an interview on 8/10/23 at 2:16 P.M., the resident said staff do not get him/her dressed in the morning. If he/she had an appointment, he/she had to use a stick to get dressed and retrieve his/her clothing 4. Review of Resident #21's admission MDS dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Required physical assistance of one staff for personal hygiene and bathing; -Had limited range of motion in one upper extremity; -Had no behaviors or rejection of care; -Had diagnosis of dementia, hemiplegia (paralysis on one side of body) and stroke. Review of the resident's care plan dated 8/8/23, showed: -Resident was to be clean and well-groomed at all times; -Resident needed assistance with ADLs related to decreased endurance, weakness, and pain related to hemiplegia affecting right side; -Did not contain direction or guidance for personal hygiene or grooming including facial hair preferences. Observation on 8/8/23 at 11:13 A.M., showed the resident in his/her bed with long facial hair. Observation on 8/8/23 at 2:32 P.M., showed the resident in his/her room with long facial hair. 5. Review of Resident #33's admission MDS dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Required physical assistance of one staff for personal hygiene and bathing; -Had no behaviors or rejection of care; -Had diagnosis of cancer and stroke. Review of the resident's care plan dated 7/7/23 showed: -Resident was to be clean and well-groomed at all times; -Resident needed assistance with ADLs related to decreased endurance, weakness, and pain related to stroke; -Did not contain direction or guidance for personal hygiene or grooming including facial hair preferences. Observation on 8/9/23 at 8:57 A.M., showed the resident in his/her room with long facial hair. Observation on 8/11/23 at 8:36 A.M., showed the resident up with a walker with long facial hair. 6. Review of Resident #313's Entry MDS dated [DATE], showed the resident admitted to the facility on [DATE]. Review of the Resident's Baseline Care plan dated 8/1/23, showed staff assessed the resident as: -Cognitively intact; -Required physical assistance of one staff for grooming and bathing; -Required assistance with ADL tasks. Observation on 8/8/23 at 11:33 A.M., showed the resident sat in his/her wheelchair with long facial hair. Observation on 8/8/23 at 2:28 P.M., showed the resident sat in his/her wheelchair with long facial hair. Observation on 8/10/23 at 11:29 A.M., showed the resident sat in his/her wheelchair with long facial hair. During an interview on 8/8/23 at 11:42 A.M., the resident said he/she did not like to have long facial hair and usually plucked it but did not have tweezers. He/She said the staff have not offered to help him/her with shaving or tweezing. 7. During an interview on 8/10/23 at 2:24 P.M., Certified Nurse Aid (CNA) G said residents should be showered at least twice a week or more. They had showers in the resident rooms and shower chairs to use if the resident required use of a mechanical lift. There should be no reason why a resident would not receive a shower because they required a mechanical transfer. During an interview on 8/10/23 at 2:39 P.M., CNA L said staff assisted residents that required help to brush their teeth, comb their hair, bathe, cut finger nails, and shave if needed. During an interview on 8/11/23 at 8:17 A.M., Registered Nurse (RN) U said showers should be done according to resident preferences but at least twice a week. Personal grooming of dependent residents should be offered by staff, or completed as needed. During an interview on 8/11/23 at 9:30 A.M., Licensed Practical Nurse (LPN) C said staff assist residents to shave with showers twice weekly. He/She did not notice if any residents needed a shave. During an interview on 8/11/23 at 9:38 A.M., CNA K said residents are shaved on shower days which was scheduled twice weekly. He/She said showers and refusals of care should be charted on shower sheets and signed by the resident as refused. CNA K said showers and shaves are getting done. During an interview on 8/11/23 at 10:19 A.M., the Director of Nursing (DON) said staff should offer to shave residents daily or per the resident's preference. He/She said he/she does not think shaving preferences should be in the care plan, instead staff should ask daily if the resident would like shaved. During an interview on 8/11/23 at 10:20 A.M., the administrator and DON said shaving is offered daily or whatever preference the resident has. Showers are at least two times a week. ADLs are care planned and the level of assistance is included in the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to secure and store medications in a manner to prevent access to residents, visitors and staff. Additionally, facility staff failed to provide safe mechanical lift transfers for two residents (Residents #5 and #7) in a manner to prevent accidents. The facility census was 64. 1. Review of the facility's Storage of Medications policy, dated November 2020, showed: -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; -Compartments (including, but not limited to, drawers, cabinets, rooms refrigerators, carts and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. Observation on 8/8/23 at 3:06 P.M., showed a medication cart sat near the nurse station unlocked and unattended with three residents present in the area. Additionally, the top drawer contained two medication cups stacked on top of one another. The top medication cup contained an oval yellow tablet and a white oval tablet. The bottom medication cup contained six white round tablets. Further observation of the cart showed the top drawer contained seven insulin pens, finger stick devices, insulin pen needles, resident eye drops and inhalers. The second and third drawers contained bubble packed medications for the residents that reside on the 100 hallway, including a narcotic box that was not behind double lock and various over the counter medications. Observation on 8/9/23 at 8:42 A.M., showed Certified Medication Technician (CMT) F stepped away from the medication cart, entered a resident room down the hall, left the cart unlocked and unattended. Additional observation showed a family member stood by the cart. Observation on 8/10/23 at 10:41 A.M., showed CMT F stepped away from the medication cart and left the cart unlocked on Providence hall. Observation on 8/11/23 at 9:18 A.M., showed the Providence medication cart was unlocked and unattended. During an interview on 8/10/23 at 10:44 A.M., CMT F said sometimes he/she forgets to lock the cart and is just a human error. He/She said failing to lock a medication cart could result in someone getting inside and taking things causing harm. During an interview on 8/11/23 at 9:30 A.M., Licensed Practical Nurse (LPN) C said staff were instructed to lock the medication carts when stepping away from them so others could not get into them and get hurt or take medications that were not prescribed. During an interview on 8/11/23 at 10:19 A.M., the Director of Nursing (DON) said staff were expected to lock the medication carts when out of sight. Failure to lock the medication carts could result in someone coming by and taking things from the cart and getting hurt. 2. Review of the facility's Central Venous Catheter Flushing and Locking policy, revised March 2022, showed staff are instructed to use preservative free 0.9% sodium chloride (normal saline) for flushing a central venous access device (CVAD) and lock CVADs with either preservative free normal saline or heparin according to the manufacturer's directions. 3. Review of Resident #308's Entry Minimum Data Set (MDS), a federally mandated assessment tool, dated 8/07/23, showed facility staff assessed the resident as did not receive intravenous (IV) medications while a resident or while not a resident. Review of the resident's Physician Order Sheet (POS), dated August 2023 showed an order dated 8/07/23 to flush Percutaneously (through the skin) Inserted Central Catheter (PICC) line with 10 milliliter (mls) of normal saline, discard, draw labs, then flush with 5 mls of 10 units/mL heparin. Observation on 8/10/23 at 3:29 P.M., showed LPN C entered the resident's room to respond to an intravenous pump alarm. Further observation showed LPN C opened a drawer in the resident's bathroom and removed a normal saline flush syringe. Further observation showed the bathroom drawer also contained one heparin flush syringe. Observation on 8/10/23 at 3:38 P.M., showed one normal saline flush syringe and one heparin flush syringe on the resident's bedside table and a box of normal saline and heparin flush syringes on the window sill. 4. Review of Resident #324's admission MDS, dated [DATE], showed facility staff assessed the resident received IV medications while a resident and while not a resident. Review of the resident's POS, dated August 2023 showed the record did not contain an order for heparin flushes. Observation on 8/08/23 at 12:03 P.M., showed one normal saline flush syringe and heparin flush syringe on the dresser at the foot of the resident's bed. Observation on 8/08/23 at 3:06 P.M., showed one normal saline flush syringe and heparin flush syringe on the dresser at the foot of the resident's bed. Observation on 8/09/23 at 10:20 A.M., showed a box of saline flush syringes with four heparin flush syringes on the window sill in the resident's room. Observation on 8/09/23 1:54 P.M., showed a box of saline flush syringes with four heparin flush syringes on the window sill in the resident's room. Observation on 8/10/23 at 8:20 A.M., showed a box with 13 normal saline flush syringes and four heparin flush syringes on the window sill in the resident's room. During an interview on 8/10/23 at 3:22 P.M., LPN C said normal saline and heparin flush syringes should not be on the bedside table or the window sill. The LPN also said heparin is a medication but he/she did not know the facility policy on keeping heparin in resident rooms. During an interview on 8/11/23 at 8:23 A.M., LPN E said heparin flushes should not be left in the resident's room since it was a medication. LPN E said there had to be a doctor's order for heparin flushes and if there was not an order there was no reason for heparin to be in the resident's room. LPN E said whoever flushed the resident's central venous access was responsible for verifying flush orders. During an interview on 8/11/23 at 10:19 A.M., the DON said heparin flush syringes should not be in a resident's room because it was a medication. There should be an order for it and shouldn't be in room without a doctor's order. 5. Review of Resident #319's Entry tracking MDS, dated [DATE], showed it did not contain information related to the resident's cognitive status or medication usage. Review of the resident's medical record showed it did not contain documentation of a medication self-administration assessment. Review of the resident's POS, dated August 2023 showed the record did not contain a physician order for the resident to self administer medications. Review of the resident's care plan showed staff were instructed to administer medications as ordered by the physician. Review of the resident's Medication Administration Record (MAR), dated August 2023 showed facility staff documented they administered medications on 8/09/23. Observation on 8/09/23 at 8:46 A.M., showed the resident sat in a wheelchair at the bedside eating breakfast. Further observation showed a small cup of pills on the tray next to the breakfast plate. Observation on 8/10/23 at 8:48 A.M., showed the resident was not in the room and a breakfast tray set on the bedside table and had a small cup that contained eight pills. Further observation showed approximately one minute later the resident was wheeled into the room by Occupational Therapist (OT) M. During an interview on 8/09/23 at 8:47 A.M., the resident said he/she has to eat before taking pills and staff never watched him/her take morning medications. During an interview at 8:50 A.M., OT M said the resident was at the bathroom sink when the pills were dropped off and the resident went to therapy about 8:20 A.M. During an interview on 8/10/23 at 3:22 P.M., LPN C said staff should watch every resident take medications and should never leave medications on the bedside table. During an interview on 8/11/23 at 10:19 A.M., the DON said a resident would have to be assessed and determined to be capable to self administer medications. The DON also said staff should observe the resident take medications and medications should not be on breakfast tray. 6. Review of the facility's Lifting Machine, Using a Mechanical policy, dated July 2017, showed the policy did not contain direction regarding the legs of the mechanical lift device. 7. Review of Resident #5's Quarterly MDS, dated [DATE], showed facility staff assessed the resident as follows: - Severe cognitive impairment; - Required extensive assistance from one person for transfers; - Required extensive assistance from one person for personal hygiene; - Totally dependent on one person for bathing. Observation on 8/9/23 at 10:19 A.M., showed Certified Nurse Aid (CNA) W and CNA X lifted the resident from a wheelchair to the resident's bed. CNA W pushed the mechanical lift to the wheelchair and spread the legs of the lift device to get it above the resident and around the wheelchair. CNA X and CNA W attached the sling to the lift. CNA W raised the resident while CNA X supported the resident. When CNA W moved the lift away from the chair he/she closed the legs of the lift device, turned the lift around and pushed the lift over to the resident's bed and did not have the legs open. 8. Review of Resident #7's Quarterly MDS dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Required physical assistance of two staff for bed mobility and toileting; -Dependent on two staff for transfers; -Had no functional limitation in range of motion. Observation on 8/9/23 at 10:49 A.M., showed CNA K lifted the resident from the bed using a mechanical lift. He/She moved the resident from the bed to the wheelchair and did not support the resident while he/she suspended in the air. When the resident was positioned over the wheelchair, LPN D guided the resident into the wheelchair as the lift was lowered. During an interview on 8/9/23 at 11:02 A.M., CNA K said staff should use two staff for mechanical lift transfers so one could handle the lift and the other could handle the resident so the resident does not fall from the lift. During an interview on 8/9/23 at 11:07 A.M., LPN D said staff should have hands on residents during a mechanical lift transfer but because the room was so small and the wheelchair was in the way so he/she could not get to the resident to help guide the resident to the chair. During an interview on 8/10/23 at 2:41 P.M., CNA G said two staff perform a mechanical lift transfer. One staff operates the lift and the other staff supports the resident. The legs of the lift device should be open to the widest position for stability. During an interview on 8/10/23 at 2:41 P.M., CNA L said the legs of the lift device should be spread when you go around the wheelchair then closed to be able to move. During an interview on 8/11/23 at 8:21 A.M., Registered Nurse (RN) U said two staff perform a mechanical lift transfer. One to operate the lift and the other to steady the resident. The legs of the mechanical lift device should be open for safety. During an interview on 8/11/23 at 10:29 A.M., the administrator and the DON said two staff conduct a mechanical lift transfer. One to operate the lift and the other to steady the resident. The legs should be opened for stability when the resident is attached to the mechanical lift device.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to conduct or complete entrapment assessments and measurements to identify areas of possible entrapment on admission and quarterly for five of eight sampled residents (Resident #1, #26, #36, #37, and #308) who used bed rails. The facility census was 64. 1. Review of the facility's policy titled, Bed Safety and Bed Rails, date revised August 2022, showed staff are directed to do the following: -Bed rails (also referred to as side rails, safety rails, grab assist bars in this policy) are adjustable metal or rigid plastic bars that attach to the bed; -Bed rails are available in a variety of types, shapes, and sizes ranging from one-half, one-quarter, or one-eighth lengths; -The resident's sleeping environment is evaluated by the interdisciplinary team; -Bed frames, mattresses, and bed rails are checked for compatibility and size prior to use; -Bed dimensions are appropriate for the resident's size; -Regardless of mattress type, width, length, and/or depth, the bed frame, bed rail, and mattress will leave no gap wide enough to entrap a resident's head or body. Any gaps in the bed system are within the safety dimensions established by the FDA; -Maintenance staff routinely inspect all beds and related equipment to identify risks and problems including potential entrapment risks; -The maintenance department provides a copy of inspections to the administrator and reports results to the QAPI committee for appropriate action. Copies of the inspection results and QAPI committee recommendations are maintained by the administrator and/or safety committee; -The use of bed rails or side rails is prohibited unless the criteria for bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent; -Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtained informed consent. Overview of FDA potential zones of entrapment with FDA dimension recommendations: -Zone 1: Within the rail, any open space between the perimeter of the rail can present a risk of head entrapment, the FDA recommends a space less than 4 3/4 inches; -Zone 2: Under the rail, the gap under the rail between the mattress, may allow for dangerous head entrapment, the FDA recommends a space less than 4 ¾ inches; -Zone 3: Between the rail and the mattress, this area is the space between the inside surface of the bed rail and the mattress and if too big it can cause a risk of head entrapment, the FDA recommends a space less than 4 3/4 inches; -Zone 4: Under the rail and the end of the rail, gap between the mattress and the lowermost portion of the rail poses a risk of neck entrapment, the FDA recommends a space less than 2 3/8 inches; -The FDA has not provided dimension recommendations for Zones 5-7 (Zone 5: between split bed rails; Zone 6: between the end of the bed rail and the side edge of the head or foot board; Zone 7: between the head or foot board and the end of the mattress). These zones should be assessed for entrapment risk. The facility should refer to manufacturer guidelines for the bed rails, mattresses, and beds. 2. Review of Resident #1's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/01/23, showed staff assessed the resident as follows: -Staff did not assess resident's cognition level; -Independent for bed mobility; -Independent for transfers. Review of the resident's medical record showed the record did not contain a quarterly bed rail assessment, entrapment zones and measurements or a consent for the use of the bed rails after 4/2022. Observation on 08/09/23 at 8:19 A.M., showed the resident sat on the side of the bed with both bed rails in the upright position while he/she put his/her shoes on. Observation on 08/10/23 at 01:46 P.M., showed the resident in bed with his/her eyes closed and both bed rails in the upright position. Observation on 08/10/23 at 03:10 P.M., showed the resident in bed awake with both bed rails in the upright position. 3. Review of Resident #26's 5-day Prospective Payment System (PPS) MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Required two staff physical assistance for bed mobility and transfers; -Did not use restraints. Review of the resident's Bed Rail Assessment, dated 7/21/23, showed the resident used a left and right upper bed rail for transfers and bed mobility. Additionally, the assessment did not contain possible entrapment zones or measurements. Observation on 8/8/23 at 3:17 P.M., showed the resident in bed with both bed rails in the upright position. During an interview on 8/8/23 at 3:22 P.M., the resident said the rails are used for moving him/herself in bed. 4. Review of Resident #36's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Resident required supervision of one staff member for bed mobility; -Resident required limited assistance of one staff member for transfers. Review of the resident's Bed Rail Assessment, dated 2/3/23 and 5/2/23, showed the assessment did not contain entrapment zones and measurements or a consent for the use of the bed rails. Observation on 08/09/23 at 09:07 A.M., showed the resident in bed with his/her eyes closed with both bed rails in the upright position. Observation on 08/09/23 at 03:44 P.M., showed the resident awake in bed with both bed rails in the upright position. Observation on 08/10/23 at 10:46 A.M., showed the resident in bed with both side rails in the upright position. Observation on 08/10/23 at 03:08 P.M., showed the resident in bed with both side rails in the upright position. Observation on 08/11/23 at 08:29 A.M., showed the resident in bed with both side rails in the upright position 5. Review of Resident #37's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Independent with bed mobility; -Independent with transfers. Review of the resident's Bed Rail Assessment, dated, 10/20/22, 1/24/23, 4/24/23, and 7/24/23, showed the assessment did not contain entrapment zones and measurements or a consent for the use of the bed rails. Observation on 08/09/23 at 08:19 A.M., showed the resident in bed with both bed rails in the upright position. Observation 08/10/23 at 07:40 A.M., showed the resident in bed asleep with both bed rails in the upright position. Observation on 08/11/23 at 08:25 A.M., showed the resident in bed with both bed rails in the upright position. 6. Review of Resident #308's Annual MDS dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Required two staff physical assistance for bed mobility and transfers; -Did not use restraints. Review of the resident's Bed Rail assessment dated [DATE], showed the resident used a left and right upper bed rail for bed mobility. Additionally, the assessment did not contain possible entrapment zones or measurements. Observation on 8/8/23 at 10:56 A.M., showed the resident in bed with both side rails in the upright position. Observation on 8/9/23 at 9:01 A.M., showed the resident in bed on a low air loss mattress with both side rails in the upright position. During an interview on 8/8/23 at 11:02 A.M., the family said the resident used the bed rails to help turn and reposition in bed. During an interview on 8/9/23 at 9:15 A.M., the family said the resident was issued a new bed with a new mattress because the resident was restless, trying to climb out of bed. During an interview on 08/09/23 at 01:34 P.M., the Administrator and Director of Nursing (DON) both said that bed rail assessments are to be completed upon admission and quarterly. The DON said that staff are expected to get the consent signed as well on admission and quarterly with each bed rail assessment. He/She said that the staff print bed rail assessment out, have it signed by the resident or responsible party, and then scan it back into the resident's chart under documents once it is signed. The Administrator and DON both said that the entrapment assessment is part of the bed rail assessment they use but no measurements are recorded on it. The DON said that they have standing orders on admission for bed rails. During an interview on 8/11/23 at 9:30 A.M., Licensed Practical Nurse (LPN) C said bed rails are assessed on admission for gaps in the mattress and the bed rail, but does not think they are measured. He/She said gaps between the mattress and the bed rail could result in the resident slipping between and getting hurt. During an interview on 08/11/23 at 10:19 A.M., the DON said that entrapment measurements should be done to ensure safety. He/She said that measurements should be done where a gap exist such as between the mattress and footboard, or between the mattress and enabling bar. He/She said that the measurements should be done quarterly with each bed rail assessment. The administrator said that the maintenance director is responsible for ensuring these are completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility staff failed to wear hairnets and beard guards, to ensure the ice machine drained through an air gap, to maintain the kitchen in a clean and sanitary manner, to store food in a manner to prevent outdated usage and cross contamination, and to perform handwashing when appropriate. These failures had the potential to affect all residents. The census was 64. 1. Review of the facility's Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices policy, dated November 2022, showed hairnets and beard guards are worn when cooking, preparing, or assembling food to keep hair from contacting exposed food, clean equipment, utensils, and linens. Observation on 8/8/23 at 11:15 A.M., showed dietary aide (DA) R prepared residents' lunch plates for service. Further observation showed the DA wore a hairnet, and the hairnet did not cover hair around the DA's face, which measured two inches. Observation on 8/8/23 at 11:17 A.M., showed cook Q prepared the residents' lunch meal. Further observation showed the cook had a full beard and mustache which measured two to three inches, and the cook did not wear a beard guard. Observation on 8/8/23 at 11:20 A.M., showed dietary supervisor (DS) Y worked in the walk-in refrigerator. Further observation showed the DS wore a hairnet, and the hair net did not cover all of the DS's hair, which measured one to two inches around face and neck. Observation on 8/8/23 at 11:22 A.M., showed cook P prepared the residents' dinner meal. Further observation showed the cook had a full beard and mustache which measured half inch to three-quarter inch, and the cook did not wear a beard guard. Observation on 8/8/23 at 11:45 A.M., showed DA S prepared residents' lunch plates for service. Further observation showed the DA had a goatee which measured one inch, and the DA did not wear a beard guard. Observation on 8/9/23 at 10:00 A.M., showed cook Q prepared the residents' lunch meal. Further observation showed the cook had a full beard and mustache which measured two to three inches, and the cook did not wear a beard guard. Observation on 8/9/23 at 10:02 A.M., showed DA R prepped food items for the residents' lunch meal. Further observation showed the DA wore a hair net, and the hair net did not cover hair around the DA's face, which measured two inches. During an interview on 8/9/23 at 12:31 P.M., the dietary manager said the dietary manager and the dietary supervisor were responsible to ensure staff wore hairnets and beard guards according to policy. He/She said the facility had a policy regarding hair nets and beard guards, and staff were trained on the policy. The dietary manager said staff should wear beard guards anytime they have facial hair, and the hair nets should cover all of the hair. He/She was aware staff were not wearing beard guards, and there was no reason for the failure. He/She said he/she noticed staff wore hairnets in a manner that did not cover all their hair, and he/she verbally reminded them to cover all the hair when he/she saw it. During an interview on 8/9/23 at 1:00 P.M., the administrator said the dietary manager was responsible to ensure staff wore hair nets and beard guards according to facility policy. He said the facility had a policy on hair nets and beard guards, and staff were trained on the policy. The administrator said staff should wear hair nets at all times, beard guards if they have facial hair of any length, and the hair nets and beard guards should cover all of the hair. 2. Review of the facility's Ice Machines and Ice Storage Chests policy, dated January 2012, showed the policy did not address drainage through an air gap. Observation on 8/8/23 at 11:50 A.M., showed CNA H scooped ice from the ice machine, located in the kitchen, into a cooler. Further observation showed the ice machine did not drain through an air gap, and the bottom of the drain pipe contained a black and brown substance. During an interview on 8/8/23 at 11:51 P.M., CNA H said the ice in the cooler was used for resident drinks. Observation on 8/8/23 at 10:05 A.M., showed the ice machine, located in the kitchen, did not drain through an air gap, and the bottom of the drain pipe contained a black and brown substance. During an interview on 8/9/23 at 12:31 P.M., the dietary manager said the dietary manager and the maintenance director were responsible to inspect and maintain the ice machine. He/She said the facility had a policy regarding the ice machine, and he/she was trained on the policy. The dietary manager said an outside company cleaned the ice machine every six months, and he/she checked the ice machine every month. The dietary manager said she inspected the ice machine for dirt and mold, but he/she was not aware the ice machine should drain through an air gap. During an interview on 8/9/23 at 1:00 P.M., the administrator said the dietary manager and the maintenance director were responsible to inspect and maintain the ice machine. He said the facility had a policy on the ice machine, and staff were trained on the policy. The administrator said the maintenance director contracted with an outside company to clean the ice machine, and the dietary manager visually inspected the machine between cleanings. The administrator said he was not aware the ice machine did not drain through an air gap, but it was expected the ice machine would be maintained according to regulations. 3. Review of the facility's Sanitization policy, dated November 2022, showed: - All kitchens are kept clean, free from garbage and debris; - All utensils, counters, shelves, and equipment are kept clean. Review of the facility's Daily Cleaning Schedule, undated, showed direction for staff to clean the mixer, prep tables and countertops, beverage table, coffee urns, stovetop, grill, and kitchen floor. Review of the facility's Weekly Cleaning Schedule, undated, showed direction for staff to clean the range hood, coffee machine, and shelves. Observation on 8/8/23 at 11:26 A.M., showed the following: - Stand mixer visibly dirty with brown spots; - Wall at coffee maker visibly dirty with brown spots; - Metal service table with toaster visibly dirty with smudges and drips on the drawer front; - Small refrigerator near stove visibly dirty with drips and spots; - Metal work table with plate warmer visibly dirty on two lower shelves with crumbs and spots. Further observation showed pans and and racks stored in the crumbs; - Steam table visibly dirty with drips and brown accumulation around knobs, with crumbs and spots on the bottom shelf. Further observation showed serving pans stored inverted in the crumbs and spots, and cook P used a pan from the shelf for resident dinner preparation; - Floor under and around cooking equipment under the suppression hood visibly dirty with crumbs and grease buildup; - Warmer visibly dirty with white spots, smudges, and crumbs on the door; - Stove visibly dirty with brown spots, drips, crumbs, and splatters on the oven doors and around knobs. Further observation also showed the oven door handles sticky to touch; - Fryer visibly dirty with drips and spots on front and sides; - Grill visibly dirty with with brown and white spots and splatters; - Two drawer refrigerator visibly dirty with crumbs, chunks, drips, and brown buildup on drawers; - Tilt skillet visibly dirty with brown and white buildups and crumbs; - Single door, metal, lower cabinet visibly dirty with yellow spots, chunks, and drips; - Suppression nozzles visibly dirty with dust. Further observation showed an uncovered pot of water sat on the stove under the suppression nozzles. Observation on 8/9/23 at 10:07 A.M., showed: - Stand mixer visibly dirty with brown spots; - Wall at coffee maker visibly dirty with brown spots; - Metal service table with toaster visibly dirty with smudges and drips on the drawer front; - Small refrigerator near stove visibly dirty with drips and spots; - Metal work table with plate warmer visibly dirty on two lower shelves with crumbs and spots. Further observation showed pans and and racks stored in the crumbs; - Steam table visibly dirty with drips and brown accumulation around knobs, with crumbs and spots on the bottom shelf. Further observation showed serving pans stored inverted in the crumbs and spots, and cook P used a pan from the shelf for resident dinner preparation; - Floor under and around cooking equipment under the suppression hood visibly dirty with crumbs and grease buildup; - Warmer visibly dirty with white spots, smudges, and crumbs on the door; - Stove visibly dirty with brown spots, drips, crumbs, and splatters on the oven doors and around knobs. Further observation also showed the oven door handles sticky to touch; - Fryer visibly dirty with drips and spots on front and sides; - Grill visibly dirty with with brown and white spots and splatters; - Two drawer refrigerator visibly dirty with crumbs, chunks, drips, and brown buildup on drawers; - Tilt skillet visibly dirty with brown and white buildups and crumbs; - Single door, metal, lower cabinet visibly dirty with yellow spots, chunks, and drips; - Suppression nozzles visibly dirty with dust. Further observation showed an uncovered pot of water sat on the stove under the suppression nozzles. During an interview on 8/9/23 at 12:31 P.M., the dietary manager said all dietary staff were responsible to maintain the kitchen in a clean and sanitary manner. He/She said the facility had a checklist for cleaning the kitchen, but no one had been completing the checklist. The dietary manager said it was expected staff would clean their work stations after each service and the floors at the end of the day. She said staff should clean any area they saw was visibly dirty when they saw it. During an interview on 8/9/23 at 1:00 P.M., the administrator said the dietary manager was responsible to ensure the kitchen was maintained in a clean and sanitary manner. He said the facility had a cleaning policy and logs for the kitchen, and it was expected staff would follow the policy and complete the logs. The administrator was not aware the dietary staff were not completing the cleaning logs. 4. Review of the facility's Food Receiving and Storage policy, dated November 2022, showed: - All foods stored in the refrigerator or freezer are covered, labeled, and dated (use by date); - Foods in the walk-in are stored off the floor; - The policy did not address dry food storage regarding label, date, and protection from air. Observation on 8/8/23 at 12:00 P.M., of the walk-in freezer, showed: - Two bags of white patties unlabeled; - One ziploc contained round brown disks, unlabeled and undated; - Four boxes of bread sat directly on the freezer floor. Observation on 8/8/23 at 12:05 P.M., of food preparation station, showed: - 11 containers of various open spices, five pounds, undated; - Container of open salt undated; - Baking soda with the box open, unprotected and undated; - Kosher salt with the box open, unprotected and undated; - Shaker of white powder unprotected, unlabeled, and undated; - Open container of [NAME] seasoning undated; - Open container of Greek seasoning undated; - Ziploc bag of Hillbilly Joe's seasoning undated; - 25 containers of various seasonings, 18-22 ounces, undated. Observation on 8/8/23 at 2:50 P.M., of the two drawer refrigerator, showed a plate with two slices of bread, unlabeled and undated. Observation on 8/9/23 at 10:10 A.M., of the walk-in freezer showed: - Two bags of white patties unlabeled; - Four boxes of bread sat directly on the freezer floor. Observation on 8/9/23 at 10:12 A.M., of the food preparation station, showed: - 11 containers of various open spices, five pounds, undated; - Container of open salt undated; - Box open baking soda unprotected and undated; - Box open kosher salt unprotected and undated; - Shaker of white powder unprotected, unlabeled, and undated; - Open container of [NAME] seasoning undated; - Open container of Greek seasoning undated; - Ziploc bag of Hillbilly Joe's seasoning undated; - 25 containers of various seasonings, 18-22 ounces, undated. During an interview on 8/9/23 at 12:31 P.M., the dietary manager said the dietary supervisor was responsible to ensure food was stored in a manner that prevented outdated usage and cross contamination. He/She said the facility had a policy regarding food storage, and the staff were trained on the policy. The dietary manager said the dietary supervisor checked food storage every day, and the dietary supervisor put away the food deliveries. The dietary manager said food deliveries should be put away as soon as possible and should not be left sitting on the floor. She said all open food should be labeled, dated, and protected; and staff should label and date any bags of food that were removed from the original boxes. During an interview on 8/9/23 at 1:00 P.M., the administrator said the dietary manager was responsible to ensure food was stored correctly. He said the facility had a policy on food storage, and staff were trained on the policy. The administrator said food deliveries should be put away as soon as possible and not left on the floor. He said it was expected all food in storage was labeled, dated, and protected. 5. Review of the facility's Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices policy, dated November 2022, showed employees must wash their hands: - After personal body functions (blowing/wiping nose); - Whenever entering or re-entering the kitchen; - After handling soiled equipment or utensils; - During food preparation, as often as necessary, to remove soil and contamination and to prevent contamination when changing tasks; - After engaging in other activities that contaminate the hands; - Gloves are considered single-use items and must be discarded after completing the task for which they are used; - Gloves are removed, hands are washed, and gloves are replaced. Observation on 8/8/23 at 11:52 A.M., showed cook Q knocked over the wet floor sign. Further observation showed the cook used his/her bare hands to pick up the sign from the floor. The cook walked into the walk-in refrigerator, picked up a container of sliced cheese. The cook donned gloves, prepared resident lunch plates, and touched the plates, baked potatoes, and service utensils. The cook did not hand wash after picking up the wet floor sign and before donning gloves. Observation on 8/8/23 at 11:55 A.M. showed cook Q used his/her gloved hands to get a paper towel and wipe his/her face. Further observation showed the cook used the same gloved hands to prepare resident plates and to touch the plates, baked potatoes, and service utensils. The cook did not remove his/her gloves and hand wash after wiping his/her face with the paper towel. Observation on 8/8/23 at 12:20 P.M., showed DA T entered the kitchen from the utility hallway and touched the door handle with his/her bare hands. Further observation showed the DA put away clean dishes, and he/she touched the food surface area of plates and bowls. The DA did not perform handwashing after entering the kitchen and before touching the clean dishes. Observation on 8/8/23 at 3:12 P.M., showed DA R worked in the dishwasher station. Further observation showed the DA did not hand wash after he/she touched dirty dishes and before he/she touched clean dishes. During an interview on 8/9/23 at 12:31 P.M., the dietary manager said the dietary manager and the dietary supervisor were responsible to ensure staff wore gloves and performed hand washing appropriately. He/She said the facility had a policy regarding hand washing and glove use, and the staff were trained on the policy. The dietary manager said it was expected staff would perform hand washing after entering the kitchen, before and after glove use, when they moved from a dirty task to a clean task, and after touching their personal self. During an interview on 8/9/23 at 1:00 P.M., the administrator said the dietary manager was responsible to ensure dietary staff hand washed and used gloves according to facility policy. He said the facility had a policy on handwashing and glove use, and staff were trained on the policy. The administrator said it was expected the dietary staff hand washed and used gloves according to facility policy.

Based on interview and record review, facility staff failed to notify the resident and/or resident representative in writing of a facility initiated transfer to a hospital, including the reasons for the transfer, the bed hold policy, or required agency contact information for three sampled residents (Resident #12, #32, and #53). The facility census was 63. 1. Review of the facility's Transfer or Discharge Notice policy, revised March 2021, showed the following: -Residents and/or representatives are notified in writing, and in a language and format they understand, at least thirty (30) days prior to a transfer or discharge; -Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge: - The safety of individuals in the facility would be endangered; - The health of individual in the facility would be endangered; - The resident's health improves sufficiently to allow a more immediate transfer or discharge; - An immediate transfer or discharge is required by the resident's urgent medical needs; and/or - The resident has not resided in the facility for thirty (30) days; -The resident and representatives are notified in writing of the following information: - The specific reason for the transfer or discharge; - The effective date of the transfer or discharge; - The location to which the resident is being transferred or discharged ; - An explanation of the resident's right to appeal the transfer or discharge to the state, including: - The name, address, and telephone number of the Office of the State Long-Term Care Ombudsman; - The name, address, email and telephone number for the agency responsible for the protection and advocacy of residents with intellectual and developmental (or related) disabilities (as applies); - How to get assistance completing the appeal process; - The facility bed-hold policy; - The name, address, and telephone number of the Office of the State Long-term Care Ombudsman; - The name, address, email and telephone number of the agency responsible for the protection and advocacy of residents with intellectual and developmental (or related) disabilities (as applies); - The name, address, email and telephone number of the agency responsible for the protection and advocacy of residents with a mental disorder or related disabilities (as applies); and - The name, address, and telephone number of the state health department agency that has been designated to handle appeals of transfers and discharge notices. 2. Review of Resident #12's medical record showed the resident was discharged and transferred to the hospital from the facility on 1/18/22. Further review showed the record did not contain documentation the resident or resident representative were notified with the required information in writing. During an interview on 04/26/22 at 1:37 P.M., the resident said when transferring to the hospital, he/she and their representative were not notified regarding a bed hold policy. 3. Review of Resident #32's medical record showed the resident was transferred to the hospital from the facility on 4/26/22. Further review showed the record did not contain documentation the resident or resident representative were notified with the required information in writing. 4, Review of Resident #53's medical record showed the resident was discharged and transferred to the hospital from the facility on 4/19/22. Further review showed the record did not contain documentation the resident or resident representative were notified with the required information in writing. 5. During an interview on 4/28/22 at 9:40 A.M., the Director of Nursing said nursing contacted the families by phone regarding resident transfers to the hospital, and that the Social Services Director was responsible for the paperwork. During an interview on 4/28/22 at 9:48 A.M., the Social Services Director said residents and/or representatives were notified of resident transfers verbally in person or by phone, and no written notifications were issued.