Based on observation, interview, and record review, it was determined that the facility failed to follow the health care provider's order for a therapeutic diet for a swallowing issue for 1 of 2 residents reviewed for nutrition in a final sample of 14 residents (Resident identifier is #43). Findings include:Review on 8/5/25 of Resident #43's physician's order revealed a dietary order dated 4/10/25 for Regular/Liberalized dysphagia (difficulty swallowing) advanced texture, pureed fruit and vegetables. Review on 8/5/25 of Resident #43's Care Plan revealed that Resident #43 was at nutritional risk for dysphagia with a goal of exhibiting no overt dysphagia with texture modification with a target date of 9/11/25. Further review revealed there was an intervention to provide a dysphagia diet as ordered. Observation on 8/5/25 at 12:15 p.m. of Resident #43 revealed that he/she was in their bed with their lunch tray set up in front of them with Resident #43's meal ticket which read Pureed Fruits and Vegetables. Further observation revealed there was a bowl of sliced whole pears on the tray. Interview on 8/5/25 at 12:23 p.m. with Staff A (Licensed Nursing Assistant) confirmed that the pears were served to Resident #43 whole. Interview on 8/5/25 at 12:25 p.m. with Staff B (Dietician) and Staff C (Dietary Manager) confirmed that Resident #43's fruits and vegetables should have been pureed. Observation on 8/6/25 at 8:13 a.m. of Resident #43 in the dining room eating breakfast revealed a bowl of watermelon, that had been cut into pieces. Interview on 8/6/25 at 8:20 a.m. with Staff D (Medication Nursing Assistant) confirmed that the watermelon was not pureed. Review on 8/6/25 of Resident #43's Speech Therapy Discharge Summary signed by Staff F (Speech Language Pathologist) on 7/3/25 revealed that Resident #43 had been on services for dysphagia therapy from 6/3/25 through 7/3/25. Further review revealed that the discharge recommendations were for pureed fruits and vegetables. Interview on 8/6/25 at 12:00 p.m. with Staff F confirmed that Resident #43's had recently been treated for swallowing issues and that the Resident's fruit and vegetables should have been pureed. Review on 8/6/25 of the facility's Diet and Nutrition Care Manual, page 2-20 revealed . Dysphagia Puree (Level 1) Diet . All foods are pureed to simulate a soft food bolus, eliminating the whole chewing phase . Food . Fruits (include a variety; with more fruit than juice as appropriate) Pureed consistency . Review on 8/6/25 of the facility's policy titled Therapeutic Diet Orders, implemented 9/1/24, revealed . The facility provides all residents with foods in the appropriate form . as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care . 5. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form . as prescribed .

Based on interview and record review, it was determined that the facility failed to ensure the residents' right to formulate advance directives for 2 out of 2 residents reviewed for Advance Directives in a final sample of 15 residents. (Resident Identifier's are #102 and #152.) Findings include: Resident #102 Review on 2/19/25 of Resident #102's medical record revealed a physician's order, dated 2/15/25, for Full Code (meaning the patient wishes to receive all possible life-saving measures in the event of a cardiac or respiratory arrest). Further review of Resident #102's medical record revealed a Portable Do Not Resuscitate (DNR) form, dated 7/11/22, that indicated Resident #102 was a DNR (meaning the patient wishes not to have cardiopulmonary resuscitation attempted on them if their heart or breathing stops). Review on 2/20/25 of Resident #102's care plan for advanced directives revealed Resident #102's code status was DNR. Interview on 2/20/25 at approximately 12:20 p.m. with Staff C (Registered Nurse) confirmed the above findings. Resident #152 Review on 2/19/25 of Resident #152's physician orders revealed an order for DNR, dated 2/18/25. Review on 2/19/25 of Resident #152's care plan for advanced directive revealed was Full Code, dated 2/14/25. Interview on 2/20/25 at approximately 11:30 a.m. with Staff A (Nurse Manager) confirmed the above findings.

Based on interview and record review, it was determined that the facility failed to inform each resident before, or at the time of admission, of services available in the facility and of charges for those services for 1 resident in a final sample of 15 residents. (Resident identifier is #43.) Findings include: Interview on 2/19/25 at approximately 12:00 p.m. with Resident #43's DPOA (Durable Power of Attorney) revealed that his/her spouse was admitted to the facility in December 2024. He/she stated that they gave the facility their prescription card but was told that they needed to use the facility's pharmacy. Interview revealed they have been billed monthly for co-pays from the facility's pharmacy. They would not have co-pays at their pharmacy and the facility did not tell them they would be charged. Interview on 2/21/25 at approximately 8:30 a.m. with Staff B (Admissions Coordinator) revealed that during the admission process, the option of using an outside pharmacy was not discussed with Resident #43 or their DPOA. Staff B also revealed that Resident #43's DPOA gave him/her an outside pharmacy prescription card during admission. Review on 2/21/25 of the facility policy titled Arrangements with Noncontract Pharmacy, dated 8/20, revealed the following: Policy, A resident or responsible party may request that medications be obtained from a pharmacy other than the facility's contract provider pharmacy, .Procedures, 1. The facility informs the resident and/or responsible party of relevant policies and procedures related to purchasing medications from a noncontract pharmacy

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to follow physician's orders for 1 of 2 residents review for pain management in a final sample of 15 residents (Resident identifier is #44.) Findings include: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 614 .Do not give a medication until you are certain that you can follow the seven rights of medication administration . Page 672 .seven rights of medication administration include right medication, right dose, right patient, right route, right time, right documentation and right indication . Review on 2/20/25 of Resident #44's Medication Administration Record (MAR) revealed a physician order for Acetaminophen Tablet 325 mg [milligrams] Give 2 tablet by mouth every 4 hours as needed for Mild Pain More than 3 doses in 48 hours, notify physician/advanced practice nurse . Review on 2/20/25 of Resident #44's MAR for January and February 2025 revealed that Resident #44 received 4 doses within 48 hours of the above PRN order during the following time periods: Between 1/28/25 and 1/29/25 (1/28/25 at 1:28 am. and 3:54 p.m., 1/29/25 at 4:47 p.m. and 11:07 p.m.,) Between 2/4/25 and 2/6/25 (2/4/25 at 4:36 p.m., 2/5/25 at 1:26 a.m. and 10:51 a.m., 2/6/25 at 2:36 a.m.) Further review of Resident #44's MAR for January and February 2025 revealed that Resident #44 was reporting pain at 5 or above on a numeric pain scale of 1 to 10 for the following days: 1/2/25 at 6:19 a.m., 1/6/25 at 7:18 p.m., 1/9/25 at 7:45 a.m. and 4:49 p.m., 1/13/25 at 4:27 p.m., 1/17/25 at 2:09 a.m., 1/18/25 at 2:31 a.m., 1/20/25 at 5:06 a.m., 4:41 p.m. and 11: 07 p.m., 1/22/25 at 4:59 p.m., 1/23/25 at 6:43 a.m., 1/25/25 at 5:58 a.m., 1/26/25 at 2:36 p.m. and 6:53 p.m., 1/27/25 at 4:39 p.m., 1/28/25 at 1:28 a.m. and 3:54 p.m., 1/29/25 at 11:07 p.m., 1/30/25 at 11:55 a.m. and 5:58 p.m. and 1/31/25 at 4:20 p.m. 2/1/25 at 1:57 a.m., 2/2/25 at 5:21 a.m. and 11:54 p.m., 2/4/25 at 4:36 p.m., 2/5/25 at 1:26 a.m. and 10:51 a.m., 2/6/25 at 2:36 a.m., 2/7/25 at 12:47 a.m. , 2/8/25 at 2:18 a.m., 2/9/25 at 12:49 a.m., 2/10/25 at 2:05 a.m., 2/12/25 at 1:36 a.m., 2/13/25 at 3:50 p.m., 2/16/25 at 6:34 a.m., 2/17/25 at 5:43 a.m., 2/18/25 at 6:04 a.m., 2/19/25 at 2:37 p.m., and 2/20/25 at 3:04 a.m. Review on 2/20/25 of Resident #44's medical record revealed no documentation that the provider was notified when Resident #44 used more than 3 doses in 48 hours of the Acetaminophen PRN order or that they were given Acetaminophen when experiencing pain outside of the PRN order parameters. Interview on 2/20/25 at approximately 1:20 p.m. with Staff A (Nurse Manager) confirmed that there was no documentation that the provider was notified when Resident #44 used more than 3 doses in 48 hours of the Acetaminophen PRN order. Staff A revealed that mild pain would be considered less than 5 on a numeric pain scale of 1 to 10. Staff A also confirmed that Resident #44 was given Acetaminophen outside of the PRN order parameters and there was no documentation that the provider was notified. Interview on 2/20/25 at approximately 2 p.m. with Staff G (Advanced Practical Registered Nurse) confirmed that they had not been notified that Resident #44 had used more than 3 doses in 48 hours of the Acetaminophen PRN order or that they were given Acetaminophen when experiencing pain outside of the PRN order parameters.

Based on interview and record review, it was determined that the facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours a day, 7 days a week, for 4 days in the month of September 2024. Findings include: Review on 2/19/25 of the Facility's Payroll Based Journal Staffing Data Report for Quarter 4 2024 (July 1-September 30, 2024) revealed that there were no RN hours submitted for the following days: 9/1/24, 9/15/24, 9/28/25, and 9/29/24. Interview on 2/20/25 at 1:00 p.m. with Staff D (Director of Nursing) confirmed the above findings and revealed that the facility could not provide documentation to show that there was an RN on duty during the above dates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and manufacturer's instruction review, it was determined that the facility failed to ensure that medications were labeled and dated in accordance with currently acceptable professional principles for 2 out of 2 medication carts observed. (Resident identifiers are #152 and #36.) Findings include: Observation on 2/19/25 at 9:07 a.m. of the [NAME] Front medication cart revealed a small clear plastic medication cup in the top drawer containing 3 pills (medications). The cup was unlabeled and undated. Interview on 2/19/25 at 9:10 a.m. with Staff C (Registered Nurse) confirmed the above findings and revealed that the medications belonged to Resident #36. Observation on 2/19/25 at 9:45 a.m. of the [NAME] Woods medication cart revealed one Symbicort inhaler, not in a box or bag, with no resident identifier or open date or open expiration date. Further observation revealed an Advair Diskus inhaler in a box for Resident #152 without an open date or open expiration date. The pharmacy instructions on the box stated to discard one month after opening. Interview on 2/19/25 at 9:50 a.m. with Staff E (Registered Nurse) confirmed the above findings and revealed that both inhalers had been used. Staff E did not know to whom the Symbicort belonged. Review on 2/19/25 of the Manufacturer's Instructions for Symbicort revealed that the inhaler should be discarded when the labeled number of inhalations and have been used or within 3 months after removal from the pouch. Review on 2/19/25 of the Manufacturer's Instructions for the use of Advair Diskus revealed that the inhaler should be discarded one month after opening the foil pouch or when the counter reads 0.

Based on interview, record review, and policy review, it was determined that the facility failed to ensure that medical records were accurately documented for 1 out of 1 resident reviewed for Post Traumatic Stress Disorder. (Resident Identifier is #202.) Findings include: Review on 2/20/25 of Resident #202's medical record revealed a diagnosis list, dated 2/13/25, that showed Resident #202 had a diagnosis of Post Traumatic Stress Disorder. Further review of Resident #202's medical record revealed a Social Services Assessment and Documentation, signed on 2/17/25 by Staff F (Social Worker). Section C of the assessment titled Mental Health and Wellness .4. Trauma History: Does the patient/resident report or does the medical record reflect any history of trauma and/or Post-Traumatic Stress Disorder (PTSD)? The box is shaded in for the answer 2 NO Interview on 2/20/25 at 1:49 P.M. with Staff F revealed that he/she did not ask Resident #202 about the trauma and did not completed the assessment accurately. Review on 2/20/25 of the facility's policy titled: Trauma Informed Care dated 09/01/2024 2. The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI), admission Assessment, the history and physical and social history/assessment, and others. 6. The facility will identify triggers which may re-traumatize residents with a history trauma. Trigger-specific interventions will identity way to decrease the resident's exposure to triggers which re-traumatize the resident , as well as identify ways to mitigate or decrease the effect of the trigger on the resident, and will be added to the residents care plan.

Based on observation and interview, it was determined that the facility failed to ensure resident's needs were accommodated by keeping their call bell within reach for 1 of 1 reviewed for environment in a final sample of 16 residents (Resident Identifier #12). Findings include: Observation on 9/10/24 at approximately 11:44 a.m. revealed Resident #12's call bell hanging over their roommates light fixture over their roommates bed. Interview on 9/10/24 at approximately 11:44 a.m. with Resident #12 revealed that he/she would yell for help if needed because he/she is unable to reach the call bell. Observation on 9/11/24 at approximately 10:29 a.m. of Resident #12 revealed the call bell hanging over their roommates light fixture over their roommates bed in the same spot as the day prior. Resident #12 was sitting in their wheel chair on a hoyer pad by their window. Resident #12 was unable to reach the call bell on the opposite side of his/her bed. Observation on 9/11/24 at approximately 3:18 p.m. of Resident #12 revealed the call bell hanging over their roommates light fixture over their roommates bed. Resident #12 was napping in bed and unable to reach the call bell.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to provide a clean and homelike environment on 1 of 2 units observed. Observation on 9/11/24 from approximately 7:00 a.m. until 7:20 a.m. of the [NAME] Unit revealed three large areas of smeared brown substance adhered to the carpet. One area (approximately 4 feet (ft.)) long and 1 ft. wide) was on the floor in the hallway and the two other areas (approximately 2 ft. long and 1 ft. wide) were on the floor in front of the nursing station. Further observation revealed two residents walking on the areas. Interview on 9/11/24 at approximately 7:15 a.m. with Staff H (Licensed Nursing Assistant) revealed that the areas on the floor were from a resident having loose stools on 9/10/24 in the evening.

Based on observation, interview, and record review, it was determined that the facility failed to provide showers for 1 out of 3 residents reviewed for Activities of Daily Living (ADL's) in a final sample of 19 residents (Resident Identifier #42). Findings include: Review on 9/13/24 of the facilities policy titled, Resident Showers, not dated, revealed: Policy Explanation and Compliance Guidelines: 1. Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. Resident #42 Review on 9/11/24 of Resident #42's medical record, Care Plan Meeting Note, dated 7/5/24 revealed Resident #42's family was concerned about Resident #42 not getting his/her shower weekly. Review on 9/12/24 of Resident #42's bathing documentation for July, August and September 2024 revealed that Resident #42 did not receive any showers. There was no documentation of refusal of showers. Interview on 9/12/24 at approximately 1:35 p.m. with Staff J (Clinical Nursing Officer) confirmed that there was no documentation that Resident #42 received a shower in the above time period reviewed. Review on 9/12/24 of the facility policy titled, Resident Showers, Dated 2024 revealed: .1. Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety .

Based on interview, and record review, it was determined that the facility failed to ensure that facility-sponsored groups and individualized activities were provided to support residents based on the resident's preferences, interests, and all needs for each resident for the weekend days in September 2024. Findings include: Interview on 9/10/24 at approximately 2:15 p.m. with the facility's Resident Council (8 residents) revealed that all the residents that attended complained that there were no weekend activities the past 2 weekends and that nothing was on the September activities calendar for the weekends. 1 resident stated that he/she watched television all day and 7 residents stated that there was nothing for them to do. Review on 9/11/24 of the September 2024 activity calendars revealed that there were no activities documented on Saturdays and Sundays (9/1/24, 9/7/24, 9/8/24, 9/14/24, 9/15/24, 9/21/24, 9/22/24, 9/28/24, and 9/29/24). Interview on 9/11/24 at 9:55 a.m. with Resident #37 and Resident #43 revealed that they would attend activities on the weekends. Interview on 9/11/24 at 10:00 a.m. with Staff C (Director of Activities) confirmed the above findings. Staff C stated that he/she works Monday through Friday. He/she stated that there was nothing planned for the residents to do on Saturday and Sundays in September when he/she wasn't working, and his/her office was locked and that was where the activity supplies were kept.

Based on interview and record review, it was determined that the facility failed to ensure that a resident with a pressure ulcer had necessary treatment and services, which included documentation of weekly assessments that contained measurements and descriptions of the pressure ulcer and treatment orders for pressure ulcers for 1 out of 1 residents reviewed for pressure ulcers (Resident Identifier #1). Findings include: Review on 9/11/24 of Resident #1's physician progress note dated 7/9/24 revealed the following note: Left leg had been placed in a cast. [Pronoun omitted] started to develop pain around [pronoun omitted] Achilles tendon. [Pronoun omitted] was seen for follow-up and found to have a pressure ulcer. Review on 9/12/24 of Resident #1's skin and wound evaluations revealed that on the following dates, wound measurements were taken: 7/13/24, 8/1/24, 8/8/24, 8/10/24, and 8/25/24. Interview on 9/12/24 at approximately 12:00 p.m. with Staff E (Director of Nursing) confirmed the above findings and that measurements were not taken weekly. Review on 9/12/24 of the facility policy titled, Pressure Injury Prevention and Management, dated 2023 revealed: .5. Monitoring, a. The RN [Registered Nurse], Unit Manager, or designee, will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance at least weekly, and document a summary of findings in the medical record .

Based on record review and interview, it was determined that the facility failed to ensure that resident's diabetes regimen included timely medication administration and adequate monitoring for 1 of 3 residents reviewed for insulin in a final sample of 19 residents (Resident Identifier #30). Findings Include: Resident #30 Interview on 9/10/24 at approximately 10:45 a.m. with Resident #30 revealed he/she was a diabetic and concerned about his/her blood sugars being inconsistent and he/she questioned whether he/she was receiving the correct insulins. Review on 9/10/24 of Resident #30 medical record revealed physician orders for Fiasp FlexTouch Subcutaneous Solution Pen-injector 100 unit/milliliter (ML), Inject 10 units subcutaneously two times a day for Diabetes Mellitus with breakfast and lunch, scheduled at 8 a.m. and 12 p.m. Review on 9/10/24 of Resident #30 Medication Administration Record (MAR) revealed on 8/7/24 for the 8:00 a.m. Fiasp Insulin dose, it was administered at 10:32 a.m. (2.5 hours late). Review on 9/10/24 of Resident #30 MAR revealed on 8/19/24 for the 12:00 p.m. Fiasp Insulin dose, it was administered at 1:26 p.m. (1.5 hours late). Review on 9/10/24 of Resident #30 MAR revealed on 8/28/24 for the 8:00 a.m. Fiasp Insulin dose, it was administered at 10:11 a.m. (2.25 hours late). Review on 9/10/24 of Resident #30 medical record revealed physician orders for Fiasp FlexTouch Subcutaneous Solution Pen-injector 100 unit/ML, Inject as per sliding scale: if 121-250 = 16 units; 251-300 = 18 units; 301 - 350 = 24 units; 351 - 400 = 30; Call MD/NP if above 400; 400 - 450 = 36 subcutaneously before meals, scheduled at 7:30 a.m., 11:30 a.m., and 4:30 p.m. Review on 9/10/24 of Resident #30 MAR revealed the Fiasp Insulin to scale on 8/1/24, the 7:30 a.m. dose was administered at 10:42 a.m. (over 3 hours late - not before breakfast). On 8/1/24, the 11:30 a.m. dose was administered at 1:30 p.m. (2 hours late - not before lunch). On 8/1/24, the 4:40 p.m. dose was administered at 5:44 p.m. (1 hour late - not before dinner). Review on 9/10/24 of Resident #30 MAR revealed the Fiasp Insulin to scale on 8/9/24, the 4:30 p.m. dose was administered at 6:10 p.m. (1 hour and 40 minutes late - not before dinner). Review on 9/10/24 of Resident #30 MAR revealed the Fiasp Insulin to scale on 8/15/24, the 7:30 p.m. dose was administered at 10:21 a.m. (2 hours and 50 minutes late - not before breakfast) and on 8/15/24, the 11:30 a.m. dose was administered at 1:03 p.m. (1 hour and 30 minutes late - not before lunch). Review on 9/10/24 of Resident #30 medical record revealed physician orders for Lantus Solostar Subcutaneous Solution Pen-injector 100 unit/ML, Inject 40 units subcutaneously in the morning, scheduled at 8:00 a.m. Review on 9/10/24 of Resident #30 MAR for 8:00 a.m. Lantus revealed on 8/1/24 the dose was administered at 10:43 a.m. (2 hours and 40 minutes late). Review on 9/10/24 of Resident #30 medical record revealed physician orders for Lantus Solostar Subcutaneous Solution Pen-injector 100 unit/ML, Inject 20 units subcutaneously at bedtime, scheduled for 8:00 p.m. Review on 9/10/24 of Resident #30 MAR for 8:00 p.m. Lantus revealed on 8/20/24, the dose was administered at 10:27 p.m. (2 1/2 hours late). Review on 9/12/24 of Facility Policy, Medication Administration, undated, revealed: Policy: Medications are administered .as ordered by the physician and in accordance with professional standards of practice .12.b. Administer within 60 mins [minutes] prior to or after scheduled time unless otherwise ordered by the physician . Interview on 9/12/24 at approximately 12:15 p.m. with Staff E (Director of Nursing) confirmed above insulin findings for Residents #30. Review on 9/10/24 of Resident #30 medical record revealed physician orders for Insta-Glucose Gel 77.4%, Give 1 dose by mouth as needed for blood glucose [BG] less than 70, Pt [patient] arousable conscious and able to swallow Hold all diabetic medications until provider authorizes resumption. Remain with pt. in bed/chair for safety. Repeat blood glucose in 15 mins [minutes]. Review on 9/10/24 of Resident #30 MAR for September 2024 revealed on 9/1/24 at 4:30 p.m. a capillary blood glucose (CBG) of 56. Sliding scale insulin was held, but Insta Glucose was not signed off as administered and no repeat CBG was documented. Review on 9/10/24 of Resident #30 MAR for September 2024 revealed on 9/10/24 at 7:30 a.m. a CBG of 68. Sliding scale insulin was held, but Insta Glucose was not signed off as administered and no repeat CBG was documented. Review on 9/10/24 of Resident #30 Nurses Notes dated 9/1/24 and 9/10/24 revealed no indication of treatment of low blood sugar or repeat CBGs, or provider notification. Interview on 9/12/24 at approximately 1:30 p.m. Staff K (Advanced Practice Registered Nurse) confirmed he/she was not notified of the above findings and confirmed if nothing was documented it was not done.

Based on observation, interview, and record review, it was determined that the facility failed to ensure a medication error rate was less than 5 percent (%) for medication administration for 2 of 36 medications observed (5.56 % error rate) (Resident Identifier #34). Findings include: Review on 9/12/24 of Resident #34's September 2024 Medication Administration Record (MAR) revealed the following physician's orders: 1. Olanzapine 2.5 milligram (mg) by mouth in the morning for Borderline personality 2. Metoprolol Succinate Extended Relief (ER) 24 hour 100 mg, give 1 tablet by mouth one time a day for hypertension. Observation on 9/12/24 at approximately 7:30 a.m. of Staff N (Registered Nurse) administering medications to Resident #34 revealed Staff N was going to administer an Olanzapine 5 mg (prescribed 2.5 mg) and was not going to administer Metoprolol Succinate ER 24 hour 100 mg. Interview on 9/12/24 at approximately 7:30 a.m. with Staff N confirmed the above findings. Review on 9/12/24 of the facility policy titled, Medication Administration, dated 2024 revealed: .10. Ensure that the six rights of medication administration are followed: .c. Right Dosage . There were 2 medication errors out of a total of 36 medication pass opportunities resulting in a 5.56% error rate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to maintain locked storage of medications, failed to ensure resident medications had accurate labeling of medications in 1 of 2 med carts, and medications were discarded after expiration in 1 of 1 medication rooms observed ([NAME] Medication Room and Brettonwoods Medication Cart). Findings include: [NAME] Medication Room Observation on [DATE] at approximately 9:15 a.m. of [NAME] Medication room medication refrigerator revealed one open vial of Tuberculin PPD-Aplisol without an open date or open expiration date and one open vial of Tuberculin PPD-Aplisol with an open date of [DATE] (expired on 9/6). Review on [DATE] of Tuberculin PPD-Aplisol manufacturer instructions revealed: .Vials in use more than 30 days should be discarded due to possible oxidation and which may affect potency . Interview on [DATE] at approximately 9:15 a.m. with Staff M (Registered Nurse) confirmed above findings. Brettonwoods Medication Cart Observation on [DATE] at approximately 9:45 a.m. of Brettonwoods medication cart revealed a medication cup with prepoured pills without a resident identifier. Observation on [DATE] at approximately 9:45 a.m. of Brettonwoods medication cart revealed open in use Insulin Basaglar (Lantus) Qkwikpen with no open date or open expiration date. Review on [DATE] of Lantus Manufacturer instructions revealed .Do not use your pen .for more than 28 days after you first start using the pen . Interview on [DATE] at approximately 9:45 a.m. with Staff L (Medication Nursing Assistant) confirmed above findings. Resident #26 Observation on [DATE] at approximately 7:30 a.m. of Resident #26 room revealed 2 bottles of nasal spray on his/her side table. Interview on [DATE] at approximately 7:30 a.m. with Resident #26 revealed he/she self administers his/her nasal sprays and has no place to lock it in his/her room. Observation on [DATE] from approximately 7:10 a.m. through 7:20 a.m. revealed an unlocked medication cart in the hallway of the [NAME] Woods Unit. There were no staff in the area of the medication cart. Three residents were in the hallway in the area of the medication cart. Review on [DATE] of the facility policy titled, Medication Storage, dated 2024 revealed: .1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refridgerators, medication rooms) . Observation on [DATE] at approximately 7:15 a.m. in the [NAME] Woods Medication Cart revealed: Resident #34's Lantus with an open date of [DATE]. Review on [DATE] of the manufacturer's instructions for Lantus revealed: .Throw away pen you are using after 28 days, even if it still has insulin left in it . Interview on [DATE] at approximately 7:20 a.m. with Staff N (Registered Nurse) confirmed the medication cart was left unlocked and the Lantus was expired. Observation on [DATE] at approximately 7:30 a.m. of medication administration with Resident #34 revealed Staff N waste an Olanzapine 2.5 milligram (mg) tablet in the uncovered trash receptacle attached to the medication cart. Interview on [DATE] at approximately 7:30 a.m. with Staff N revealed that this is where he/she wastes medications if they are not narcotics. Review on [DATE] of the facility policy titled, Hazardous Waste Pharmaceuticals (HWP), dated 2024 revealed: .5. HWP's will be discarded in containers approved for disposal of HWP's .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #47 Review on 9/12/24 of Resident #47's August 2024 and September 2024 Medication Administration Audit report revealed the following medication administrations were documented as given outside of the ordered timeframe's: -Ativan Oral Tablet 0.5 milligram (mg) (Antianxiety), Give 1 tablet via PEG-Tube [Percutaneous endoscopic gastrosomy] every morning [7 a.m. -10 a.m.] and at bedtime for anxiety: 8/15/24 morning dose administered at 3:56 p.m; 8/16/24 morning dose administered at 10:40 a.m.; 8/19/24 morning dose administered at 1:43 p.m ; 8/20/24 bed time dose administered at 8:38 a.m.; 8/21/24 morning dose administered at 10:08 a.m. and bed time dose at 5:25 p.m.; 8/22/24 morning dose administered at 2:22 p.m.; 8/23/24 morning dose administered at 10:25 a.m.; 8/24/24 morning dose administered at 10:31 a.m.; 8/26/24 morning dose administered at 10:44 a.m.; 8/28/24 morning dose administered at 10:54 a.m.; 8/29/24 morning dose administered at 10:47 a.m.: 8/31/24 morning dose administered at 2:42 p.m.; 9/2/24 morning dose administered at 11:15 a.m.; 9/3/24 morning dose administered at 11:12 a.m. and bed time dose at 5:45 p.m.; 9/10/24 morning dose administered at 10:27 a.m.; 9/11/24 morning dose administered at 10:56 a.m. -Eliquis Oral Tablet 2.5 mg (Anticoagulant), Give 0.5 tablet via J-Tube [jejunostomy] two times a day for A-fib [Atrial fibrillation] scheduled for administration in AM and PM: 8/15/204 morning dose administered at 3:58 p.m. and the evening dose administered 5:45 p.m. (only 2 hours between doses); 8/19/24 morning dose administered at 1:42 p.m.; 8/31/24 morning dose administered at 2:46 p.m.; 9/2/24 administered at 11:15 a.m. and 4:40 p.m. Interview on 9/12/24 at approximately 1:00 p.m. with Staff D (Staff Development) confirmed that the above medications were administered outside of the ordered time frames. Resident #26 Review on 9/11/24 of Resident #26's medical record revealed a physicians order for Lotrisone Cream 1-0.005, apply to both feet topically two times a day for foot [fungal] rash for 3 months, with a start date of 8/27/24. Review on 9/11/24 of Resident #26's August 2024 MAR revealed the Lotrisone Cream was not signed off as administered from 8/19/24 through 8/30/24. Review on 9/11/24 of Nurses Note 8/19/24 through 8/30/24 revealed med unavailable or waiting on delivery for Lotrisone. Interview on 9/12/24 at approximately 10:30 a.m. with Staff G (Registered Nurse) confirmed Lotrisone was not given the above dates. Interview on 9/10/24 at 1:36 p.m. with Resident #26 revealed that Resident #26 had cataract surgery on 6/12/24 and he was given 2 orders for eyes drops to be administered multiple times a day for so many days. Resident #26 stated that when he/she was out of the facility at an appointment, he/she missed receiving the eye drops and when he/she returned to the facility, the eye drops were never given, therefore, there were times he/she missed receiving the maximum amount he/she was supposed to receive them in a day. Review on 9/12/24 of Resident #26's June 2024 and July 2024 MAR revealed the following: -Moxifloxacin HCI Opthmalic Solution 0.5%, Instill drop in left eye four times a day for cataract surgery, start date 6/15/24, discharge date [DATE]. Resident #26 was not administered drops 11 out of 49 times during the period reviewed. -Moxifloxacin HCI Opthmalic Solution 0.5%, Instill drop in left eye four times a day for cataract surgery, discontinue once bottle empty, start date 6/27/24, discharge date [DATE]. Resident #26 was not administered drops 14 of 66 times during period reviewed. -Prednisolone Acetate Opthalmic Suspension, Instill 1 drop in left eye four times a day for cataract surgery, start date 6/15/23, discharge date [DATE]. Resident #26 was not administered drops 11 out of 49 times during period reviewed. -Prednisolone Acetate Opthalmic Suspension, Instill 1 drop in left eye three times a day for cataract surgery for 7 days, start date 6/27/24. Resident #26 was not administered drops 7 out of 21 times during period reviewed. Interview on 9/12/24 at 1:40 p.m. with Staff N (Registered Nurse) confirmed the above findings. Staff N stated that he/she would notify the provider if a dose was missed. Interview on 9/12/24 at 11:42 p.m. with Staff K revealed that Staff K was never notified that Resident #26 missed the eye drops. Interview further revealed that his/her expectation would be that the eye drops would have been administered either prior to Resident #26 leaving the facility or once Resident #26 returned to ensure that the eye drops were administered the maximum amount in a day. Based on interview and record review, it was determined that the facility failed to follow physician orders or provide medications timely for 5 residents in a final sample of 19 residents (Resident Identifiers are #1, #17, #26, #34, #47). Findings include: Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336 - Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . [NAME], [NAME]; [NAME], [NAME] A.; [NAME], Wendy; and [NAME], [NAME]. Clinical Nursing Skills & Techniques. 10th ed. [NAME], Pennsylvania: Elsevier, 2022. Page 597 - Safe Medication Preparation: Right Time With time-critical medications (e.g., antibiotics, anticoagulants, insulin, immunosuppressives), early or delayed administration of the maintenance doses of more than 30 minutes before or after the scheduled dose will most likely cause harm or result in subtherapuetic responses in a patient. Resident #1 Review on 9/12/24 of Resident #1's July 2024's Treatment Administration Record revealed the following physician's order: Apply Aquacel AG Maxorb and cover with Coban. Change daily. One time a day for skin breakdown, wound. Start Date 7/17/24. Further review on 7/23, 7/24, 7/26, 7/28 and 7/30 revealed this was not documented as being performed. Interview on 9/12/24 at approximately 11:00 a.m. with Staff E (Director of Nursing) confirmed Resident #1's dressings were not documented as being changed. Resident #34 Review on 9/12/24 of Resident #34's September Medication Administration Audit Report revealed the following: -9/12/24 Lantus 40 Units was scheduled for 7:00 a.m. and was administered at 9:18 a.m.; -9/9/24 All by mouth (PO) and Lantus 40 Units were scheduled for 7:00 a.m. were administered at 12:30 p.m.; - 9/9/24 Hydralazine HCL (Hydrochloric Acid) 100 mg was scheduled at 7:00 a.m. and at 2:00 p.m. On this date, Resident #34 received Hydralazine HCL at 12:30 p.m. and again at 2:01 p.m.; -9/3/24 All PO medication that was scheduled for 7:00 a.m. was administered at 9:49 a.m.; -9/2/24 Metoprolol Succinate Extended Release (ER) 100 mg was scheduled for 7:00 a.m. and was administered at 10:44 a.m.; -9/1/24 All PO medication that was scheduled for 7:00 a.m. and was administered at 10:00 a.m Interview on 9/12/24 at approximately 1:30 p.m. with Staff K (Advance Practice Registered Nurse) revealed that he/she was not aware of Resident #34's late medication administration. Staff K also revealed that on 9/9/24 he/she would have expected Resident #34's 2:00 p.m. dose of Hydralazine to be held. Resident #17 Review on 9/12/24 of Resident #17's August and September 2024's Medication Administration Record (MAR) revealed the following physician's order: Weigh weekly, (dry weight 241) update Provider for 3 pound or more weight gain since previous weight, in the morning every Mon [Monday] for CHF [congestive heart failure] diuretic use, Start Date 8/26/24. Further review revealed Resident #17's weight was 253.2 on 8/26 there was no weight obtained on 9/2 and 9/9. Interview on 9/12/24 at approximately 1:30 p.m. with Staff K confirmed the weights were not obtained. Staff K revealed that he/she was unaware that Resident #17's weights were not obtained and that no one notified Staff K of Resident #17's weight gain on 8/26.

Based on interview and record review, it was determined that the facility failed to ensure the activities program was directed by a qualified professional for a facility census of 78 residents. Findings include: Interview on 9/11/24 at 9:56 a.m. with Staff C (Director of Activities) revealed that he/she was promoted to Director of Activities in September 2024. He/she had been working as an activities aid at the facility since June 2024. Interview further revealed that Staff C had no prior certifications in activities, degrees in recreation, or any prior experience working in an activity program. Interview on 9/11/24 at 10:00 a.m. with Staff A (Administrator) confirmed the above findings and that Staff C was not qualified. Review on 9/11/24 of the facility's job description for Director of Recreation Services, revised 4/25/17, revealed: . Education/Vocational Requirements: 1. Certification in accordance with regulatory agencies governing the center, by the National Certification Council of Activity Professionals (ADC) or the National Council of Therapeutic Recreation Certification (CTRS), or 2. Bachelor degree in therapeutic recreation preferred or completion of the NAAP/NCCAP Basic and Advanced Management Course for Activity Professionals, or 3. Has 2 years' experience in a social or recreational program within the last 5 years, one of which was full time in a patient activity program in a health care setting .

Based on interview and record review, it was determined the facility failed to designate an Infection Preventionist that completed specialized training in infection prevention and control. Findings include: Record review on 9/11/24 revealed that the facility could not provide evidence of specialized training in infection control for Staff D (Infection Preventionist). Interview on 9/11/24 at 10:30 a.m. with Staff D revealed that Staff D was hired on 5/23/24 and was currently designated as the Infection Preventionist. Interview on 9/11/24 at 12:00 p.m. with Staff E (Director of Nursing) confirmed the above findings. Review on 9/11/24 of the facility's job description for Infection Preventionist, revised 8/3/20, revealed: .Specific Education/Vocational Requirements .2. Must complete specialized training in infection prevention within 90 days of hire . Review on 9/12/24 of the facility's policy, Infection Prevention and Control Program (IPCP), revised 7/1/24, revealed: .The Infection Preventionist develops, implements, monitors and maintains the IPCP and fulfills the basic requirements for the role .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to provide sufficient nursing staff, as determined by their facility assessment, to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in a census of 48 residents. Interview on 9/10/24 at approximately 1:40 p.m. with Resident #26 revealed that he/she was frequently told that staff were too busy and it caused delays in the care that he/she needed, and medications administered were frequently late. Interview on 9/10/24 at approximately 1:00 p.m. with Resident #45 revealed that the facility was short staffed, and it caused longer responses to call lights and getting the assistance he/she needed. Resident #45 stated: I waited on the toilet for 45 minutes the other day. Interview on 9/11/24 at approximately 8:00 a.m. with Staff H (Licensed Nursing Assistant (LNA)) and Staff L (Medication Nursing Assistant (MNA)) revealed that at times, it is just an MNA on a unit and the nurse from the other unit would need to come over for medication administration, causing late administatration of tube feeds and insulins. Staff H and Staff L stated that residents were not receiving the care needed for basic incontinence and showers were not being given because of low staffing. The residents have had an increase in incontinence because we don't have enough staff to answer the call lights and others who are incontinent have to sit and wait until we can get to them to be changed. Interview on 9/11/24 at approximately 9:00 a.m. with Resident #21 (Resident Council President) revealed that staffing was a real problem in the facility and worse on the 3-11 and 11-7 shifts. He/she said that sometimes there was only 1 nurse in the facility for 50 residents. Interview on 9/11/24 at approximately 10:00 a.m. with Staff R (LNA) revealed that when there was only 1 LNA to 25 residents, and it makes it very difficult for residents to get showers. Interview on 9/11/24 at approximately 3:00 p.m. with Staff P (LNA) revealed that he/she works 7-3 shift. He/she stated that when he/she knows that there was only 1 LNA scheduled for 3-11 shift, he/she would make sure that the residents who are 2 assists were put back in bed prior to him/her leaving to help the LNA who was scheduled for 3-11 p.m. shift. Interview on 9/11/24 at approximately 3:00 p.m. with Staff Q (LNA) revealed that he/she works 3-11 and 11-7. He/she stated that during many shifts, he/she was the only LNA on the Bretten Woods unit. Staff Q stated that when there was 1 LNA on a shift, it is difficult during meals, some residents will eat in bed and the residents who need assistance or supervision with meals, he/she would bring them out to the nursing station to watch them while he/she was feeding other residents. Staff Q said that residents would wait for incontinent care if he/she was the only LNA on shift. This happens more often than not stated Staff Q. Review on 9/12/24 of the facility assessment revealed: .Staffing break down with Census . based on 45 - 50 Residents . Days (7 a.m. -3 p.m.): [NAME] Woods: 1 Nurse/Medtech; 2 LNA's. [NAME]: 1 Nurse; 1 Medtech; 2 LNA's. Evenings (3 p.m. -11 p.m.) [NAME] Woods: 1 Nurse/Medtech; 2 LNA's. [NAME]: 1 Nurse; 2 LNA's. Nights (11 p.m. -7 a.m.) [NAME] Woods: 1 Nurse/Medtech; 1 LNA. [NAME]: 1 Nurse; 1 LNA. Review on 9/12/24 of the Facility Daily Staffing Sheets for 7/1/24 to 9/11/24 revealed: [NAME] Woods -On 7/1/24 3 p.m. - 11p.m., there was 1 LNA (there should have been 2) and 11 p.m. to 7 a.m., there was no nurse/med tech (should have been 1); -On 7/2/24 3 p.m. - 5 p.m., there was no nurse/med tech (there should have been 1), from 3 p.m. - 7 p.m., there was 1 LNA (there should have been 2), and on 11 p.m. to 7 a.m., there was no nurse/med tech (should have been 1); -On 7/3/24 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2) and 11 p.m. to 7 a.m., there was no nurse/med tech (there should have been 1); -On 7/4/24 3 p.m. - 11 p.m. there was 1 LNA (there should have been 2); -On 7/5/24 3 p.m. - 7 p.m., there was no LNA (there should have been 2), 7 p.m. - 11 p.m., there was 1 LNA (there should have been 2), and 11 p.m. to 7 a.m., there was no nurse/med tech (there should have been 1); -On 7/7/24 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 7/8/24 3 p.m. - 7 p.m., there was 1 LNA (there should have been 2); -On 7/9/24 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2); - On 7/10/24 11 p.m. - 7 a.m., there was no nurse/med tech (there should have been 1); -On 7/11/24 11 p.m. - 7 a.m., there was no nurse/med tech (there should have been 1); -On 7/12/24 7 p.m. - 11 p.m., there was 1 LNA (there should have been 2) and 11 p.m. - 7 a.m., there was no nurse/med tech (there should have been 1); -On 7/13/24 7 a.m. - 3 p.m., there was 1 LNA (there should have been 2), 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 7/14/24 7 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 7/15/24 3 p.m. - 11 p.m. and 11 p.m. - 7 a.m., there was no nurse/medtech (there should have been 1); -On 7/16/24 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 7/17/24 3 p.m. - 7 p.m., there was 1 LNA (there should have been 2); -On 7/18/24 3 p.m. - 7 p.m., there was no LNA (there should have been 2); -On 7/19/24 7 a.m. - 3 p.m., there was 1 LNA (there should have been 2), 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2), 7 p.m. - 11 p.m., there was 1 LNA (there should have been 2), and 11 p.m. - 7 a.m., there was no nurse/medtech (there should have been 1); -On 7/22/24 3 p.m. - 7 p.m., there was 1 LNA (there should have been 2); -On 7/23/24 7 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 7/24/24 3 p.m. - 7 p.m., there was 1 LNA (there should have been 2), 5 p.m. - 5 a.m., there was no nurse/medtech (there should have been 1); -On 7/25/24 11 p.m. - 7 a.m., there was no nurse/medtech (there should have been 1); -On 7/26/24 3 p.m. - 11 p.m. and 11 p.m - 7 a.m., there was no nurse/medtech (there should have been 1); -On 7/27/24 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 7/29/24 7 p.m. - 11 p.m., there was 1 LNA (there should have been 2) and 11 p.m - 7 a.m., there was no nurse/medtech (there should have been 1); -On 7/30/24 7 p.m. - 11 p.m. there was 1 LNA (there should have been 2) and 11 p.m. - 3 a.m., there was no LNA (there should have been 1); -On 8/6/24 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 8/16/24 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 8/20/24 7 a.m. - 3 p.m., there was 1 LNA (there should have been 2); -On 8/23/24 3 p.m. - 7 p.m., there was 1 LNA (there should have been 2); -On 8/24/24 7 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 8/25/24 7 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 8/30/24 3 p.m. - 7 p.m., there was 1 LNA (there should have been 2); -On 9/1/24 3 p.m. - 7 p.m., there was 1 LNA (there should have been 2); -On 9/2/24 3 p.m. - 7 p.m., there was 1 LNA (there should have been 2); -On 9/4/24 3 p.m. - 7 p.m., there was 1 LNA (there should have been 2); -On 9/9/24 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2). [NAME] -On 7/2/24 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 7/3/24 3 p.m. -7 p.m., there was 1 LNA (there should have been 2); -On 7/4/24 3 p.m. - 7 p.m., there was 1 LNA (there should have been 2); -On 7/5/24 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 7/7/24 11 p.m. to 7 a.m., there was no nurse/med tech (there should have been 1); -On 7/8/24 from 3p.m. - 11 p.m. there was 1 LNA (there should have been 2); -On 7/9/24 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 7/13/24 3 p.m. - 7 p.m., there was 1 LNA (there should have been 2) and 3 p.m. - 11 p.m. there was no nurse (there should have been 1); -On 7/14/24 7 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 7/15/24 7 p.m. - 11 p.m., there was 1 LNA (there should have been 2) and 3 p.m. - 11 p.m. there was no medtech (there should have been 1); -On 7/16/24 7 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 7/16/24 3 p.m. - 7 p.m., there was 1 LNA (there should have been 2); -On 7/17/24 3 p.m. - 11 p.m. there was no medtech (there should have been 1); -On 7/18/24 3 p.m. -7 p.m., there was no nurse/medteach (there should have been 1) and 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 7/19/24 7 a.m. - 3 p.m., there was 1 LNA (there should have been 2) and 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 7/20/24 11 p.m. - 7 a.m., there was no nurse/medtech (there should have been 1); -On 7/21/24 11 p.m. - 7 a.m., there was no nurse/medtech (there should have been 1); -On 7/22/24 3 p.m. - 7 p.m., there was 1 LNA (there should have been 2) and 3 p.m. - 11 p.m., there was no medtech (there should have been 1); -On 7/23/24 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 7/24/24 3 p.m. - 7 p.m., there was no nurse/medtech (there should have been 1) and 3 p.m. - 11 p.m., there was no medtech (there should have been 1); -On 7/26/24 3 p.m. - 11 p.m., there was 1 LNA and no medtech (there should have been 2 LNA's and 1 medtech); -On 7/30/24 3 p.m. - 11 p.m., there was no medtech (there should have been 1); -On 8/2/24 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 8/4/24 11 p.m. - 7 a.m., there was no LNA (there should have been 1); -On 8/8/24 3 p.m. - 11 p.m., there was no medtech (there should have been 1); -On 8/9/24 3 p.m. - 7 p.m., there was 1 LNA (there should have been 2); -On 8/11/24 11 p.m. - 7 a.m., there was no LNA (there should have been 1); -On 8/14/24 3 p.m. - 11 p.m., there was no medtech (there should have been 1); -On 8/17/24 3 p.m. - 11 p.m., there was no medtech (there should have been 1); -On 8/19/24 3 p.m. - 11 p.m., there was 1 LNA and no medtech (there should have been 2 LNA's and 1 medtech); -On 8/23/24 3 p.m. - 11 p.m., there was no medtech (there should have been 1); -On 8/25/24 3 p.m. - 11 p.m., there was no medtech (there should have been 1); -On 8/26/24 3 p.m. - 11 p.m., there was no medtech (there should have been 1); -On 8/27/24 3 p.m. - 7 p.m., there was no nurse or medtech (there should have been 1); -On 8/29/24 3 p.m. - 7 p.m., there was no nurse (there should have been 1) and 3 p.m. - 11 p.m., there was no medtech (there should have been 1); -On 8/30/24 3 p.m. - 11 p.m., there was no medtech (there should have been 1); -On 8/31/24 3 p.m. - 11 p.m., there was no medtech (there should have been 1); -On 9/1/24 3 p.m. - 11 p.m., there was no medtech (there should have been 1); -On 9/2/24 3 p.m. - 11 p.m., there was no medtech (there should have been 1); -On 9/3/24 7 a.m. - 3 p.m., there was no medtech (there should have been 1); -On 9/4/24 7 a.m. - 3 p.m. and 3 p.m. -11 p.m., there was no medtech (there should have been 1); -On 9/5/24 3 p.m. - 11 p.m., there was no medtech (there should have been 1); -On 9/6/24 11 p.m. - 7 a.m., there was no nurse/medtech (there should have been 1); -On 9/8/24 7 a.m. - 3p.m., there was 1 LNA and no medtech (there should have been 2 LNA's and 1 medtech) and 3 p.m. - 11 p.m., there was no medtech (there should have been 1); -On 9/9/24 7 a.m. - 7 p.m., there was 1 LNA (there should have been 2); -On 9/10/24 5 p.m. - 8 p.m., there was 1 nurse/medtech (there should have been 2); -On 9/11/24 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2). Interview on 9/12/24 at approximately 10:30 a.m. with Staff B (Scheduler) confirmed the above staffing. Review on 9/12/24 of the daily census for 7/1/24 to 9/11/24 revealed that the facility has maintained a census of 45 to 50 residents during the above noted shifts. Interview on 9/12/24 at approximately 1:20 p.m. with Staff K (Advanced Practice Registered Nurse) stated he/she had concerns with staffing and residents not getting care such as consistent wound care. Staff K stated that he/she was doing wound care for residents himself/herself once the orders were placed to ensure they getting done.

Based on interview and record review, it was determined that the facility failed to follow established infection control guidelines for facility water management by not having a system to monitor control measures to minimize the risk of Legionella and other opportunistic pathogens that has the potential to effect the facility census of 48 residents who resided at the facility. Findings include: Interview on 9/11/24 at approximately 10:30 a.m. with Staff D (Infection Preventionist) revealed they did not know if the facility had a system to monitor control measures in place to prevent the introduction and spread of Legionella. Review on 9/12/24 of the facility's policy, Legionella Water Management, dated 2017, revealed: .These domestic unmixed water tanks have a high-volume use and high temperature that make it completely inhospitable for the Legionella bacteria to grow. These tanks are also purged at the base to remove any settled impurities monthly by the maintenance staff using the TELS Maintenance System. All basement boiler and water flow systems are monitored for flow, pressure, temperature, and function daily .In the event of the plumbing maintenance or repair that disturbs the integrity of piping in the domestic water supply system: all fixtures directly supplied by the plumbing that is maintained or repaired, must flush for ten minutes .Baseboard heating systems, facility air conditioners, stored emergency water, eyewash stations, nebulizers, oxygen concentrators, outside watering spigots . Review on 9/12/24 of the facility's boiler room daily inspection and maintenance logs, revealed the following: -In August 2024, 10 out of 31 days, the temperature and pressures were monitored; -In September 2024, 4 out of 14 days, the temperature and pressures were monitored. The facility was unable to provided evidence of additional documentation for the control measures in place to prevent the introduction and spread of Legionella. Interview on 9/12/24 at 11:14 a.m. with Staff I (Maintenance Director) confirmed the above findings.

Based on interview and record review it was determined that the facility failed to follow its policy for tracking, investigating, and prompt resolution for 2 out of 4 residents reviewed for grievances (Resident Identifiers are #1 and #2). Findings include: Review on 2/1/24 of the facility's policy Grievance/Concern with an effective date of 6/1/96 and revised on 1/8/24 revealed, .Service location leadership will investigate, document, and follow up on all concerns and grievances registered by any patient . Social Services personnel will serve as patient advocates in the grievance/concern process. The Administrator will serve as the Grievance Officer who is responsible for overseeing the grievance process . receiving and tracking grievances through to their conclusion . Process . 1.4 The right to obtain a written decision regarding their grievance . 3. Upon receipt of the grievance/concern, the Grievance/Concern Form will be initiated by the staff member receiving the concern . 4. Upon receipt of the Grievance/Concern Form, The Administrator or designed will document the grievance/concern on the Grievance Concern Log. 5. When the grievance/concern is logged, the Administrator and appropriate department manager will be notified . 7 Written resolution for grievances will be offered per the resident's right and will include: 7.1 Date the grievance was received; 7.2 Summary statement of the grievance; 7.3 Steps taken to investigate the grievance; 7.4 Summary of the pertinent findings or conclusions regarding the grievance; 7.5 Statement as to whether the grievance was confirmed or not confirmed; 7.6 Any corrective action(s) taken or to be taken by the Center as as [sic] result of the grievance/concerns; and 7.7 Date the written resolution was issued . Resident #1 Interview on 2/1/24 at 11:30 a.m. with Resident #1 revealed that he/she had complained to Staff B (Unit Manager) at the end of December 2023/early January 2024 regarding concerns that Staff A (Licensed Practical Nurse) did not administer medications to him/her for 3 nights. Resident #2 Interview on 2/1/24 at 11:45 a.m. with Resident #2 revealed that he/she had verbally told Staff B about concerns regarding Staff A not giving his/her medications timely. Review on 2/1/24 of a note dated 1/4/24 and 1/5/24 written by Resident #2 revealed concerns regarding Staff A not providing medications and assistance to residents. At the bottom of the note Staff C (Director of Nursing) wrote 1/5/24 Reviewed pt [patient] concerns with [Staff A]. Review on 2/1/24 of the December 2023 and January 2024 grievances revealed no grievances were logged for Resident #1 or Resident #2 regarding the above complaints. Interview on 2/1/24 at 12:15 p.m. with Staff B confirmed that he/she had received the above concerns regarding Staff A from Resident #1 and Resident #2 and verbally reported them to Staff C. Staff B also revealed the same concerns were brought up during the January Resident Council. Interview on 2/1/24 at 12:25 p.m. with Staff D (Social Worker) confirmed that he/she knew about the above grievances for Residents #1 and #2, but did not have a record of it and was not sure of all the details. Interview on 2/1/24 at 1:20 p.m. with Staff E (Activity Director) revealed that Resident #2 had complained about Staff A during the January 8, 2024, Resident Council meeting and submitted a written grievance to Staff D. Interview on 2/1/24 at 1:30 p.m. with Resident #3, who attends Resident Council, revealed that at the last resident council meeting a few residents complained about not getting medication on time. Review on 2/1/24 of the January 5, 2024 Resident Council Minutes revealed the following; -Nursing: residents concerned about nursing staff taking extended breaks (over 1 hour) every shift they work. -Residents state they do not think they get their medication timely. -Residents are concerned about the amount of time staff are on their cell phones when call bells are going off. -Residents state staff do not always completely set up residents for morning care at once, feel like they are not getting enough care. Interview on 2/1/24 at 1:30 p.m. with Staff C and Staff F (Interim Administrator) revealed there were no grievances logged or investigated for December or January regarding the above for Resident #1 or Resident #2. Interview on 2/1/24 at 1:35 p.m. with Staff E confirmed that he/she had given a grievance (written by Resident #2) to Staff D after the January Resident Council Meeting. Interview on 2/1/24 at 1:55 p.m. with Staff C revealed that he/she could not recall if Staff B had told him/her about the above grievances. Interview on 2/1/24 at approximately 1:56 p.m. with Staff F confirmed that he/she was not aware of the above grievances including the above issues from the Resident Council Meeting on January 5, 2024.

Based on interview and record review it was determined that the facility failed to report allegations of abuse to the State Survey Agency (SSA) for 3 out of 4 grievances reviewed for alleged abuse (Resident Identifiers are #2, #3, and #4). Findings include: Review on 11/7/23 of the Facility Grievance Log from September 2023 to November 2023 revealed the following allegations: 9/21/23 - Resident #2 reported staff rudeness. 10/10/23 - Resident #3's wife reported that the resident called her and reported that a brief was thrown at Resident #3 and he/she was told to change it themself. 11/6/23 - Resident #4 reported rudeness by Staff C (Licensed Nursing Assistant) Interview on 11/7/23 at approximately 11:20 a.m. with Staff B (Director of Nursing) revealed that he/she is the person responsible for reporting allegations. Staff B confirmed that the above allegations were not reported to the SSA. Staff B had no knowledge of the allegation on 11/6/23 from Resident #4 with Staff C. Review on 11/8/23 of the facility policy titled, OPS 300 Abuse Prohibition, Revision Date 10/24/22 revealed: . 7. Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or designee will perform the following. 7.2 Report allegations involving abuse (physical, verbal, sexual, mental) not later than 2 hours after the allegation is made 7.4 Report allegations to the appropriate state and local authority(s) involving neglect, exploitation or mistreatment ., within 24 hours if the event does not result in serious bodily injury 7.5 Notify local law enforcement, Licensing Boards and Registries, and other agencies as required 7.7 Initiate an investigation within 24 hours of an allegation of abuse that focuses on: 7.7.1 whether abuse or neglect occurred and to what extent; 7.7.2 clinical examination for signs of injuries, if indicated. 7.7.3 causative factors; and 7.7.4 Interventions to prevent further injury

Based on interview and record review it was determined that the facility failed to ensure that alleged violations of neglect were thoroughly investigated for 2 out of 4 grievances reviewed (Resident Identifiers are #2 and #3). Findings include: Review on 11/7/23 of the Facility Grievance Log from September 2023 to November 2023 revealed the following allegations: 9/21/23 - Resident #2 reported staff rudeness. 10/10/23 - Resident #3's wife reported that the resident called her and reported that a brief was thrown at Resident #3 and he/she was told to change it themself. Interview on 11/7/23 at approximately 2:20 p.m. with Staff B (Director of Nursing) confirmed that the above allegations were not investigated. Review on 11/8/23 of the facility policy titled, OPS 300 Abuse Prohibition, Revision Date 10/24/22 revealed: 7. Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or designee will perform the following. 7.7 Initiate an investigation within 24 hours of an allegation of abuse that focuses on: 7.7.1 whether abuse or neglect occurred and to what extent; 7.7.2 clinical examination for signs of injuries, if indicated. 7.7.3 causative factors; and 7.7.4 Interventions to prevent further injury

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility failed to follow physician orders for 1 of 2 residents reviewed for physician orders (Resident Identifier is #1). Findings include: Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Review on 11/7/23 of Resident #1's October 2023 Medication Administration Record (MAR) revealed the following: Please obtain UA [urinalysis]/culture if indicated. For increased frequency and increased incontinence. one time for UTI [Urinary Tract Infection] symptoms for 1 day, Start Date 10/27/23. Further review revealed that the urine was checked off in the MAR as being obtained on 10/27/23 at 11:16 p.m. Interview on 11/7/23 at approximately 11:30 a.m. with Staff B (Director of Nursing) confirmed that Resident #1's MAR was checked off as the urine being obtained on 10/27/23. Review on 11/7/23 of Resident #1's medical record revealed the following Nurse Practitioner encounter note, dated 10/31/23: I asked for a urine specimen to be obtained for culture and sensitivity and once obtained that [pronoun omitted] should start on Bactrim DS [Double Strength]. It appears that the urine specimen was not obtained, partial doses of the antibiotic were provided. Interview on 11/8/23 at approximately 10:30 a.m. with Staff A (Nurse Practioner) revealed that he/she was not informed of the urine not being obtained until 11/1/23. Staff A revealed that he/she would expect to be notified if an order was unable to be completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to provide sufficient staffing numbers to meet the residents' needs. Findings include: Review on 11/7/23 of a witness statement to an allegation of abuse on 9/29/23 written by Staff E (Anonymous) revealed the following: On Friday morning, 9/29/23 around 7 a.m. [pronoun omitted] was informed that [pronoun omitted] was the only aide on [NAME] Wing Interview on 11/7/23 at approximately 11:20 a.m. with Staff E revealed that the resident care suffers. We all have a job to do and I help the LNAs [Licensed Nursing Assistants] as much as I can but it is not enough. When there is one LNA on the floor that leaves them with about 30 residents to care for. Staff E also revealed that there is no assistance on the floor from ancillary staff when call-outs happen. We do the bare minimum and the best that we can. Interview on 11/7/23 at approximately 2:45 p.m. with Staff D (LNA) revealed that the facility staffs the units with two LNAs each. It is impossible to take care of the residents in the way they deserve and require. We have a resident who requires 1 on 1 assistance with meals that take about an hour to eat. When we are assisting that resident, there is no one else to assist on the floor. Currently, there are 5 residents on this unit [[NAME]] that require assist at meals. Staff D revealed that residents are incontinent at times because there is not enough staff to answer the call lights on the unit. Review on 11/7/23 of the LNA assignment sheets on the [NAME] Unit revealed: 8 residents require two-person assist with either care or transfers Interview on 11/8/23 at approximately 7:20 a.m. with Staff F (LNA) revealed that because of staffing the residents' care is suffering. The other night there was only one LNA assigned to the unit [[NAME]] on the night shift for about 34 residents. There are currently 4-5 residents that require two-person assist with care and transfers. Residents fall sometimes because we can't get to them in time. Interview on 11/8/23 at approximately 10:15 a.m. with Resident #5 revealed that the facility is rarely fully staffed and it causes longer responses to call lights and getting the assistance he/she needs. Interview on 11/8/23 at approximately 10:30 a.m. with Resident #6 revealed that the residents are frequently told that the facility is short-staffed and it causes delays in the care that they need. Review on 11/8/23 of the facility assessment revealed: Minimum Staffing Certified Nursing Assistant (CNA) [NAME] Woods Unit - 2 (with a census of 27) [NAME] Unit - 3 (with a census of 32) Review on 11/8/23 of the Staffing Personnel - Total Number Needed, Average, Range, or Ratio revealed: Nurse Aides Day Shift - 5 LNAs Evening Shift - 4 LNAs Night Shift - 3 LNAs Review on 11/8/23 of the Facility Daily Staffing Sheets revealed: 10/23/23 - 3-11 shift - 3 LNAs 10/24/23 - 3-11 shift - 2.5 LNAs 10/26/23 - 3-11 shift - 2 LNAs 10/27/23 - 3-11 shift - 2.5 LNAs and 11-7 shift - 2 LNAs 10/30/23 - 3-11 shift - 2 LNAs and 11-7 shift - 2 LNAs 10/31/23 - 3-11 shift - 2 LNAs 11/01/23 - 7-3 shift - 3 LNAs Review of the daily census revealed that the facility has maintained a census of 68 to 71 residents during the above noted shifts. Review on 11/8/23 of the facility policy titled, OPS Staffing/Center Plan, Revision Date 8/7/23 revealed: Policy .Centers will provide qualified and appropriate staffing levels to meet the needs of the patient population 4. The Center maintains appropriate staffing levels, with qualified personnel, 24 hours/day, seven days/week on each shift to assure that patients are safe and their needs are met.