**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, facility investigation review, medical record review, and interview, the facility failed to report an allegation of abuse and failed to report to local law enforcement, Adult Protective Services (APS), and the Long-Term Care Ombudsman, within 24 hours for the allegations of suspected abuse for 5 of 5 (Resident #11, #12, #17, #19, and #25) sampled residents reviewed for abuse and resident rights. The findings include: 1. Review of the facility undated policy titled, Resident Rights, revealed The resident has the right to a dignified existence, self-determination .The resident has the right to be treated with respect and dignity . Review of the facility undated policy titled, ABUSE, NEGLECT, AND EXPLOITATION, revealed Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation .Residents must not be subject to abuse by anyone, including but not limited to .facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving resident, family members, legal guardians, friends or other individuals .Anyone in the facility can report suspected abuse to the abuse agency hotline. When abuse, neglect or exploitation is suspected, the Licensed Nurse should .Respond to the needs of the resident and protect them from further incident (document) .Notify the Director of Nursing and Administrator (document) .Initiate an investigation immediately .Contact State Agency and the local Ombudsman office to report the alleged abuse .If a crime, or suspicion of a crime has occurred, notify the local law enforcement agency .Each covered individual shall report to the State Agency and one or more law enforcement entities .any responsible suspicion of a crime against any individual who is a resident of or is receiving care from the facility .Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause suspicion result in serious bodily or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury . 2. Review of the Facility Reported Investigation dated 3/11/2025, revealed an allegation of physical and verbal abuse when Certified Nursing Assistant (CNA) C reported to the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) that while working with CNA B on 3/9/2025, CNA B handled Resident #12 in a rough manner when assisting CNA C with repositioning Resident #12 and when CNA B ripped off Resident #19 ' s brief in a rough manner and spoke to the Resident in a harsh tone. CNA C did not report the occurrences until 3/11/2025, 2 days later. As a result of the facility ' s investigation, it was determined that Residents #11, #17, and #25 were all subject to abusive behavior from CNA B while receiving care and services and it was not reported. 3. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE], with diagnoses including Dementia, Muscle Weakness, Anxiety, Depression, Diabetes and Benign Prostatic Hyperplasia. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #11 has a Brief Interview for Mental Status (BIMS) score of 5, indicated the resident had severe cognitive impairment, dependent on staff for Activities of Daily Living skills (ADLs), and incontinent of both bowel and bladder. 4. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnoses including Alzheimer ' s Cerebrovascular Disease, Hemiplegia and Hemiparesis, Catatonic Disorder, and Psychomotor Deficit. Review of the annual MDS dated [DATE] revealed Resident #12 had a BIMS score of 8, indicated the Resident had moderate cognitive impairment, dependent on staff for ADLs, and incontinent of both bowel and bladder. 5. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE], with diagnoses including Alzheimer ' s, Rheumatoid Arthritis, Urinary Tract Infection, Dementia, and Anxiety. Review of the significant change MDS dated [DATE], revealed a BIMS of 14 which indicated the Resident was cognitive intact, required substantial/maximal assistance with ADLs, and incontinent of both bowel and bladder. 6. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE], with diagnoses including Alzheimer ' s, Muscle Weakness, Dementia, Age Related Debility, Adjustment Disorder, and Pain in Right Hip. Review of the significant change MDS dated [DATE], revealed no BIMS score assessed and Resident with short-long term memory problems and severely impaired for cognitive skills for daily decision making, dependent on staff for ADLs, and incontinent of both bowel and bladder. 7. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE], with diagnoses including Diabetes, Age-Related Physical Debility, Muscle Weakness, Depression, and Incontinence. Review of the annual MDS dated [DATE], revealed a BIMS of 13 which indicated the Resident was cognitive intact, dependent on staff for ADLs, and incontinent of both bowel and bladder. 8. During a telephone interview on 610/2025 at 11:32 AM, CNA F confirmed she had provided a written statement to the facility regarding the allegation of abuse involving CNA B. CNA F confirmed that she witnessed several incidents in the past involving CNA B and stated she did report to some nursing staff but was unsure their names. CNA F was read her witness statement and confirmed that she wrote the statement and all information in the statement was witnessed at various times and was unsure of the dates or times. CNA F confirmed she witnessed CNA B being rough, rude, and belittling residents. CNA F confirmed she witnessed CNA B speaking hateful and slapping Resident #25 on the leg telling him to straighten out his legs when giving him incontinent care. CNA F confirmed that in her statement she wrote that she witnessed CNA B being rough with Resident #11 and pointing her finger in his face aggravating him. CNA F confirmed that in her statement she witnessed CNA B talking and belittling Resident #17 for having an incontinent incident. CNA F confirmed she has witnessed CNA B being hateful and rude and she failed to report it and that she should have. During an interview on 6/10/25 at 1:57 PM, LPN D confirmed she had given a handwritten statement regarding CNA B and her attitude towards residents. LPN D confirmed she had spoken with CNA B on one occasion about her attitude towards residents especially how she responded to residents and was not being patient with residents. LPN D confirmed that residents had requested for CNA B not to come into their rooms to take care of them because of her attitude. LPN D confirmed she did not report that to the DON, ADON, or the Administrator, and that she should have. During an interview on 6/10/2025 at 2:15 PM, the ADON confirmed that CNA C reported on 3/11/2025 to both her and the DON that CNA B had been both physically and verbally abusive to Resident #12 and #19 on 3/9/2025. The ADON confirmed that CNA C should have reported it the same day it occurred and not 2 days later. The ADON confirmed that initially they thought it may have been that CNA B was having a bad day but as they began to speak with other staff it was disclosed that other residents were involved and that it was more than a bad day. The ADON confirmed the other 3 residents that were involved were Resident #11, Resident #17, and Resident #25, with staff alleging physical and verbal abuse from CNA B. During an interview on 6/10/25 at 2:18 PM, the DON confirmed that on 3/11/2025 CNA C told both him and the ADON that she witnessed some disturbing behavior from CNA B on 3/9/2025 involving 2 residents. The DON confirmed that the staff member was CNA B and the initial residents involved were Resident #12 and Resident #19 and the date of occurrence was 3/9/2025. The DON confirmed that CNA C did not report the occurrences to anyone until 3/11/2025 when she returned back to work and then an investigation was started. The DON confirmed that once the investigation began that other staff reported other incidents that they witnessed that involved other residents. The DON confirmed the other residents were Resident #11, Resident #17, and Resident #25. The DON confirmed that it was reported that CNA B was rude, hateful in speaking with residents, and was very rough when caring for the residents. The DON confirmed that neither Adult Protective Services, Local Law Enforcement, and/or the Ombudsman were notified of the occurrences. The DON confirmed that it should have been reported by staff on 3/9/2025 when it was witnessed and an investigation should have been started on that date. During an interview on 6/10/25 at 3:22 PM, the Administrator confirmed that on 3/11/2025 he was told about an incident that occurred on 3/9/2025 that involved CNA B and 2 residents. The Administrator stated that when he was initially told he thought maybe it was just a staff member having a bad day but then after further investigation he realized it was more than that and it involved other residents. The Administrator confirmed the staff member was CNA B and the initial residents involved were Resident #12 and Resident #19 and that it was reported to him that CNA B was rough during care and had a bad attitude and by the 3rd or 4th staff statement that it was definitely an allegation of abuse. The Administrator confirmed that CNA C reported it to the DON and the ADON on 3/11/2025 but it occurred on 3/9/2025 and she should have reported to the nurse when it was witnessed. The Administrator Stated that all suspected allegations or any allegation should be reported immediately when witnessed and an investigation should be started at that time to include statements from staff and residents, assess the residents, skin sweeps, and informing the physician and the family. During an interview on 6/10/2025 at 3:46 PM, CNA C confirmed that on March 9th she was working with CNA B on Hall 2 and she asked CNA B for assistance in giving care to Resident #12 and Resident #19. CNA C confirmed they went into Resident #12 ' s room first to give her care and instead of unfastening the resident ' s brief she just ripped the brief off of the resident and then she assisted me in Resident #19 ' s room and was speaking rude and abusive to the resident. CNA C confirmed she was in disbelief of her actions in both rooms. CNA C confirmed that neither Resident #12 or Resident #19 could assist with their care or could give the care to themselves, or could make their needs or wants known, and that staff has to assist with all their care needs. CNA C confirmed she had heard that she was rough and had an attitude with residents but had never witnessed it until that day, 3/9/2025. CNA C confirmed that she did not report to anyone about the 2 occurrences until 3/11/2025 when she reported to the DON and the ADON, 2 days later when she returned back to work. CNA C confirmed that she should have reported to the nurse on the date she witnessed the incidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interviews, the facility failed to follow a physician's order related to contact isolation precautions for 1 of 2 residents sampled (Resident #12) reviewed for infection control. The findings include: 1. Review of the facility policy titled, Infection Control and Prevention Policy, dated 2017, revealed It is the policy of this facility to establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infection by providing a safe and sanitary environment .A resident with an infection .shall be placed in isolation precautions . 2. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnosis including Alzheimer, Cerebrovascular Disease, Hemiplegia, and Polyneuropathy. Review of a Microbiology report dated 6/8/2025, revealed Resident #12 had a urine culture that grew out Extended-Spectrum Beta-Lactamases (ESBL) (bacteria is resistant to a wide range of antibiotics) in her urine. Review of a Physician's Order dated 6/8/2025, revealed an order for CONTACT ISOLATION PRECAUTIONS RELATED TO UTI (urinary tract infection) with ESBL . During an observation on 6/9/2025 at 11:25 AM and 4:41 PM, and 6/10/2025 at 7:50 AM, revealed on Resident #12's door a Personal Protective Equipment (PPE) door organizer with a purple square and code key that indicated Resident #12 was in enhanced barrier precautions. During an interview on 6/10/2025 at 10:48 AM, the Assistant Director of Nurses (ADON) was asked what kind of isolation Resident #12 was in. The ADON stated, Contact Isolation. The ADON was showed Resident #12's door that had enhanced barriers signage on it, she stated, It will be changed to contact isolation. During an interview on 6/10/2025 at 2:37 PM, the Director of Nurses confirmed Resident #12 was in Contact Isolation and the room signage was incorrect.

Based on policy review, facility working schedule review, calculated time by calendar day list review, Employee Timesheet review, and interview, the facility failed to ensure there was Registered Nurse (RN) coverage for 8 consecutive hours a day, 7 days a week, for 37 days ranging from January 2025 through June 2025. The census was 35. The findings include: 1. Review of the facility undated policy titled, Nursing Staff-Staffing Policy, revealed .The facility will assure that there is sufficient qualified nursing staff available at all times to provide nursing and related services to meet the resident's needs safely and in a manner that promotes each resident's rights, physical, mental and psychological well-being .The facility will provide at a minimum .55 hours of licensed nursing staff per resident day . 2. Review of the facility Nurses Working Schedule for January 2025, February 205, March 2025, April 2025, May 2025, and June 2025, revealed there was no RN scheduled for 1/4, 1/5, 1/11, 1/12, 1/18,1/19, 1/26, 2/1, 2/2, 2/8, 2/9, 2/15, 2/16, 2/22, 2/23, 3/1, 3/2, 3/8, 3/9, 3/15, 3/16, 3/22,3/23, 3/29, 3/30, 4/5, 4/6, 5/10, 5/11, 5/17, 5/18, 5/24, 5/25, 5/31, 6/1, 6/7, and 6/8. Review of the facility's Calculated Time by Calendar Day, report for May 2025, revealed there was no RN calculated time for RN hours worked on 5/10, 5/11, 5/17, 5/18, 5/24, 5/25, 5/31, and 6/1. Review of RN A ' s Employee Timesheet dated January 2025, February 2025, and March 2025, revealed RN A did not have any hours worked on 1/4, 1/5, 1/11, 1/12, 1/18, 1/19, 1/26, 2/1, 2/2, 2/8, 2/9, 2/15, 2/16, 2/22, 2/23, 3/1, 3/2, 3/8, 3/9, 3/15, 3/16, 3/22, 3/23, 3/29, and 3/30 which indicated there was no RN coverage for those days. Review of the Director of Nursing's (DON) Employee Timesheet dated January 2025, February 2025, and March 2025, revealed the DON did not have any hours worked on 1/4, 1/5, 1/11, 1/12, 1/18, 1/19, 1/26, 2/1, 2/2, 2/8,2/9,2/15, 2/16, 2/22, 2/23, 3/1, 3/2, 3/8, 3/9, 3/15, 3/16, 3/22, 3/23, 3/29, and 3/30 which indicated there was no RN coverage for those days. 3. During an interview on 6/10/2025 at 8:15 AM, the DON confirmed there was no RN coverage on the following weekends of 2025 for the dates 5/10, 5/11, 5/17, 5/18, 5/24, 5/25, 5/26, 5/31, and 6/1 on the licensure sheet. The DON was asked if the facility had RN coverage on any weekends. The DON stated, No. During an interview on 6/10/2025 at 8:29 AM, the DON was asked what the facility does when there is not an RN available to work the required 8 consecutive hours a day. The DON stated, If anything requires an RN, the charge nurse calls me or RN A. Our sister facility staffs an RN on weekends next door, and they can come if there is an emergency. During an interview on 6/10/2025 at 1:19 PM, the Administrator confirmed that the facility did not have RN coverage on any weekend. The Administrator stated, We applied for a waiver, but it hasn ' t been granted.

Based on policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when 4 of 10 staff members (Certified Nursing Assistant (CNA) #1, CNA #2, Licensed Practical Nurse (LPN) #1, and Assistant Director of Nursing (ADON) observed during dining failed to use courtesy titles to address residents, failed to provide privacy while assisting with dining, and stood over residents while assisting with dining. The findings include: 1. Review of the facility's undated policy titled, Residents Dignity revealed, .Dignity .means .our interactions .should maintain/enhance his/her self-esteem and self-worth .ensure dignity is provided by .pulling privacy curtain and closing door .respect residents space .knock on door .request permission to enter room .address the resident with the name of their choice . 2. Observation in Resident #35's room during dining on 10/23/2023 at 11:49 AM, revealed CNA #1 entered the room with Resident 35's meal tray and failed to knock on door or acknowledge self before entering. Observation in Resident #35's room during dining on 10/2/2023 at 7:35 AM, revealed CNA #2 entered the resident's room with their meal tray and failed to acknowledge self or knock on the door. CNA #2 sat down to assist Resident #35 with their meal and failed to pull the privacy curtain or shut the door for privacy while assisting Resident #35 with their meal. 3. Observation in Resident #24's room during dining on 10/23/2023 at 11:52 AM, revealed CNA #1 entered the resident's room with the meal tray and asked, Are you hungry, honey. CNA #1 failed to use a courtesy title when addressing Resident #24. 4. Observation in Resident #29's room during dining on 10/23/2023 at 11:53 AM, revealed that CNA #1 entered Resident #29's room with the meal tray, placed the meal tray on the over bed table, sat to assist Resident #29 with the meal and failed to pull the privacy curtain or close the door. Observation in Resident #29's room during dining on 10/24/2023 at 7:31 AM, revealed CNA #2 assisted Resident #29 with their meal and failed to pull privacy curtain or shut the door for Resident #29's privacy while assisting with their meal. 5. Observation in Resident #6's room during dining on 10/23/2023 at 11:52 AM, revealed LPN #1 entered with the meal tray for Resident #6 and failed to knock or acknowledge self. Observation in Resident #6's room during dining on 10/23/2023 at 12:08 PM, revealed LPN #1 assisted Resident #6 with their meal and failed to pull the curtain or shut the door to provide the resident with privacy while assisting with the meal. LPN #1 exited Resident #6's room to assist another resident and failed to knock or acknowledge self upon re-entrance into Resident #6's room. Observation in Resident #6's room during dining on 10/24/2023 at 7:30 AM, revealed CNA #1 entered Resident #6's room with the meal tray and failed to pull the privacy curtain or shut the door to ensure privacy for Resident #6 while assisting with their meal. 6. Observation in Resident #5's room during dining on 10/23/2023 at 11:54 AM, revealed LPN #1 took a meal tray from the cart, entered Resident #5's room, and placed the meal tray on the over bed table, sat at bedside to assist Resident #5 with their meal while visible from the hallway. CNA #1 failed to provide Resident #5 with privacy while assisting with the meal. Observation in Resident #5's room during dining on 10/24/2023 at 7:32 AM, revealed the ADON entered the room with a meal tray and stood over Resident #5 while assisting with their meal. 7. Observation in Resident #13's room during dining on 10/23/2023 at 12:00 PM, revealed CNA #1 entered Resident #13's room with the meal tray and stated to the resident, Is your foot hurting, baby and Here's your sweater, baby, and Come put your sweater on, baby, and referred to her as sweetheart. CNA #1 failed to address Resident #13 with a courtesy title. 8. Observation in Resident #7's room during dining on 10/24/2023 at 7:34 AM, revealed CNA #2 entered the resident's room with a meal tray, placed the tray on the over bed table, sat and began to assist Resident #7 with their meal and failed to pull the privacy curtain or shut the door for privacy while assisting Resident #7 with their meal. 9. During an interview on 10/25/23 at 2:42 PM, the ADON was asked how residents should be addressed. The ADON confirmed that all residents should be addressed with their appropriate name and titles unless otherwise care planned and should not be referred to with a pet name. The ADON was asked what position staff should be in when assisting a resident with a meal. The ADON confirmed that staff should be in the sitting position when assisting with resident meals. The ADON was asked what should staff do before entering a resident's room. The ADON confirmed that staff should knock, announce themselves before entering a resident's room, and they should close the privacy curtain while assisting with a meal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to date and label Percutaneous Endoscopic Gastrostomy (PEG) tube (plastic tube inserted into the stomach to administer liquid food/supplement) feedings for 1 of 2 (Resident #16) sampled residents reviewed for enteral feeding. The findings include: 1. Review of the facility's undated policy titled, Gastrostomy/Nasogastric Tube Feeding, revealed .Provide nourishment to the resident who is unable to obtain nourishment orally. 2. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses of Dementia, Gastro-Esophageal Reflux Disease, Aphasia, Gastrostomy, and Dysphagia. Review of the admission Minimum Data Set assessment dated [DATE], revealed Resident #16 was assessed as being severely cognitively impaired and receiving nutrition through a feeding tube (peg). Review of a Physician's Order dated 10/21/2023 revealed, .Nutren 1.5 per peg tube at 66 ml (milliliters)/hr (hour) and 46 ml/hr H2O (water flush). Observation in Resident #16's room on 10/23/23 at 8:23 AM, revealed an enteral feeding bag without the date, time, or label indicating description of the solution in the bag. Observation and interview in Resident #16's room on 10/24/23 at 8:54 AM, revealed an enteral feeding bag without a date, time, or label. The Assistant Director of Nursing (ADON) entered the resident's room with a marker and added a date of 10/24/2023, time of 4:00 AM, rate of 66 ml/hr and name of the solution to the enteral feeding bag. The ADON was asked were you the nurse who hung this bag at 4 AM. The ADON stated, No. The ADON confirmed that she was not present at the time the enteral feeding system was started on 10/24/2023 at 4:00 AM and without being present she was unsure what the solution was in the enteral feeding bag. During an interview on 10/25/23 at 2:42 PM, the ADON confirmed that all enteral feeding bags should be labeled, dated, and timed with the name of the solution in the bag.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly and securely stored when 1 of 3 Licensed Practical Nurse (LPN) left unsecured and unattended medication on top of a medication cart. The findings include: 1. Review of the facility's undated policy titled, Medication Cart, revealed .all containers will be labeled and dated .medication will be kept locked . Review of the facility's undated policy titled, Medication Storage Room, revealed .Medication .will be kept locked when not in use . 2. Observation outside Resident #23's room on 10/24/2023 at 7:34 AM, revealed an orange liquid in a clear medication cup on top of Medication Cart #2. 3. During an interview on 10/24/2023 at 7:35 AM, LPN #4 confirmed that she left the oral medication on top of the medication cart outside Resident #23's room. LPN #1 was asked should medication be left open, unsecured, and out of sight of the nurse during medication administration, LPN #4 stated, No. During an interview on 10/25/2023 at 6:25 PM, the Assistant Director of Nursing (ADON) was asked should medication be left outside of a resident's room on top of the medication cart unsecured and unattended. The ADON stated No.

Based on policy review, facility working schedule, calculated time by calendar day list, and the facility detailed hours report, the facility failed to ensure there was Registered Nurse (RN) coverage for 8 consecutive hours a day, 7 days a week, for 29 days ranging from April 1, 2023, through 10/20/2023. The facility's census was 39. The findings include: 1. Review of the facility's undated policy titled, The facility will assure that there is sufficient qualified nursing staff available at all times to provide nursing and related services to meet the resident's needs safely and in a manner that promotes each resident's rights, physical, mental and psychological well-being .The facility will provide at a minimum .55 hours of licensed nursing staff per resident day . 2. Review of the facility's Nurses Working Schedule for April 2023, revealed there was no RN scheduled to work 8 consecutive hours on 4/1/2023, 4/2/2023, 4/8/2023, 4/9/2023, 4/15/2023, 4/16/2023, 4/22/2023, 4/23/2023, 4/29/2023 and 4/30/2023. Review of the facility's Calculated Time by Calendar Day, report for April 2023, revealed there was no RN calculated time, indicating a RN worked 8 consecutive hours on 4/1/2023, 4/2/2023, 4/8/2023, 4/9/2023, 4/15/2023, 4/16/2023, 4/22/2023, 4/23/2023, 4/29/2023 and 4/30/2023. Review of the facility's Detailed Hours report for April 2023, revealed no RN punched in or out indicating working hours on 4/1/2023, 4/2/2023, 4/8/2023, 4/9/2023, 4/15/2023, 4/16/2023, 4/22/2023, 4/23/2023, 4/29/2023 and 4/30/2023. 3. Review of the facility's Nurses Working Schedule for May 2023, revealed there was no RN schedule to work for 8 consecutive hours on 5/6/2023, 5/7/2023, 5/13/2023, 5/20/2023, 5/21/2023, 5/27/2023, 5/28/2023, and 5/29/2023. Review of the facility's Calculated Time by Calendar Day, report for May 2023, revealed there was no RN calculated time indicating that a RN worked 8 consecutive hours on 5/6/2023, 5/7/2023, 5/13/2023, 5/20/2023, 5/21/2023, 5/27/2023, 5/28/2023, and 5/29/2023. Review of the facility's Detailed Hours report for May 2023, revealed no RN punched in or out indicating that a RN worked 8 consecutive hours on 5/6/2023, 5/7/2023, 5/13/2023, 5/20/2023, 5/21/2023, 5/27/2023, 5/28/2023, and 5/29/2023. 4. Review of the facility's Nurses' Working Schedule for June 2023, revealed there was no RN schedule to work 8 consecutive hours on 6/3/2023, 6/4/2023, 6/10/2023, 6/18/2023, 6/19/2023, 6/20/2023, 6/21/2023, and 6/27/2023. Review of the facility's Calculated Time by Calendar Day, report for June 2023, revealed there were no RN calculated hours, indicating that an RN worked 8 consecutive hours on 6/3/2023, 6/4/2023, 6/10/2023, 6/18/2023, 6/19/2023, 6/20/2023, 6/21/2023, and 6/27/2023. Review of the facility's Detailed Hours report for June 2023, revealed no RN punched in or out, indicating that a RN worked 8 consecutive hours on 6/3/2023, 6/4/2023, 6/10/2023, 6/18/2023, 6/19/2023, 6/20/2023, 6/21/2023, and 6/27/2023. 5. Review of the facility's Nurses' Working Schedule for October 2023, revealed there was no RN schedule to work 8 consecutive hours on 10/7/2023, 10/8/2023, 10/14/2023, and 10/15/2023. Review of the facility's Calculated Time by Calendar Day, report for October 2023, revealed there were no RN calculated hours, indicating that an RN worked 8 consecutive hours on 10/7/2023, 10/8/2023, 10/14/2023, and 10/15/2023. Review of the facility's Detailed Hours report for October 2023, revealed no RN punched in or out, indicating that a RN worked 8 consecutive hours on 10/7/2023, 10/8/2023, 10/14/2023, and 10/15/2023. 6. During an interview on 10/24/23 at 11:24 AM, Licensed Practical Nurse (LPN) #4 was asked does she work the weekends. LPN #4 confirmed that she works every other weekend. LPN #4 was asked if there was RN coverage on the weekends that she work. LPN #4 confirmed that there is not always RN coverage and sometimes the RN only works a half day. During an interview on 10/24/23 at 3:57 PM, LPN #5 was asked if there is RN coverage on the weekends. LPN #5 confirmed that there is not always RN coverage on the weekends that she is scheduled to work. During an interview on 10/25/23 at 1:03 PM, the Staffing Coordinator was asked how many RNs are on the facility's employee roster. The Staffing Coordinator confirmed that the only RN is the Director of Nursing (DON). The Staffing Coordinator was asked what hours does the DON work. The Staffing Coordinator confirmed the DON generally works Monday through Friday 8 AM to 5 PM. The Staffing Coordinator was asked is there 8 consecutive hours of RN coverage 7 days a week. The Staffing Coordinator confirmed that there is no RN coverage on the weekends and the only RN in the building is the DON. The Staffing Coordinator confirmed that there are times when the DON is out that there is no RN coverage. The Staffing Coordinator confirmed she was aware that there should be 8 consecutive RN coverage hours for 7 days a week. The Staffing Coordinator confirmed that if there was a RN on duty that the time punches would indicate that information and if there are no hours, then there was no RN on duty for those days. During an interview on 10/25/23 at 1:25 PM, the Interim DON confirmed that she has been the Interim DON since the end of September. The Interim DON was asked has there been times on the weekend, during the week and on holidays when the facility did not have RN coverage for 8 consecutive hours. The Interim DON confirmed that there has been times since April 2023 that the facility has been without RN coverage and when there has been less than 8 consecutive RN hours. The Interim DON confirmed that both she and the former DON would work some weekends, but their hours of employment were Monday through Friday and they did not always work the weekends. The Interim DON confirmed she was aware that there should be 8 consecutive RN hours 7 days a week. The Interim DON confirmed that if there were no RN hours showing on the facility's Detailed Hours Report and the facility's Calculated Time by Calendar Day report that no RN worked that day. During an interview on 10/25/23 at 1:41 PM, the former DON confirmed that he was aware that there was no 8 consecutive hours of RN coverage for 7 days a week and on the weekends in April 2023, May 2023, and June 2023. The former DON confirmed that if he covered as the RN he would have clocked in and if it was not on the Detailed Hours Report or the Calculated by Calendar Days Report then there was no RN coverage. The former DON confirmed that he was aware that the RN hours had to be consecutive and could not be less than 8 consecutive hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to follow Physician's Orders for siderails for 1 of 2 sampled residents (Resident #9) reviewed for physical restraints/siderails. The findings include: Review of the facility's undated policy titled, .Resident Rights, revealed .The resident has a right .to be free from any physical .restraints . Review of the facility's undated policy titled, .Restraints, revealed .if a restraint is needed it will be the least restrictive possible . Review of the medical record, revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of Atherosclerotic Heart Disease, Depression, Diabetes, and Hypertension. Review of the Physician's Orders dated 8/5/2021, revealed .Side Rails ½ [one-half] x [times] 2 to assist with repositioning and safety . Review of the Care Plan dated 9/22/2021, revealed, .SIDE RAILS .½ rails up x 2 to assist with repositioning as per Dr.s [Doctor's] order . Observation in the resident's room on 12/12/2021 at 10:18 AM, 12:23 PM, and 2:45 PM, and on 12/13/2021 at 8:44 AM, revealed Resident #9 was resting in bed and all four ½ side rails were raised. During an interview on 12/13/2021 at 5:02 PM, the Director of Nursing (DON) confirmed that Resident #9 should have had two ½ side rails raised on the bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure residents were free from significant medication errors when 1 of 3 nurses (Licensed Practical Nurse (LPN) #1) failed to administer the ordered dose of Sliding Scale Insulin for 1 of 9 sampled residents (Resident #18) observed during medication administration. The findings include: Review of the facility's undated policy titled, .ADMINISTRATION OF DRUGS . revealed .Medications must be administered in accordance with the written orders of the attending physician . Review of the facility's undated policy titled, .SLIDING SCALE INSULIN . revealed .PURPOSE: To ensure insulin is administered .Use resident specific sliding scale as ordered by MD [Medical Doctor] . Review of the medical record, revealed Resident #18 was admitted to the facility on [DATE] with diagnoses of Diabetes, Adjustment Disorder with Anxiety, Depression, Interstitial Pulmonary Disease, Heart Failure, and Chronic Kidney Disease. Review of the Physician's Order dated 11/8/2021, revealed HumaLOG Solution .greater than 400 give 12 units and notify MD [Medical Doctor] . Observation and interview in the resident's room on 12/13/2021 at 4:41 PM, revealed LPN #1 performed a blood glucose check on Resident #18. The resident's blood glucose was 484 milligrams/deciliter (mm/dL). LPN #1 returned to the medication cart and checked the Physician's Sliding Scale Insulin order. LPN #1 was asked what was the Physician's Order for a blood glucose of 484. LPN #1 stated, .351-400 give 10 units .I'm going to give the 10 units and notify the doctor and see if he wants to do anything else . LPN #1 dialed the insulin pen to 10 units and showed the surveyor the pen. Observation in the resident's room on 12/13/2021 at 4:52 PM, revealed LPN #1 administered 10 units of Humalog insulin to Resident #18 using an insulin pen. During an interview on 12/14/2021 at 8:30 AM, the DON was asked to review Resident #18's Physician's Order for Sliding Scale Insulin. The DON confirmed 12 units of insulin should have been administered for a blood sugar over 400. The DON confirmed Resident #18 was administered 10 units of insulin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure documentation of medications when 2 of 3 nurses (Licensed Practical Nurse (LPN) #1 and LPN #2) failed to document medications administered on the Medication Administration Record (MAR) for 2 of 9 residents (Resident #28 and #29) observed during medication administration. The findings include: Review of the facility's undated policy titled, .Administration of Drugs, revealed .The nurse administering the medication must record such information on the resident's MAR before administering the next resident's medication .The nurse administering the medications must initial the resident's MAR on the appropriate line and date for that specific day . Review of the medical record, revealed Resident #28 was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease, Dementia, Heart Disease, Hypertension, and Acquired Absence of Part of Lung. Review of the Physician's Order dated 7/13/2021, revealed Acetaminophen 325 milligrams (mg) was ordered every 6 hours as needed for mild pain. Observation in the resident's room during medication administration on 12/13/2021 at 10:55 AM, revealed Resident #28 was administered Acetaminophen 325 mg by LPN #1. LPN #1 failed to document that Acetaminophen 325 mg was administered on the MAR on 12/13/2021. During an interview on 12/14/2021 at 8:30 AM, the Director of Nursing (DON) confirmed the Acetaminophen should have been documented as administered on the MAR. During an interview on 12/14/2021 at 11:39 AM, LPN #1 confirmed that she did not document the Acetaminophen administration on 12/13/2021 on the MAR until 12/14/2021. Review of the medical record, revealed Resident #29 was admitted to the facility on [DATE] with diagnoses of Schizoaffective Disorder, Gastrostomy, Dementia, Alzheimer's Disease, Psychotic Disorder, Bipolar Disorder, and Extrapyramidal and Movement Disorder. Review of the Physician's Order dated 11/8/2021, revealed: a.UTI [urinary tract infection] HEAL 30 ML [milliliters] PER PEG [percutaneous endoscopic gastrostomy tube] .BID [two times a day] . b.Depakene Solution 250 MG/5ML .Give .via [through] PEG-Tube .two times a day . c.LORazepam .Give 0.25 mg via PEG-Tube .two times a day . d.Mylanta .Give 10 ml via PEG-Tube .two times a day . e.Memantine HCL [Hydrochloride] .Give 5 mg . f.ZyrTEC .10 MG .via PEG-Tube .in the evening . Observation in the resident's room during medication administration on 12/13/2021 at 4:55 PM, LPN #2 administered the UTI Heal 30 ml, Depakene Solution 250mg/5ml, Lorazepam 0.25 mg, Mylanta 10 ml, Memantine HCL 5 mg, and Zyrtec 10 mg per PEG tube. Review of the December 2021 MAR revealed on 12/13/2021 at 5:00 PM, the following medications were not documented as administered: a. UTI Heal 30 mg b. Depakene Solution 250mg/5ml c. Lorazepam 0.25 mg d. Mylanta 10 ml e. Memantine HCL 5 mg f. Zyrtec 10 mg During an interview on 12/14/21 at 8:30 AM, the DON confirmed LPN #2 did not document the medications were administered on 12/13/2021 at 5:00 PM.