**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility failed to ensure a resident was treated with dignity and respect for 1 of 4 sampled residents (#16) reviewed for abuse. This placed residents at risk for lack of dignity and respect. Findings include: Resident 16 was admitted to the facility in 3/2025, with diagnoses including anxiety. An admission MDS dated [DATE] indicated Resident 16 was cognitively intact. The Baseline Care Plan dated 3/28/25, indicated Resident 16 used anti-anxiety medications, with interventions including she/he could become overwhelmed. Staff could assist with one-on-one support. Resident 16 required moderate assistance of one staff member for stand pivot transfers and toileting. A 3/29/25 facility investigation was initiated after two residents complained about Staff 5 (Former CNA). Multiple grievances against Staff 5 led to him being placed on administrative leave. Resident 16 filed a grievance on 3/29/25, which detailed an incident on 3/28/25 during the evening or night shift. Resident 16 reported she/he had requested a female CNA to assist with her/his shower, to which Staff 5 responded one was not available and you're not my type. During assistance with toileting and assisting Resident 16 into bed a call light fell off the bed. Resident 16 reported Staff 5, with clenched teeth and after getting close to her/his face stated, I don't understand you fucking people leaving your shit on the bed. Resident 16 also stated Staff 5 folded her/his walker and threw it in the corner of the room. Resident 16 reported Staff 5 was angry about her/him needing to use the potty, and Staff 5 refused to deal with her/him. Staff 5 got a urinal and stated, fucking tired of this, then told Resident 16 to put her/his legs on the bed. Resident 16 was too slow; Staff 5 reportedly grabbed her/his legs and roughly tossed them on the bed. While Resident 16 used the urinal, Staff 5 kept ranting. An item dropped behind the bed, and Staff 5 became scary, clenching his teeth and getting into Resident 16's face saying, what's wrong with you fucking people. You put your personal shit all over your bed. Staff 5 then pulled the bed out and found the call light. Resident 16 was crying, and Staff 5 stated she/he did not need to cry and patted her/his hand. The investigation indicated Staff 5 reported he was in a hurry on 3/28/25 and felt he may have been short but never intended to be. On 6/12/25 at 9:19 AM, Staff 5 (Former CNA) stated he did not remember Resident 16. Staff 5 denied throwing the walker, though he conceded he might have inadvertently moved a walker quickly, causing it to hit a wall. Staff 5 also admitted he might have inadvertently used profanity in a resident's room and not intentionally moved a resident's legs roughly. Staff 5 mentioned numerous complaints from multiple residents at the facility and stated he resigned as there was no resolution. On 6/12/25 at 10:12 AM, Staff 6 stated she heard residents complain about Staff 5, describing him as gruff with the residents and was rough around the edges. On 6/12/25 at 10:38 AM, Resident 16 stated on the night of 3/28/25 a male CNA came into her/his room to assist her/him with toileting. Resident 16 stated she/he asked for a female caregiver and Staff 5 informed her/him there was no female CNA available and stated, you are not my type. Resident 16 stated Staff 5 assisted her/him with toileting and getting into bed. Staff 5 folded up the walker and he threw it, and it hit hard. Resident 16 stated she/he was frightened. Staff 5 stated he did not have time for this bull shit and picked Resident 16 up and plopped her/him on the bed. Resident 16 stated he picked her/him up from underneath the arm pits and he was very strong. During the time he put her/him into the bed an object fell behind the bed. Staff 5 was very close to her/his faced and stated, I am so fucking sick of you guys putting stuff on the end of the bed. Resident 16 stated it scared her/him. Staff 5 picked up the items behind the bed, patted Resident 16 on the back and told her/him everything was okay. On 6/12/25 at 11:53 AM, Staff 2 (DNS) and Staff 3 (Regional RN Consultant) stated the facility ruled out abuse and neglect as Resident 16's story would go back and forth with her/his statement. Staff 2 stated she felt everything was resolved with Resident 16. The deficient practice was identified as Past Noncompliance based on the following: On 3/31/25, the deficient practice was identified by the facility and was corrected when the facility completed an investigation and identified system failures in the identification of potential abuse and neglect. The Plan of Correction included: *On 3/31/25, Staff 7 (RN) was educated on abuse and neglect policies, along with grievances which could potentially rise to the level of an allegation of abuse or neglect which should be reported to the Administrator immediately. *Ten additional residents were interviewed. All indicated they felt safe at the facility and vocalized no concerns regarding staff care and services. *Staff 5 was provided education regarding communication and perception of communication by others. Staff 5 was provided a work plan which included access to counseling services and offered additional time off. Staff 5 was assigned training, which included Stress Management and Building up Emotional Intelligence. This training must be completed prior to returning to the facility along with abuse and neglect training. *All staff educated on grievances and understanding that grievances could potentially rise to the level of alleged abuse or neglect along with the facility's reporting abuse and neglect policy.

Based on interview and record review it was determined the facility failed to follow physician orders for 1 of 5 residents(#50)reviewed for unnecessary medications. This placed residents at risk for adverse side effects to medications. Findings include: Resident 50 was admitted to the facility in 11/2024 with diagnoses including congestive heart failure. A 12/20/24 physician order for Enestro (a heart and blood pressure medication) indicated to hold the medication if Resident 50's systolic blood pressure(SBP)was less than 120. A review of the 1/2025 MAR revealed on 1/2/25 the PM dose of Enestro was given with a SBP of 118 and on 1/4/25 the PM dose of Enestro was given with a SBP of 110. A review of the 2/2025 MAR revealed on 2/1/25 the PM dose of Enestro was given with a SBP of 104. On 2/14/25 at 11:58 AM Staff 2(DNS)acknowledged Resident 50 received Enestro on 1/2/25, 1/4/25, and 2/1/25 when the medication should have been held per orders. On 2/14/25 at 2:19 PM Staff 10(LPN)stated he gave Enestro on 2/1/25 when it should have been held based on the blood pressure parameter order. On 2/14/25 at 2:30 PM Staff 16(RN)stated she gave Enestro on 1/4/25 when it should have been held based on the blood pressure parameter order. On 2/14/25 at 2:47 PM Staff 17(CMA)stated she gave Enestro on 1/2/25 when it should have been held based on the blood pressure parameter order.

Based on observation, interview, and record review it was determined the facility failed to provide assistive devices for 1 of 5 sampled residents (#313) reviewed for nutrition. This placed residents at risk for unmet needs. Findings include: Resident 313 was admitted to the facility in 1/2025 with diagnoses including anxiety. A 1/23/25 Nutrition Evaluation indicated Resident 313 had difficulty grasping a fork related to hand tremors and the RD recommended adaptive ware (flatware in foam tubes to make it easier to grip) for all meals. A 1/23/24 order indicated Resident 313 was to have adaptive flatware for all meals. On 2/10/25 at 12:52 PM Resident 313 was observed eating in the dining room, no adaptive ware was observed. On 2/11/25 at 1:38 PM Resident 313's tray was observed without adaptive ware. On 2/12/25 at 12:25 PM Resident 313's tray was observed without adaptive ware. On 2/12/25 at 12:25 PM Staff 18 (Dietary Aide) stated adaptive ware are added to the trays during the tray line in the kitchen based on what the tray tickets indicated. On 2/13/25 at 2:52 PM Staff 13 (RD) stated she met with Resident 313 on 1/23/25 and she/he had a hard time holding her/his fork so, with Resident 313's agreement, she put in orders to use adaptive ware with meals. On 2/13/25 at 3:16 PM Staff 14 (Culinary Manager) stated the order for adaptive ware for Resident 313 was in the orders but was not on the tray tickets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 6 was admitted to the facility in 8/2019 with diagnoses including severe protein calorie malnutrition and osteoporosis. An 8/28/23 Quarterly MDS indicated Resident 6 was cognitively intact. On 10/16/23 and 10/17/23 between 2:30 PM and 4:15 PM Resident 6 was observed driving her/his power wheelchair in the facility parking lot towards the street. A Care Plan last updated on 10/16/23 revealed Resident 6 had unsafe community behaviors. The care plan did not include any interventions regarding her/his unsafe community behaviors. On 10/17/23 at 2:10 PM Staff 18 (RN) stated Resident 6's typical behavior was to get into her/his power wheelchair around 2:00 PM or 3:00 PM, leave the facility, and return around 3:30 AM. Staff 18 stated she was unsure of where Resident 6 went, but per other staff Resident 6 was either in the facility parking lot, at stores, or the two nearby parks. Staff 18 further stated Resident 6 did not tell staff where she/he went. On 10/17/23 at 11:47 PM Staff 17 (CNA) stated Resident 6 was out of the facility in her/his power wheelchair and did not expect her/him to return until 3:00 AM or 3:30 AM when she/he was ready to go to bed. On 10/20/23 at 9:00 AM Staff 2 (DNS) acknowledged Resident 6's care plan was not updated to reflect the resident's preference for being in the community all day and there were no interventions in place for safety. Based on observation, interview and record review it was determined the facility failed to update resident care plans for 2 of 2 sampled residents (#s 6 and 36) reviewed for accidents. This placed residents at risk for lack of ADL care needs and safety. Findings include: 1. Resident 36 was admitted to the facility in 9/2023 with diagnoses including multiple pressure ulcers and legal blindness. Review of Resident 36's Care Plan initiated 9/29/23, revealed the resident had an ADL self-care performance deficit related to blindness, decreased mobility and wounds. The resident required one or two-person extensive assist with toileting, substantial/maximum assistance for repositioning, personal hygiene and dressing. The resident was encouraged to use her/his pressure sensitive call device to ring for assistance. The admission MDS, dated [DATE], revealed Resident 36 had a BIMS score of 11 which indicated the resident had moderate cognitive impairment. Random observations from 10/16/23 through 10/18/23 revealed Resident 36 was in bed and whistled until staff entered her/his room and her/his call light was not activated. On 10/18/23 at 6:24 AM Staff 4 (CNA) and 6:45 AM Staff 3 (RN) stated Resident 36 was legally blind and had a touch pad alarm but whistled for assistance. Staff 4 and Staff 3 stated Resident 36 did not use the touch pad alarm. On 10/18/23 at 6:43 AM Resident 36 stated she/he did not use the call device but whistled for help. On 10/18/23 at 11:01 AM Staff 14 (RN) stated Resident 36 never used her/his touch pad alarm and whistled when she/he needed assistance with her/his ADL care needs. On 10/18/23 at 7:41 PM Staff 13 (CNA) stated Resident 36 was dependent for all ADL care needs and had a difficult time using her/his touch pad alarm and whistled to get staff attention. On 10/19/23 at 12:22 PM Staff 12 (LPN/Resident Care Manager) stated Resident 36 had a touch pad alarm but whistled to alert staff when she/he needed assistance. Staff 12 acknowledged this was not on the care plan and needed to be updated to reflect Resident 36's ADL care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to implement care planned interventions related to fall safety for 1 of 2 sampled residents (#36) reviewed for accidents. This placed residents at risk for injury. Findings include: Resident 36 was admitted to the facility in 9/2023 with diagnoses including multiple pressure ulcers and legal blindness. A review of an incident report, dated 10/1/23, indicated Resident 36 had an unwitnessed fall and was found next to her/his bed on 10/1/23. The resident indicated she/he attempted to reposition herself/himself in bed, slid off the bed and onto the floor. The resident was assessed and not injured from the fall. Review of Resident 36's Care Plan, initiated 9/29/23, revealed the resident was at risk for falls related to visual impairment and impaired functional mobility. A revision on 10/6/23 revealed the resident had a non-injury fall out of bed on 10/1/23 and interventions included a fall mat at bedside, bed in a low position and the resident was placed on the falling star program (more frequent checks). The admission MDS dated [DATE], revealed Resident 36 had a BIMS score of 11 which indicated the resident had moderate cognitive impairment. Random observations from 10/16/23 through 10/18/23 revealed Resident 36 was in bed and the bed was approximately two feet from the floor with a fall mat next to her/his bed. On 10/18/23 at 6:24 AM Staff 4 (CNA) stated Resident 36 had a non-injury and stated Resident 36's bed was to be in the lowest position. Staff 4 acknowledged Resident 36's bed was not in the lowest position. On 10/18/23 at 11:01 AM Staff 14 (RN) stated Resident 36 was a fall risk and her/his bed was to be in the lowest position. Staff 14 acknowledged the bed was approximately two feet from the floor and was not in the lowest position. On 10/19/23 at 12:22 PM Staff 12 (LPN/Resident Care Manager) stated Resident 36 had a non-injury fall out of bed and staff were expected to follow the care plan and ensure her/his bed was in the lowest position while the resident was in bed.

Based on interview and record review it was determined the facility failed to ensure residents were free from unnecessary bowel medications for 1 of 5 sampled residents (#18) reviewed for unnecessary medications. This placed residents at risk for loose stools and diarrhea. Findings include: Resident 18 was admitted to the facility in 2023 with diagnoses including diabetes. Resident 18's current physician orders indicated the resident had an order for MiraLAX (a laxative) once daily for constipation. The medication was to be held for loose stools. Bowel elimination records from 9/20/23 through 10/17/23 revealed Resident 18 had loose stools or diarrhea documented on the following dates: - 9/20/23, 9/28/23, 9/29/23, 10/4/23, 10/6/23, 10/13/23, and 10/17/23. Resident 18's MARs from 9/20/23 through 10/17/23 indicated the scheduled MiraLAX was not held for the loose stools. On 10/18/23 at 2:20 PM Staff 5 (LPN) stated Resident 18's MiraLAX should have been held on the days the resident had loose stools. On 10/19/23 at 12:09 PM Staff 2 (DNS) verified Resident 18 was administered MiraLAX with documented loose stools and stated her expectation was for medications to be administered according to the physician's orders.

Based on interview and record review it was determined the facility failed to obtain informed consent prior to initiating psychotropic medication for 1 of 5 sampled residents (#6) reviewed for medications. This placed residents at risk for lack of informed consent. Findings include: Resident 6 admitted to the facility in 2018 with diagnoses including stroke and depression. The 7/1/22 Quarterly MDS revealed Resident 6 had a BIMS score of 13, indicating she/he was cognitively intact. Resident 6's physician orders revealed an 8/16/22 order for trazodone (an antidepressant) for insomnia. A review of Resident 6's 8/2022 and 9/2022 MAR revealed she/he received trazodone each night after 8/16/22. A review of the medical record revealed no documentation of Resident 6's consent to receive trazodone. On 9/9/22 at 9:40 AM Resident 6 stated she/he did not know what medications she/he received. On 9/9/22 at 11:11 AM Staff 2 (Interim DNS) stated there was no consent in the medical record for Resident 6 to receive trazodone.

Based on interview and record review it was determined the facility failed to follow up regarding Advance Directives for 2 of 4 sampled residents (#s 4 and 5) reviewed for Advance Directives. This placed residents at risk for not having their healthcare wishes honored. Findings include: 1. Resident 4 was admitted to the facility in 2019 with diagnoses including stroke. On 9/7/22 at 8:13 AM Resident 4 was asked about Advance Directives. Resident 4 stated she/he did not have an Advance Directive and the facility did not ask about Advance Directives. Care Conference Notes from 9/2021 to current were reviewed. There was no information related to Advance Directives documented in the notes. Review of the medical record revealed no information related to Resident 4's desire to execute Advance Directives. On 9/8/22 at 2:15 PM Staff 1 (Administrator) stated the facility asked about an Advance Directive upon admission and they were reviewed at every care conference. Staff 1 added if information related to Advance Directives was not in the care conference notes, it was not reviewed or offered. 2. Resident 5 was admitted to the facility in 2019 with diagnoses including diabetes. Care Conference Notes from 5/2021 to current were reviewed. There was no information to indicate advance directives were discussed with Resident 5. Review of the medical record revealed no information related to Resident 5 having an advance directive or her/his desire to execute an Advance Directive. On 9/8/22 at 2:15 PM Staff 1 (Administrator) stated the facility asked about an Advance Directive upon admission and reviewed at every care conference. Staff 1 added if information related to Advance Directives was not in the care conference notes, it was not reviewed or offered.

Based on interview and record review it was determined the facility failed to assess and care plan a restraint for 1 of 1 sampled resident (#9) reviewed for accidents. This placed residents at risk for restraint use. Findings include: Resident 9 was admitted to the facility in 2020 with diagnoses including Parkinson's Disease. An investigation note for a fall on 8/7/22 recommended the use of a seatbelt in Resident 9's wheelchair. A review of the medical record indicated there was no information related to the addition of a seatbelt or who applied the seatbelt to Resident 9's wheelchair. There was no information related to seatbelt use for Resident 9 until 9/6/22. A Health Status note dated 9/6/22 indicated Resident 9 had a seatbelt. A Care Plan Change note dated 9/7/2022 indicated due to multiple falls Resident 9 would benefit from the use of a seatbelt. On 9/9/22 at 11:15 AM Staff 13 (CNA) was asked about the use of the seatbelt for Resident 9 and Staff 13 indicated Resident 9 used the seatbelt for approximately one month. On 9/9/22 at 11:42 AM Resident 9's seatbelt was reviewed with Staff 1 (Administrator) and Staff 2 (Interim DNS). Staff 1 stated they just found out Resident 9 used a seatbelt. Staff 1 added upon review of the medical record they identified there was no information or assessment for the use of the seatbelt for Resident 9.

2. Resident 8 admitted to the facility in 2018 with diagnoses including multiple sclerosis (a neurological disease.) A 7/15/22 Annual MDS revealed Resident 8 had limited ROM in her/his upper and lower extremities. An 8/3/22 physician order indicated physical therapy was to evaluate and treat Resident 8 as indicated. There were no orders for ROM for Resident 8. An 8/12/22 Physical Therapy Daily Treatment Note revealed Resident 8 had a physical therapy evaluation and it recommended Resident 8 receive ROM from CNA staff three to five days a week on her/his hips, knees and ankles. A review of Resident 8's current care plan revealed no documentation related to ROM. The 8/2022 and 9/2022 Documentation Survey Reports revealed no documentation ROM exercises were completed with Resident 8. On 9/7/22 at 1:52 PM Staff 4 (CNA) stated she did ROM with Resident 8 by extending Resident 8's arms when getting dressed and in the showers. Staff 4 stated Resident 8's care plan did not indicate if ROM was to be completed. On 9/8/22 at 11:03 AM Staff 14 (CNA) stated she was unaware of ROM exercises for Resident 8. On 9/8/22 at 12:12 PM Staff 5 (Therapy Director) stated Resident 8 was evaluated for ROM and the CNAs were to complete ROM exercises. Staff 5 stated Resident 8 needed ROM to prevent contractures and it was best if ROM was completed daily. On 9/8/22 at 3:08 PM Staff 3 (RNCM) stated Resident 8's medical record did not have charting or orders to direct facility staff to do ROM, did not include what exercises were to be completed and did not include when the exercises were to be completed. Staff 3 further stated it was dependent on the CNAs or nurses to remember to do the ROM exercises and to know the residents and what they needed. Based on observation, interview and record review it was determined the facility failed to provide services related to ROM and splints for 2 of 3 sampled residents (#s 1 and 8) reviewed for positioning and mobility. This place residents at risk for ROM decline. Findings include: 1. Resident 1 admitted to the facility in 8/2019 with diagnoses including muscular dystrophy (disease of progressive loss of muscle mass and increased weakness) and chronic pain. An 8/16/21 signed physician order revealed OT was to evaluate and treat Resident 1 for hand/wrist splints for contracture prevention. An 8/17/21 OT Plan of Care Evaluation revealed Resident 1 would benefit from bilateral resting hand splints for the prevention of contractures of the wrist/hand and without therapy Resident 1 was at risk for bilateral hand contractures. The 10/17/21 Annual MDS revealed Resident 1 had upper and lower extremity impairments to both sides and there was no indication splints or ROM services were provided. Resident 1's 8/23/22 revised care plan did not include information regarding her/his hand/wrist contractures, provision of restorative ROM or use of splints on either hand. On 9/6/22 at 5:29 PM Witness 1 (Family) stated hand/wrist splints were ordered for Resident 1 but the use of the splints were not mentioned during recent care plan meetings. On 9/7/22 at 12:12 PM and 9/8/22 at 12:39 AM Resident 1 was observed in her/his wheelchair with her/his hands resting on a pillow on her/his lap. All of Resident 1's fingers were curled into a fist and no splints were observed on either hand. On 9/7/22 at 1:29 PM Staff 4 (CNA) stated she worked with Resident 1 since 10/2021 provided ROM by stretching Resident 1's hands during bathing but did not document the information into Resident 1's medical record. Staff 4 acknowledged she did not see ROM services listed for Resident 1 in her/his care plan and had no knowledge of any hand/wrist splints for Resident 1. On 9/7/22 at 1:44 PM Staff 5 (Therapy Director) stated he believed the hand/wrist splints for Resident 1 were ordered but was unsure if they ever arrived. On 9/9/22 at 1:00 PM Staff 2 (Interim DNS) acknowledged there was no evidience the hand/wrist splints for Resident 1 were ordered or implemented.

Based on interview and record review it was determined the facility failed to follow up on pharmacy recommendations for 1 of 5 sampled residents (#9) reviewed for medications. This placed residents at risk for unnecessary medications. Findings include. Resident 9 was admitted to the facility in 2020 with diagnoses including Parkinson's Disease. A Pharmacy Review conducted 6/2022 indicated the need to clarify an antibiotic order based on Resident 9's noted allergy to the antibiotic. A Pharmacy Review conducted 8/2022 repeated the recommendation to clarify the antibiotic allergy and review the need for continued use of a proton pump inhibitor (used to decrease stomach acid). A review of the medical record revealed there was no follow up to the pharmacy recommendations for Resident 9. On 9/9/22 at 11:42 AM Pharmacy Reviews were discussed with Staff 1 (Administrator) and Staff 2 (Interim DNS). Staff 1 stated she was not aware pharmacy reviews were conducted. Staff 1 provided no additional information.

Based on observation, interview and record review it was determined the facility failed to provide routine dental services to meet resident needs for 1 of 2 sampled residents (#6) reviewed for dental care. This placed residents at risk for unmet dental needs. Findings include: Resident 6 admitted to the facility in 2018 with diagnoses including stroke. Resident 6 was observed on 9/6/22 at 1:16 PM with many upper teeth missing. A 3/30/22 Oral Dental Assessment revealed Resident 6's last dental appointment was unknown and a dental appointment was to be scheduled the week of 4/4/22 through 4/8/22. At the time of this survey a review of the medical records revealed no documentation of a dental appointment after the 3/30/22 assessment. On 9/8/22 at 9:36 AM Staff 3 (RNCM) stated dental appointments were scheduled as needed and she did not know if Resident 6 saw the dentist. On 9/8/22 at 11:08 AM Staff 1 (Administrator) stated there was nothing in the chart indicating Resident 6 was seen by the dentist after the 3/30/22 Oral Dental Assessment.

Based on observation, interview and record review it was determined the facility failed to ensure AGP (aerosol generating procedure) precautions were used according to CDC guidelines for 1 of 1 sampled resident (#10) reviewed for respiratory care. This placed staff and residents at increased risk for infections and contracting COVID-19. Findings include: A review of Emerging Threats-Acute Respiratory Syndromes Coronavirus (COVID) policy and procedure dated 6/1/22 revealed the following: - AGP to reduce the risk of transmission during bronchoscopy, sputum induction, intubation and extubation, autopsies, cardiopulmonary resuscitation, and open suctioning of airways. -Procedure should be performed in an airborne isolation room if available (negative pressure) and door must be closed. -Limit the number of healthcare workers present. -Staff must wear a fit tested N95 or PAPR (powered air purifying respirator). -Eye protection (goggles or face shield) should be worn if not using a PAPR. -Gown and gloves. -A patient who underwent AGP must have the door closed two hours in a standard room. Resident 10 admitted to the facility in 11/2020 with diagnoses including sleep apnea and chronic heart failure. A comprehensive care plan dated 2/22/22 revealed Resident 10 had difficulty breathing related to obstructive sleep apnea and a CPAP (continuous positive airway pressure) machine was used each night when she/he slept. Staff were to assist Resident 10 at bedtime and remove the CPAP as she/he desired. Random observations from 9/6/22 through 9/9/22 revealed Resident 10 had a CPAP machine on her/his night stand. Resident 10 did not have any AGP or PPE precautions posted or supplies available outside her/his door identifying when the CPAP was in use. On 9/7/22 at 1:10 PM Resident 10 stated she/he used a CPAP machine at night because she/he had better quality of sleep. On 9/7/22 at 4:59 PM Staff 13 (CNA) stated Resident 10 utilized her/his CPAP machine at night and was not aware of any AGP or PPE precautions needed. On 9/8/22 at 11:03 AM Staff 3 (RNCM) stated Resident 10 used a CPAP machine at night. Staff 3 stated she was not aware AGPs were required for Resident 10's CPAP machine use. On 9/9/22 at 1:34 PM Staff 1 (Administrator) and Staff 2 (DNS) stated staff were expected to implement and follow AGP precautions for Resident 10.

Based on interview and record review it was determined the facility failed to ensure the daily staff posting was accurate and complete for 12 of 36 sampled days reviewed for staffing. This placed residents and visitors at risk for lack of staffing information. Findings include: Review of the Direct Care Staff Daily Report postings from 8/1/22 through 9/5/22 revealed the following: *Nine days (8/5/22, 8/8/22, 8/26/22, 8/27/22, 8/30/22, 8/31/22, 9/1/22, 9/2/22 and 9/4/22) the actual hours worked by the RN, LPN or CNAs were not documented as required for one or more of the shifts each day. *Four days (8/31/22, 9/1/22, 9/2/22 and 9/4/22) the resident census was not documented as required for one or more of the shifts each day. *Two days (8/28/22 and 8/29/22) the nursing staff signature and resident census were missing for one or more of the shifts each day. *One day (9/3/22) the night shift information was incomplete and the total number and the actual hours worked by the RN, LPN and CNAs and the total resident census were not documented as required. On 9/9/22 at 12:18 PM Staff 1 (Administrator) and Staff 2 (Interim DNS) acknowledged the Direct Care Staff Daily Reports reviewed were inaccurate or incomplete.

Based on interview and record review it was determined the facility failed to ensure adequate RN charge nurse staffing for 15 of 28 days reviewed for staffing. This placed residents at risk for unmet needs. Findings include: A review of the facility's Direct Care Staff Daily Reports from 10/24/22 through 11/20/22 revealed 15 days with no RN coverage for eight hours each day. On 11/21/22 at 10:56 AM Staff 1 (Administrator) confirmed the lack of RN staffing.