**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not immediately inform a resident's representatives after an accident, which resulted in injury and required physician intervention for 1 of 12 sampled residents. Specifically, when a resident had a fall, sustained a femur fracture, and required hospitalization, staff did not attempt to notify additional resident representatives when the primary contact did not answer the telephone. Resident identifier: 3. Findings included: Resident 3 was readmitted to the facility on [DATE] after a brief hospital stay from December 4, 2024 to December 9, 2024 related to pneumonia. The licensor reviewed Resident 3's medical record, and the following entries were observed: On December 13, 2024, at 9:23 PM, staff member (SM) 1 documented in a progress note that resident 3 was writhing in pain. An assessment of the left lower extremity was conducted, and Resident 3 was grimacing in pain with movement, touch, and abduction. The provider was contacted, and an order was received to obtain an X-ray of the left lower extremity from the hip to the ankle. On December 13, 2024 at 11:05 PM, SM 1 documented in a progress note that resident 3's x-ray was completed and that resident 3 had a displaced fracture to the left femur. The provider was notified and gave instructions to contact the family to determine what the family's wishes for treatment were. SM 1 documented that multiple attempts to contact the sident ' s POA were made but that he was not able to get a hold of the family. Resident 3 was transferred to the emergency department on December 13, 2024 at 11:58 PM. The licensor conducted an interview with Administrative staff member (ASM) 2 on March 25, 2025, at 10:45 AM. ASM 2 was asked what the expectation would be if the facility was unable to contact the primary emergency contact when a critical incident had occurred. ASM 2 stated that the staff would be expected to notify other emergency contacts within five minutes if the primary emergency contact had not responded to phone calls. The licensor interviewed SM 1 on March 25, 2025 at 11:15 AM. SM 1 stated that he attempted to contact the primary contact (POA) multiple times, calling from a person's cell phone three times and the facility phone twice. When asked if a voice message was left, SM 1 stated, I think so. SM 1 was asked if an attempt had been made to contact other emergency contacts, and SM 1 stated, No. It wasn't a heart attack or a stroke, so SM 1 didn't think it was critical to notify other emergency contacts. The licensor conducted an interview with an emergency contact on March 25, 2025, at 11:23 AM. The emergency contact stated that the hospital notified the family that resident 3 was admitted to the hospital on [DATE], at midnight, but that resident 3's family was not notified of the hospitalization and fractured femur until December 15, 2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility did not provide written notice, including the reason for the change, before the resident's room or roommate in the facility was changed. Specifically, for 2 out of 55 sampled residents, residents did not receive written notice prior to the room change. Resident identifiers: 166 and 259. Findings Included: 1. Resident 166 was initially admitted to the facility on [DATE] and readmit to the facility on 1/25/2024 with the diagnosis of Periprosthetic fracture around internal prosthetic right hip joint, subsequent encounter, Acute kidney failure, Neoplasm of unspecified behavior of bladder, Fall on same level from slipping, tripping and stumbling without subsequent striking against object, subsequent encounter, Human immunodeficiency virus [HIV] disease. Resident 166's medical records were reviewed on 4/15/24. Resident 166's medical record was reviewed, and it documented resident 166 had been moved from room [ROOM NUMBER] A to room [ROOM NUMBER] B on 11/21/23. It should be noted that written notification informing resident 166 of a room change was not located in the medical record. On 4/16/24 at 9:43 AM, an interview was conducted with Certified Nursing Assistant (CNA) 10. The CNA 10 stated they did not believe residents needed to sign a consent when their room was changed. The CNA 10 stated residents were notified of the room change with a 24 hour notice. The CNA 10 stated residents were given the change of viewing their new room before being moved. On 4/16/24 at 10:35 AM, an interview was conducted with the Social Service Worker (SSW). The SSW stated both family and residents were given verbal notification of room changes prior to changing rooms. The SSW stated a room change notification was documented in the electronic medical record. The SSW stated the formed documented that family had been notified of the room change and that the resident was okay with the change. On 4/16/24 at 12:04 PM, an interview was conducted with the Unit Manager (UM) 2. The UM 2 stated the social worker was the one to notify residents of a room change. The UM 2 stated when a resident was issued a room change, they were in charge of making sure the new room was ready for the resident, moving the resident belongings and notifying the dietary department. The UM 2 stated they reminded the nurses to write a progress note when residents were moved. On 4/16/24 at 1:31 PM, an interview was conducted with the Resident Advocate (RA). The RA stated a resident was given a 24 hour notice prior to a room change. The RA stated family was only notified if a resident was not alert and orient. The RA stated the room change notification should be documented with every room change. The RA stated there was no written notification given to residents about room changes; only verbal notifications were given. On 4/16/24 at 1:40 PM, an interview was conducted with the Administrator (ADM). The ADM stated residents were only given verbal notifications for room changes. The ADM stated they were recently informed residents needed written notification and they were in the process of fixing the notification process. 2. Resident 259 was admitted to the facility initially on 3/13/24, and re-admitted on [DATE] with diagnoses that included cellulitis of the right leg, encephalopathy, chronic respiratory failure with hypercapnia and hypoxia, heart failure, chronic obstructive pulmonary disease, bipolar disorder, anxiety disorder, and morbid obesity. Resident 259's medical records were reviewed between 4/8/24 and 4/17/24. On 4/9/24 at 9:09 AM, resident 259 was interviewed in her room [ROOM NUMBER]-A. On 4/16/24, a review of resident 259's medical record revealed that the resident had been moved to room [ROOM NUMBER]-A. It should be noted that written documentation informing resident 259 of a room change was not found in the resident's medical record. On 4/17/24 at 10:55 AM, an interview was conducted with Licensed Practical Nurse (LPN 1). LPN 1 stated she did not know much about resident 259 and did not know why she had been moved from the 300 hallway to the 700 hallway.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 55 sampled residents, that the facility did not ensure that the resident had the right to send and receive mail including the right to privacy of such communications. Specifically, a resident received two letters via the postal service and facility staff opened the letters. Resident identifier: 26. Findings included: Resident 26 was admitted to the facility on [DATE] with diagnoses which consisted of cellulitis, orthopedic aftercare following surgical amputation, osteomyelitis, chronic kidney disease, acquired absence of right leg above knee, hyperlipidemia, hypertension, atrial fibrillation, peripheral vascular disease, gastroparesis, and type 1 diabetes mellitus. On 4/08/24 at 12:56 PM, an interview was conducted with resident 26. Resident 26 stated that the lady in the front office was opening his mail and it happened two times. Resident 26 stated that the mail was part of his divorce paperwork and dealt with his 401K. Resident 26 stated that he had to request the same information again when he did not receive the first letter. Resident 26 stated that the staff member had said it was an accident and resident 26 replied that it happened twice and that was not an accident. Review of the grievance logs from November 2023 through April 2024 revealed a concern log for resident 26 on 3/27/24. The department involved was identified as Administration. The concern form documented the incident as Does NOT want his mail opened by staff. The form further documented that the resident was missing important mail that contained legal documents. The form documented that the actions taken to prevent recurrence was that staff was educated. The form was signed by the Administrator (ADM) on 3/28/24. On 4/15/24 at 10:06 AM, an interview was conducted with Resident Advocate (RA) 1. RA 1 stated that anyone could fill out a resident grievance form on behalf of the resident. RA 1 stated that once the grievance form was filled out it would go to the department head to resolve it. RA 1 stated that ultimately all grievance forms went to the ADM. RA 1 stated that the activities department was responsible for resident mail. RA 1 stated that there had never been any time that she received mail or packages for resident 26. On 4/15/24 at 10:17 AM, an interview was conducted with the Activities Director (AD). The AD stated that they delivered the resident's mail. The AD stated that the mail was delivered to the reception desk, and they picked it up daily and delivered it to the residents. The AD stated that if a resident was not available when they attempted to deliver the mail, they would store it in the resident mail bin until they were able to deliver the items. The AD stated that she does not recall any mail being opened for resident 26. The AD stated that the resident would have to sign permission in the business office to allow any mail to be opened for them. The AD stated sometimes with Medicaid documents the residents would sign over permission for that mail to be opened for them. The AD stated that they were not supposed to open any mail unless directed by the resident. On 4/15/24 at 12:29 PM, an interview was conducted with the ADM. The ADM stated that she took over the grievance process in December 2023, but prior to that a licensed Administrator assistant handled them. The ADM stated that issues with resident mail would be investigated by herself. The ADM stated that the Business Office Manager and receptionist dispersed the mail to the activities department staff for delivery to the residents. The ADM stated that if a resident gave permission for the facility staff to open mail, then staff could do that. Otherwise, staff should not open mail without the resident or Power of Attorney (POA) consent. The ADM stated that resident 26 had a letter that was opened by the Business Office Manager Assistant (BOMA). The ADM stated that the letter said in care of Rocky Mountain Care (RMC) Clearfield and then it had resident 26's name underneath. The ADM stated that the letter was delivered to resident 26 but not immediately. The ADM stated that the BOMA said she opened the letter because it was in care of the facility, and she had been helping resident 26 with his Medicaid paperwork and thought it was that. The ADM stated that once she determined what it was, the Medicaid paperwork was scanned into the resident file. The ADM stated that resident 26 was frustrated with the situation and the ADM responded that they were doing education with the staff. The ADM stated that resident 26 told her that it was divorce paperwork and it was regarding money from Medicaid for his divorce. The ADM stated that the BOMA knew there was Medicaid paperwork coming because she had talked to resident 26 about it, so she scanned the letter over to the Medicaid case worker. The ADM stated that the BOMA did not realize that it was related to a divorce until the resident came and asked for it. The ADM stated that the resident should still have been informed of its delivery because it was his letter. The ADM stated that as far as she was aware the resident and the BOMA had an agreement for her to open the mail because she had been helping him in the past. The ADM stated that she was not sure what the process was for the BOMA to open resident mail, even if a resident gave consent. The ADM stated that she was not aware of two letters being opened and resident 26 having to request a second letter. On 4/15/24 at 12:44 PM, an interview was conducted with the BOMA. The BOMA stated that resident 26 received something in the mail and it said RMC as well and she knew that she needed it for Medicaid. The BOMA stated that she scanned the letter and then it sat in a file at her desk for maybe 5 days or so until resident 26 asked about it. The BOMA stated that she knew resident 26 was looking for a piece of mail regarding his divorce and he was getting some of his wife's 401K. The BOMA stated that when resident 26 came to ask for it that was when she gave the letter to him. The BOMA stated that she read the documents before she scanned them into her computer. The BOMA stated that she had a hard time finding resident 26 to deliver the letter and then spaced it off. The BOMA stated that she scanned the letter and sent it to the Medicaid representative for the facility to determine what to do with it. The BOMA stated that the letter was specifically for resident 26 and his records. The BOMA stated that she apologized 100 times to resident 26. The BOMA stated that they revised the mail opening process, and she would not open any of resident 26's mail again. The BOMA stated that she was told if the package or letter said RMC she could open it, but she did not have any specific resident consent to open them. The BOMA stated that now they have a resident consent form, and if it says RMC they were to obtain a verbal consent to open the letter. The BOMA stated that the documents were not scanned into the resident medical records but were contained in her email. The BOMA stated that she did not think it was pertinent to be in the resident's medical records, because it was for money that needed to be spent down so Medicaid did not close his case. The BOMA confirmed that she received a second letter for resident 26 and she opened it also. The BOMA stated that she gave resident 26 the second letter the same day she received it. The BOMA stated that resident 26 had requested a second copy because he had not received the first letter. The BOMA stated that the error was not talking to resident 26 first. It was just an error on my part. The BOMA stated that usually they put resident financial documents into the resident medical records, but she did not think this was pertinent to resident 26's chart. The BOMA stated that resident 26 had $7000 to spend down for Medicaid and usually the resident had a month to spend down. The BOMA stated that resident 26 thought he was losing his Medicaid, and this was a time sensitive issue. The BOMA stated that he had to complete a couple more steps before he had possession of his money. The BOMA stated that resident 26 did not want help with his Medicaid finances now and he had his attorneys working on it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 19 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, type 2 diabetes mellitus, major depressive disorder, lack of coordination, abnormalities of gait and mobility, protein-calorie malnutrition, dysfunction of bladder, retention of urine, muscle weakness, glaucoma, essential hypertension, anxiety disorder, bipolar disorder, hyperlipidemia, insomnia, dementia, long term use of aspirin, and chronic obstructive pulmonary disease. Resident 19's medical records were reviewed. A document titled Observation Detail List Report dated 3/25/24 documented resident 19's Brief Interview for Mental Status (BIMS) score as a 3, which indicated severe cognitive impairment. On 4/9/24 Resident 19's advanced directives were reviewed. Resident 19's advanced directives were documented on the Face Sheet as Do Not Resuscitate. A Progress Note from 3/01/24 at 2:11 PM documented [Resident 19] exhibits facial drooping, drooling, unable to speak, pupils unresponsive, and pale. RN [registered nurse] unable to get ahold of provider nor family, nor DON [Director of Nursing], nor ADON [Assistant Director of Nursing]. RN called 911 to d/c [discharge] to hospital. POLST form states FULL code, EMAR [Electronic Medication Administration Record] states DNR. After about 10 minutes [resident 19's] signs subsided. Provider arrived and again called family. Unable to reach family. Provider orders [resident 19] to stay. A Progress Note from 3/1/24 at 7:06 PM documented, RN was able to contact Hospice who were then able to provide ADON a copy of her most recent POLST form. RN placed POLST form in binder. After leaving shift, RN realized no copy was submitted to medical records for scanning into the system. RN placed nursing order to make a copy of form to submit to Medical records box this evening. Based on interview and record review it was determined, for 2 of 55 sampled residents, that the facility did not ensure that the resident's right to formulate an advanced directive, including implementing the advanced directive per the facility policy was completed. Specifically, two residents' electronic medical records (EMR) documented that the residents' code status was Do Not Resuscitate (DNR) when the resident's Provider Order for Life-Sustaining Treatment (POLST) form documented full treatment. Resident identifiers: 19 and 92. Findings included: 1. Resident 92 was admitted to the facility on [DATE] with diagnoses which consisted of osteoarthritis, schizoaffective disorder, depression, anxiety disorder, hypertension, and chronic obstructive pulmonary disease. On 4/8/24, resident 92's medical records were reviewed. Resident 92's EMR dashboard documented DNR, and that the resident was a hospice patient. Resident 92's physician orders documented Resident POLST Status=FULL CODE. On 11/10/23, resident 92's POLST form documented Full Treatment: Prolonging life by all medically effective means. Medical care may include endotracheal intubation, mechanical ventilation, defibrillation/cardioversion, vasopressors, and any other life-sustaining care that is required. The form indicated that Cardiopulmonary resuscitation was to be attempted. The form declined the use of artificial nutrition. Review of the facility policy on Communication of Code Status documented, It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information. The policy further stated that the nurse who notated the physician order was responsible for documenting the directions in all the relevant sections of the medical record. The policy was last revised in June 2023. On 4/17/24 at 9:25 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that the residents code status was located on the dashboard in the EMR and that resident 92 was DNR. On 4/17/24 at 10:04 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that there was a binder at each nurse's station that contained the resident POLST forms. The DON stated that all staff should know to look there for the resident code status. The DON stated that the code status was also in a general order in each resident chart, and it displayed on the banner at the top of the EMR. The DON confirmed that resident 92's banner documented DNR and the POLST documented full treatment. On 4/17/24 at 10:57 AM, a follow-up interview was conducted with the DON. The DON stated that she contacted resident 92's hospice provider and confirmed that the resident's code status was still full treatment. The DON stated she was not sure why the banner showed DNR. The DON stated that the potential risk was that chest compressions would be delayed or not provided at all. The DON stated that she would have to conduct an audit to make sure there were no other inaccuracies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 12 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage, paroxysmal atrial fibrillation, lack of coordination, hypothyroidism, urinary tract infection, protein-calorie malnutrition, Alzheimer's disease, hypokalemia, major depressive disorder, and essential hypertension. On 4/16/24 at 1:04 PM an observation was made of the call lights. The call light for room [ROOM NUMBER] was turned on at 1:04 PM. At 1:25 PM, the call light was still on, and an interview of resident 12 was conducted. Resident 12 stated that she was waiting for someone to come in and help her find her toothbrush and toothpaste. At 1:37 PM a staff member answered the call light. The call light was on for a total of 33 minutes. 4. Resident 50 was admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder, chronic kidney disease, morbid obesity, abnormalities of gait and mobility, lack of coordination, anxiety disorder, protein-calorie malnutrition, dementia, hyperlipidemia, unspecified convulsions, insomnia, need for assistance with personal care, and hypertension. On 4/16/24 at 1:15 PM an observation was made of the call lights. The call light for room [ROOM NUMBER] was turned on at 1:15 PM. At 1:27 PM, an interview with resident 50 was conducted. Resident 50 stated that he was wanting someone to bring him some food because he was hungry. At 1:54 a staff member answered the call light. The call light was on for a total of 39 minutes. Based on observation and interview, for 4 of 55 sampled residents, the facility did not treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, a staff member did not have an appropriate response to a resident statement, a resident was not provided a dignified dining experience and call lights were not answered in a timely manner. Resident identifiers: 12, 20, 50, and 259. Findings include: 1. Resident 259 was admitted to the facility initially on 3/13/24, and re-admitted on [DATE] with diagnoses that included cellulitis of the right leg, chronic respiratory failure with hypercapnia and hypoxia, heart failure, chronic obstructive pulmonary disease, bipolar disorder, anxiety disorder, and morbid obesity. On 4/9/24 at 9:09 AM, an interview was conducted with resident 259. Resident 259 stated she had not had a shower in two weeks, prior to a hospitalization and then after returning. Resident 259 stated that her skin was dry and itching. The Unit Manager (UM 1) entered the room and resident 259 proceeded to tell UM 1 that she had not showered in two weeks and wanted to take a shower. UM 1 stated, I'm pretty sure that is not true, you have had a shower in the past 2 weeks and that he would have to go check it out. The tone that UM 1 used toward the resident was condescending. Resident 259 stated she would shower herself, and UM 1 stated the resident should not be bearing weight on her leg and needed assistance. Resident 259's medical record was reviewed between 4/8/24 and 4/17/24. An admission Minimum Data Set (MDS) dated [DATE] revealed resident 259 had a Brief Interview for Mental Status (BIMS) of 15, indicating resident 259 was cognitively intact. The MDS assessment also revealed that resident 259 required supervised or touching assistance for bathing. Resident 259's care plan initiated on 3/14/24 included the following problems: a. Falls; [resident's name removed] has had actual fall(s) secondary to Parkinson's, weakness, Urinary Tract Infection (UTI). The goal stated, [resident's name removed] will have no untreated injuries r/t [related to] falls through next review. Approaches included, Keep room free of clutter and tripping hazards; Encourage the use of the call light. b. Activities of Daily Living [ADL's] Functional Status/Rehabilitation Potential; [resident's name removed] is at risk for altered ADL function secondary to Parkinson's, weakness, UTI. The goal stated, [resident's name removed] will not have any unaddressed complications secondary to decreased ADL self-performance through next review. Approaches included, Assist in completing ADL tasks each day; Provide dignity and respect and encourage independence .Encourage use of call lights when ADL assistance is needed. On 4/17/24 at 12:50 PM, an interview was conducted with the Director of Nursing (DON). The DON stated if a resident stated they had not showered, her expectation of the staff member would be to try to resolve the concern. The DON stated she could not imagine a staff member saying something like that to a resident. The DON asked who the staff member was and stated she did not like that at all. The DON stated she would look into the concern. 2. Resident 20 was admitted to the facility on [DATE] with diagnoses that included [NAME] Sachs disease, anxiety disorder, seizures, dysphagia, lack of coordination, moderate and protein-calorie malnutrition. Resident 20's medical record was reviewed between 4/8/24 and 4/17/24. An annual MDS assessment dated [DATE] revealed that resident 20 required substantial/maximal assistance with upper and lower body dressing. The assessment also revealed that resident 20 required moderate assistance with eating. A physician order dated 2/10/23 revealed, [resident's name removed] uses weighted utensils and may need increased assistance with meals. Resident 20's care plan initiated on 7/29/2020 included: a. Nutrition Status; [resident's name removed] is at risk for nutritional deficits secondary to hx [history] of wt [weight] loss, and decreased dexterity of limbs. She has PO [by mouth] intake, and artificial nutrition via peg tube. The goal was [resident's name removed] weight will remain stable, through next review. Approaches included, Bolus enteral feeds as allowed; Diet/Supp [supplement] as ordered. Peg tube in place .[resident's name removed] has a non-spill cup available for use and foods as finger-style food per preferences. b. Cognitive Loss; [resident's name removed] has impaired decision making r/t [NAME] Sachs disease. The goal was [resident's name removed] will have positive experiences in daily routine without overly demanding tasks and without becoming overly stressed. Approaches included, .Provide cues and supervision for ADLs PRN [as needed]. On 4/10/24 at 9:00 AM, resident 20 was observed to be in a wheelchair sitting by the nurses station. A bedside table was in front of resident 20 with a breakfast tray containing 2 boiled eggs, an orange slice, and another breakfast item that appeared to be a small breakfast burrito. Resident 20 picked up one of the boiled eggs and held it in her hand. With her other hand, resident 20 pushed the orange slice onto the bedside table. The Certified Nursing Assistant Coordinator (CNAC) wheeled resident 20 down to the dining room, where breakfast was being served, and placed her at a table by herself. UM 1, who was passing drinks in the dining room, approached resident 20 and asked if she would like some orange juice. Resident 20 nodded in the affirmative and UM 1 poured ½ of a small cup of orange juice and put it on the table. Resident 20 reached for the cup, putting 3 fingers into the cup, and attempted to drink from it. Resident 20 could not properly tip the glass to drink from it. UM 1 took the cup from resident 20's hand and put it on the table and walked away to continue pouring beverages to other residents. Resident 20 was observed to put her fingers around the cup, pick it up, and consume the entire cup of juice. Resident 20 continued to hold the cup and move it around on her lap. UM 1 returned to resident 20's table with some napkins and sat down at the table with resident 20, then got back up again. At 9:06 AM, UM 1 returned to the table with a regular fork. UM 1 put the fork into resident 20's hand. UM 1 asked resident 20 if she liked her eggs sunny-side up. UM 1 then got up from the table again and began bussing tables from the resident's who had finished their meals and left the room. Resident 20 dropped her cup onto the floor. A staff member brought a clothing protector to resident 20 and placed it on her. UM 1 brought an open Styrofoam container to resident 20's table and placed it in front of her, removing the plate further away. UM 1 sat down again next to resident 20. UM 1 asked resident 20 if she would like for him to dice or cut up her food. UM 1 attempted to take the fork out of resident 20's hand, but she held on tight to it. Resident 20 began to push around the Styrofoam container on the table with her free hand. UM 1 picked up a small cup containing cut up fruit and placed it in front of resident 20. Resident 20 picked up the fruit cup and placed it on top of her other hand a few times, then placed her fingers into the cup. Resident 20 was unable to properly hold the fruit cup and eventually dumped the contents on to the floor. UM 1 attempted to feed resident 20 a fork with what appeared to be scrambled eggs on it. Resident 20 did not open her mouth, so UM 1 put the fork down and closed the Styrofoam container. UM 1 then got up and left the table. UM 1 returned to the table with a wet cloth and put the cloth on the table. UM 1 left the table and began bussing tables again. At 9:18 AM, UM 1 put another ½ cup of orange juice on resident 20's table. UM 1 then picked up his mobile phone and adjusted the volume of the music that was being played in the dining room. At 9:20 AM, resident 20 was pushing the Styrofoam container around on the table and knocked the cup of orange juice into her lap, getting her dress wet, and spilling the juice onto the table and the floor. UM 1 walked over to the table where resident 20 was sitting, and picked the plate, the Styrofoam container, the fork and tray and returned them to the kitchen. Resident 20 continued to hold the cup in her hand. At 9:28 AM, UM 1 returned to the table and began wiping resident 20's hands with the cloth he had put on the table earlier. UM 1 attempted to give resident 20 her toy back, but then began to play with it himself, bending it into different shapes. At 9:31 AM, resident 20 started to slide out of her chair. UM 1 got up from the table and prevented resident 20 from sliding to the floor. Resident 20 then pulled her legs up to her chest and tried to sit in the chair with her legs up against her. UM 1 repositioned resident 20 into the wheelchair, took off the clothing protector and began to wheel her down the hallway. A staff member walking by asked resident 20 what happened to her (referring to the large wet spot on her dress). UM 1 responded [Note: it is unknown what UM 1 said in the response], the staff members began to laugh. UM 1 continued down the hallway with resident 20. At 9:35 AM, UM 1 wheeled resident 20 into her room and pulled the curtain. At 9:40 AM, resident 20 was observed to be laying on her bed in the dress that was wet, and her legs were partially covered with a sheet. On 4/10/24 at 10:08 AM, resident 20 was observed to be in her bed with the same dress on that she was wearing at breakfast time. On 4/10/24 at 10:33 AM, resident 20 was observed to be in her bed with the same dress on. On 4/10/24 at 10:34, a continuous observation was started. On 4/10/24 at 12:29 PM, Certified Nursing Assistant (CNA) 1 entered resident 20's room. CNA 1 checked on resident 20's roommate. On 4/10/24 at 12:31 PM, CNA 1 checked on resident 20. Resident 20 was positioned perpendicular to the bed, was curled up with her dress scrunched up. Resident 20's head was close to the edge of the bed and her feet were on the opposite side of the bed. Resident 20 was observed to have taken the pillow case off of the pillow. CNA 1 repositioned resident 20 and checked her brief. CNA 1 adjusted and straightened resident 20's clothing. On 4/10/24 at 12:40 PM, an interview was conducted with CNA 1. CNA 1 stated resident 20 likes to wiggle and move while on her bed. CNA 1 stated they put a fall mat next to her bed and keep the bed next to the wall and close to the floor. CNA 1 stated she tried to go in and reposition resident 20 as needed. On 4/10/24 at 12:46 AM, an observation was made of resident 20 who was still in the position on the bed as before. On 4/10/24 at 12:56, the continuous observation was discontinued. On 4/17/24 at 12:24 PM, an interview was conducted with CNA 1. CNA 1 stated resident 20 was dependent for all Activities of Daily Living (ADLs), and could not do anything on her own. CNA 1 stated resident 20 was moderately able to communicate her needs. CNA 1 stated resident 20 could answer yes or no questions. CNA 1 stated resident 20 would rip her brief off if she was in need of a brief change. CNA 1 stated resident 20 did require assistance for eating, but she mostly refused food. CNA 1 stated at meal time once the tray is placed down, staff would ask if she wanted a bite of food. CNA 1 stated once the utensil got close to resident 20's mouth, she would turn her head away and refuse to eat. CNA 1 stated resident 20 would eat bananas and some yogurt, but mostly she drank the MedPass the nurses provided her. CNA 1 stated staff were required to hold the cup for resident 20 because if she held it herself, she would pour it out.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that, for 3 of 55 sampled residents, that the facility did not provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. Specifically, there were multiple instances where the facility was dirty and not homelike. Resident identifiers: 20, 80, and 259. Findings Include: 1. Resident 259 was admitted to the facility initially on 3/13/24, and re-admitted on [DATE] with diagnoses that included cellulitis of the right leg, encephalopathy, chronic respiratory failure with hypercapnia and hypoxia, heart failure, chronic obstructive pulmonary disease, bipolar disorder, anxiety disorder, and morbid obesity. On 4/9/24 at 9:20 AM, an interview was conducted with resident 259. Resident 259 stated she went out to smoke twice daily. Resident 259 stated in the smoking area, the cigarette ashtray was broken with cigarette butts overflowing with cigarette butts all over the ground. On 4/8/24 at 1:42 PM, an observation was made of the facility courtyard. There were two cigarette ashtray towers that were full of cigarette butts and the butts were overflowing onto the ground. The two garbage cans in the courtyard were full of trash and the trash was spilling onto the ground. There was also a 6 foot long piece of a metal rain gutter strewn in the middle of the cement walkways in the courtyard. On 4/10/24 at 9:15 AM, an additional observation was made of the facility courtyard. The cigarette ashtray towers were still full of cigarette butts and the two garbage cans were still full of trash. The piece of rain gutter that had been on the ground was now laying in one of the tulip beds in the courtyard. On 4/17/24 at 12:30 PM, an observation was made of the smoking area. The cigarette ashtray tower was not secured on the base and there were several cigarette butts surrounding the ashtray tower. On 4/17/24 at 2:15 PM, an interview was conducted with Housekeeper (HK) 1. HK 1 stated that she has never had to clean the courtyard. HK 1 stated that she was unsure whether or not housekeeping is responsible for cleaning the courtyard. HK 1 stated that resident rooms should be cleaned every day. On 4/17/24 at 2:20 PM, an interview was conducted with HK 2. HK 2 stated that housekeeping is not responsible for the courtyard. On 4/17/24 at 2:23 PM, an interview was conducted with HK 3. HK 3 stated that maintenance is responsible for the courtyard. HK 3 stated that resident rooms should be cleaned daily. On 4/17/24 at 2:40 PM, an interview was conducted with the Assistant Director of Maintenance (ADOM). The ADOM stated that maintenance is responsible for cleaning out the cigarette butt towers and maintaining the courtyard. The ADOM stated that typically the towers are cleaned once a week, but that due to the winter weather the cleaning has not occurred. 3. Resident 80 was admitted to the facility on [DATE] with diagnoses which included encounter for other orthopedic aftercare, unspecified fracture of upper end of right tibia, dementia, unspecified fracture of upper end of left tibia, unspecified fracture of shaft of right fibula, unspecified fracture of shaft of left fibula, chronic obstructive pulmonary disease, chronic respiratory failure, type 2 diabetes mellitus, weakness, abnormalities of gait and mobility, depression, and insomnia. On 4/8/24 at 10:48 AM an interview with resident 80 was conducted. Resident 80 stated that he had a fall at the facility when he was transferring from the bed to the chair, and his bed had slipped out from underneath him. Resident 80 stated that he bed locks were not locked. Resident 80 stated that he had smashed his finger. An observation of resident 80's right ring finger was made. Resident 80's right ring finger was missing the right half of the nail. The skin appeared to be healed. Resident 80 stated that after he fell and smashed his finger, there was no bleeding, but part of the nail turned black and fell off. Resident 80's medical records were reviewed. An incident report with an Event Date of 3/8/24 documented, Residents bed was not locked, bed rolled while he was sitting on edge of bed and he fell. The resident description of the fall was documented as, sitting on side of bed, wheels not locked, bed rolled and I fell on my bottom. The incident report documented that there were no injuries noted. A Progress Note from 3/8/23 at 10:24 PM documented, This LN [Licensed Nurse] was doing med pass when I was informed by CNA that resident was on the floor, on arrival in residents room I observed him lying on floor in supine position with a pillow under his head, I assessed him for injuries, no apparent injury noted, he was A/O [alert and oriented] x 4, able to tell this writer what happened, he stated, I was sitting up on bed with my feet on floor, CNA was assisting me, she observed me fall, my bed doesn't lock and it rolled causing me to fall and I did not hit my head, just fell on my bottom. CNA [name redacted] stated the same, I saw him fall, he did not hit his head, he fell on his bottom, I helped him lie down and put pillow under his head for comfort. ROM [range of motion] was at baseline, staff assisted resident up off the floor and back into bed . A Progress Note from 3/9/24 at 2:46 PM stated, Patient encouraged to use call light for transferring assistance this shift. Patient tolerates well and is observed using call light and waiting for staff to assist him. On 4/17/24 at 2:38 PM an interview with the Director of Nursing (DON) was conducted. The DON stated that staff should be checking that the breaks are working every time prior to transferring a resident in or out of their bed. The DON stated that all of the beds have wheels and have breaks, and that the breaks should always be locked. The DON stated that the locking mechanism was broken on resident 80's bed when he fell. The DON stated that nobody had noticed that the locking mechanism was broken until resident 80 had fallen. The DON stated that maintenance immediately fixed the breaks on resident 80's bed. The DON stated that there were no routine checks completed by maintenance to ensure that the beds were safe. On 4/17/24 at 2:46 PM an interview with the Assistant Director of Maintenance (ADOM) was conducted. The ADOM stated that there were no routine checks on residents' beds. The ADOM stated that he could not recall if he had fixed resident 80's bed. The ADOM stated that maintenance only looked at the beds if there was a work order placed. 4. On 4/8/24 an observation of room [ROOM NUMBER] was made. A puddle of liquid was observed on the floor next to a resident's bed. A blanket, condiment packets, and tissues were observed on the floor in the room. The floor underneath the bed appeared to be dusty and had pieces of trash on it. 5. On 4/8/24 at 1:09 PM an observation was made of room [ROOM NUMBER]. A disposable nursing glove and a washcloth was observed to be on the ground. The floor had crumbs and debris on it. 6. On 4/9/24 at 8:51 AM an observation was made of room [ROOM NUMBER]. The floor around the bed had trash and crumbs on it. 2. Resident 20 was admitted to the facility on [DATE] with diagnoses that included [NAME] Sachs disease, pseudobulbar affect, anxiety disorder, dysphagia, abnormality of gait and mobility, lack of coordination, and bipolar disorder. Resident 20's medical records were reviewed between 4/8/24 and 4/17/24. On 4/10/24 at 8:55 AM, an observation was made of resident 20 sitting in her wheelchair across from the 300-400 hallway nurses station. The staff had placed a bedside table across her lap while the breakfast trays were being passed. While resident 20 sat there, she was observed to be pulling at the plastic covering to the bedside table that was cracked and broken in multiple places on the table. The plastic was rigid and jagged with sharp edges. On 4/17/24 at 11:56 PM, an observation was made that the damaged bedside table was still at the 300-400 hallway nurses station available for use. On 4/17/24 at 12:42 PM, an observation was made of a second bedside table in the hallway outside the door of the resident advocate. The table was damaged with the plastic covering being cracked and broken in several places on the table.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse for 3 of 55 sample residents. Specifically, a resident stated they had been abused and not follow up investigation was documented, interviews were not documented with all staff members involved in the investigation, and a through investigation was not conducted. Resident identifier: 79, 82 and 86. Findings include: 1. Resident 79 was admitted to the facility on [DATE] with diagnoses which included acute respiratory failure with hypoxia, critical illness myopathy, tracheostomy status and anxiety disorder. Resident 79's medical record was reviewed from 4/8/24 through 4/17/24. Resident 79 quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident's Brief Interview for Mental Status (BIMS) score was 14 indicating cognition is intact. A form titled exhibit 358 revealed an employee reported that resident 79 had been unchanged for sometime by CNA 6, who knew that the resident was soiled. The employee also reported CNA 6 used vulgar language while speaking with resident 79. The document revealed, resident 79 doesn't feel unsafe in the facility. A form titled exhibit 359 revealed a follow up interview was completed with the witness. The witness was asked what vulgar language [CNA 6] used toward the resident . When asked why [resident 79] was left wet, she stated that her and [CNA 6] were performing a bed bath for a different resident that lasted 1.5 hours then made their way back to [resident 79] to change her. The conclusion documented based on the inconsistency of the witness interviews, resident interviews, resident chart reviews, and staff interviews the allegation could not be verified or refuted. A review of the facilities internal investigation revealed an interview was conducted with resident 79. Resident 79 was asked the following questions: a. Have you every felt abused, neglected, or exploited at this facility? Resident 79 responded, Yes, ignored, not listened too, put off multiple. b. Do you know who to report abuse, neglect, exploitation, or theft to in this facility? Resident 79 responded, no, a written note stated, I educated on who to report too. Resident nodded 'yes' in understanding. c. Has anyone every inappropriately touched you at this facility? Resident 79 responded yes. If yes did you report it? Resident 79 responded no. If they did not report it, what happened? Get more information/statement Resident 79 respond I'm on my own. d. Do you feel safe at this facility? Resident 79 respond No. e. Do you feel like you are getting good care at this facility? Resident 79 responded No. [It should be noted that the internal investigation documentation did not include follow up investigations regarding resident 79's responses of abuse, inappropriate touch, and feeling unsafe.] On 4/11/24 at 1:56 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 79 is nonverbal and uses a white board to communicate. When resident 79 was asked if she had been abused and answered yes. The DON stated that after that question was asked she got the Administrator (ADM). The DON stated resident 79 did not say any names. The DON stated that when the ADM asked resident 79 about it, resident 79 would touch her trach [trachea] and motion head no and touch her trach. On 4/11/24 at 2:22 PM, an interview was conducted with the Administrator (ADM). The ADM stated that resident 79 uses her whiteboard to communicate. ADM stated when she asked about inappropriate touch, and what that meant to to her, resident 79 kept pointing to her trach and saying 'I'm on my owe, I'm left here on my own.' We were unable to substantiate. 2. Resident 82 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia, personal history of traumatic brain injury, zoster encephalitis, and adjustment disorder with mixed anxiety and depressed mood. A form titled exhibit 358 revealed resident 82 was receiving a brief change by an employee and was rolled into the wall while providing cares. Resident 82 had a small scratch to left wrist. A form titled exhibit 359 revealed an employee alleged that during a brief change CNA 6 hit resident 82's knees against the wall during a brief change. When witness was asked about brief change on 82 and whether the bed was moved away from the wall, she stated that it was. They moved bed away from wall to ensure that resident didn't bump into wall during brief change. The employee states that while CNA 6 was checking the residents brief at a different time, his knees did bump into the wall. Resident 82 was not rolled into the wall during cares. An interview was conducted with CNA 6 stated that she did change resident 82. During the process she pulled his bed away from the wall to ensure that he wouldn't hit it. She pulled it so far from the was that she accidentally unplugged the bed. She completed the brief change with no incidents. In a section titled summary of interviews with staff responsible oversight and supervision of the alleged perpetrator if staff or resident documented Nurse manager and charge nurses that are responsible for oversight of the alleged perpetrator state that they have never had any complaints about [CNA 6] as a CNA. They state that she is thorough when working and completes her job. The conclusion documented, Based on the inconsistency of the witness interviews, resident interviews, resident chart reviews, and staff interviews the allegation could not be verified or refuted. [It should be noted that the facilities internal investigation was reviewed. The investigation did not contain the documented interviews conducted with the nurse manager and charge nurse.] On 4/11/24 at 2:22 PM, an interview was conducted with the ADM. The ADM stated that if there were interviews conducted during an investigation, they would be located with the investigation and that she did not usually keep documents in any other place. The ADM stated that for the investigation she interviewed CNA 6, CNA 7 and that she did talk to a nurse and nurse manager. The ADM stated that she did not type up the interview conducted with the nurse and nurse manager. 3. Resident 86 was admitted to the facility on [DATE] with diagnoses which included traumatic subdural hemorrhage, pulmonary embolism, type 2 diabetes mellitus, protein-calorie malnutrition, essential hypertension, weakness, lack of coordination, abnormalities of gait and mobility, dysphagia, insomnia, anxiety disorder, depression, anemia, and chronic pancreatitis. Resident 86's electronic medical record was reviewed. A Progress Note from 3/31/24 at 1:18 PM stated, One of the residents came up to this nurse and said that a patient [sic] fell. Went into the room where is implied was someone on the floor. Found this resident layin [sic] on the floor. One of his shoes was half way on and half way off. Assessed the patient and asked him where his pain was. He said that it was in his back. He did not complain of any pain when touching him to see where the pain was. The aide and this nurse assisted getting him back into his wheelchair. He was asked to do some ROM [Range of Motion] and he then complained that his left shoulder was hurting him. He had ice applied. MD [Medical Director] was notified at 1945 [2:45 PM] and On call management was notified. This nurse was informed to monitor the patient. Family representative was notified late by text message after some monitoring had been done. The next nurse will continue to monitor. A Progress Note from 4/1/24 at 12:22 PM documented, Distal clavicle Minimally displaced fracture and arthritic changes present. Provider notified. Orders from provider to get an ortho consult and apply a sling to patient. Since pt [patient] cont [continues] to c/o [complain of] pain to L [left] shoulder and at this time shows limited ROM to shoulder (states im sore) - admin [administer] prn [as needed] Tylenol with positive effects and also repositioned pt and redirected as pt is baseline confused and oriented to name only. At this time pt is resting comfortably in bed, eyelods [sic] closed, resp [respiratory] rate even and unlabored, [NAME] [sic] aroused . A Progress Note from 4/7/24 at 5:25 PM documented, .Had ortho appointment today after falling and suffering a L clavicular fracture. Not a surgical candidate . States he has had pain with activity . A Facility Reported Incident Document 359 was reviewed. The summary of interviews with the alleged victim was documented as, Resident is not interviewable. When asked how he fell, resident was not able to verbalize any details regarding the incident. The summary of interviews with witnesses documented, Resident roommate notified nurse that [resident 86] fell, as he was in his room with him. He was not able to very the details regarding the incident, just that he heard [resident 86] fall in his room and saw him on the ground. The summary of interviews with the alleged perpetrator was documented as, NA [not applicable]. The summary of interviews with staff responsible for oversight and supervision of the location where the alleged victim resides was documented as, Nurse that was overseeing [resident 86]'s care was interviews. Nurse states that his roommate came out of the room and said that he heard somebody fall, and checked the other side of the curtain and found resident on the floor. When nurse went into resident room, resident was close to his wheelchair with a show half on/half off. It appeared that resident was trying to self transfer. The allegation was not verified by the facility and it was documented that, residents interviews, staff interviews, chart reviews, and care plan review refute the allegation. This allegation is not verified. The 359 report included the interview Registered Nurse (RN) 7. The interviewer asked two questions; How did you know that [Resident 86] fell? And What did you witness?. RN 7 reported, His roommate came out and said that he had heard somebody fall and that his roommate was on the ground. He said he didn't know what happened. I walked into the patient room and found [Resident 86] on the floor by his wheelchair. His shoe was half on and half off. I asked his what happened, he said he didn't know what happened or why he was on the floor. No staff members in the room when it happened. It looks like he was trying to self transfer. On 4/16/24 at 10:55 AM an interview with the Administrator was conducted. The Administrator explained that she interviewed RN 7 because RN 7 was the one who was standing by the room, and she was the one who assessed the resident when it happened. The Administrator stated that she did not interview any other staff members because RN 7 was able to see that there were no other staff around or in the area when resident 86 fell. The Administrator was asked if she was investigating abuse or neglect for this incident, to which the administrator responded, neither, well if I had to pick one, I would say possible neglect. The administrator stated that because it was an unwitnessed fall, there were not any staff to interview about it because they did not witness the fall. The Administrator stated that prior to the fall, resident 86 may have been in the dining room eating lunch, and then walked back to his room. The Administrator stated that she did not know this for certain. The Administrator stated that she did not know when the last cares were performed for resident 86 prior to the fall. The Administrator stated that she did not know if resident 86 was exhibiting any different behaviors from his baseline prior to the fall. The Administrator stated that after each time a resident had a fall, new interventions are implemented to try to prevent future falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 60 was admitted [DATE] with diagnoses including end stage renal disease, insomnia unspecified, essential (primary) hypertension, peripheral vascular disease unspecified, other intervertebral disc degeneration lumbosacral region, dependence on renal dialysis, displaced avulsion fracture (chip fracture) of left talus, subsequent encounter for fracture with routine healing, type 2 diabetes mellitus with diabetic polyneuropathy, and dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Resident 60's medical record was reviewed from 4/8/24 through 4/17/24. Resident 60's most recent Brief Interview for Mental Status (BIMS) Score from her most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] was a 15, indicating no cognitive impairment. Resident 60's MDS Assessment also indicated that Resident 60 required partial/moderate assistance to shower and bathe herself. Resident 60's care plan was reviewed. A focus dated 7/3/23 revealed, [Resident 60 is at risk for altered ADL [activities of daily living] function secondary to ESRD [end stage renal disease], impaired mobility, morbid obesity, vision impairment. This focus was last revised on 4/8/24. The goal for this focus was documented as, .will not have any unaddressed complications secondary to decreased ADL self performance, through next review. The target date for this goal was listed as 4/30/24. The interventions for this goal were documented as: Requests medications at bedside to promote independence. This intervention was initiated on 2/6/24. Assist in completing ADL tasks each day. Provide dignity and respect, and encourage independence. The intervention was initiated on 7/3/23. Encourage use of call lights when ADL assistance is needed. This intervention was initiated on 7/3/23. Encourage PT/OT [physical therapy/occupational therapy] services as prescribed. This intervention was initiated on 7/3/23. Resident 60's shower schedule was reviewed. Resident 60 was scheduled to have showers or baths on Mondays, Wednesdays, and Fridays. Review of Resident 60's showers documented in the electronic medical record revealed that from admission to 4/10/24, Resident 60 received showers on the following dates: a. 6/30/23 b. 7/5/23 c. 7/7/23 d. 7/10/23 e. 7/13/23 f. 7/17/23 g. 7/24/23 (Note: This was 7 days after the previous shower or bath.) h. 7/26/23 i. 7/28/23 j. 8/4/23 (Note: This was 7 days after the previous shower or bath.) k. 8/9/23 l. 8/14/23 m. 8/18/23 n. 8/23/23 o. 8/25/23 p. 8/29/23 q. 8/30/23 r. 9/1/23 s. 9/4/23 t. 9/8/23 u. 9/15/23 (Note: This was 7 days after the previous shower or bath.) v. 9/22/23 (Note: This was 7 days after the previous shower or bath.) w. 9/25/23 x. 9/29/23 y. 10/2/23 z. 10/4/23 aa. 10/6/23 ab. 10/9/23 ac. 10/13/23 ad. 10/23/23 (Note: This was 10 days after the previous shower or bath.) ae. 10/25/23 af. 10/27/23 ag.11/1/23 ah. 11/6/23 ai. 11/8/23 aj. 11/15/23 (Note: This was 7 days after the previous shower or bath.) ak. 11/27/23 (Note: This was 12 days after the previous shower or bath.) al. 12/4/23 (Note: This was 7 days after the previous shower or bath.) am. 12/13/23 (Note: This was 9 days after the previous shower or bath.) an. 12/15/23 ao. 12/29/23 (Note: This was 14 days after the previous shower or bath.) ap. 1/5/24 (Note: This was 7 days after the previous shower or bath.) aq. 1/10/24 ar. 1/12/24 as. 1/19/24 (Note: This was 7 days after the previous shower or bath.) at. 1/24/24 au.1/25/24 av. 1/29/24 aw. 2/5/24 (Note: This was 7 days after the previous shower or bath.) ax. 2/9/24 ay. 2/14/24 az. 2/16/24 ba. 2/26/24 bb. 2/29/24 bc. 3/8/24 (Note: This was 7 days after the previous shower or bath.) bd. 3/11/24 be. 3/15/24 bf. 3/20/24 bg. 3/22/24 bh. 3/27/24 bi. 4/1/24 bj. 4/7/24 (Note: This was 6 days after the previous shower or bath.) bk. 4/8/24 [Note: According to the shower schedule, resident 60 should have also received showers or baths on 7/19/23, 7/21/23, 7/31/23, 8/2/23, 8/7/23, 8/11/23, 8/16/23, 8/21/23, 9/6/23, 9/11/23, 9/13/23, 9/18/23, 9/20/23, 9/27/23, 10/11/23, 10/16/23, 10/18/23, 10/20/23, 11/3/23, 11/13/23, 11/17/23, 11/20/23, 11/22/23, 11/24/23, 11/29/23, 12/1/23, 12/6/23, 12/8/23, 12/11/23, 12/13/23, 12/15/23, 12/18/23, 12/20/23, 12/22/23, 12/25/23, 12/27/23, 1/1/24, 1/3/24, 1/8/24, 1/17/24, 1/22/24, 1/26/24, 1/31/24, 2/2/24, 2/7/24, 2/12/24, 2/19/24, 2/21/24, 2/23/24, 3/1/24, 3/4/24, 3/6/24, 3/13/24, 3/18/24, 3/25/24, 3/29/24, 4/3/24, and 4/5/24 ] Resident 60's medical record indicated that only four shower refusal forms had been completed during this time frame, and they were signed on 10/30/23, 11/10/23, 12/30/23, 1/15/24. On 4/8/24 at 2:48 PM, an interview was conducted with Resident 60. Resident 60 stated that she feels like she never gets her showers. Her most recent shower had been a bed bath the previous day, but prior to that she had not had a shower for over a week. Resident 60 stated that staff will tell her they will complete her shower, but then never follow through with their promises. Resident 60 stated that she requires staff assistance to use the restroom. On 4/16/24 at 1:16 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that when a resident refuses a shower, a refusal sheet needs to be completed. CNA 1 stated that the completed refusal sheet is supposed to be given to the nurse on duty for the shift. CNA 1 stated that if a resident says that they do not want a shower when prompted, then the CNA should ask again later during their rounds. CNA 1 stated that showers are documented on paper or in the electronic medical record. CNA 1 stated that Resident 60 requires limited 1 person assistance when she showers and that typically one staff member will help Resident 60 shower. On 4/16/24 1:18 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that each time a resident refuses a shower a refusal sheet should be filled out. RN 2 stated that the nurse on duty is required to sign the shower refusal sheet. RN 2 stated that if a CNA tells her that a resident is refusing a shower, she is required to go investigate why the resident is refusing the shower and see if she can convince the resident to shower. RN 2 stated that after she signs a shower refusal sheet, she gives the refusal sheet back to the CNA. RN 2 stated that the CNA either puts the refusal sheet under the CNA coordinator's office door or gives it directly to the CNA coordinator. On 4/16/24 1:57 PM, an interview was conducted with the Certified Nursing Assistant Coordinator (CNAC). The CNAC stated that refusal sheets on the long term care side of the building are turned into him and that refusal sheets on the rehabilitation side of the building are turned in directly to the Director of Nursing (DON). The CNAC stated that shower refusals should be documented in the electronic charting. The CNAC stated that before a refusal sheet is completed, a CNA should try at least 3 times to get a resident to shower. The CNAC stated that the nurse needs to be notified that a resident has refused a shower and that the nurse should attempt to get the resident to shower before signing the refusal sheet. The CNAC stated that all shower sheets eventually make it the DON. On 4/16/24 at 2:02 PM, an interview was conducted with the DON. The DON stated that shower refusal sheets should be uploaded to the resident's medical record and a progress note should be entered stating that the resident refused a shower. The DON stated that if there are no refusal sheets uploaded to a resident ' s chart and if there are no progress notes documenting a shower refusal, then there is no proof the shower refusal occurred. The DON was unable to find any refusal sheets or progress notes in Resident 60's medical record. 2. Resident 3 was admitted to the facility on [DATE] with diagnosis which included fracture of the left femur, morbid obesity, abnormalities of gait and mobility, weakness, and pain. On 4/16/24 at 1:34 PM, an interview was conducted with resident 3. Resident 3 stated that she was not getting bed baths as often as she would like. Resident 3 stated she felt that she had gone a week without a bed bath. Resident 3's admission MDS dated [DATE] indicated that resident 3 was dependent on staff for showering/bathing. Resident 3's care plan did not reference the resident's need for assistance with showering/bathing. Resident 3's orders included showers Monday, Wednesday, Friday. A review of resident 3's showers documented in the electronic medical record revealed that from 3/1/24 to 3/30/24, resident 3 received showers on the following dates: a. 3/11/24 Complete bed bath b. 3/26/24 Partial bed bath c. 3/28/24 Complete bed bath Resident 3's medical record indicated that no shower refusal forms had been completed during this time frame. On 4/16/24 at 1:55 PM, an interview was conducted with CNA 5. CNA 5 stated that resident 3 will normally get a bed bath and that the facility is responsible for her bed baths. CNA 5 stated that if resident 3's hospice company completes a bed bath they will let the staff know and the staff will document the bed bath was completed. CNA 5 stated that if a resident refuses a bed bath then it will be documented on a refusal sheet. Based on interview, record review, and observation, the facility did not ensure that for 3 of 55 sample residents, the appropriate treatment and services were provided to maintain or improve the residents' ability to carry out activities of daily living. Specifically, residents were not provided showers in a timely manner. Resident identifiers: 3, 46, and 60. Findings include: 1. Resident 46 was admitted to the facility on [DATE] with diagnoses that included right knee flail joint, morbid obesity, weakness, insomnia, schizoaffective disorder, depression, osteoarthritis, and chronic pain. On 4/8/24 at 3:16 PM, an interview was conducted with resident 46. When asked if he was receiving assistance with showers, resident 46 stated, a shower? What's that? and then laughed. Resident 46 stated that he was supposed to receive a shower with staff assistance on Mondays, Wednesdays, and Fridays. Resident 46 stated that he was only receiving showers once a week, and that he once went three weeks without a shower. Resident 46's medical record was reviewed from 4/8/24 through 4/17/24. Resident 46's admission Minimum Data Set (MDS) dated [DATE] indicated that resident 46 had impairment on both upper extremities, and was dependent on staff for showering/bathing. Resident 46's care plan did not reference the resident's need for assistance with showering/bathing. Review of resident 46's showers documented in the electronic medical record revealed that from admission to 4/15/24, resident 46 received showers on the following dates: a. 2/6/24 (Note: This was the 12th day of the resident's stay.) b. 2/14/24 (Note: This was 8 days after the previous shower). c. 2/16/24 d. 2/19/24 e. 2/26/24 (Note: This was a week after the previous shower). f. 3/1/24 g. 3/3/24 h. 3/5/34 i. 3/8/24 j. 3/13/24 k. 3/18/24 l. 3/22/24 m. 3/25/24 n. 3/29/24 o. 4/1/24 p. 4/5/24 q. 4/8/24 r. 4/10/24 s. 4/12/24 t. 4/15/24 [Note: According to the schedule, resident 46 should have also received showers on 2/28/24, 3/11/24, 3/15/24, 3/20/24, 3/27/24, and 4/3/24.] Resident 46's medical record indicated that only one shower refusal form had been completed during this time frame, and was signed on 2/25/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident 34 was admitted [DATE] with diagnoses including other lack of coordination, chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease unspecified, morbid (severe) obesity due to excess calories, other abnormalities of gait and mobility, muscle weakness (generalized) and major depressive disorder recurrent unspecified. Resident 34's medical record was reviewed from 48/24 through 4/17/24. Resident 34's most recent Brief Interview for Mental Status (BIMS) Score from his most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] was a 15, indicating no cognitive impairment. According to this same MDS, Resident 34 was completely dependent on staff to complete baths or showers. According to the MDS, Resident does none of the effort to complete the activity. Resident 34's shower schedule was reviewed. Resident 34 was scheduled to have showers on Tuesdays, Thursdays, and Saturdays. Review of Resident 34's showers documented in the electronic medical record revealed that from 1/1/24 to 4/17/24, Resident 34 received showers on the following dates: a. 1/4/24 b. 1/13/24 (Note: This was 9 days after the previous shower or bath). c. 1/20/24 (Note: This was 7 days after the previous shower or bath.) d. 1/27/24 (Note: This was 7 days after the previous shower or bath.) e. 1/30/24 f. 2/3/24 g. 2/17/24 (Note: This was 14 days after the previous shower or bath.) h. 2/24/24 (Note: This was 7 days after the previous shower or bath.) i. 2/27/24 j. 3/1/24 k. 3/5/24 l. 3/7/24 m. 3/8/24 n. 3/12/24 o. 3/22/24 (Note: This was 10 days after the previous shower or bath.) p. 3/25/24 q. 3/29/24 r. 4/11/24 (Note: This was 13 days after the previous shower or bath.) s. 4/12/24 t. 4/13/24 [Note: According to the schedule, resident 34 should have also received showers or baths on 1/2/24, 1/9/24, 1/11/24, 1/16/24, 1/18/24, 1/23/24, 1/25/24, 2/1/24, 2/6/24, 2/8/24, 2/10/24, 2/13/24, 2/15/24, 2/20/24, 2/22/24, 2/29/24, 3/14/24, 3/16/24, 3/19/24, 3/21/24, 3/26/24, 3/28/24, 3/30/24, 4/2/24, 4/4/24, 4/6/24, and 4/9/24. ] There were no shower refusals documented in Resident 34's progress notes for this time period nor were there any shower refusal sheets for this time period uploaded into Resident 34's electronic medical record. On 4/16/24 at 1:43 PM, Resident 34 was overheard complaining to the Certified Nursing Assistant Coordinator about not receiving a shower since the week prior. On 4/16/24 at 1:48 PM, Resident 34 was overheard complaining to the Director of Nursing about his showers. Resident 34 stated the aides at the facility will tell him they are coming right back to complete his shower and that they often do not return for two hours after saying this. On 4/16/24 at 1:16 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that when a resident refuses a shower, a refusal sheet needs to be completed. CNA 1 stated that the completed refusal sheet is supposed to be given to the nurse on duty for the shift. CNA 1 stated that if a resident says that they do not want a shower when prompted, then the CNA should ask again later during their rounds. CNA 1 stated that showers are documented on paper or in the electronic medical record. On 4/16/24 1:18 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that each time a resident refuses a shower a refusal sheet should be filled out. RN 2 stated that the nurse on duty is required to sign the shower refusal sheet. RN 2 stated that if a CNA tells her that a resident is refusing a shower, she is required to go investigate why the resident is refusing the shower and see if she can convince the resident to shower. RN 2 stated that after she signs a shower refusal sheet, she gives the refusal sheet back to the CNA. RN 2 stated that the CNA either puts the refusal sheet under the CNA coordinator's office door or gives it directly to the CNA coordinator. On 4/16/24 1:57 PM, an interview was conducted with the Certified Nursing Assistant Coordinator (CNAC). The CNAC stated that refusal sheets on the long term care side of the building are turned into him and that refusal sheets on the rehabilitation side of the building are turned in directly to the Director of Nursing (DON). The CNAC stated that shower refusals should be documented in the electronic charting. The CNAC stated that before a refusal sheet is completed, a CNA should try at least 3 times to get a resident to shower. The CNAC stated that the nurse needs to be notified that a resident has refused a shower and that the nurse should attempt to get the resident to shower before signing the refusal sheet. The CNAC stated that all shower sheets eventually make it the DON. The CNAC stated that activity did not occur in the electronic medical record does not count as a shower refusal. On 4/16/24 at 2:02 PM, an interview was conducted with the DON. The DON stated that shower refusal sheets should be uploaded to the resident's medical record and a progress note should be entered stating that the resident refused a shower. The DON stated that if there are no refusal sheets uploaded to a resident's chart and if there are no progress notes documenting a shower refusal, then there is no proof the shower refusal occurred. 3. Resident 82 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia, personal history of traumatic brain injury, zoster encephalitis, and adjustment disorder with mixed anxiety and depressed mood. An admission Minimum Data Set (MDS) dated [DATE] documented, resident 82 was Dependent- Helper does ALL of the effort. Resident does none of the effort to complete the activity. for oral hygiene, Toileting, shower/bathe, dressing, and mobility. Resident 82's care plan did not reference the resident's need for assistance with showering/bathing. Resident 82's medical records were reviewed from 4/8/24 through 4/17/24. The following dates were charted for resident 82's showers: a. 2/1/24 Total dependence b. 2/2/24 Activity did not occur c. 2/5/24 Total dependence d. 2/7/24 (unanswered) e. 2/9/24 Activity did not occur f. 2/12/24 Activity did not occur g. 2/14/24 Activity did not occur h. 2/16/24 Activity did not occur i. 2/19/24 (unanswered) j. 2/20/24 Total dependence k. 2/22/24 Total dependence l. 2/24/24 Total dependence m. 2/26/24 Activity did not occur n. 2/29/24 Total dependence On 2/14/24 at 11:17 PM, a nursing progress note documented, resident noted with dried spit to face. wet cloth given and resident attempted to wash own face. resident then clearly stated shower. shower bed obtained, attempted to wash self as staff completed cares. resident was already asleep by the time placed back in bed. resident allowed RT[Respiratory Therapist] to place trach back in and trach cares performed. no s/s[signs/symptoms] of distress. medications tolerated well. [It should be noted resident 82 had a shower documented on 2/5/24 then a progress note documented a shower on 2/14/24 a 9 day gap between showers. The next shower documented on 2/20/24, a 6 day gap between showers.] On 2/15/24 at 4:35 AM, a respiratory note documented, Resident appears stable at this time .Resident can't use the call light; several checks are done throughout shift .Resident requested shower; this RT [Respiratory Therapist] at standby for shower [It should be noted resident 82 requested a shower, but there is no documentation of a shower being completed until 5 days after this request.] On 4/16/24 at 1:57 PM, an interview was conducted with Certified Nursing Assistant Coordinator (CNAC). CNAC stated that showers are a hot topic in every CNA meeting and that they need to get done. He stated that when a resident shower is documented as 'activity did not occur', it does not count as a refusal. CNAC stated that some CNAs thought 'activity did not occur' is a refusal but it was not. On 4/16/24 at 3:20 PM, an interview was conducted with CNA 6. CNA 6 stated that dependant nonverbal residents were not able to refuse, unless the resident seemed agitated or anxious, but the residents would still get a bed bath with just a wipe. CNA 6 stated that if a resident was wiped down it would be charted as a partial bed bath. CNA 6 stated that the importance of the dependant nonverbal residents receiving showers were important because they often are not mobile and more prone to infections. She stated that the showers would help the residents feel like a person and are beneficial to prevent infections, skin break down and bed sores. On 4/16/24 at 3:33 PM, an interview was conducted with the DON. The DON stated that there was not a good reason for a dependent nonverbal resident to miss a scheduled shower day, unless the resident was combative then that would count as a refusal. The DON stated that the dependant nonverbal residents should get their scheduled showers because the resident could get sweaty and build up bodily oils and the showers help with checking the skin for changes or sores. Based on interview and record review, for 4 of 55 sampled residents, the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal and oral hygiene. Specifically, residents requiring assistance with bathing were not provided regular showers or bed baths. Resident identifiers: 2, 34, 82, and 259. Findings include: 1. Resident 2 was admitted to the facility on [DATE] with diagnoses that included orthopedic aftercare following surgical amputation, cellulitis of lower limb, chronic non-pressure ulcer of foot, urinary incontinence, hemiplegia and hemiparesis on left non-dominant side, dysphagia, and abnormal gait and mobility. Resident 2's medical records were reviewed between 4/8/24 and 4/17/24. A review of resident 2's Minimum Data Set (MDS) admission assessment dated [DATE] revealed that it was very important for resident 2 to choose between a tub bath, shower, bed bath or sponge bath. The MDS also revealed that resident 2 was dependent for bathing activities. For the 7 day look-back period, it was documented that the activity had not occurred due to medical conditions and safety concerns. Physician orders dated 3/5/24 revealed resident 2's shower days to be Sundays, Mondays and Thursdays. Resident 2's care plan did not reference the need for assistance with bathing/showering. A review of resident 2's POC [point of care] bathing/showering documentation revealed: a. 3/7/24; Thursday, Physical help in part of bathing/1 person physical assist/shower. b. 3/11/24; Monday, 1 person assistance/total dependence/complete bed bath. c. 3/25/24; Monday, 1 person assistance/total dependence/complete bed bath. [Note: this was a lapse of 14 days since the previous shower.] d. 3/28/24; Thursday, 1 person assistance/physical help in part of bathing/shower. e. 4/1/24; Monday, 1 person assistance/total dependence/shower. f. 4/4/24; Monday, 2 person physical assistance/help limited to transfer/shower. 2. Resident 259 was admitted to the facility initially on 3/13/24, and re-admitted on [DATE] with diagnoses that included cellulitis of the right leg, encephalopathy, chronic respiratory failure with hypercapnia and hypoxia, heart failure, chronic obstructive pulmonary disease, bipolar disorder, anxiety disorder, and morbid obesity. On 4/9/24 at 11:41 AM, an interview was conducted with resident 259 who stated she had not had a shower in 2 weeks since before she was admitted to the hospital. Resident 259 stated she was itching all over. Resident 259's medical record was reviewed between 4/8/24 and 4/17/24. A review of resident 259's Minimum Data Set (MDS) admission assessment dated [DATE] revealed it was very important for resident 259 to choose between a tub bath, shower, bed bath or sponge bath. The MDS also revealed that resident 259 required substantial/maximal assistance transferring into the shower, and required supervision or touching assistance while in the shower. A physician order dated 4/4/24 revealed resident 259's shower days were Thursdays and Mondays between 6:00 AM and 6:00 PM. A review of resident 259's POC tasks revealed resident 259 received a shower: a. 3/17/24; 1 person physical assist/ physical help in part of bathing/shower. b. 3/28/24; 1 person physical assist/ physical help in part of bathing/shower. [Note: a lapse of 11 days since previous shower] c. 3/30/24; shower per progress note. d. 4/11/24; set up help only/tub bath. [Note: a lapse of 7 days since resident 259 was readmitted from the hospital] e. 4/13/24; physical help in part of bathing/shower. f. 4/15/24; Resident refused. [It should be noted that resident 259 was admitted to the hospital between 4/1/24 and 4/4/24.] On 4/10/24 at 9:45 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated she had not worked much with resident 259 or resident 2. CNA 1 stated that after a shower was given to a resident the shower sheet was given to the nurse to sign. CNA 1 stated the shower book at the nurses station had refusal sheets that the residents were required to sign if they refused a shower. CNA 1 stated she would check with the resident a couple of times before having them sign the shower sheet. CNA 1 stated on some days there was a float CNA that would be willing to help out with showers, but the CNA assigned to the hallway was responsible for making sure the residents received showers on their shower days. CNA 1 stated showers were documented in the resident's POC within the medical record. CNA 1 stated showers were usually given when the resident wanted to have one. CNA 1 stated she felt there was enough time to complete showering tasks during her shift. On 4/10/24 at 9:50 AM, an interview was conducted with Registered Nurse (RN) 2 who stated the CNA should be having the residents fill out a refusal form every time the resident refused a shower.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident 102 was admitted [DATE] with diagnoses including metabolic encephalopathy, sepsis unspecified organism, acute kidney failure unspecified, alcohol dependence with withdrawal unspecified, type 2 diabetes mellitus with diabetic neuropathy unspecified, essential (primary) hypertension, and cellulitis of left lower limb. Resident 102's medical record was reviewed from 4/8/24 through 4/17/24 Resident 102's progress notes indicated that although the resident had been seen by a Nurse Practitioner (NP) multiple times, the resident had not been seen by a physician since the resident's admission. It should be noted resident 102 had 19 documented nurse practitioner visits. 4. Resident 166 was initially admitted to the facility on [DATE] and readmit to the facility on 1/25/2024 and discharged from the facility on 2/15/24 with the diagnosis of Periprosthetic fracture around internal prosthetic right hip joint, subsequent encounter, Acute kidney failure, Neoplasm of unspecified behavior of bladder, Fall on same level from slipping, tripping and stumbling without subsequent striking against object, subsequent encounter, Human immunodeficiency virus [HIV] disease. Resident 166 medical records were reviewed on 4/15/24. Resident 166's progress notes were reviewed and there was no documentation to indicate resident 166 had been seen by the MD while a resident in the facility. It should be noted resident 166 had 22 documented nurse practitioner visits. 3. Resident 62 was admitted to the facility on [DATE] with diagnoses which included nontraumatic intracranial hemorrhage, tracheostomy status, hydrocephalus, and acute respiratory failure with hypoxia. Resident 62's medical records were reviewed from 4/8/24 through 4/17/24. On 4/3/24 at 10:25 PM, the provider progress notes documented that resident 62 was seen by the Medical Director (MD). It should be noted that the visit occurred 69 days after resident 62's admission to the facility. 2. Resident 19 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, type 2 diabetes mellitus, major depressive disorder, lack of coordination, abnormalities of gait and mobility, protein-calorie malnutrition, dysfunction of bladder, retention of urine, muscle weakness, glaucoma, essential hypertension, anxiety disorder, bipolar disorder, hyperlipidemia, insomnia, dementia, long term use of aspirin, and chronic obstructive pulmonary disease. Resident 19's medical records were reviewed from 4/8/24 through 4/17/24. Progress notes revealed that resident 19 was seen by the MD on 4/24/23, 8/7/23, and 4/5/24. It should be noted that resident 19 went 9 months without seeing the MD from 8/7/23 to 4/5/24. 6. Resident 49 was admitted to the facility on [DATE] with diagnoses which included acute respiratory failure, pneumonia, type 2 diabetes mellitus, insomnia, hypertension, major depressive disorder, and dementia. On 4/8/24, resident 49's medical records were reviewed. On 4/16/24 at 8:40 AM, the provider progress notes documented that resident 49 was seen by the Medical Director (MD). It should be noted that the visit occurred 83 days after resident 49's admission to the facility. On 4/17/24 at 1:45 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the Administrator (ADM) and the medical records staff ensured that the residents were seen by the MD within the first 30 days after admission. On 4/17/24 at 1:49 PM, an interview was conducted with the ADM. The ADM stated that the process for scheduling physician visits was that upon admission the medical records staff scheduled the resident for the 30-day, 60-day, and 90-day visits. On 4/17/24 at 1:52 PM, an interview was conducted with the Medical Records Staff (MRS). The MRS stated that she entered the resident into the electronic medical record (EMR) when they were admitted , and then scheduled the residents for their physician visits. The MRS stated that she printed out a report to see who was last seen and when each resident was due for their next physician visit. The MRS stated that she checked the schedule monthly, reviewed the progress notes for any physician visits, and then updated the scheduler for any needed appointments. The MRS stated that they had a turnover and vacancy for the Medical Director (MD). The MRS stated that the previous medical director (PMD) last day at the facility was March 1, 2024, and the new MD started April 1, 2024. The MRS stated that the whole month of March 2024 there would not be any visits completed by a MD. Probably a lot of missed visits in there. The MRS stated that resident 49 was admitted to the facility on [DATE] and the PMD missed a scheduled visit on 2/23/24. The MRS stated that resident 46 was admitted to the facility on [DATE] and the PMD missed a scheduled visit on 2/25/24. The MRS stated that resident 19 was admitted to the facility on [DATE] and she was not able to view the scheduled MD visits that far back. The MRS stated that resident 19's progress notes documented provider visits as follows: on 1/20/23 a visit by the Doctor of Osteopathic Medicine (DO); on 1/30/23 PMD visit; on 2/6/23 a DO visit; and on 3/13/23 a DO visit. The MRS stated that resident 166 was admitted to the facility on [DATE] and the PMD missed scheduled visits on 1/30/24 and 2/24/24. The MRS stated that resident 62 was admitted to the facility on [DATE] and the physician (MD 1) missed the scheduled visit on 2/24/24. The MRS stated that MD 1 visited resident 62 on 4/3/24. The MRS stated that resident 102 was admitted to the facility on [DATE] and the PMD missed a scheduled visit on 2/23/24. Based on interview and record review, the facility did not ensure that for 6 of 55 sample residents, the residents were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter. Specifically, residents were being seen by an alternate provider such as a Nurse Practitioner, instead of a physician. Resident identifiers: 19, 46, 49, 62, 102, and 166. Findings include: 1. Resident 46 was admitted to the facility on [DATE] with diagnoses that included right knee flail joint, morbid obesity, weakness, insomnia, schizoaffective disorder, depression, osteoarthritis, and chronic pain. Resident 46's medical record was reviewed from 4/8/24 through 4/17/24. Resident 46's progress notes indicated that although the resident had been seen by a Nurse Practitioner (NP) multiple times, the resident had not been seen by a physician since the resident's admission nearly 3 months prior.

17. Cross refer to F550 18. Cross refer to F584 19. Cross refer to F676 20. Cross refer to F677 21. Cross refer to F689 RESIDENT/FAMILY INTERVIEWS 1. On 4/8/24 at 2:27 PM an interview with resident 19's family member was conducted. Resident 19's family member stated that resident 19 slipped outside on ice when at the facility, and the fall resulted in a broken hip. Resident 19's family member stated that he was unhappy that there was ice in areas where residents could walk. Resident 19's family member stated that he believed there was not enough staff in the facility to keep the residents safe. Resident 19's family member stated that resident 19 had developed a sore on her toe that went unnoticed for so long that it required surgery, and he believed that the sore went unnoticed due to low staffing. 2. On 4/9/24 at 9:18 AM, an interview was conducted with resident 259. Resident 259 stated that the facility did not have enough staff and that during the evening it gets worse. 3. On 4/8/24 at 11:38 AM, an interview was conducted with resident 26. Resident 26 stated that he has had to wait up to 45 minutes for his call light to be answered. 4. On 4/8/24 at 12:00 PM, an interview was conducted with resident 99. Resident 99 stated that he has had to wait 30 to 45 minutes for his call light to be answered. Resident 99 also stated there were big differences between night and day with staffing Resident 99 stated that at night, his medications were late, sometimes as late as 2 hours. 5. On 4/8/24 at 3:25 PM, an interview was conducted with resident 37. Resident 37 stated that at nighttime especially, there was not enough staff. Resident 37 stated there were only 1 to 2 staff at night, which was not enough for the 100, 200, and 400 halls. 6. On 4/8/24 at 12:11 PM, an interview was conducted with resident 60. Resident 60 stated, it would be nice if someone came when I turn on my call light. Resident 60 stated she often waited an hour for her call light to be answered. Resident 60 stated she had not had any staff enter her room since earlier that morning, and that staff did not check on residents unless residents pushed their call light. Resident 60 stated that there was not enough staff, especially on weekends. Resident 60 stated she was not receiving her showers as scheduled. Resident 60 stated that she fell once while waiting for staff to help her. [Cross refer to F676 and 689] 7. On 4/8/24 at 1:41 PM, an interview was conducted with resident 98. Resident 98 stated that she waited at least 40 minutes for her call light to be answered, and that there were not enough staff on any shift. 8. On 4/8/24 at 10:39 AM, an interview was conducted with resident 23. Resident 23 stated that sometimes there was only 1 CNA on shift, which is kind of frustrating, I've waited 4 hours one time. 9. On 4/9/24 at 11:35 AM, an interview was conducted with resident 309. Resident 309 stated that there was not enough staff, and that she often sat in a soiled brief for a long time especially at night. Resident 309 stated that she had recently been diagnosed with a urinary tract infection which she believed was from sitting in her feces for extended periods of time. Resident 309 also stated that her medications were late. 10. On 4/8/24 at 2:27 PM, an interview was conducted with resident 208. Resident 208 stated that she often has to yell out to get staff's attention. Resident 208 stated that when you are yelling for help they oughtta take two minutes and see what we are yelling about. Resident 208 also stated that her roommate has had to go to the nurses station in order to find help because the staff were not answering the resident's call light. Resident 208 stated that sometimes she got agitated but I wouldn't be so agitated if they would get my pain medicine quicker. 11. On 4/8/24 at 10:40 AM, an interview was conducted with resident 56. Resident 56 stated that at night he usually had to wait at least 30 minutes for his call light to be answered. 12. On 4/8/24 at 3:16 PM, an interview was conducted with resident 46. Resident 46 stated that the facility did not have enough staff. When asked for further clarification, the resident stated that he was waiting for one to two hours for his call lights to be answered. Resident 46 stated that even if his call light was answered promptly, the staff would turn off the light, and say they would be right back, but never returned. STAFF INTERVIEWS 13. On 4/16/24 at 2:58 PM an interview with CNA 9 was conducted. CNA 9 stated she previously worked at the facility. CNA 9 stated that the facility was always understaffed. CNA 9 stated that management did not think that the facility was understaffed, but CNA's were unable to get all of their work done CNA 9 stated that she used to work on the weekends. CNA 9 stated that she would notice that resident bed sores were getting worse each weekend that she worked, and CNA 9 believed it was due to low staffing and CNA's not having time to change resident's briefs or reposition residents. CNA 9 stated that she quit working at the facility because she did not agree with the work environment. 14. On 4/11/24 at 8:05 AM, a telephone interview was conducted with Certified Nurse Assistant (CNA) 4. CNA 4 stated that she stopped picking up shifts at the facility because administration would not listen to her. CNA 4 stated that the facility was very busy, short staffed, and residents were not getting the care that they needed or deserved. CNA 4 stated that on one occasion a licensed nurse asked for her assistance with a dressing change and during this time the dietary manager yelled at her for not answering call lights. CNA 4 stated that she was unavailable to answer the call lights because she was in the middle of assisting the nurse. CNA 4 stated that there were times that they were unable to complete resident showers because they were short staffed. CNA 4 stated she was told to put off resident showers and do other things like pass meal trays instead. 15. On 4/11/24 at 1:25 PM, a telephone interview was conducted with CNA 3. CNA 3 stated she was no longer employed at the facility. CNA 3 stated, I can't do it and reported that the facility overworked her. CNA 3 stated that the facility administration was not listening to what she had to say. CNA 3 stated that she was assigned to areas with residents that were 500 pounds and she would have to roll that resident by herself. CNA 3 stated that it was hard, she voiced this to management and asked for more training. CNA 3 stated that every once in awhile she was able to get some tasks completed. 16. On 4/17/24 at 9:49 AM, an interview was conducted with CNA 2. CNA 2 stated that she worked for an agency company and had worked several shifts at the facility. CNA 2 stated that sometimes when the facility was understaffed it was hard to complete tasks. CNA 2 stated that it took longer to answer call lights and residents could wait up to 30 minutes for help, especially if they were feeding someone or showering a resident. On 4/17/24 at 3:25 PM an interview with the Director of Nursing (DON) was conducted. The DON stated that she was responsible for the nurses schedule as of recently. The DON stated that the Certified Nursing Assistant Coordinator (CNAC) was responsible for the Certified Nursing Assistant (CNA) schedule. The DON stated that it was standard for the nurses to be staffed one nurse per hallway. The DON stated that the number of nurses did not change much, but the number of CNA's on staff was based on census. The DON stated that sometimes schedulers would take into account the level of cares required for the residents. The DON stated that the average ratio is 1 CNA per 9 residents. The DON stated that the max ratio was 1 CNA per 14 residents, however it was rare that the facility was staffed at the max ratio. On 4/17/24 at 3:28 PM an interview with the CNAC was conducted stated that if the facility was staffed at the max ratio, management would step in and help the CNA's. The CNAC stated that at night, the ratio was 1 CNA per 15 residents on average. The CNAC stated that he believed that if there was enough staff to complete all the required work of the staff managed their time appropriately. The CNAC stated that CNA's had monthly meetings along with all staff meetings where education was provided. The CNAC stated that the CNA's exceeded 12 hours of continuous education per year. The CNAC stated that examples of education given was dementia care, effective communication, specific resident needs, and infection control. Based on interview, observation and record review, the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, multiple residents and staff voiced concern about the staffing level, showers were not provided as scheduled, call lights were not answered timely, and the environment was observed to be soiled. Resident identifiers: 19, 23, 26, 37, 46, 56, 60, 98, 99, 208, 259, and 309. Findings include:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined that the facility did not ensure that all drugs and biological's were labeled in accordance with currently accepted professional principles, were stored under proper temperature controls, and included the expiration date when applicable. Specifically, a resident had insulin pens at bedside with out storage to prevent access to the insulin by other residents. Medication was left at the bedside of a resident who was not assessed for self administration of medication. A multi use vials of medications were opened and available for use date indicated medications were expired and still available for use. The medication fridge indicated temperatures too cold for safe medication storage. Resident identifiers: 15, 21, and 92. Findings included: 1. Resident 21 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus with diabetic polyneuropathy, chronic venous hypertension, acquired absence of right leg below knee. On 4/08/24 at 10:30 AM, an observation was made of resident 21. Resident 21 had 3 insulin injecting pens on his bedside table. An interview was conducted with resident 21. Resident 21 stated that he has had diabetes since 2009 and was able to take care of his own insulin injections. He stated that the nursing staff would check his blood sugar and tell him what the reading was, then he would inject his own insulin. Resident 21 stated that he often keeps the insulin pens on his bedside table. Resident 21's medical record was reviewed from 4/8/24 through 4/17/24. A physicians order dated 1/8/24, documented, May leave medications/insulins @ bedside. Pt may self administer insulin injections A document titled Self-Administration of Medication, revealed in the STORAGE OF MEDICATION section, Where will self-administered medications be stored? . Nursing Medication Cart was marked. The PLAN OF CARE was described as nurses to set-up meds [medications] & deliver to pt [patient] at each med pass. On 4/9/24 at 9:32 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that if a resident wanted to self administer insulin the nurses would need to make sure that they resident could do it correctly. RN 1 stated that there were residents that were confused or depressed, if they would found the insulin at the bedside it could be problematic to leave it at bedside, the residents could give themselves a dose of insulin and die. On 4/9/24 9:43 AM , an interview was conducted with RN 5. RN 5 stated that for a resident to be able to administer medications on their own the resident must complete a self administration assessment. RN 5 stated that the assessment would be located in the residents chart. RN 5 stated that for resident 21 the nursing staff would check his blood sugar and take his insulin pens to the room, and that the nurses would place the correct does on the pen and would confirm the amount with resident 21. RN 5 stated that resident 21 would then take the insulin pen and was able to administer his own insulin, then the nurses would take the insulin pens and place them back in the medication cart until the next blood sugar check was due. On 4/9/24 at 9:51 AM, an interview was conducted with Resident 21. Resident 21 stated that the nurses could leave the insulin in his room. He stated that he would only administer insulin after his blood sugar had been checked by a nurse Resident 21 stated that the insulin pens have a removable safety needle for administration then he kept on his bedside table, and the needles were able to twist off of the insulin pen and are discard after use. Resident 21 stated that the nurses would bring him his insulin pens in the morning and place them on his bedside table and would leave the insulin in his room for the rest of the day. On 4/15/24 at 11:47 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that if a resident can self administer insulin, the expectation of the nursing staff is that insulin pens should be kept in the nurses medication cart. She stated that when the nurses check the resident blood sugar the nurse would prepare the insulin pen and then give the insulin to the resident to administer it. The DON stated that the removable needles should not be stored at the residents bedside. The DON stated that the nurses are expected to take the medication to the resident and should watch the resident administer the insulin. The DON stated that resident 21 is very particular about his insulin and was not sure if he had worked out something with the provider about keeping the insulin at the bedside, she stated that if he could keep them at the bedside it should be documented on how to store safely store the medication, to have storage so other residents don't have access to them. The DON stated that the concern with having insulin and insulin needles at the bedside is that residents could access them, she stated that if someone used insulin that was not diabetic could lower there blood sugar and could possibly cause death. 2. Resident 92 was admitted to the facility on [DATE] with diagnoses which consisted of osteoarthritis, schizoaffective disorder, depression, anxiety disorder, hypertension, and chronic obstructive pulmonary disease. On 4/08/24 at 1:55 PM, an interview was conducted with resident 92. Resident 92 reported that she had diarrhea last night. Resident 92 stated that the nurse gave her a pill for her diarrhea and then pointed to a medication cup located on the bedside table. A medication pill was observed inside the cup. On 4/8/24, resident 92's medical records were reviewed. On 3/28/24 at 1:18 PM, resident 92's self-administration of medication assessment documented that the resident did not want to self-administer medications. No documentation could be found that the resident was assessed to be safe to self-administer medications. 3. Resident 15 was admitted to the facility on [DATE] with diagnoses which consisted of schizophrenia, hypothyroidism, laceration of head, chronic kidney disease, anxiety disorder, and fracture of skull and facial bones. On 4/8/24, resident 15's medical records were reviewed. On 10/2/23, a Montreal Cognitive Assessment (MOCA) score was 7/30 which would indicate that the resident was severely cognitively impaired. On 10/26/23 at 2:47 PM, resident 15's self-administration of medication assessment documented that the resident did not want to self-administer medications. No documentation could be found that the resident was assessed to be safe to self-administer medications. On 4/10/24 at 7:47 AM, an observation was made of Registered Nurse (RN) 1 administering medications to resident 15. RN 1 dispensed a Vitamin D3 2000 units tablet, a multivitamin tablet, and a fludrocortisone 0.1 milligram tablet into a medication cup. RN 1 delivered the medication to resident 15 and left the medication on the bedside table. On 4/10/24 at 7:53 AM, an interview was conducted with RN 1. RN 1 stated he was not going to check the medications off in the Medication Administration Record (MAR) until he verified that they had been taken. RN 1 stated that he did not have a physician order that stated that medications could be left at the resident bedside for self-administration. 4. On 4/10/24 at 7:05 AM, the medication cart on the front of the 100 hallway was inspected. A multidose Lispro insulin vial for resident 105 was observed open and dated 3/10/24. An immediate interview was conducted with RN 3. RN 3 stated that he thought the insulin was good for 28 days once opened. On 4/10/24 at 8:43 AM, the medication cart on the 400 hallway was inspected. A multidose vial of Insulin Aspart for resident 63 was observed open and dated 3/11/24. An immediate interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that the medication expired yesterday and confirmed it was still available for use. LPN 2 stated that she would give the vial to her manager, verify that it was expired and then have them discard it. 5. On 4/10/24 at 9:10 AM, the medication room for the 500 and 600 hallway was inspected. Initial inspection of the medication fridge revealed that the thermometer was reading a temperature of 16 degrees. The fridge was immediately closed, and RN 4 was asked to verify the temperature. RN 4 stated that the temperature was 20 degrees. RN 4 stated that the temperature was too cold and not safe to store medications. RN 4 stated that she was going to adjust the temperature a bit. RN 4 stated that she would contact the pharmacy to determine the safe temperature range for the medications that were stored inside the fridge. Review of the temperature log dated 4/10/24 documented the temperature as 34 degrees. Inventory of medications located inside the fridge were: a. Ceftriaxone 2 grams/50 milliliters, 3 bags for resident 163. b. Ceftriaxone 2 grams/50 milliliters, 8 bags for resident 360. c. Insulin Degludec injection, 3 pens. d. Humalog Lispro insulin multidose vial, 10 vials. e. Lantus Solostar pen, 2 auto inject pens for resident 62. f. Lantus Solostar pen, 5 auto inject pens for resident 24. g. Lispro insulin multi dose vial for resident 24. h. Victoza injection, 1 pen. i. Toujeo Max Solostar, 2 pens for resident 21. j. Humalog Insulin pen, 5 pens for resident 21. k. Insulin Aspart Flex pen- 4 pens for resident 31 l. Humalog Kwikpen, 1 pen for resident 31. m. Levemir Flex pen, 1 pen for resident 31. n. Humalog multidose vial for resident 43. o. Insulin Glargine pen for resident 43. p. Insulin Lispro Kwikpen, 4 pens for resident 79. q. Insulin Glargine pen for resident 79. r. Novolog Flex Pen RN 4 immediately contacted the pharmacy by telephone. The pharmacist informed RN 4 that they would have to replace all the insulin pens because they could not determine if they were frozen without opening the pen. The pharmacist stated that they could leave the multidose vials of insulin out of the fridge if they could verify that it was not frozen. RN 4 stated that the intravenous antibiotics were still good as long as they could visualize that they were not frozen. On 4/15/24 at 11:48 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that her expectation for licensed nurses (LN) was that they were present when a resident was administering the medication on their own. The DON stated that medications should be stored in the medication cart and the LN could give them to the resident to self-administer. The DON stated that it was the same process for insulin administration. The DON stated that the LN should prepare the insulin, give it to the resident to self-administer, and then take the used syringe and vial back. The DON stated that the expectation was that the insulin was not kept at the resident bedside, and supplies such as needles would not be at the bedside. The DON stated that the assessment for the resident to self-administer medication consisted of an observation of self-administration; verifying that the resident can say what the medication was, the dosage, and when and how it should be taken. The DON stated that once the resident could demonstrate these tasks they could self-administer medications with the physician's approval. The DON stated that she would expect to see this assessment completed for any resident who had medications left at the bedside. The DON stated that if the assessment was not completed, then medication should not be left at the bedside. The DON stated that the LN should observe that the medication was self-administered and not leave them at the bedside. Some residents can say all of those things and prefer to have it left at the bedside and could take it at lunch. The DON stated that resident 92's self-administration assessment documented no to self-administer, and everything else on the assessment grayed out and the observation was done. The DON stated that for resident 92 this meant that no medication should be left at the resident's bedside. The DON stated that RN 4 informed her of the observation of the medication fridge temperature. The DON stated that all the medications were taken out, and what needed to be destroyed was destroyed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food safety. Specifically, the facility did not label or date multiple food items in the walk-in fridge and refrigerator, there were physical food contamination hazards present in the kitchen, and kitchen staff did not prepare and serve food in a hygienic manner. Findings Include: On 4/8/24 at 8:54 AM, an observation was made of one of the facility's freezers. Inside was an undated tub of ice cream, a box of open undated Udi buns, undated pie crusts, a package of undated [NAME] Spunkmeyer cookie dough, a bag of undated whipped topping, 7 undated frozen pies, and 2 bags of undated frozen fruit. On 4/8/24 at 8:58 AM, an observation was made of a ceiling vent and the ceiling directly above a food preparation area. The vent was covered in dust and the ceiling paint was peeling and flaky. On 4/8/24 at 9:00 AM, an observation was made of the food dry storage. There were open, undated bags of breakfast cereal including Frosted Flakes, Cheerios, and Fruit Loops stored in a plastic tub. There was an open, undated box of spanish rice. On 4/8/24 at 9:03 AM, an observation was made of the walk in refrigerator. There was noted to be undated lemonade, apple juice, cranberry juice, chocolate milk, orange juice, fruit punch, grape juice, and 2% milk sitting in an ice bath on a cart. There was an undated bag of deli ham on one of the shelves. There was an entire undated, unlabelled whole ham stored on one of the shelves. There were undated cookies, undated carrot cups, and undated pear cups stored on a baking sheet. There was a bag of celery torn open with no dates. On 4/8/24 at 9:10 AM, an observation was made of the walk-in freezer. There was an undated frozen ham stored in the freezer. There were also undated frozen potatoes, an undated open box of beef patties, an undated open box of corn dogs, and an undated open bag of chicken drumsticks. On 4/9/24 at 1:24 PM an observation was made of the juice and beverage cart in the facility hallways. None of the juice carafes were dated. On 4/10/24 at 11:29 AM, an observation was made of the walk-in refrigerator. There was an undated carafe of purple liquid with the label Apple Juice written on it. There was no date on the carafe. There was a container of cream ranch dressing with the date 12/1/23 from the manufacturer on the lid. There was a bottle of chocolate syrup dated 2/23/24. There was a bottle of breakfast syrup dated 12/16/23. There was a bottle of prune juice with no date and a resident's name written on it. On 4/10/24 at 11:37 AM, an observation was made of the lunch tray line. [NAME] 1 was observed to scratch her hair and then touched the plate warmer and a cookie sheet used to hold prepared food. [NAME] 1 was observed leaning over the plate warmer to look at the menu for the day. [NAME] 1's visibly soiled sweatshirt came into contact with plates on the plate warmer. At 11:43 AM, [NAME] 1 touched her face and then touched a hotel pan containing corn dogs. At 11:50 AM, [NAME] 1's sweatshirt touched several of the plates on the tray line. At 11:54 Am, [NAME] 1's sweatshirt came into contact with plates on the plate warmer again. On 4/10/24 at 12:35 PM, an observation was made of [NAME] 2. [NAME] 2 dropped a food thermometer on the ground after taking the temperature of food in the oven. [NAME] 2 rinsed the thermometer under running water in a hand washing sink, and then put the thermometer back in its case without sanitizing it. On 4/10/24 at 12:39 PM, an interview was conducted with [NAME] 3. [NAME] 3 stated that staff used to use sanitizing wipes to sanitize food thermometers, but they ran out of the wipes and now staff sanitized thermometers by dipping them into a sanitizer solution. On 4/10/24 at 11:13 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that the walk-in fridge and freezer should both be checked daily to see if anything needs to be thrown away. The DM stated that items should only be stored in the refrigerator for three days. The DM stated that both the walk-in fridge and freezer are cleaned out every Monday and Thursday. The DM stated that items in the fridge should be labeled and dated with the use by date. The DM stated that a maintenance order had been submitted for the peeling paint on the ceiling above food preparation areas. The DM stated that the kitchen used bleach in the sanitizing solution used to clean the kitchen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 3 was admitted to the facility on [DATE] with diagnosis which included polyneuropathy, weakness, type 2 diabetes mellitus, and other abnormalities of gait and mobility. Resident 3's medical record was reviewed from 4/8/24 through 4/17/24. On 3/17/24 at 3:45 PM, a nursing progress note indicated that resident 3 had REOPENED WOUND TO SACRUM REPORTED TODAY, HOSPICE NURSE . NOTIFIED . CLEANSED WITH NS [normal saline] . On 3/17/24 a physicians order documented, WOUND CARE: Sacrum-clean wound with wound cleaner or normal saline. Skin prep peri-wound. Apply collagen AG to wound base and cover with bordered foam. Change 3X (times)/WEEK and as needed if soiled or dislodged . A document titled Long Term Weekly assessment dated [DATE], revealed a section titled Integumentary documenting skin integrity as No wound present. A document titled Weekly Skin Assessment documented No wound present. On 4/17/24 at 3:24 PM, an interview was conducted with Registered Nurse (RN) 4. RN 4 stated that a weekly skin check is completed on the residents and the resident has a new skin condition it will be documented in there. RN 4 stated that if a wound already existed then it would still be documented on the assess to indicated the resident still has a skin issue. On 4/17/24 at 3:35 PM, an interview was conducted with the Director or Nursing (DON). The DON stated that if a resident has a skin issue or wound it would be documented it the chart. The DON stated that it wouldn't always be documented in the skin assessment, and that it just depends on the nurse if they will chart it. The wound would be charted as a progress note or it would be on the TAR (Task Administration Record). 2. Resident 19 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, type 2 diabetes mellitus, major depressive disorder, lack of coordination, abnormalities of gait and mobility, protein-calorie malnutrition, dysfunction of bladder, retention of urine, muscle weakness, glaucoma, essential hypertension, anxiety disorder, bipolar disorder, hyperlipidemia, insomnia, dementia, long term use of aspirin, and chronic obstructive pulmonary disease. A documented titled Observation Detail List Report from 2/3/24 documented, No wound present in the Skin Integrity section. A documented titled Observation Detail List Report from 2/8/24 documented, No wound present in the Skin Integrity section. A Physician Assistant note from 2/9/24 at 5:55 AM was reviewed and the Physician Assistant did not address the pain in the right 1st and 2nd toe as reported by a nurse in the progress note from 1/23/24. A documented titled Observation Detail List Report from 2/15/24 documented, No wound present in the Skin Integrity section. A Physician Assistant note from 2/19/24 at 8:27 AM documented, Nurse concerned about her toe. Right great toe very red and sore, 2nd toe now with redness. [Resident 19] seems sore when this area is examined. Has had a referral for podiatry pending for several weeks. Replaced this. No fever. Some honey colored crusting noted. A Progress Note from 2/19/24 at 4:17 PM documented, Provider orders podiatry referral (transport notified); Keflex 500mg [milligram] Po [by mouth] QID [four times a day] x 7 days (medication administered now), Wound care daily with Bactroban (Wound care performed). Orders placed . 2nd toe appears to have integument alteration but is difficult to fully assess d/t [due to] pain and [resident 19]'s inability to provide any hx [history] . A Progress Note from 2/20/24 at 3:43 PM documented, Appt [appointment] with podiatry . Provider writes: Significant R>L food PAD w/ [with] R 2nd toe necrosis and rubor on dependency. URGENT: recommend arterial vascular studies to the BLE's [bilateral lower extremities] before any procedures/debridement. Provider orders refer to vascular consult . A Progress Note from 2/22/24 at 6:33 PM documented, 2nd toe is getting deeper coloration today. Otherwise s/s [signs and symptoms] are the same. Wound care performed with great difficulty but dressing in place a [sic] this time. A Progress Note from 2/26/24 at 11:05 AM documented, 2nd toe vascular appt scheduled 3/8. She is taking IM [intermuscular] Rocephin QD currently. RN [registered nurse] concerned about [resident 19]'s abilities, comfort, and desires. She may endure a lot of distress and an extended process of appointments, surgery, and wound care should her toe need to be amputated. [Resident 19] may be candidate to return to hospice. ADON [Assistant director of nursing]/provider/hospice notified . A Progress Note from 3/4/24 at 12:43 documented, Wound care performed, Deep purple area on plantar and mesial aspect of 2nd toe, and beneath the toenail of the hallux . A Progress Note from 3/7/24 at 6:01 PM documented, Pt [patient] saw vascular specialist today. Progress note from vascular physician stated: I attempted to call and speak with [resident 19]'s nurse, but no one would answer the phone. I am a previous provider for [resident 19] as I was a rounding nurse practitioner there at one time, so I am familiar with her past medical history. She has dementia, and is unable to give me info. I cannot feel good pulses in her bilateral feet unsure how long. Wound, but she expressed discomfort during evaluation and scans. Dx [diagnosis] PVD she is in need of bilateral angiogram for revascularization starting on the right side due to wounds her left lower extremity will follow a week later. A documented titled Observation Detail List Report from 3/7/24 documented, No wound present in the Skin Integrity section. Based on interview and record review, the facility did not ensure that for 3 of 55 sample residents, medical records were complete and accurately documented. Resident identifiers: 3, 19, and 46. Findings include: 1. Resident 46 was admitted to the facility on [DATE] with diagnoses that included right knee flail joint, morbid obesity, weakness, insomnia, schizoaffective disorder, depression, osteoarthritis, and chronic pain. Resident 46's medical record was reviewed from 4/8/24 through 4/17/24. Resident 46's progress notes indicated that on 2/25/24 a Psych (psychiatric) NP (Nurse Practitioner) eval (evaluation) done. per provider orders, discontinue seroquel, start ability 5mg (milligrams) QAM (every morning) x (for) 1 week then increase to 10 mg QAM. The psychiatric evaluation could not be located in resident 46's medical record. On 4/17/24 at 3:40 PM, an interview was conducted with the Director of Nursing (DON). The DON confirmed that the psychiatric evaluation completed for resident 46 on 2/25/24 was not in the resident's medical record.

On 4/17/24 at 3:27 PM an interview with the Administrator was conducted. The Administrator stated that the QAPI team met at least quarterly but tried to meet monthly if possible. The Administrator stated that the QAPI team consisted of the Administrator, the Medical Director, the Dietary Manager, the Director of Nursing, the Resident Advocate, Social Work, Nurse Management, and Therapy. The Administrator stated that every month, members of the QAPI team would bring information including quarterly measures, grievances, infection control updates, among other assignments that the staff go over and determine what areas needed to be improved. The Administrator stated that once an improvement process had begun, monitors were put in place and were checked as needed. The Administrator stated that if the improvement process was not working, then they would change the process and continue to monitor until the improvement process met satisfactory levels. The Administrator stated that a recent process that the QAPI team worked on was increasing the Physician visits for residents. Based on interview, record review, and observation, the facility did not establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. In addition, the facility did not develop and implement appropriate plans of action to correct identified quality deficiencies. Resident identifiers: 19, 20, 60, 80, 166, and 260. Findings include: 1. Based on interview and record review it was determined that for 1 of 55 residents that the facility did not ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must: Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and if necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments. Specifically, a staff member documented a problem with a resident's toe, and it was not addressed by a doctor for 27 days, at which point the toe had become necrotic and surgery was required. Resident identifier: 19. [Cross refer to F687] 2. Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained free of accident hazards as was possible and each resident received adequate supervision and assistance to prevent accidents. Specifically, for 6 of 55 sampled residents, a resident was left unsupervised with a damaged bedside table and the resident was observed pulling on the broken plastic with sharp edges, a resident fell outside while smoking resulting in femur fracture, a resident bed was not locked in place resulting in a fall with a finger injury, a resident was being assisted with a transfer by a family member outside, resulting in the resident falling and dislocating a shoulder, a resident sustained an unwitnessed fall and remained on the floor for an extended period of time, and a resident with a history of falling was observed to be on the floor for more than 30 minutes. These findings resulted in a citing of harm for three residents. Resident identifiers: 19, 20, 60, 80, 166, and 260. [Cross refer to F689] 3. During the previous recertification survey completed on 8/9/22, the facility was cited for F584, F677, F725, F761, F842, and F867, among others. During the current recertification survey, these deficiencies were cited again.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined, the facility did not ensure that each resident's medical record included documentation that indicated that the resident or resident's representative was provided education regarding the benefits and potential side effects of the influenza and pneumococcal immunizations; and that the resident either received the influenza and pneumococcal immunizations or did not receive the influenza and pneumococcal immunizations due to medical contraindications or refusal. Specifically, for 3 sampled residents, the facility did not keep documentation within the residents' medical record regarding the residents' pneumococcal consent status or education of the benefits and potential risks associated with the immunization. Resident identifiers: 3, 15, and 19. Findings Included: 1. Resident 3 was admitted to the facility on [DATE] with the following diagnoses of polyneuropathy, unspecified fracture of left femur, type 2 diabetes mellitus without complications, gastro-esophageal reflux disease without esophagitis, and anxiety disorder. Resident 3's medical record was reviewed on 4/17/24. A review of the immunization section of the medial record documented that on 10/5/23, resident 3 had received their pneumococcal vaccine outside of the nursing home. A consent/refusal or education regarding the pneumococcal immunization was not provided or located in resident 3's medical record to indicate it had been offered. 2. Resident 15 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses of undifferentiated schizophrenia, hypothyroidism, chronic kidney disease, unspecified protein-calorie malnutrition, and anxiety disorder. Resident 15's medical record was reviewed on 4/17/24. On 10/25/23, an immunization forecast revealed that resident 15 was due for their pneumococcal immunization on 8/1/10. A consent/refusal or education regarding the pneumococcal immunization was not provided or located in resident 15's medical record to indicate it had been offered. 3. Resident 19 was admitted to the facility on [DATE] with the following diagnoses of Alzheimer's disease, Type 2 diabetes mellitus without complications, Major depressive disorder, Neuromuscular dysfunction of bladder, Chronic obstructive pulmonary disease, Generalized anxiety disorder, and insomnia. Resident 19's medical record was reviewed on 4/17/24. The immunization record documented resident 19 had been administered the pneumococcal vaccine on 12/26/22 at the facility. A consent/refusal or education regarding the pneumococcal immunization was not provided or located in resident 19's medical record. On 4/17/24 at 1:59 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated when a resident was admitted to the facility, staff looked up their vaccination information in USIIS [Utah Statewide Immunization Information System] to see if the resident was up to date with their immunizations. The ADON stated resident records were updated when they received any immunization while in the facility. The ADON stated resident filled out forms to indicate if they accepted or denied the vaccine being offered to them. The ADON stated those forms were the consent forms and they were part of the acceptance or declination process for immunizations. The ADON stated if a resident had already received a vaccine elsewhere, then the resident was responsible for filling out a consent form declining the vaccine at the facility. The ADON stated if a resident declined a vaccine, it meant either the resident did not want it, or they have already received it. The ADON stated the pneumococcal vaccine was offered on a resident-by-resident basis and/ or upon request. The ADON they followed the CDC [center for disease control and prevention] guidelines on administering vaccines. On 4/17/24 at 2:41 PM, an interview was conducted with the Director of Nursing (DON). The DON stated resident consents forms for immunizations were in the resident medical record. The DON stated there was a process in place to get the immunization consents forms scanned into the resident's medical record. The DON stated the flu shot was offered from October to March and the pneumococcal vaccine was offered on admit. The DON stated they were working on improving their system with the covid and pneumococcal vaccines. The DON stated they were working on making sure residents were being offered their pneumococcal and covid when needed. The DON stated they were aware there were residents that had not been offered their pneumococcal vaccine for a while and were working on getting those residents up to date. The DON stated consent forms were done when residents were offered any kind of immunization, and it indicated if a resident wanted the vaccine or had refused it. The DON stated the main purpose of the consent form was to make sure resident consent was obtained prior to giving what was being offered to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility did not have adequate outside ventilation by means of windows, or mechanical ventilation, or a combination of the two. Specifically, there were numerous odors throughout the facility. Findings Include: On 4/8/24 at 10:30 AM an observation was made of the 200 hallway. There was a strong odor of bowel movement throughout the hallway. On 4/8/24 at 11:53 AM, an observation was made of the 300 hallway. There was a strong smell of urine throughout the entire hallway. On 4/10/24 at 8:22 AM, an observation was made of the 400 hallway. There was a strong odor of urine throughout the hallway. On 4/10/24 at 8:32 AM an observation was made in the 100 hallway. There was a strong odor of bowel movement throughout the entire hallway. On 4/10/24 at 8:42 AM, an observation was made of the 400 hallway. The strong odor of urine was still present. On 4/10/24 at 9:17 AM, an observation was made of the intersection between the 200 hall and the 300 hall. There was an odor of urine. On 4/10/24 at 2:30 PM, an observation was made of the hallway near room [ROOM NUMBER] and the soiled laundry entrance. There was an odor of garbage and feces. On 4/10/24 at 3:49 PM an observation was made in the 100 hallway. There was a strong odor of bowel movement throughout the entire hallway. On 4/16/24 at 1:05 PM, an observation was made of the hallway near room [ROOM NUMBER] and room [ROOM NUMBER]. There was an odor of urine. On 4/17/24 at 11:45 AM, an observation was made at the nurses station between the 300 and 400 hallways. There was a strong smell of feces. On 4/17/24 at 1:41 PM, an observation was made of the hallway near room [ROOM NUMBER] and room [ROOM NUMBER]. There were odors of urine and feces. On 4/17/24 at 1:42 PM, an observation was made of the nurse's station at the intersection of the 200 hall and 300 hall. There were odors of urine and feces. On 4/17/24 at 1:43 PM, an observation was made of the hallway outside rooms 107,109, 110, and 111. There were odors of feces and urine. On 4/17/24 at 1:50 PM, an observation was made of the 300 hall near room [ROOM NUMBER]. There was an odor of feces. On 4/17/24 at 1:51 PM, an observation was made of the hallway outside rooms 201, 202, 203, 204. 205, 207, and 208. There was an odor of urine. On 4/17/24 at 2:15 PM, an interview was conducted with Housekeeper (HK) 1. HK 1 stated that when housekeeping cleans, they use a natural odor freshener spray to remove odors. On 4/17/24 at 2:20 PM, an interview was conducted with HK 2. HK 2 stated that housekeeping staff use pine sol to clean the floor and remove odors and that housekeeping staff use a fresh bottle spray to manage odors throughout the building. On 4/17/24 at 2:23 PM, an interview was conducted with HK 3. HK 3 stated that housekeeping staff use Febreze and Pine Sol to remove odors throughout the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 of 10 sampled residents, that the facility did not immediately inform the resident, consult with the resident's physician when there was an accident, significant change or an alteration in treatment. Specifically, physician's were not notified when there were significant medication errors. Resident identifiers: 1 and 4. Findings include: 1. Resident 1 was admitted to the facility [DATE] and readmitted on [DATE] with diagnoses which included unspecified atrial fibrillation, unilateral primary osteoarthritis, abnormalities of gait and mobility, muscle weakness, pain in left hip, hypothyroidism, essential hypertension, systolic congestive heart failure, pain, insomnia, neuromuscular dysfunction of bladder, chronic obstructive pulmonary disease, gout, depression, obstructive sleep apnea, morbid obesity, and chronic respiratory failure. On [DATE] resident 1's medical record was reviewed. A Nursing Note dated [DATE] at 6:52 AM written by Licensed Practical Nurse (LPN) 1 stated, Resident complained of SOB (shortness of breath) around 0510 (5:10 AM). This nurse checked VS (vital signs) BP (blood pressure) = 74/62, P (Pulse) = 42, T (temperature) = 97.7, SpO2 (Oxygen saturation) = 95% on RA (room air), RR (respiratory rate) = 20, noted on the face, resident was swetting (sic), labored breathing and lethargic. Responsive to stimuli. Called the on call provider, no answer. Called 911, EMT (Emergency Medical Technicians) team arrived and transferred resident to [name redacted] hospital. Notified the family and notified the facility thru (sic) the on call nurse. A Nursing Note dated [DATE] at 7:59 AM was recorded as Late Entry on [DATE] 8:15AM written by Registered Nurse (RN) 1 stated, Last evening this nurse inadvertently administered verapamil ER (extended release) 180mg (milligrams) tablet along with residents scheduled medications (amiodarone and Eliquis) at 2100 (9:00 PM). Notified [name redacted], manager on call of [name of facility]. Monitored resident closely and she felt well during the night. Vital signs at 0000 (12:00 AM): BP 128/69, HR (heart rate) 82, RR = 18, O2 (Oxygen) 96% on 3 LMP (liters per minute) O2. Temp 97.9. Resident was alert and oriented x 4, asymptomatic. Vital signs at 0300 (3:00 AM): BP 103/74, HR 75, RR 20, Temp 98.0. Resident was alert and oriented x4, asymptomatic. Them started feeling ill and c/o (complained of) SOB (shorness of breath) this morning around 0500 (5:00 AM). Pt (patient) started to get diaphoretic. Vital signs at 0505 (5:05 AM): HR was between 40-55, RR 20, BP 102/76, oxygen 95% on 3 LPM O2. Called EMS (Emergency Medical Services), they transported resident to [name redacted] Emergency Department. This nurse called and informed ED [Emergency Department] physician at [name redacted] hospital that Verapamil ER 180mg, Amiodarone 200mg, and Eliquis 5mg tablets were given last night. A document titled Event Report created [DATE] for resident 1 was reviewed. The document contained a description of the medication error from [DATE]. The documented reported that resident 1 had taken her roommates medications which included Verapamil, Tylenol, Buspirone, memantine, Senna Plus, and simvastatin. The document reported that resident 1 was notified of the error on [DATE]. The immediate measures taken reported in the documented stated, Provider attempted to be notified, vitals observes, EMS contacted and transported to hospital. According to resident 1's Medication Administration Report (MAR) for [DATE], on the evening of [DATE] resident 1 recieved her own medications which included; a. Amiodarone 200 mg b. Eliquis 5 mg c. Melatonin 3 mg In addition to resident 1's own medication, resident 1 also recieved her roommates which included; a. Tylenol 650 mg b. Buspirone 10 mg c. Mematine 10 mg d. Senna Plus e. Simvastatin 10 mg f. Verapamil ER (extended release) 180 mg On [DATE] at 1:14 PM, an interview with RN 1 was conducted. RN 1 stated she had a shift on [DATE] was from 6:00 PM to 6:00 AM. RN 1 stated that it was her second time working at this facility through a temporary staffing agency and she did not have an assigned area to work. RN 1 stated that she was assisting CNA's (Certified Nursing Assistants) and nurses. RN 1 stated that around 8:30 PM on [DATE] she began assisting LPN 1 with medication administration. RN 1 stated that LPN 1 was behind on medication administration and LPN 1 decided to pull the medications, hand them to RN 1, and RN 1 would deliver them to the residents. RN 1 stated at around 9:00 PM, RN 1 and LPN 1 got to resident 1's room. RN 1 stated resident 1 had a roommate. RN 1 stated that LPN 1 stated, I'm going to give you both the cups for this room and LPN 1 explained that one cup was for resident 1 and one cup was for the roommate. RN 1 stated that the roommate's medication included a nutritional supplement called Boost. LPN 1 stated that resident 1 was alert and oriented and the roommate was confused. RN 1 stated that when she went to resident 1's bedside, RN 1 had accidentally switched the cups of medication and attempted to give resident 1 medication that was meant to be for the roommate. RN 1 stated resident 1 told RN 1 that she did not drink boost. RN 1 stated that she left the room to let LPN 1 know that resident 1 was unsure about the medications. LPN 1 stated that the resident was confused and to let the resident know that those were the doctor's orders. RN 1 stated she returned to resident 1's room, believing it was the roommate, and told resident 1 to take the medications. RN 1 stated resident 1 swallowed the medications that belonged to her roommate. RN 1 stated that she then realized that she mistakenly administered the medications to the wrong resident. RN 1 stated that she administered Tylenol, Buspirone, memantine, Senna Plus, simvastatin, and verapamil ER. RN 1 stated that she reported the mistake to LPN 1, and LPN 1 told her, It's okay it happens sometimes and then LPN 1 administered resident 1's correct medications which included amiodarone and Eliquis. RN 1 stated that after the incident, she did CNA cares due to the facility being short on CNA's that night. RN 1 stated that she did not know if LPN 1 called a physician or the on-call nurse manager to report the medication error. RN 1 stated that her and LPN 1 monitored resident 1 throughout the night and resident 1 was stable until around 5:00 AM on [DATE]. RN 1 stated that once resident 1's vitals became unstable, resident 1 was send to the emergency department. RN 1 stated that she called the physician at the emergency department to inform them of the medication error. RN 1 stated that the right thing to do would have been to notify a physician immediately after the medication error, contact the nurse manager, hold all other medications and wait for orders from a physician. On [DATE] at 1:38 PM, an interview with LPN 1 was conducted. LPN 1 stated that she was 9 weeks into her 13-week contract with the facility. LPN 1 was working a 6:00 PM to 6:00 AM shift on [DATE]. LPN 1 stated that she was extremely busy on the night of [DATE] and did not have any CNA's on her hallway. LPN 1 stated that RN 1 was a float nurse and offered to help LPN 1 with passing medications. LPN 1 stated that at resident 1's room, LPN 1 handed RN 1 the medications for that room and RN 1 accidentally gave resident 1 the medications that should have been given to her roommate. LPN 1 stated that after the medication error, LPN 1 gave resident 1 her correct medications, which included amiodarone and Eliquis. LPN 1 stated that she attempted to call the on-call physician on her personal cellphone, but the call would not go through. LPN 1 stated that she was unable to send picture evidence of the attempted phone call because it was accidentally deleted. LPN 1 stated that she did not attempt to call anyone else because she was too busy assisting other residents. LPN 1 stated that she monitored resident 1 throughout the night and took vitals. LPN 1 stated around 5:30 AM resident 1's blood pressure and pulse were dropping, so she attempted to call the on-call physician. LPN 1 stated that the on-call physician did not answer so LPN 1 sent resident 1 to the ER. The hospital records titled Emergency Department Document from [DATE] for resident 1 was reviewed. The hospital records stated, Shortly after the patient arrived the nurse from the skilled nursing facility called and indicated that the night nurse had accidentally given the patient 180 mg of verapamil extended release. Prior to this a septic workup had been started. The chest x-ray did no show any acute infiltrate. The CBC and CMP were reassuring. The patient was given aggressive IV (intervenous) hydration and despite this her blood pressure continued to drop. Her oxygen saturation was inconsistent The patient became pulseless and CPR (Cardiopulmonary Resuscitation) was started .the patient was admitted to [doctors name redacted] service in the ICU (Intensive Care Unit). The hospital records titled Death Discharge Summary from [DATE] for resident 1 stated, According to ER physician, patient was short of breath and very agitated. She was very bradycardic. I was told that patient may have received 180 mg of extended [release] verapamil yesterday by mistake .She was given calcium gluconate. As she was altered, they decided to intubate her. I was called to this patient to the ICU .Code blue was called . Patient was found to be extremely acidotic due to lactic acid. We did not pursue dialysis per family request . Patient ultimately expired on [DATE] at 13:52. The hospital records reported that the immediate cause of death is severe bradycardia due to possible accidental overdose, complicated by cardiac arrest and severe acidosis with renal failure. On [DATE] at 12:37 PM, an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated that if a medication error occurs, the nurses should stop administering other medications immediately, notify the physician of that error, follow the physician's orders, and assess the resident. The ADON stated that he was on-call the night of [DATE] and was notified the following morning of the medication error, which was approximately 10 hours after resident 1 had taken the wrong medications. The ADON stated that he should have been notified of the medication error immediately and he would have instructed LPN 1 to stop what she was doing, assess the resident, and to not proceed with that patient until there were instructions from the physician. On [DATE] at 1:00 PM, an interview with the Administrator (ADMIN) was conducted. The ADMIN stated that the facility conducted an investigation after the medication error. The ADMIN stated that the facility ended the work contract with LNP 1. The ADMIN stated that the facility created a four-step action plan, identified a problem, conducted education with all the nurses, and the facility was working on completing medication administration audits with all the nurses. On [DATE] at 3:09 PM, an email from the ADMIN reported that the ADMIN reviewed the on call provider call log from the physician group and no calls were made on behalf of resident 1 on the night of [DATE]. 2. Resident 4 was admitted to the facility on [DATE] with diagnoses which included hemiparesis following cerebral infarction affecting, bipolar, borderline personality, and type 2 diabetes. A list of resident with medication errors was provided. Resident 4 was listed as having a medication error on [DATE]. An Medication Error/Treatment Error Event was reviewed. The from was created on [DATE] at 2:39 PM. The medication error was on [DATE] at 7:50 PM. The description was Incorrect Lantus dosage given at NOC (night) by RN, AM (morning) RN was given report of Pt (patient) getting an increased dose of Lantus as stated by NOC RN, NOC RN stated the Pt MD (medical doctor) has increased the dose when questioned by Pt. The medication error was NOC administered 100 units of Lantus at Bedtime, when Pt questioned the amount the NOC RN stated it had been increased by MD to 100 unit. The physician was notified on [DATE] at 2:35 PM. Resident 4's medical record was reviewed on [DATE] and [DATE]. Resident 4's physician's order dated [DATE] revealed to following: a. Lantus 100 unit/mL (milliliter) solution to administer 25 units subcutaneously at bedtime for type 2 diabetes mellitus b. Insulin Lispro 100 unit/ml solution; 100 unit/mL; Amount to Administer: Per Sliding Scale; If Blood Sugar is 0 to 150, give 0 Units. If Blood Sugar is 151 to 200, give 2 Units. If Blood Sugar is 201 to 250, give 4 Units. If Blood Sugar is 251 to 350, give 8 Units. If Blood Sugar is 351 to 400, give 10 Units. If Blood Sugar is greater than 400, call MD. Resident 4's [DATE] MAR revealed Lantus was administered: a. On [DATE] resident 4 was administered 8 units by LPN 2. b. On [DATE] resident 4 was administered 100 units by Licensed Nurse (LN) 1. c. On [DATE] resident 4 was administered 10 units by LPN 2. Resident 4's [DATE] MAR further revealed resident 4's blood glucose was 415 on [DATE] and resident 4 was not administered Insulin Lispro sliding scale insulin and 10 units of Lantus. On [DATE] at 10:49 AM, an interview was conducted with resident 4. Resident 4 stated not to long ago, a nurse came into her room and told her that a nurse had administered 100 units of her long acting insulin the night before. Resident 4 stated the next day she felt horrible, sick, nauseated, and sweaty. Resident 4 stated that she was not sure if her blood sugar had been checked throughout the night. On [DATE] at 3:14 PM, an interview was conducted with LN 2. LN 2 stated she was an agency nurse and started her shift on [DATE] at 6:00 AM. LN 2 stated the previous nurse had told her during report that the physician increased resident 4's Lantus to 100 units. LN 2 stated that amount did not make sense. LN 2 stated resident 4's blood sugar was really low the next morning. LN 2 stated she did not want to administer the short acting insulin because of resident 4's blood sugar. LN 2 stated she checked the order and it was for 25 units not 100 units. LN 2 stated she got another nurse to confirm the physician's order. LN 2 stated as an agency staff member she did not know how to maneuver through the physician's orders in the electronic medical record. LN 2 stated she reviewed the nursing progress notes and there was no information that the 100 units had been ordered. LN 2 stated she then notified the Unit Manager (UM). LN 2 stated she did not know the time that the Lantus was administered. LN 2 stated that resident 4's blood sugar was low but not low enough to report to MD. LN 2 stated that the UM reported the medication error to the physician and the UM did not inform her of any new physician's orders. LN 2 stated that by dinner her blood sugar was with in normal range. LN 2 stated that resident 4's blood sugar was 81 at breakfast and 84 at noon, so that was why LN 2 started to question the 100 units. LN 2 stated resident 4's blood sugar was usually not below 130-140. It should be noted the physician was not contacted until the following day when LN 2 noticed the medication error. On [DATE] at 2:00 PM, an interview was conducted with LPN 2. LPN 2 stated she was an agency nurse. LPN 2 stated that resident 4 had a physician's order for Lantus 25 units every night. LPN 2 stated that she must have accidentally put the short acting insulin in as the long acting. LPN 2 stated she always went into resident 4's room and let her know she was administering 25 units. LPN 2 stated that she was able to remember the medication dosage that she administered to a resident over two weeks ago, eventhough, LPN 2 stated she had a lot of patients in that hallway and was asked questions while charting and was distracted. LPN 2 stated she was frequently interrupted by family members, residents were high acuity, there was a high census, and there was not a short shift nurse, so she had to have the 300 hall and 400 hall. LPN 2 stated she remember resident 4's blood sugar was 415 on [DATE]. LPN 2 stated that she documented in the doctor's log at the nurses station. LPN 2 stated she called doctor later after resident 4's blood sugar had decreased. LPN 2 stated she documented in the doctors log what had happened. LPN 2 states she administered 25 units of Lantus and 10 units of the short acting insulin. LPN 2 stated she should have documented in a progress note what happened. On [DATE], the Staff Development Coordinator (SDC) provided an physician's on call log. Resident 4's name was on the log with a blood sugar of 422. The log had multiple resident names on it and there was no additional information that the physician had been contacted. On [DATE] at 1:41 PM, an interview was conducted with the ADON. The ADON stated that resident 4 received 100 units of Lantus instead of 25 units. The ADON stated resident 4's blood sugar was in the 80s the next morning. The ADON stated he was not sure who discovered the medication error. The ADON stated there was an event form created the next day by LN 2. The ADON stated the nurse from the night before did not document anything. The ADON stated he was not aware of any other information regarding the Lantus doses on [DATE] and [DATE]. On [DATE] at 11:23 AM, an interview was conducted with the Minimum Data Set (MDS) coordinator. The MDS coordinator stated when a nurse had a medication error, the nurse was to immediately ensure patient safety, vital signs were normal at baseline and notify the physician right away. The MDS coordinator stated the nurse was to follow physician's orders. On [DATE] at 11:57 AM, an interview was conducted with Unit Manager (UM) 1 and the Director of Nursing (DON). UM 1 stated when there was a medication error nurses should notify the physician, family and resident, and administration staff. UM 1 stated the nurse was to follow any orders that the physician gave based on the medications. UM 1 stated the nurse needed to start alert charting and monitoring for a few days to make sure there were no side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined, the facility did not review and revise the comprehensive care plan after each assessment. Specifically, for 1 out of 37 sampled residents, the care plan did not address a resident's intravenous (IV) hydration status. Resident identifier: 80. Findings included: Resident 80 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia, pulmonary hypertension, type 2 diabetes mellitus, cognitive communication deficit, adult failure to thrive, pulmonary hypertension, hypothyroidism, celiac disease, benign prostatic hyperplasia, morbid obesity, hyperlipidemia, disorder of phosphorus metabolism, hypomagnesemia, major depressive disorder, essential tremor, hypertension, and obstructive sleep apnea. On 8/1/22 at 8:44 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that resident 80 had an IV infusion of magnesium with normal saline (NS) every other day. On 8/1/22 at 11:41 AM, an interview was conducted with resident 80. Resident 80 stated that he gets IV fluids on Tuesdays and Friday due to his falls and issues with dizziness. On 8/1/22, resident 80's medical record was reviewed. Resident 80's physician's orders revealed a current order for NS 0.9% intravenous, give 1 liter (L) wide open on Tuesdays and Fridays. The order was initiated on 7/6/22. Review of resident 80's progress notes revealed the following: a. On 4/28/22 at 3:37 PM, the note documented Nurse Practitioner (NP) ordered IV 1 L NS wide open once patient returns to room. b. On 4/29/22 at 12:01 PM, the NP documented Again following up with IV fluid therapy. He looks dramatically better today. He says this is the best he has felt in quite some time. I do not have lab results yet which is unusual. I will have the nurse locate these. He reports that his diarrhea has stopped and that his nausea is much improved. We will stop the order for stool studies as this seems to have resolved spontaneously. He is happy and pleasant and has no complaints or concerns today. Nurse as he is doing well. c. On 4/29/22 at 4:53 PM, the note documented, 1 liter NS IV wide open once, per facility provider. d. On 5/3/22 at 3:38 PM, the note documented, NP in to see Patient. New order received: IV NS 1 L wide open. Patient alert and oriented x [times] 4 (self, place, time, situation) verbalized understanding of new order. e. On 5/3/22 at 7:36 PM, the NP documented, He is not feeling great again. Is requesting more IV fluids as he feels much better. Review was his last labs show a bump in his creatinine. Will repeat this and closely follow. He reports doing much better with fluid. He says his stool has gotten loose again and it resolved with IV hydration. He looks okay today though he does look a bit worse than a few days ago still with good urine output. No other changes or concerns noted f. On 5/6/22 at 2:50 PM, the note documented, New order from provider. IV NS 1 L QD [every day] wide open x 3 days. g. On 5/6/22 at 5:30 PM, the NP documented, Discussion about kidney function. Patient states he is always had stage III kidney disease. I had one lab reading that showed normal kidney function and the rest has been in the mid 2 range. Today he is at 2.3. He feels much better with IV fluids. Will see if his kidney function changes at all with fluids for the next few days and if this impacts how he feels. Reports fatigue and a bit of malaise but overall is doing okay h. On 5/10/22 at 8:27 PM, the NP documented, He reports feeling better with IV fluids. He really can tell a difference most of the time after receiving them. Review of his lab work today. His kidney function improved very slightly with increased hydration but not dramatically. I think his baseline creatinine is established now between 2 and 2.5. i. On 5/17/22 at 3:41 PM, the note documented that the NP ordered IV NS 1 L wide open. j. On 5/17/22 at 5:22 PM, the NP documented, Review patient's recent status. We have hydrated him a few times and he is doing very well when we give him fluids. If multiple days past without fluids he seems to decline a bit. I am not sure why this is. His magnesium has maintained. His blood sugars overall doing well. If we do not hydrate him often he seems to develop loose stool, again which I have no explanation for. He does have a scratchy voice which has been present for about 2 weeks now. He does not have a sore throat and denies any other symptoms of illness now. He says he feels like fluid would help him feel better today. He does report some mild malaise. k. On 5/18/22 at 6:56 PM, the NP documented, Follow-up with patient today after receiving a liter yesterday. Patient states he feels so much better states the dizziness thus far is gone. Discussed with him possibly getting a couple liters throughout the week and correlation to his magnesium infusions. l. On 5/23/22 at 4:17 PM, the note documented that the NP was .notified via telephone of Patient's continued dizziness, new order received: Normal Saline one Liter via IV on Tuesdays and Fridays x 1 week. m. On 5/27/22 at 5:13 PM, the NP documented, [Name of resident 80 removed] is doing well. He reports feeling dramatically better with fluid. His magnesium level is doing well at 1.8. I have no idea why he continues to need IV fluid but he does much better with it. n. On 6/6/22 at 4:12 PM, the note documented that the NP ordered IV NS every Tuesdays and Fridays per the resident request. o. On 6/17/22 at 6:40 PM, the NP documented, Wants to have IV fluids again. Tolerating oral mag ok - some nausea. Overall doing ok. p. On 7/6/22 at 6:06 PM, the note documented that resident 80 had a double lumen peripherally inserted central catheter (PICC) line placed in the right upper extremity. The provider ordered 1 L NS wide open when PICC line was accessible. q. On 7/11/22 at 4:56 PM, the NP documented, He is doing much better with IV infusions. Today his magnesium is up to 1.7. I am adjusting his nausea medicines to when necessary as he has been doing better. I am stopping his oral magnesium. Uncertain why he cannot absorb this via an oral route. May consider a GI [Gastroenterology] consult. He does not have chronic diarrhea. A quarterly Minimum Data Set assessment dated [DATE], documented under nutritional status that resident 80 had parenteral/IV feeding. The assessment further documented under special treatments that resident 80 had received IV medications in the last 14 days. Resident 80's care plans were reviewed and revealed a care plan for nutritional status. The nutrition care plan did not address resident 80's IV hydration or interventions specific to IV fluids. No other care plan focus area was identified related to IV hydration. On 8/9/22 at 8:46 AM, an interview was conducted with Corporate Resource Nurse (CRN) 1. CRN 1 stated that per the NP notes resident 80 was not eating well and that was the reason for the IV hydration. CRN 1 stated that the IV hydration should be addressed in a care plan somewhere and believed it might be located in the nutrition care plan. On 8/9/22 at 9:24 AM, a follow up interview was conducted with CRN 1. CRN 1 stated that resident 80 did not have a care plan for his IV hydration needs and that a care plan was created today.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined, the facility did not ensure that services provided met professional standards of quality. Specifically, for 1 out of 37 sampled residents, a percutaneous endoscopic gastrostomy (PEG) tube feeding did not have the bag labeled with the formula type, rate of infusion, resident identification information, date and time of administration, or the nurse initials who initiated the infusion. Resident identifier: 99. Findings included: Resident 99 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included [NAME]-Sachs disease, bipolar disorder, pseudobulbar affect, anxiety disorder, periodontal disease, hypotension, seizures, gastro-esophageal reflux disease, thrombocytopenia, dysphagia, moderate protein-calorie malnutrition, pain, muscle spasms, right artificial hip joint, and gastrostomy tube. On 8/1/22 at 8:44 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that resident 99 had a tube feed (TF) that ran every 12 hours at night. RN 2 stated that the TF was disconnected and flushed this morning. On 8/1/22 at 12:43 PM, an observation was made of resident 99 sleeping on a mattress that was located on the floor. A floor mat was observed on the left side of the mattress. Resident 99 was positioned on the right lateral side and an infusion pump was noted at the bedside. On 8/2/22 at 8:02 AM, an observation was made of resident 99. Resident 99's TF was observed infusing at a rate of 60 milliliters (ml) per hour (hr) with a water flush infusing at a rate of 30 ml/hr. The TF was labeled 8/2/22 at 9:40 PM, and the water bag was labeled 8/1/22. The infusion pump showed that the TF had 475 ml remaining. The TF formula was contained in a ready-to-hang enteral feeding container (1000 ml bottle) and was labeled Jevity 1.2 CAL (calorie). Resident 99 was observed lying on the left lateral side, flat on the mattress on the floor. On 8/4/22 at 7:39 AM, an observation was made of resident 99's TF. The TF was observed infusing at a rate of 60 ml/hr with a water flush infusing at a rate of 30 ml/hr. The TF formula was contained in a enteral feeding pump bag and had approximately 300 ml of formula remaining. The TF bag was not labeled with the resident name, date and time the infusion was administered, type of formula contained within the bag, or the nurse initials who initiated the infusion. The water pump bag was not labeled with a date. Resident 99 was observed lying on the left lateral side, flat on the mattress located on the floor. Review of resident 99's physician's orders revealed the following: a. JEVITY 1.2 at 60 ml/hr for 12 hours. On at 8:00 PM and off at 8:00 AM. The order was initiated on 7/26/22. b. FLUSH WITH WATER at 30 ml/hr for 12 hours through pump at bedtime. The order was initiated on 7/26/22. Resident 99's care plan for feeding tube documented that resident 99 had a PEG tube in place for nutritional supplementation. Interventions identified were dietician/nutritional evaluation and treatment as needed, ensure supplies, formula, and tubing were changed as prescribed, ensure tube placement as prescribed, evaluate for signs and symptoms of aspiration and notify the physician of positive signs, position head of bed at least 30 degrees to prevent aspiration, and TF insertion cares as ordered. The care plan and interventions were initiated on 6/21/22. Resident 99 had a benefits verses risk evaluation completed on 2/2/22 at 5:21 PM. The form documented that resident 99 had a mattress on the floor per the care plan and family request to aid with fall prevention, and that resident 99 required tube feedings for aid with nutrition. The risk related to noncompliance documented that having the mattress on the floor did not allow the head of the bed to be elevated during times when the tube feed was running. The form documented that the risks were discussed with the family and they understood the risk for aspiration related to the placement of the mattress. The form documented that the family would like to remain with having the mattress on the floor for the resident's safety. It should be noted that the form did not contain any signatures by the resident representative. On 8/4/22 at 11:43 AM, an interview was conducted with RN 3. RN 3 stated that resident 99 had a PEG tube for supplemental feedings. RN 3 stated that resident 99 was not eating much so the TF was started. RN 3 stated that resident 99 was dependent for all activities of daily living except feeding. RN 3 stated that resident 99 was alert and oriented to self only. RN 3 stated that resident 99's bed was on the floor for a fall intervention. RN 3 stated that when resident 99 was seated in a wheelchair she would not try to get out, but if she was in a bed she tried to get out. RN 3 stated that he disconnected resident 99's TF at approximately 11:30 AM. The TF bag was observed still hanging at the bedside. RN 3 stated that when hanging a TF they should label the bag with the resident's name, time, and formula type. RN 3 confirmed that the current bag was not labeled. RN 3 was asked how he knew what formula was in the bag without a label. RN 3 replied, that's a good question, you don't. RN 3 stated that he knew the staff member from last night who hung the bag, and that resident 99 had Jevity ordered. RN 3 stated that the TF was ordered to run for 12 hours through the night. On 8/4/22 at 12:18 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the Licensed Practical Nurse and RN can both access the TF. The DON stated that the bags of the formula should be labeled with the date, formula type, resident name, and nurse initials who hung the feed, and that it was treated like any other medication order. Review of the Lippincott Nursing Procedures documented under Tube Feedings and Preparation of equipment to Make sure the formula is labeled clearly with the patient identification information, the type of formula, the method of administration, the date and time of preparation, and the name of the person preparing the formula if appropriate. Wolters Kluwer. Lippincott Nursing Procedure. Seventh Edition. Philadelphia, PA. (2013), pp. 801.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined, the facility did not provide necessary respiratory care and services consistent with the resident's care plan and goals. Specifically, for 1 out of 37 sampled residents, a resident's oxygen tubing and prefilled humidifier bottle were not changed as ordered by the physician, and the filter on the concentrator was not cleaned as ordered by the physician. Resident identifier: 14. Findings included: Resident 14 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, type 2 diabetes mellitus without complications, chronic systolic (congestive) heart failure, acute and chronic respiratory failure, morbid obesity, generalized anxiety disorder, post-traumatic stress disorder, borderline personality disorder, and unspecified psychosis. On 8/2/22 at 8:16 AM, an observation was made of resident 14 receiving oxygen at 4 liters per minute via nasal canula from an oxygen concentrator. The oxygen concentrator was observed to have a dirty filter, an empty prefilled humidifier bottle, and no date or staff initials on the tubing or prefilled humidifier bottle that indicated when they were last changed. On 8/2/22 at 1:39 PM, an interview was conducted with Certified Nursing Assistant (CNA) 11. CNA 11 stated on Thursdays the oxygen tubing, catheters, urinals, and anything plastic were changed. CNA 11 stated after the oxygen tubing and other plastic supplies were replaced, they were dated and initialed by the person who changed the items so everyone would know they had been changed. CNA 11 stated the filter on the concentrator should be changed but was unsure who was responsible to change it. On 8/2/22 at 1:44 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated she did not know who was responsible to change the filter on the concentrator but stated she would find out. LPN 1 stated she cleaned the filters because she was used to doing it. On 8/2/22 at 1:48 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated there was no policy that she had seen that specified who was supposed to clean the filters on the oxygen concentrators. RN 2 stated she would do it if needed. On 8/2/22 at 1:57 PM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated the CNAs were responsible to change oxygen tubing, the prefilled humidifier bottle, and clean the concentrator filter on the Thursday night shift. On 8/3/22 at 9:30 AM, it was observed that there was no date or initials on resident 14's oxygen tubing or prefilled humidifier bottle, and the concentrator filter was observed to be dirty. On 8/4/22, a review of resident 14's medical record was completed. Resident 14's Care Plan had an identified problem which stated, Category: Respiratory [name of resident 14 removed] requires respiratory support at this time secondary to acute and chronic respiratory failure, chronic systolic (congestive) heart failure, and OSA [obstructive sleep apnea]. The goal associated with the problem stated, [Name of resident 14 removed] will have no unaddressed complications secondary to respiratory needs, through next review. On approach associated with the problem and goal stated, Oxygen tubing/soft supply changes, as prescribed. The disciplines responsible for this approach were CNA, NP [nurse practitioner], Nursing, Physical Therapy. A physician's order dated 1/11/21, documented to change the oxygen tubing, humidifier, and clean the concentrator filter each Thursday at night. A review of the Point of Care tasks to be completed by the CNA showed a miscellaneous task that stated change O2 [oxygen] tubing, humidifier, and clean concentrator filter each Thursday NOC [night]. The following were documented: a. In June, the task was scheduled to be completed on the following days, not Thursdays as ordered: 6/1/22, 6/3/22, 6/7/22, 6/10/22, 6/13/22, 6/14/22, 6/17/22, 6/20/22, 6/21/22, and 6/24/22. The task was not completed on 6/3/22, 6/10/22, 6/17/22, and 6/24/22. b. In July, the task was scheduled to be completed on the following Fridays, not Thursdays as ordered: 7/1/22, 7/8/22, 7/15/22, 7/22/22, and 7/29/22. Documentation revealed that the task was only completed one time on 7/22/22. Documentation revealed that the task to change the oxygen tubing and prefilled humidifier bottle, and to clean the concentrator filter was not completed each Thursday as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined, the facility did not ensure that pain management was provided to residents who required such services. Specifically, for 1 out of 37 sampled residents, a resident reported uncontrolled pain and missed pain medication administration. Resident identifier: 62. Findings included: Resident 62 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included non-ST elevation (NSTEMI) myocardial infarction, pneumonia, bipolar disorder, anxiety disorder, chest pain, hypotension of hemodialysis, end stage renal disease, congestive heart failure, gastro-esophageal reflux disease, hypothyroidism, paraplegia, morbid obesity, history of transient ischemic attack, pain, hyperlipidemia, type 2 diabetes mellitus, essential hypertension, pulmonary embolism, insomnia, major depressive disorder, colostomy, artificial opening of urinary tract, and pelvic inflammatory disease. On 8/1/22 at 12:27 PM, an interview was conducted with resident 62. Resident 62 stated that she received pain medication for back and leg pain. Resident 62 stated that she received Oxycodone every 4 hours and Morphine every 12 hours for pain. Resident 62 stated that last week the nightly dose of pain medication was missed on multiple occasions and her pain was uncontrolled. Review of resident 62's physician's orders revealed the following: a. Acetaminophen (Tylenol) capsule 650 milligram (mg) every 6 hours at 7:00 AM, 1:00 PM, and 7:00 PM. The order was initiated on 7/19/22. b. Baclofen tablet 5 mg every day. The order was initiated on 7/7/22. c. Morphine tablet extended release 15 mg two times a day at 5:00 AM and 5:00 PM. May give Morphine with Oxycodone before leaving for dialysis. The order was initiated on 8/12/21, discontinued on 5/4/22, initiated on 5/4/22, discontinued on 7/6/22, and initiated again on 7/6/22. d. Nitrostat (nitroglycerin) tablet, sublingual 0.4 mg sublingual, every 15 minutes times 3 as needed. The order was initiated on 7/6/22. e. Oxycodone tablet 10 mg every 4 hours at 5:00 AM, 9:00 AM, 1:00 PM, 5:00 PM, 9:00 PM, and 1:00 AM. The order was initiated on 2/14/22, discontinued on 4/29/22, and initiated on 7/6/22. f. Tylenol 650 mg every 4 hours at 7:00 AM, 11:00 AM, 3:00 PM, 7:00 PM, 11:00 PM, and 3:00 AM Special Instructions: Not To Exceed 3 grams of Tylenol in 24 hours from all sources. The order was initiated on 2/14/22 and discontinued on 7/6/22. g. Complete and document pain assessment using numeric/facial/[NAME] pain scale every shift. The order was initiated on 8/3/20. Review of resident 62's July 2022 Medication Administration Record (MAR) revealed the following: a. The Tylenol 650 mg every 6 hours was documented as administered only 3 times a day instead of 4 times a day as ordered by the physician. b. The Oxycodone 10 mg was documented as not administered on 7/22/22 at 1:00 AM due to NOT GIVEN BY NOC [night time] SHIFT. No pain score was documented at this time. c. The Tylenol 650 mg every 4 hours was documented as not administered on 7/2/22 at 7:00 PM due to unable, nurse busy. The order was discontinued on 7/6/22. d. The pain scale ordered for every shift was not documented on 7/21/22 (night), 7/23/22 (night) and 7/27/22 (day and night). No documentation was noted to explain the omitted assessments. Resident 62's pain scores for July 2022 were reviewed. Pain scores ranged from 0/10 to 10/10, with an average monthly score of 5 (139 observations with a total score of 707). On 8/1/22 at 11:31 AM, resident 62's pain assessment was conducted. The assessment documented that resident 62 had reported a 8/10 pain over the last 5 days, and had experienced pain frequently. Resident 62 reported receiving the scheduled pain medication, but did not receive any as needed (PRN) pain medication. The assessment documented that resident 62's pain was managed to their satisfaction. The assessment documented an acceptable pain level of 3/10. Review of resident 62's concern forms revealed a complaint of late medication administration on 7/25/22. The form stated that the overnight nurse was slow and she received her medication late. The form documented that the facility identified that it was an agency nurse who was responsible for the late administration. Review of resident 62's care plan revealed a focus area of at risk for pain secondary to diabetes and polyneuropathy. The interventions identified were to provide non-drug interventions such as re-positioning, distractions, exercise, rest, deep breathing/relaxation exercises, socialization, aromatherapy, and snacks. The care plan further documented to monitor for side effects of the pain medication, to administer medications as prescribed, and to monitor the pain as prescribed. The care plan was initiated on 7/31/20. On 8/4/22 at 2:17 PM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated pain assessments were completed once a shift and every time there was a scheduled pain medication. RN 3 stated that they would conduct a pain assessment if a resident asked for pain medication. RN 3 stated that the MAR would alert the nurse to re-assess the pain after a PRN pain medication was administered. RN 3 stated that for scheduled pain medication the system would not cue them to conduct a follow-up pain evaluation, but that he would assess the resident with a follow-up pain score to determine if the medication administered was effective. RN 3 stated that if a resident reported that the pain medication was not effective at relieving the pain they would inform the physician. RN 3 stated that they would also offer non-pharmacological intervention for pain such as distraction, repositioning, and ambulation. RN 3 stated that it had never been too busy for him to not administer a resident's pain medications. RN 3 stated that if the MAR had any omitted or forgotten administrations he would contact the previous nurse to verify, and if it was not given he would contact the physician. RN 3 stated that resident 62 usually had generalized pain status post dialysis, and pain in the legs and feet. On 8/8/22 at 11:07 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that if a nurse was not able to administer a medication that it should be documented in a progress note, the physician needed to be notified as well as the oncoming shift. The DON stated that there was no situation that a medication should be documented as not administered. On 8/8/22 at 1:55 PM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated that resident 62 had a recent concern with an agency nurse and medications not being administered on time. UM 1 stated that the medications were administered late and occurred a couple of weeks ago. UM 1 stated that she had filled out a grievance form for the incident but had not turned it in yet. UM 1 stated that the facility had informed the agency that they did not want that nurse returning to their facility. On 8/8/22 at 2:59 PM, an interview was conducted with the Corporate Resource Nurse (CRN) 2. CRN 2 stated that the Tylenol was ordered for every 6 hours or 4 times a day and according to the MAR the medication was only being administered three times a day. On 8/9/22 at 8:11 AM, an interview was conducted with CRN 1, CRN 2, and the DON. CRN 1 clarified that the Tylenol every 6 hours was not given per the physician's orders and they informed the physician and changed the order yesterday. CRN 1 stated No good excuse there. CRN 1 stated that the Oxycodone was not administered and a medication error was completed. CRN 1 stated that nursing staff that documented unable to administer the pain medication because they were too busy was an agency nurse. CRN 1 stated that the pain scale should be documented every shift on the MAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 62 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included non-ST elevation (NSTEMI) myocardial infarction, pneumonia, bipolar disorder, anxiety disorder, chest pain, hypotension of hemodialysis, end stage renal disease, congestive heart failure, gastro-esophageal reflux disease, hypothyroidism, paraplegia, morbid obesity, history of transient ischemic attack, pain, hyperlipidemia, type 2 diabetes mellitus, essential hypertension, pulmonary embolism, insomnia, major depressive disorder, colostomy, artificial opening of urinary tract, and pelvic inflammatory disease. On 8/2/22, resident 62's medical record was reviewed. Review of resident 62's physician's orders revealed an order for Carafate (sucralfate) tablet; 1 gram by mouth four times a day. The order was initiated on 11/26/21, discontinued on 7/6/22, and restarted again on 7/6/22, with an open end date. Review of the pharmacy monthly medication review revealed the following: a. On 3/10/22, the pharmacist recommended to discontinue Sucralfate and initiate Pantoprazole 20 milligrams daily. The physician's response was to discontinue the Sucralfate and reassess the need for Pantoprazole. The physician signed the consultation report with the new orders on 3/15/22. Review of the March, April, May, June, and July 2022 Medication Administration Record revealed that the Carafate was not discontinued per the physician's orders. b. No documentation could be found that a pharmacy medication review was completed in December 2021. On 8/8/22 at 10:53 AM, an interview was conducted with the DON. The DON stated that monthly pharmacy reviews were scanned into the residents medical records and a progress note was documented after each review. The DON stated that the records could be in medical records waiting to be scanned in. On 8/8/22 at 11:07 AM, a follow-up interview was conducted with the DON. The DON stated that she gave the providers the pharmacy recommendations, and once they agreed with the recommendation they could change the order. On 8/9/22 at 8:11 AM, an interview was conducted with CRN 1 and the DON. The DON stated that she or the floor nurse would be responsible for ensuring that the pharmacy recommendations were implemented. The DON stated that if the physician/provider decided to change any order based on a pharmacy recommendation they had the ability to notify the floor nurse to implement those order changes. The DON stated that she would get a copy of the signed pharmacy recommendations with the physician response and any new orders. CRN 1 stated that ultimately it should be audited by the DON to ensure that that the recommendations were being implemented. Based on interview and record review, it was determined, the irregularities noted by the pharmacist during the drug regimen review must be reported to the attending physician and the facility's Medical Director and Director of Nursing (DON), and these reports must be acted upon. Specifically, for 2 out of 37 sampled residents, a pharmacy recommendation to attempt a gradual dose reduction (GDR) on a resident's medication was not acted upon when the physician agreed with the pharmacy recommendation. In addition, . Resident identifiers: 7 and 62. Findings included: 1. Resident 7 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, cerebral palsy, dysphagia, anxiety disorder, bipolar disorder, Parkinson's disease, sleep disorder, convulsions, and pain. Resident 7's medical record was reviewed on 8/2/22. The Pharmacy Consultation Report dated 3/10/22, documented [Name of resident 7 removed] has a long standing order for Lamotrigine 150 mg [milligrams] twice daily. Please attempt a gradual dose reduction (GDR) OR provide a statement of contraindication to attempt a GDR at this time. The Physician's Response documented I accept the recommendation(s) above, please implement as written. The Consultation Report was signed and dated by the physician in March 2022. A physician's order dated 2/11/21, documented Lamictal (lamotrigine) tablet 150 mg, oral, twice a day related to bipolar disorder. [Note: A GDR or a statement of contraindication to attempt a GDR was unable to be located within the medical record.] On 8/8/22 at 2:04 PM, an interview was conducted with Corporate Resource Nurse (CRN) 1 and the DON. CRN 1 stated that GDR medications were reviewed during the psychotropic review meeting and/or if the pharmacist made a pharmacy recommendation. The DON stated that the pharmacist would review the resident medications monthly and would send the recommendations to her via email. The DON stated she would print the recommendations for the provider to review. The DON stated the provider would give the recommendations back to her and she would document the recommendations in the residents medical record. On 8/9/22 at 9:12 AM, an interview was conducted with the DON. The DON stated that resident 7 did not have a GDR on the lamotrigine as recommended by the pharmacist because there was a contraindication in place and resident 7 was being followed by mental health. [Note: The Physician Rationale for Psychotropic Medication Management form dated 2/15/21, documented a contraindication for resident 7's lamotrigine. The pharmacy recommendation dated 3/10/22, documented that the physician agreed with the recommendation to GDR the lamotrigine.]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined, the facility did not ensure each resident's drug regimen remained free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which would indicate the dose should be reduced or discontinued. Specifically, for 2 out of 37 sampled residents, a resident's medications were not administered per the physician's orders and medications were omitted and documented as not being administered at all. Resident identifiers: 62 and 80. Findings included: 1. Resident 62 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included non-ST elevation (NSTEMI) myocardial infarction, pneumonia, bipolar disorder, anxiety disorder, chest pain, hypotension of hemodialysis, end stage renal disease, congestive heart failure, gastro-esophageal reflux disease, hypothyroidism, paraplegia, morbid obesity, history of transient ischemic attack, pain, hyperlipidemia, type 2 diabetes mellitus, essential hypertension, pulmonary embolism, insomnia, major depressive disorder, colostomy, artificial opening of urinary tract, and pelvic inflammatory disease. On 8/2/22, resident 62's medical record was reviewed. Review of resident 62's physician's orders revealed the following: a. Acetaminophen (Tylenol) capsule 650 milligram (mg) every 6 hours at 7:00 AM, 1:00 PM, and 7:00 PM. The order was initiated on 7/19/22. b. Tylenol 650 mg every 4 hours at 7:00 AM, 11:00 AM, 3:00 PM, 7:00 PM, 11:00 PM, and 3:00 AM. Special Instructions: Not To Exceed 3 grams of Tylenol in 24 hours from all sources. The order was initiated on 2/14/22 and discontinued on 7/6/22. c. Oxycodone tablet 10 mg every 4 hours at 5:00 AM, 9:00 AM, 1:00 PM, 5:00 PM, 9:00 PM, and 1:00 AM. The order was initiated on 2/14/22, discontinued on 4/29/22, and initiated on 7/6/22. d. Novolog Flexpen U-100 Insulin pen; 100 unit/milliliter; amt: Per Sliding Scale; If Blood Sugar is 151 to 200, give 2 Units. If Blood Sugar is 201 to 250, give 4 Units. If Blood Sugar is 251 to 300, give 6 Units. If Blood Sugar is 301 to 350, give 8 Units. If Blood Sugar is 351 to 400, give 10 Units. If Blood Sugar is 401 to 450, give 12 Units. If Blood Sugar is greater than 450, give 12 Units. Special Instructions: If blood sugar (BS) was greater than 450 give insulin and recheck BS in 2 hours. Administer before meals at 8:30 AM, 12:30 PM, and 5:30 PM. The order was initiated on 7/6/22. e. Carafate (sucralfate) tablet 1 gram (gm) four times a day. Special Instructions: Not to be given within 2 hours of other medications. The order was initiated initiated on 11/26/21 and discontinued on 7/6/22. Review of resident 62's July 2022 Medication Administration Record (MAR) revealed the following: a. The Tylenol 650 mg every 6 hours was documented as administered only 3 times a day instead of 4 times a day as ordered by the physician. b. The Oxycodone 10 mg was documented as not administered on 7/22/22 at 1:00 AM, due to NOT GIVEN BY NOC [nighttime] SHIFT. c. The Tylenol 650 mg every 4 hours was documented as not administered on 7/2/22 at 7:00 PM, due to unable, nurse busy. The order was discontinued on 7/6/22. d. The Novolog Flexpen was not documented as administered on 7/23/22 at 8:30 AM and on 7/27/22 at 5:30 PM. On 3/10/22, the pharmacy recommendation was to discontinue the Sucralfate. The physician agreed to the recommendation and signed the consultation report on 3/15/22. Review of the March, April, May, and June 2022 MAR revealed that the medication was not discontinued per the physician's order. On 7/28/22, a medication error form was completed for the Novolog insulin. The description of the error documented that the insulin was not administered or documented at 5:30 PM. It should be noted that the form did not contain the date but correlated to the missed dose on 7/27/22 at 5:30 PM. The correction/measures to prevent reoccurrence documented that education was provided to the agency nurse. The form documented that the physician was informed of the medication error on 7/28/22 at 12:00 PM. The form was completed and signed by the Director of Nursing (DON). On 8/4/22 at 2:17 PM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that resident 62 usually had generalized pain status post dialysis, and pain in the legs and feet. RN 3 stated that it had never been too busy for him to not administer a resident's pain medications. RN 3 stated that if the MAR had any omitted or forgotten medication administrations, he would contact the previous nurse to verify, and if it was not given he would contact the physician. On 8/8/22 at 11:07 AM, an interview was conducted with the DON. The DON stated that if a nurse was not able to administer a medication that it should be documented in a progress note, the physician needed to be notified as well as the oncoming shift. The DON stated that there was no situation that a medication should be documented as not administered. On 8/8/22 at 2:59 PM, an interview was conducted with the Corporate Resource Nurse (CRN) 2. CRN 2 stated that the Tylenol was ordered for every 6 hours or 4 times a day and according to the MAR the medication was only being administered three times a day. On 8/9/22 at 8:11 AM, an interview was conducted with the CRN 1, CRN 2, and the DON. CRN 1 clarified that the Tylenol every 6 hours was not given per the physician's order, and they informed the physician and changed the order yesterday. CRN 1 stated No good excuse there. CRN 1 stated that the oxycodone was not administered, and a medication error was completed. CRN 1 stated the nursing staff that documented unable to administer the pain medication because they were too busy was an agency nurse. The DON stated that she provided education to the nurse for the Novolog medication error. The DON stated that the education provided included the importance of giving the medication on time, what could happen if not given on time, the importance of documenting the missed administration and notifying the physician and family. The DON stated that the nursing staff would typically administer the insulin prior to the dialysis appointment because the staff at the dialysis center could not give it. The DON stated that she would get a copy of the signed pharmacy recommendations with the physician response and any new orders. CRN 1 stated that ultimately it should be audited by the DON to ensure that the recommendations were being implemented. 2. Resident 80 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia, pulmonary hypertension, type 2 diabetes mellitus, cognitive communication deficit, adult failure to thrive, pulmonary hypertension, hypothyroidism, celiac disease, benign prostatic hyperplasia, morbid obesity, hyperlipidemia, disorder of phosphorus metabolism, hypomagnesemia, major depressive disorder, essential tremor, hypertension, and obstructive sleep apnea. On 8/1/22 at 11:26 AM, an interview was conducted with resident 80. Resident 80 stated that he had to go to the emergency room for a critically low magnesium level of 1.2. Resident 80 stated that the low magnesium level was due to a nurse not administering the intravenous (IV) magnesium. Resident 80 stated that he was scheduled to get IV magnesium every other day, and the infusion took approximately 4 hours to run. Resident 80 stated that on 7/24/22, the day shift nurse did not administer the medication. Resident 80 stated that the facility conducted an investigation and the nurse had documented that the IV magnesium was administered when it actually was not. Resident 80 stated that when the facility looked into the missed dose they identified that the IV pole at resident 80's bedside still contained the completed IV infusion bag for 7/22/22. Resident 80 stated Friday's bag was hanging instead of Sunday. Resident 80 stated that his magnesium level drops quickly if the medication was not administered. Resident 80 stated that after the dose was missed his subsequent dose schedule was mixed up and he ended up missing a second dose. Review of resident 80's physician's orders revealed the following: a. Magnesium IV 4 gm intravenous once a day on even days, infuse over 4 hours. The order was initiated on 7/6/22 and discontinued on 7/21/22. b. Magnesium IV 4 gm intravenous once a day on even days. Infuse over 4 hours with 1 liter of normal saline at a rate of 125 milliliters/hour (ml/hr). The order was initiated on 7/21/22 and discontinued on 7/25/22. c. Magnesium IV 4 gm intravenous once a day on even days. Infuse over 4 hours with 1 liter of normal saline at a rate of 125 ml/hr. The order was initiated on 7/27/22. Review of the July 2022 MAR revealed that resident 80 missed his IV magnesium on 7/18/22 and 7/26/22. The MAR documented that the medication was administered on 7/24/22. On 7/25/22 at 11:56 AM, resident 80's progress note documented that resident 80 informed the nurse that he did not get his IV magnesium yesterday. The physician was notified and ordered to administer the medication today. The medication was documented as administered at 11:50 AM, with normal saline. Review of the Medication Error Form documented that on 7/24/22, the IV magnesium was not administered. On 7/25/22 at 8:00 AM, the physician was notified and ordered to give the medication today and resume normal schedule. The form documented that education was provided to the nurse by the DON. On 8/8/22 at 2:35 PM, an interview was conducted with CRN 1 and the DON. CRN 1 stated that resident 80's missed magnesium dose on 7/26/22, was due to the medication schedule being adjusted for a previous missed dose. On 8/9/22 at 9:24 AM, a follow-up interview was conducted with CRN 1. CRN 1 stated that resident 80 had missed doses and the order was not changed to reflect the dose administered on 7/25/22. CRN 1 stated that the nurse who reported the missed dose had found the previous administration bag hanging at the bedside empty and dated for the dose administered on 7/22/22. CRN 1 stated that was how the Nurse Practitioner determined that the administration for 7/24/22, was missed also.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined, the facility did not ensure that a resident who used psychotropic drugs was not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. Residents who use psychotropic drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Specifically, for 1 out of 37 sampled residents, a resident received one GDR on an antipsychotic medication for bipolar disorder that was initiated by the facility on 9/1/21. Resident identifier: 7. Findings included: Resident 7 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, cerebral palsy, dysphagia, anxiety disorder, bipolar disorder, Parkinson's disease, sleep disorder, convulsions, and pain. Resident 7's medical record was reviewed on 8/2/22. A physician's order dated 9/1/21, documented Latuda (lurasidone) tablet 20 milligrams (mg) oral once a day related to bipolar disorder. The physician's order was discontinued on 9/8/21. A physician's order dated 9/8/21, documented Latuda tablet 40 mg oral once a day. The physician's order was discontinued on 10/28/21. On 10/28/21 at 2:15 PM, a Nursing note documented Resident c/o [complains of] latuda causing shakiness to hands. Provider notified and gave new order. new order: Change latuda from 40 mg to 20 mg daily. Resident notified of new order. A physician's order dated 10/28/21, documented Latuda tablet 20 mg oral once a day. The physician's order was discontinued on 11/17/21. On 11/17/21 at 1:43 PM, a Nursing note documented Resident having depressed thoughts. Provider notified and gave new orders. New orders: Increase Latuda to 40 mg QD [every day]. Please find out when next psych [psychiatric] appt [appointment] is. Transportation notified to find out about psych appt. Resident aware of new orders. A physician's order dated 11/18/21, documented Latuda tablet 40 mg oral once a day. The physician's order was discontinued on 12/10/21. A physician's order dated 12/21/21, documented Latuda tablet 40 mg oral once a day. [Note: The dosage of the Latuda was not changed from the physician's order dated 11/18/21.] On 8/8/22 at 2:04 PM, an interview was conducted with Corporate Resource Nurse (CRN) 1 and the Director Of Nursing (DON). CRN 1 stated that GDR medications were reviewed during the psychotropic review meeting and/or if the pharmacist made a pharmacy recommendation. The DON stated that resident 7 would be reevaluated in September during the psychotropic review meeting. On 8/9/22 at 9:12 AM, a follow up interview was conducted with the DON. The DON stated resident 7's Latuda was ordered by the mental health clinic on 8/31/21. The DON stated the Latuda was started at 20 mg QD times 7 days, then it was increased to 40 mg QD. The DON stated a GDR to reduce the Latuda down to 20 mg was done on 10/28/21. The DON stated that the Latuda was increased back to 40 mg on 11/17/21, due to resident 7 having increased depression. The DON stated the reduction on 10/28/21, was a failed GDR of resident 7's Latuda. The DON stated the pharmacist would base the next GDR attempt off of the failed GDR and the most recent increase of the Latuda on 11/18/21. The DON stated that resident 7 would be discussed at the next psychotropic drug review on 8/11/22. [Note: A GDR must be attempted in 2 separate quarters, with at least 1 month between attempts, within the first year in which an individual was admitted on a psychotropic medication or after the facility had initiated such medication, and then annually. Resident 7's Latuda was initiated by the facility on 9/1/21.]

Based on observation and interview, it was determined, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with accepted professional principles, included the accessory and cautionary instructions and the expiration date when applicable, and were stored in locked compartments. Specifically, observations were made of medications left unattended on top of the medication cart and a medication was found available for use without an expiration date or dosage visible. Findings included: 1. On 8/3/22 at 7:59 AM, an observation was made of Licensed Practical Nurse (LPN) 1 during morning medication administration on the 300 hallway. LPN 1 was observed to leave the following medications unattended on top of the medication cart while inside a resident room; Meropenem 500 milligram intravenous, Combigan 0.2-0.5 % drops, Dorzolamide 2 % drops, and Prednisone acetate 1% drops. On 8/3/22 at 8:05 AM, upon return to the medication cart with LPN 1 the above medications were observed missing from the top of the cart. An immediate interview was conducted with Unit Manager (UM) 1 and LPN 1. UM 1 was standing next to the medication cart, and was asked where the missing medications were. UM 1 pulled the medications out from behind the medication cart where they were concealed. LPN 1 stated that she did not normally leave medication unattended on top of the cart, but she forgot this time. UM 1 confirmed that LPN 1 did not ask her to watch the medication for her prior to stepping away from the medication cart. 2. On 8/3/22 at 8:19 AM, the medication room for the 100 and 200 hallway was inspected with the Director of Nursing (DON). A bottle of Lorazepam was located inside the medication fridge. The medication bottle was observed missing part of the drug label, as if it had been wet and tore off. The medication label had the resident identification and drug name visible, but the dosage amount and expiration date were missing. The DON stated that there was no way to determine the expiration date or dosage of the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined, the facility did not provide the special eating equipment and utensils for residents who needed them. Specifically, for 1 out of 37 sampled residents, the facility did not provide the resident with weighted utensils to assist with dining. Resident identifier: 80. Findings included: Resident 80 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia, pulmonary hypertension, type 2 diabetes mellitus, cognitive communication deficit, adult failure to thrive, pulmonary hypertension, hypothyroidism, celiac disease, benign prostatic hyperplasia, morbid obesity, hyperlipidemia, disorder of phosphorus metabolism, hypomagnesemia, major depressive disorder, essential tremor, hypertension, and obstructive sleep apnea. On 8/1/22 at 9:24 AM, an interview was conducted with the Central Supply Manager (CSM). The CSM stated that resident 80 had refused his breakfast and was upset. The CSM stated that resident 80 required weighted utensils and they were not provided with his meal. The CSM stated that resident 80 reported that he has had this problem for months now. On 8/1/22 at 9:30 AM, a follow up interview was conducted with the CSM. The CSM stated she spoke with the Dietary Manager (DM) and the built up and weighted utensils looked the same. The CSM stated that the DM had said that she would provide the kitchen staff with education on the correct assistive device for resident 80. Resident 80 was observed informing Registered Nurse (RN) 2 that he had refused breakfast because he had not received the weighted utensils. RN 2 stated that she had informed the DM several times and has had to go and get resident 80's weighted utensils for him in the past. Resident 80 informed RN 2 that he did not have any insulin and his blood sugar was 107. Resident 80 informed RN 2 that the CSM had informed the DM of the utensil issue. Resident 80 was heard informing RN 2 that this had been going on for months. On 8/1/22 at 9:33 AM, an interview was conducted with resident 80. Resident 80 reported that he had not been receiving the weighted utensils with meals and that this had been going on for months. Resident 80 stated that he was so frustrated that the weighted utensils were not being provided from the kitchen, and that he needed these to eat due to his tremors. Resident 80 stated that he felt like his concerns were not being addressed. On 8/1/22, resident 80's medical record was reviewed. On 7/14/22, resident 80's diet orders were for a regular diet, regular texture, and thin liquids. The order did not state that resident 80 required any assistive devices for eating. Review of resident 80's progress notes revealed no documentation that resident 80 required weighted utensils or any other assistive device for eating. On 7/31/22 at 8:11 AM, the physician's note documented, . has had a decline in adl [activities of daily living] participation and has begun having a failure to thrive. Pt [patient] requires assist with adls due to tremors, safety, fatigue and weakness. No documentation was found in the progress note that indicated that resident 80 used any assistive devices for eating. On 3/25/22 at 1:28 PM, the nutritional assessment documented a diagnosis of adult failure to thrive. The assessment documented good oral intake of 76-100% of meals consumed. The assessment documented not applicable for adaptive devices. Review of resident 80's diet ticket documented under devices Weighted Utensils. Under the note section of the ticket it stated, WEIGHTED SILVERWARE (MAKE SURE THEY ARE WEIGHTED, NOT JUST BUILT UP). On 3/23/22, resident 80's admission Minimum Data Set (MDS) assessment documented that resident 80 was a setup with supervision assistance for eating. On 6/23/22, resident 80's quarterly MDS assessment documented that resident 80 was a setup with supervision assistance for eating. On 3/17/22, resident 80's Abnormal Involuntary Movement Observation (AIMS) documented that resident 80 had minimal upper extremity movements that included choreic movements, e.g. rapid, objectively purposeless, irregular spontaneous; athetoid movements, e.g. slow, irregular, complex and serpentine. The incapacitation's due to the abnormal movements were documented as minimal. The AIMS score was a 2 and the recommendation was to continue with the current plan of care. On 3/18/22, the occupation therapy (OT) evaluation documented a goal of therapy for resident 80 was Patient will safely perform self feeding tasks with SBA [stand by assist] with use of built-up and weighted spoon for grasp / release of items, for proper positioning during meals and for use of compensatory strategies in order to increase ability to eat in environment with minimal to no supervision or assistance needs. The assessment documented that resident 80 was a minimum assistance for the self feeding tasks. The assessment documented that resident 80's fine motor coordination was impaired. On 3/30/22, resident 80 was discharged from OT services and the summary documented that resident 80 was a modified independence for self feeding tasks. Review of resident 80's care plan for nutritional status documented that resident 80 was at risk for deficits secondary to failure to thrive, morbid obesity, diabetes, and the need for a therapeutic diet. Interventions identified for functional ability stated to provide assistance with meals as needed. No documentation was found that resident 80 required weighted utensils for eating. On 8/8/22 at 11:44 AM, an interview was conducted with the DM. The DM stated that there had been an influx of new staff in the last month and this had contributed to resident 80 not receiving the correct assistive device. The DM stated that she believed the kitchen staff were putting built up utensils instead of weighted utensils or they were not being provided at all on resident 80's meal trays. The DM stated that she now highlighted the meal ticket, asked the cooks to verify the weighted utensils were provided, and staff were circling it on the meal ticket. The DM stated that she had provided more staff education on resident 80's weighted utensils.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, the facility did not maintain records on each resident that were complete, accurately documented, and readily accessible. Specifically, for 2 out of 37 sampled residents, progress notes for a resident had notes from other residents located inside their medical record, and pharmacy monthly medication reviews were not located in the resident's medical record. Resident identifiers: 62 and 80. Findings included: 1. Resident 80 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia, pulmonary hypertension, type 2 diabetes mellitus, cognitive communication deficit, adult failure to thrive, pulmonary hypertension, hypothyroidism, celiac disease, benign prostatic hyperplasia, morbid obesity, hyperlipidemia, disorder of phosphorus metabolism, hypomagnesemia, major depressive disorder, essential tremor, hypertension, and obstructive sleep apnea. On 8/4/22, resident 80's progress notes were reviewed and the following inaccurate documentation was found: a. On 4/27/22 at 10:03 AM, the Nurse Practitioner (NP) note documented a full history and physical for a [AGE] year old female resident with a primary diagnosis of right femur fracture. The note also contained the female resident's first name. It should be noted that resident 80 was a [AGE] year old male resident. b. On 5/7/22 at 1:57 AM, the nursing note documented a female resident returned from the emergency department after a transfer for altered mental status. The female resident was diagnosed with a urinary tract infection and antibiotics were prescribed. It should be noted that resident 80 was a [AGE] year old male resident. On 8/9/22 at 8:11 AM and again at 9:24 AM, an interview was conducted with Corporate Resource Nurse (CRN) 1 and CRN 2. CRN 1 confirmed the progress notes located in resident 80's medical record were for other residents. CRN 2 stated that they were aware that the NP had been documenting in the wrong resident medical records. 2. Resident 62 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included non-ST elevation (NSTEMI) myocardial infarction, pneumonia, bipolar disorder, anxiety disorder, chest pain, hypotension of hemodialysis, end stage renal disease, congestive heart failure, gastro-esophageal reflux disease, hypothyroidism, paraplegia, morbid obesity, history of transient ischemic attack, pain, hyperlipidemia, type 2 diabetes mellitus, essential hypertension, pulmonary embolism, insomnia, major depressive disorder, colostomy, artificial opening of urinary tract, and pelvic inflammatory disease. On 8/2/22, resident 62's medical record was reviewed. Review of resident 62's monthly pharmacy medication reviews revealed missing documentation for the following months; August 2021, October 2021, November 2021, and February 2022. On 8/9/22 at 8:11 AM, an interview was conducted with the Director Of Nursing (DON). The DON stated that she called the pharmacy and obtained copies of the missing pharmacy reports for August 2021, October 2021, November 2021, and February 2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 8/8/22 at 12:15 PM, an interview with the Director of Maintenance (DOM) was conducted. The DOM stated that there were seven housekeepers employed at the facility, and five of those employees worked full time Monday through Friday. The DOM stated that each housekeeper was responsible for cleaning their assigned hallway. The DOM stated that rooms were cleaned every day except for the 100 hall which was skipped on Wednesdays, and rooms were only cleaned once on the weekends. The DOM stated that housekeepers were responsible for sweeping, mopping, emptying garbage, and cleaning the bathrooms of the rooms the housekeepers were assigned to clean. The DOM stated that if a housekeeper calls off work, the other housekeepers would work together to assure all the rooms were cleaned. The DOM stated that he was responsible for following up with grievances and resident council complaints regarding housekeeping issues. 5. On 8/1/22 at 12:34 PM, an interview was conducted with resident 62. Resident 62 stated that the weekend housekeeper was great, but during the week the housekeeper comes in maybe once. Resident 62's room was observed with many stacked storage bins and boxes of wound and urinary catheter supplies. The floor was observed with debris located around the bed. A concern form dated 5/11/22, from resident 62 documented Resident would like room swept and trash cans emptied daily/on regular basis by housekeeping. States that this is only happening 'maybe' weekly. The immediate action taken was the room swept and garbage emptied. The form documented that they spoke with resident 62 about requesting trash be emptied by Certified Nurse Assistance (CNAs) as needed. Resident was educated about potential difficulty for staff to properly clean due to extensive amount of personal belongings. Offered assistance to [name or resident 62 removed] to downsize to create improvement in her environment. The actions documented to prevent recurrence was Coordinated with DON [Director of Nursing] on their staff also. Reviewed with housekeeping about scheduled cleaning. Sweeping happens daily. Trashes emptied as needed by CNAs. 6. On 8/1/22 at 11:17 AM, an interview was conducted with resident 80. Resident 80 stated that his room was not cleaned over the weekend. Resident 80 stated that he emptied his own garbage today. An observation was made of food debris on the floor. Resident 80 stated that he was a messy eater due to his tremors and the room was not cleaned. Resident 80 stated that the bed linen was only changed when he received a shower. Resident 80 stated that with his delay in showers his linens were not changed timely or when they were soiled. Resident 80 stated that on two occasions he vomited and soiled his bed linen, and the linen was not changed for days resulting in the vomit drying on the linen. Resident 80 stated that when he vomited into the garbage can the bag was changed but the vomit on the inside of the can was not cleaned. The Resident Council Minutes dated 6/1/22, documented a new concern of Residents would like to know how often cleaning of rooms is supposed to be done and report that garbage in Day room [ROOM NUMBER] and the courtyard are not getting emptied regularly. The Resident Council Minutes dated 7/6/22, documented the department response to the June concern as Resident rooms are getting done everyday to every other day. Maintenance will ensure day room gets dumped more often. Maintenance is responsible for courtyard trash and will dump on regular basis. Based on observation and interview, it was determined, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, for 5 out of 37 sampled residents, resident rooms were observed to be unclean with debris on the floor. In addition, Hoyer lifts for resident care were observed to be soiled. Resident identifiers: 7, 19, 26, 62, and 80. Findings included: 1. On 8/1/22 at 8:31 AM, an observation was made on the 300 hallway of a dirty Hoyer lift. The Hoyer lift was outside of room [ROOM NUMBER] and the base of the Hoyer lift was observed soiled. On 8/1/22 at 9:02 AM, an observation was made on the 100 hallway of a dirty Hoyer lift. The Hoyer lift was observed to be stationed outside of resident room [ROOM NUMBER]. The base of the Hoyer lift was observed to be soiled. The daily shower log documented that the walkers and wheelchairs were scheduled to be cleaned on Monday, Wednesday, and Friday on the night shift for the 300 hallway. On 8/9/22 at 10:21 AM, an interview was conducted with Certified Nursing Assistant (CNA) 9. CNA 9 stated she was an agency CNA and was at the facility to do resident showers. CNA 9 stated she did not really know when to sanitize the equipment at the facility. CNA 9 stated that personally she would clean the Hoyer lift after she finished transferring and showering residents for the day. On 8/9/22 at 10:23 AM, and interview was conducted with CNA 5. CNA 5 stated she would sanitize the Hoyer lift when she was finished transferring her residents. On 8/9/22 at 10:26 AM, an interview was conducted with CNA 8. CNA 8 stated when she was finished transferring her residents, she would wipe down the Hoyer lift with bleach or sanitizing wipes. 2. On 8/1/22 at 9:00 AM, an observation of resident 19's room was conducted. Resident 19's room was observed to have debris on the floor near the bed. On 8/1/22 at 10:52 AM, an observation of resident 19's room was conducted. Resident 19's room was observed to have debris on the floor. On 8/2/22 at 1:11 PM. an observation of resident 19's room was conducted. Resident 19's room was observed to have debris on the floor. 3. On 8/1/22 at 9:14 AM, an interview was conducted with resident 7. Resident 7 stated that his room may go a couple days between cleanings and it would depended on the staff if his room was cleaned. Resident 7 stated that his motorized wheelchair had never been cleaned and resident 7 did not know that staff were suppose to clean his motorized wheelchair. Resident 7 stated he did not know if his motorized wheelchair needed to be cleaned. An observation of resident 7's room was conducted. Resident 7's room was observed to have debris on the floor around and under the bed. On 8/1/22 at 11:56 AM, an observation of resident 7's room was conducted. Resident 7's room was observed to have debris on the floor near the bed and the bedside table. On 8/2/22 at 1:11 PM, an observation of resident 7's room was conducted. Resident 7's room was observed to have debris on the floor near the bed and the bedside table. 4. On 8/1/22 at 11:56 AM, an observation of resident 26's room was conducted. Resident 26's room was observed to have debris on the floor. On 8/2/22 at 1:11 PM, an observation of resident 26's room was conducted. Resident 26's room was observed to have debris on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined, the facility did not ensure that residents who are unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, for 10 out of 37 sampled residents, residents who were dependent on staff for showers, did not receive showers on a consistent and regular basis. Resident identifiers: 19, 26, 29, 32, 54, 62, 63, 80, 81, and 84. Findings include: 1. Resident 29 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included acute respiratory failure with hypoxia, constipation, pain, hypoglycemia, essential hypertension, and hemiplegia, unspecified affecting unspecified side. On 8/2/22 at 9:31 AM, an interview was conducted with resident 29. Resident 29 stated he was dependent on staff for assistance with his activities of daily living (ADLs). Resident 29 stated he can not bathe, dress, or transfer himself without help. Resident 29 stated he cannot remember his shower days, but he thought his last shower was Friday. Resident 29 stated he thought next time he would get a bed bath because the facility did not have enough shower chairs that roll, and it was hard to get him into the chairs. An observation was made that resident 29's hair appeared greasy. On 8/2/22 at 1:32 PM, an interview was conducted with Certified Nursing Assistant (CNA) 5. CNA 5 stated there was a shower CNA, but CNAs still did showers. CNA 5 stated that the CNAs do not like to record the showers they gave on the shower sheet, especially the agency CNAs. CNA 5 stated they had a shower refusal form that must be completed when a resident refused to shower. CNA 5 stated the resident, the CNA, and the nurse must sign the refusal form. CNA 5 stated when the CNA competed a shower, they must fill out the shower sheet and record that a shower was given in the electronic health record (EHR). CNA 5 stated all CNAs including agency, received access to the EHR, but not many CNAs would chart in the EHR. An observation was made of the facility's Daily Shower Sheet for 8/1/22. It was observed that only one shower was given on that day and there was no documentation that resident 29 received a shower. On 8/8/22, a review of resident 29's medical record was completed. Resident 29's admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 29 required substantial/maximal assistance with showering/bathing. Resident 29's quarterly MDS assessment dated [DATE], documented that resident 29 was dependent with showering/bathing. Shower sheets documented that resident 29 received a bed bath on 6/1/22. Resident 29 did not receive another bed bath or shower until 7/27/22. The Point of Care History for bathing showed that resident 29 received a shower on 6/1/22 and a bed bath on 7/1/22. No other shower or bed bath was recorded from 6/1/22 through 8/8/22. Documentation in resident 29's medical record and facility shower sheets revealed that resident 29 went 20 days without a shower or bed bath from 6/10/22 through 6/30/22 and 25 days without a shower or bed bath from 7/1/22 through 7/26/22. 2. Resident 84 was admitted to the facility on [DATE] with diagnoses which included extended spectrum beta lactamase resistance, type 2 diabetes mellitus with diabetic neuropathy, non-ST elevation (NSTEMI) myocardial infarction, xerosis cutis, rheumatoid arthritis, dry eye syndrome, age-related physical debility, bipolar disorder, hypothyroidism, essential hypertension anxiety disorder, hyperlipidemia, muscle spasm, obesity, and primary generalized osteoarthritis. On 8/1/22 at 8:10 AM, an interview was conducted with resident 84. Resident 84 stated she was supposed to have a shower last Friday but did not get one. Resident 84 stated she was supposed to receive a shower today. Resident 84 stated she use to refuse showers on occasion but had not done so for a long time. Resident 84 stated she always takes what I can get. Resident 84 stated last week she talked to the CNA Coordinator who scheduled the showers and asked her if she were going to get a shower. Resident 84 stated the CNA Coordinator said no, they were only doing showers that were priorities. Resident 84 stated she said to the CNA Coordinator, am I not a priority? On 8/1/22 at 9:34 AM, an additional interview was conducted with resident 84 who stated I hope I get a shower today. I haven't washed my hair in two weeks. On 8/2/22 at 9:39 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated the shower schedule was that on Mondays, Wednesdays, and Fridays, residents in odd numbered rooms received showers. RN 2 stated that on Tuesdays, Thursdays, and Saturdays, residents in even numbered rooms received showers. [Note: resident 84 resided in an odd number room and was scheduled to receive showers on Mondays, Wednesdays, and Fridays.] On 8/2/22 at 1:11 PM, a follow-up interview was conducted with resident 84. Resident 84 stated she did not get a shower yesterday (Monday). Resident 84 stated yesterday she asked a CNA if there was a shower CNA and if she could get a shower. Resident 84 stated the CNA told her she did not know but would find out, but never came back to let her know. On 8/4/22 at 11:04 AM, a follow-up interview was conducted with resident 84. Resident 84 stated she did not get a shower yesterday (Wednesday). Resident 84 stated she asked the nurse if she would get a shower today (Thursday). Resident 84 stated the nurse told her she was not scheduled for a shower today but should get one tomorrow. On 8/3/22, a review of resident 84's medical record was completed. Resident 84's Quarterly MDS assessment dated [DATE], documented that resident 84 required substantial/maximal assistance to shower/bathe. The facility's Daily Shower Sheets from 6/25/22 through 8/1/22, documented that resident 84 received a shower on 6/30/22, refused a shower on 7/15/22, received a shower on 7/22/22, and received a bed bath on 7/27/22. Documentation recorded on the facility's Daily Shower Sheets revealed that resident 84 went 22 days without a shower from 6/30/22 to 7/22/22 and went 5 days without a shower or bed bath from 7/22/22 to 7/27/22. The facility's Daily Shower Sheets from 6/25/22 through 8/1/22 showed that resident 84 was not given a shower on the following days: 6/25/22, 6/28/22, 7/2/22, 7/7/22, 7/9/22, 7/11/22 (not on the schedule), 7/13/22, 7/18/22, 7/20/22, 7/29/22, and 8/1/22. On 8/4/22 at 9:34 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated the facility was very short staffed with CNAs. LPN 1 stated that because they were short staffed, the call lights go off longer than usual, residents miss baths, and resident care was not adequate. 3. Resident 63 was re-admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure, dysphagia, morbid obesity, gait and mobility abnormalities, type 2 diabetes, chronic kidney disease, polyneuropathy, dependence on respirator, and bipolar disorder. On 8/1/22 at 1:49 PM, an interview was conducted with resident 63. Resident 63 stated she was not getting showers and did not know when she was supposed to have them. Resident 63 also stated she did not know when her last shower was. On 8/2/22 at 1:06 PM, an interview was conducted with CNA 1. CNA 1 stated even numbered rooms were scheduled for showers on Monday, Wednesday, and Friday, and odd numbered rooms were scheduled for Tuesday, Thursday, and Saturday. CNA 1 stated there was a designated shower CNA at the facility from 6:00 AM to 2:00 PM or 6:00 AM to 6:00 PM, depending on the shift. CNA 1 stated if they don't show up then the responsibility goes to the CNA's. CNA 1 stated if the CNAs were overwhelmed the resident would not get showered that day and would be moved as an urgent shower for the next shower day. CNA 1 stated that may mean that the residents who did not get a shower on Monday get priority for showers on Wednesday, but other residents who were also scheduled may not get a shower if there was not enough staff or enough time.C NA 1 stated she was scheduled to work Monday through Friday, or full time, and probably two of the days she was scheduled to be a shower CNA during the week. CNA 1 stated she was pulled from her shower duties to work as a CNA most of the time because there were not enough staff to provide care for the residents. CNA 1 also stated that some of the shower CNAs would mark off that a resident got a shower when the resident did not so it looked like they got their work done. CNA 1 stated once the shower CNAs and CNAs had their care assignments completed, they would turn them in to the CNA Coordinator who entered the information into the computer in the resident's medical record. On 8/2/22, resident 63's medical record was reviewed. Resident 63's significant change Minimum Data Set (MDS) assessment dated [DATE], documented that resident 63 required 2 person physical assistance for bathing. Resident 63's quarterly MDS assessment dated [DATE], documented that resident 63 required extensive 1 person assistance for bathing. The Point Of Care history for bathing in May 2022 documented resident 63 received 2 showers, on 5/10/22 and 5/17/22. The Point of Care history for bathing in June 2022 documented that resident 63 received 5 showers, on 6/9/22, 6/13/22, 6/21/22, 6/23/22, and 6/30/22. The Point Of Care history for July 2022 documented that resident 63 received 3 showers, on 7/20/22, 7/21/22, and 7/24/22. The Daily Shower Sheets were reviewed for July 2022. Resident 63 was offered a shower on 7/2/22, and refused so it was given to the night (NOC) shift. No documentation was found that the shower was given on the NOC shift. The shower sheet also documented resident 63 was provided showers on 7/7/22, 7/14/22, 7/19/22 (as a priority), and 7/21/22. In summary, documentation for resident 63's showers revealed that resident went 7 days, from 6/30/22 to 7/7/22, without showering. Resident 63 went 7 days, between 7/7/22 and 7/14/22, without showering. Resident 63 went 5 days, between 7/14/22 and 7/19/22, without showering. Resident 63 also went 8 days, between 7/24/22 and 8/2/22, without being showered. The Point Of Care history for August 2022 documented that resident 63 received 3 showers, on 8/4/22, 8/6/22, and 8/8/22. The Daily Shower Sheets documented that resident 63 received a shower on 8/2/22. It also documented that resident 63 was due to receive an urgent shower on 8/4/22, however, the shower sheet was not completed for this resident and was not signed off that resident 63 was provided a shower. 4. Resident 54 was admitted to the facility on [DATE] with diagnoses which included fracture of right femur, anxiety disorder, gastro-esophageal reflux disease, cutaneous abscess of buttock, cutaneous abscess of left lower limb, pain, osteoporosis, dysphagia, acquired absence of left leg below knee, hypothyroidism, and presence of right artificial knee joint. On 8/1/22 at 2:38 PM, an interview was conducted with resident 54. Resident 54 stated they did not receive a shower last week. Resident 54 stated the facility did not have enough staff to assist with showers and incontinence care. On 8/2/22, resident 54's medical record was reviewed. On 6/7/22, resident 54's quarterly MDS assessment documented that resident 54 was a one person limited assist for personal hygiene. The MDS assessment documented under bathing self-performance and support provided that the activity did not occur. Resident 54's daily shower logs for June and July 2022 documented the following: a. On 6/9/22, resident 54 refused bathing assistance. b. On 6/11/22, a bed bath was provided. c. On 6/14/22, resident 54 refused bathing assistance. d. On 6/16/22, a bed bath was provided. e. On 6/18/22, a bed bath was provided. f. On 6/23/22, a bed bath was provided. It should be noted that 4 days lapsed since the last documented bed bath was provided. g. On 6/25/22, a shower was provided. h. On 6/30/22, a bed bath was provided. It should be noted that 4 days lapsed since the last documented shower was provided. i. On 7/9/22, a bed bath was provided. It should be noted that 8 days lapsed since the last documented bed bath was provided. j. On 7/20/22, a bed bath was provided. It should be noted that 10 days lapsed since the last documented bed bath was provided. k. On 7/22/22, resident 54 refused bathing assistance. l. On 7/29/22, a shower was provided. It should be noted that 6 days lapsed since the last documented bed bath was provided. Review of resident 54's care plan for ADL Function documented at risk for altered ADL function secondary to wounds, pain and impaired mobility. The interventions identified were for physical therapy (PT) and occupational therapy (OT) to work on increased functional abilities for toileting independence, and to encourage PT/OT services as prescribed. On 8/4/22 at 9:00 AM, an interview was conducted with CNA 5. CNA 5 stated that resident 54 was a one person assist for showers and that her shower schedule was every Monday, Wednesday, and Friday. CNA 5 stated that resident 54 preferred a bed bath. 5. Resident 62 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included non-ST elevation (NSTEMI) myocardial infarction, pneumonia, bipolar disorder, anxiety disorder, chest pain, hypotension of hemodialysis, end stage renal disease, congestive heart failure, gastro-esophageal reflux disease, hypothyroidism, paraplegia, morbid obesity, history of transient ischemic attack, pain, hyperlipidemia, type 2 diabetes mellitus, essential hypertension, pulmonary embolism, insomnia, major depressive disorder, colostomy, artificial opening of urinary tract, and pelvic inflammatory disease. On 8/1/22 at 12:04 PM, an interview was conducted with resident 62. Resident 62 stated that she had showers scheduled every other day on Monday, Wednesday, and Friday. Resident 62 stated that the last bath was offered at 5:00 PM after dialysis, but she refused due to being tired. Resident 62 stated that the shower schedule changed frequently. Resident 62 stated that she had one bed bath last week, but the schedule was for 3 days a week. Resident 62 stated that her preference was to have a bed bath 2 days a week and her hair washed one day a week. Resident 62 stated that she was not getting her bathing preferences met. Resident 62 stated, If you ask we don't have a shower aide, and the aides don't have time. On 6/2/22, resident 62's annual MDS assessment documented one person assist for personal hygiene, but that the activity had not occurred. The MDS assessment documented under bathing self-performance and support provided that the activity did not occur. Review of the shower logs revealed that resident 62 was scheduled for a shower/bath on Monday/Wednesday/Friday. On 7/1/22 at 5:24 PM, resident 62's Point Of Care history for showers documented a partial bed bath was provided. Resident 62's shower logs for June and July 2022 documented the following: a. On 6/10/22, a bed bath was provided. It should be noted that this was the first shower documented in June 2022. b. On 6/24/22, a bed bath was provided. It should be noted that 13 days lapsed since the last documented bed bath was provided. c. On 7/15/22, a partial bed bath was provided. It should be noted that 13 days lapsed since the last documented bed bath was provided. d. On 7/20/22 resident 62 refused any bathing assistance. e. On 7/22/22 resident 62 refused any bathing assistance. f. On 7/27/22, a bed bath was provided. It should be noted that 4 days lapsed since the last documented bed bath was provided. g. On 7/29/22, resident 62 refused any bathing assistance. Review of resident 62's care plan for ADL Function documented decreased mobility and functional abilities secondary to impaired mobility. Interventions identified were to engage resident 62 in therapeutic conversations - making needs known/understanding others/verbalizing own feelings/fears with guidance from the restorative nurse aide for 15 minutes per day for 2 to 3 times per week for 4 weeks. An additional intervention identified was for resident 62 to perform active range of motion exercises to the upper and lower body. On 8/3/22 at 10:05 AM, an interview was conducted with CNA 12. CNA 12 stated that the facility had shower CNAs that come from 6:00 AM to 2:00 PM. CNA 12 stated that the shower CNA would provide the daily showers based on the schedule in the shower book and each resident would have a minimum of 3 showers/baths per week. CNA 12 stated if a resident requested more than 3 showers a week they would fit it into the schedule. CNA 12 stated that sometimes the floor CNAs gave showers but most of the time it was the shower CNA. CNA 12 stated that if a resident did not get their scheduled shower they would try to do it the next day. CNA 12 stated that the shower CNA documented on the shower log if a resident was provided a shower. CNA 12 stated since it's really busy we do the best we can. CNA 12 stated that she did not check the shower log to see who was not showered and only provided a shower if asked by a resident. CNA 12 stated that she usually did not do showers, but if a resident said they did not get one she would inform the shower CNA. CNA 12 stated that usually the shower CNA or other CNAs were not pulled from their assignments. CNA 12 stated that resident 62 preferred bed baths and did not have any preferences with bathing. On 8/4/22 at 8:50 AM, an interview was conducted with CNA 5. CNA 5 stated that resident 62's bathing schedule was for bed baths on Tuesday, Thursday, and Saturdays and that resident 62 was a one person assistance for bathing. CNA 5 stated that resident 62 did not have any preferences for bathing. 6. Resident 80 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia, pulmonary hypertension, type 2 diabetes mellitus, cognitive communication deficit, adult failure to thrive, pulmonary hypertension, hypothyroidism, celiac disease, benign prostatic hyperplasia, morbid obesity, hyperlipidemia, disorder of phosphorus metabolism, hypomagnesemia, major depressive disorder, essential tremor, hypertension, and obstructive sleep apnea. On 8/1/22 at 9:33 AM, an interview was conducted with resident 80. Resident 80 stated that he had to wait 12 days in the past for a shower. Resident 80 stated that he had not received a shower since last Tuesday (7/26/22), and before that it was 12 days in between showers. Resident 80 stated that he use to receive one shower a week. Resident 80 stated that he needed assistance with bathing from the waist down and his back. On 8/1/22 at 11:21 AM, a follow-up interview was conducted with resident 80. Resident 80 stated that he had not received any assistance with brushing his teeth and nobody has ever helped me brush my teeth here. Resident 80 stated that with his tremor he injured the back of his throat and gums while brushing which caused him to bleed. On 8/2/22, resident 80's medical record was reviewed. Review of the quarterly MDS assessment dated [DATE], documented one person limited assistance for personal hygiene and self performance and support provided for bathing was documented as activity did not occur. On 6/17/22 at 2:36 PM, the Functional abilities assessment documented that resident 80 required partial/moderate assistance for oral hygiene, upper and lower body dressing, toilet transfer, and shower/bathing. Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. Review of the shower log revealed that resident 80 was scheduled for a shower/bath on Monday, Wednesday, and Friday. Resident 80's shower logs for June and July 2022 documented the following: a. On 6/10/22, resident 80 refused any bathing assistance. The note documented that resident 80 showered on 6/9/22. It should be noted that this was the first shower documented in June 2022. b. On 6/23/22 at 9:26 PM, resident 80's progress note documented that the resident refused any bathing assistance. It should be noted that 12 days lapsed since the last documented shower was provided. c. On 6/24/22, a bed bath was provided. d. On 7/1/22, a bed bath was provided. It should be noted that 6 days lapsed since the last documented bed bath was provided. e. On 7/11/22, a shower was provided. It should be noted that 10 days lapsed since the last documented bed bath was provided. f. On 7/20/22, a shower was provided. It should be noted that 8 days lapsed since the last documented shower was provided. g. On 7/27/22, a shower was provided. It should be noted that 6 days lapsed since the last documented shower was provided. Resident 80's Point Of Care history for oral hygiene from 6/1/22 to 8/3/22, documented the following: a. On 6/23/22 at 1:58 PM, the form documented not applicable. b. On 7/7/22 at 7:51 AM, the form documented independent. c. On 7/9/22 at 7:50 AM, the form documented set up or clean-up assistance. d. On 7/20/22 at 5:59 AM, the form documented set up or clean-up assistance. e. On 8/2/22 at 8:50 AM, the form documented set up or clean-up assistance. Review of resident 80's care plan for ADL Function documented at risk for altered ADL function secondary to obesity, failure to thrive, chronic obstructive pulmonary disease (COPD), and weakness. Interventions identified were to assist in completing ADL tasks each day and encourage independence, encourage PT/OT services as ordered, and encourage the use of call lights when ADL assistance was needed. On 8/4/22 at 8:46 AM, an interview was conducted with CNA 5. CNA 5 stated that resident 80 needed assistance with with showers, and was a standby/setup assist. CNA 5 stated that resident 80 did not need assistance with brushing his teeth. On 8/4/22 at 9:23 AM, an interview was conducted with RN 3. RN 3 stated that resident 80 was independent with ambulation, but had some trouble with ADLs due to tremors from hypomagnesemia. 7. Resident 81 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, atrial fibrillation, essential hypertension, abnormalities of gait and mobility, muscle weakness, major depressive disorder, and anxiety disorder. On 8/1/22 at 11:39 AM, an observation was conducted of resident 81. Resident 81 was observed in the bed wearing a hospital gown. Resident 81 was observed to have messy hair and appeared to be unshowered. Resident 81's medical record was reviewed on 8/4/22. A care plan Problem started on 10/8/20, documented Category: ADL Functional / Rehabilitation Potential [name of resident 81 removed] is at risk for altered ADL function secondary impaired mobility. A care plan Approach started on 5/20/21, documented Assist in completing ADL tasks each day. Provide dignity and respect, and encourage independence. A quarterly MDS assessment dated [DATE], documented that resident 81 required extensive assistance of one person for personal hygiene. The bathing activity itself did not occur during the entire period and required one person physical assistance. The Point of Care History and Daily Shower Sheets were reviewed for June, July, and August 2022. The following regarding bathing activity were documented: [Note: Resident 81 should have received bathing on Tuesday, Thursday, and Saturday of each week according to the room number.] a. On 6/1/22, a shower was provided b. On 6/3/22, Hospice provided bathing c. On 6/8/22, a shower was provided d. On 6/10/22, a shower was provided [Note: Resident 81 received bathing twice the week of 6/5/22.] e. On 6/13/22, Hospice provided bathing f. On 6/14/22, a bed bath was provided g. On 6/15/22, a shower was provided h. On 6/17/22, a shower was provided i. On 6/20/22, Hospice provided bathing j. On 6/22/22, a shower was provided k. On 6/25/22, a bed bath was provided l. On 6/29/22, a shower was provided m. On 7/1/22, a shower was provided [Note: Resident 81 received bathing twice the week of 6/26/22.] n. On 7/4/22, Hospice provided bathing o. On 7/6/22, a shower was provided p. On 7/9/22, a shower was provided q. On 7/13/22, a complete bed bath was provided r. On 7/15/22, a bed bath was provided s. On 7/16/22, a bed bath was provided t. On 7/18/22, a complete bed bath was provided u. On 7/20/22, a complete bed bath was provided v. On 7/23/22, a partial bed bath was provided w. On 7/25/22, a bed bath was provided x. On 7/28/22, Hospice provided bathing [Note: Resident 81 received bathing twice the week of 7/24/22.] y. On 8/1/22, Hospice provided bathing z. On 8/5/22, Hospice provided bathing [Note: Resident 81 received bathing twice the week of 7/31/22.] On 8/8/22 at 11:27 AM, an interview was conducted with CNA 14. CNA 14 stated that resident 81 was on hospice and the hospice CNA would come to the facility a few days a week. CNA 14 stated that the hospice CNA would give resident 81 a bed bath or shower depending on how the resident 81 felt. CNA 14 stated that the H on the Daily Shower Sheet indicated that resident 81 was on hospice. CNA 14 stated the regular hospice CNA would sign off bathing on the Daily Shower Sheet. CNA 14 stated the facility had shower schedules in the shower book for even and odd days and sometimes the hospice showers did not line up with those days. 8. Resident 19 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, abnormalities of gait and mobility, generalized anxiety disorder, muscle weakness, morbid obesity due to excess calories, personality disorder, major depressive disorder, and pain. On 8/1/22 at 10:55 AM, an observation was conducted of resident 19. Resident 19 was observed in the wheelchair and resident 19's hair was observed to be messy and appeared to be greasy. Resident 19's medical record was reviewed on 8/4/22. A care plan Problem started on 8/2/22, documented Category: ADL Functional / Rehabilitation Potential [name of resident 19 removed] is at risk for altered ADL function secondary to Muscle weakness, abnormalities to gait, debility. A care plan Approach started on 8/2/22, documented Assist in completing ADL tasks each day. Provide dignity and respect, and encourage independence. A quarterly MDS assessment dated [DATE], documented that resident 19 required extensive assistance of one person for personal hygiene. The bathing activity itself did not occur during the entire period and required one person physical assistance. The Point of Care History and Daily Shower Sheets were reviewed for June, July, and August 2022. The following regarding bathing activity were documented: [Note: Resident 19 should have received bathing on Monday, Wednesday, and Friday of each week according to the room number.] a. On 6/2/22, a complete bed bath was provided b. On 6/9/22, a bed bath was provided [Note: Resident 19 received bathing once the week of 6/5/22, and went 7 days between bathing.] c. On 6/14/22, a bed bath was provided d. On 6/16/22, a bed bath was provided e. On 6/18/22, a partial bed bath was provided f. On 6/23/22, a bed bath was provided g. On 6/25/22, a bed bath was provided [Note: Resident 19 received bathing twice the week of 6/19/22.] h. On 6/30/22, a partial bed bath was provided i. On 7/2/22, a shower was provided [Note: Resident 19 received bathing twice the week of 6/26/22.] j. On 7/9/22, a shower was provided [Note: Resident 19 received bathing once the week of 7/3/22, and went 7 days between bathing.] k. On 7/14/22, refused [Note: Resident 19 received was offered bathing once the week of 7/10/22, and went 5 days between bathing being offered.] l. On 7/20/22, a bed bath was provided m. On 7/22/22, a bed bath was provided [Note: Re[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 8/3/22 at 10:04 AM, an interview was conducted with Activities Assistant (AA) 1 and AA 2. AA 1 and AA 2 stated the facility was so short staffed that they had to use a lot of agency staff. AA 2 stated she worked on Sunday, and they were very short staffed. AA 1 and AA 2 stated that at the all-staff meetings they have talked about how everyone could help out. AA 1 stated anyone could answer a call light and get water, a blanket, or pick something up off the floor for a resident. AA 1 and AA 2 stated the facility wanted all departments to work together to help the residents. AA 1 and AA 2 stated the activities department passed out dietary menus, assisted with meal trays, and passed out alternate meal menus. AA 1 and AA 2 stated the facility was so short-handed with CNAs. AA 1 stated the residents know they were short staffed, that it was not a secret. AA 1 stated the residents got really upset because they had to sit in soiled briefs for long periods of time and they did not like it. AA 2 stated the residents got upset that they did not get their meal trays on time. AA 2 stated when all department helped, the residents could see they were trying. On 8/4/22 at 9:34 AM, an interview conducted with LPN 1. LPN 1 stated staffing was okay with nurses, but the facility was very short staffed with CNAs. LPN 1 stated because they were short staffed and the call lights go off longer than usual, residents missed baths, and resident care was not adequate. LPN 1 stated she would help answer call lights when she had time. On 8/4/22 at 9:50 AM, an interview was conducted with CNA 13. CNA 13 stated that from what she knew, the facility was very short staffed. CNA 13 stated currently there were only 1 to 2 people working who were employed by the facility and the rest were agency. CNA 13 stated she could get her work done but it took longer to answer the call lights. CNA 13 stated other people were willing to help at times. On 8/4/22 at 10:08 AM, an interview was conducted with CNA 10. CNA 10 stated that staffing at the facility varied. CNA 10 stated when they were short staffed, everyone worked together to get things done. CNA 10 stated she was the shower CNA for today and had only completed 3 showers so far. CNA 10 stated she might be able to get all the assigned showers completed today, but it depended on the residents, the halls, and what has happened in the facility. CNA 10 stated if she could not get all the showers finished, the other CNAs should help. CNA 10 stated showers were not provided during mealtime, so she helped pass out trays and charted during those times. On 8/8/22 at 10:18 AM, an interview was conducted with the Director of Nursing (DON). The DON stated staffing was determined using the census and acuity of the residents and the nursing hours allotted per patient/resident day(PPD). The DON stated, each building was a little bit different. The DON stated when scheduled staff call out, she would send out urgent requests to agencies and staff for replacement. The DON also stated that management would fill in. The DON stated family and residents were encouraged to bring up concerns about staffing or anything else. The DON stated the CNA coordinator was responsible for assuring that staff were appropriately assigned to meet the resident's needs. The DON also stated that all staff were encouraged to ask for help if they had questions, and that there were CNA trainers, who were regular staff and agency staff who had worked in the facility, that were available to assist. The DON stated the facility was contracted with staffing agencies that were able to provide staff when needed. The DON stated, in-services for facility staff were ongoing and if someone was unsure about what they needed to do someone would train them on the spot. The DON stated that agencies frequently requested that their agency staff train other agency staff. The DON stated new CNAs or agency staff received 6 days of training on the floor before being by themselves. Regarding CNA staff who care for ventilator and tracheostomy residents, the DON stated that a respiratory therapist helped to train those CNAs . The DON stated ideally, the facility have their own trained staff to work with tracheostomy and ventilator residents. The DON stated the Director of Respiratory Therapy did orientation for staff about respiratory patients. On 8/8/22 at 11:44 AM, an interview was conducted with CNA 6. CNA 6 stated staffing in the facility depended on the day. CNA 6 stated today they do not have enough staff and it would have been better if there were more CNAs. CNA 6 stated she had been working at the facility less and less because they did not have enough CNAs. CNA 6 stated work was hard when there were not enough CNAs. CNA 6 stated the facility had a lot of residents that needed a lot of attention. On 8/9/22 at 8:54 AM, an interview was conducted with the Administrator. The Administrator stated that facility staffing was a twenty four hour job. The Administrator stated that staffing was based upon operational budget, PPD, census, and resident acuity level. The Administrator stated that nurse management were on call to cover empty shifts. The Administrator stated that she has had to get creative and expected everyone to work the floor but within their scope of practice. The Administrator stated that as a team they ensure that the needs of the residents were met. The Administrator stated that long call light times have been a concern and she has had a lot of involvement with the Ombudsman regarding call light response times. The Administrator stated that call light response time was not well defined and all based on perspective. 7. On 8/1/22 at 7:42 AM, an observation was made of room [ROOM NUMBER]'s call light on and the resident was heard yelling help. At 7:52 AM, staff answered room [ROOM NUMBER]'s call light. The call light was activated for 10 minutes 8. On 8/1/22 at 8:47 AM, an observation was made of the call light being activated for resident room [ROOM NUMBER]. A nurse and 2 student nurses were standing outside of resident room [ROOM NUMBER] at the medication cart. On 8/1/22 at 9:00 AM, a staff member was observed to answer the call light. The call light was activated for 13 minutes. 9. On 8/1/22 at 10:26 AM, an observation was made of the call light being activated for resident room [ROOM NUMBER]. On 8/1/22 at 10:34 AM, a resident in room [ROOM NUMBER] was heard to say I need help. On 8/1/22 at 10:35 AM, a resident in room [ROOM NUMBER] was heard to say I need help. On 8/1/22 at 10:36 AM, a resident in room [ROOM NUMBER] was heard to say I need help. On 8/1/22 at 10:37 AM, a resident in room [ROOM NUMBER] was heard to say I need help. On 8/1/22 at 10:44 AM, a resident in room [ROOM NUMBER] was heard to say I need help. On 8/1/22 at 10:45 AM, a staff member was observed to answer the call light. The call light was activated for 19 minutes. [Note: Resident room [ROOM NUMBER] was located next to the nurse's station. A nurse and 2 student nurses were observed standing outside of resident room [ROOM NUMBER] at the medication cart.] 10. On 8/1/22 at 10:37 AM, an observation was made of the call light being activated for resident room [ROOM NUMBER]. On 8/1/22 at 10:56 AM, a staff member was observed to answer the call light. The call light was activated for 19 minutes. 11. On 8/4/22 at 9:21 AM, an observation was made of the call light being activated for resident room [ROOM NUMBER]. On 8/4/22 at 9:33 AM, a staff member was observed to answer the call light. The call light was activated for 12 minutes. 12. The Resident Council notes dated 7/6/22, were reviewed. The notes documented the CNA concerns identified in June 2022 as Residents report that call light response times have increased with some staff noted to stay at nurse's stations when call lights are going off. Residents report that baths are being missed and believe that it may be when shower aides are 'pulled to cover the floor'. Residents are requesting shower aides. The action documented as taken was to encourage staff to answer lights in a timely manner and maintain resident safety. Education was provided to all CNAs that they should still be doing baths regardless of shower CNAs and not to just document refused. The notes documented that shower CNAs were scheduled when staffing allowed. The notes documented new concerns that were identified as Resident voiced concerns regarding staffing, turnover, resident reports of agency staff not showing, and reports of current staff discouraging students from coming to work here. Resident voiced concerns regarding call lights: staff answering and stating that 'I'll be back' and then not returning/staff answering call lights without completing task before leaving room. Residents voiced concerns regarding showers and refusals - stating that some staff are discouraging showers or times, saying that they don't have washcloths for them, residents voiced concerns that staff may be signing off refusals when there hasn't been a refusal, reports of aides telling residents 'no' or that they are short staffed. Nursing concerns documented for June 2022 that agency nurses were missing cares, delivering medications later, and sometimes missing medications. The action documented as taken was to ask the residents to be patient with medication administration and if they notice a medication was missing to ask for it. On 8/1/22 at 8:31 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that she had one CNA working on the 400 hallway. RN 2 stated that the hallway assignments had been redistributed so that each nurse had 22 to 24 residents each. On 8/2/22 at 1:06 PM, an interview was conducted with CNA 1. CNA 1 stated there was a designated shower CNA at the facility between 6:00 AM and 2:00 PM or 6:00 AM and 6:00 PM, depending on the shift. CNA 1 stated if the shower CNA did not show up then the responsibility goes to the CNA's. CNA 1 stated if the CNAs were overwhelmed the resident would not get showered that day and would be moved as an urgent shower for the next shower day. CNA 1 stated that may mean that the residents who did not get a shower on Monday get priority for showers on Wednesday, but other residents who were also scheduled may not get a shower if there was not enough staff or enough time. CNA 1 stated she was scheduled to work Monday through Friday or full time, and probably 2 of the days was scheduled to be a shower CNA during the week. CNA 1 stated she got pulled from providing showers to work as a CNA most of the time because there were not enough staff to provide care for the residents. On 8/2/22 at 1:48 PM, an interview was conducted with CNA 3. CNA 3 stated he worked corporate for the long term care facility and traveled to different facilities to fill in if there were staffing problems. CNA 3 stated he received text messages regarding where help was needed. CNA 3 stated that when agency staff did not show up, or there was a lack of agency staff available, he was able to come. On 8/3/22 at 7:44 AM, an interview was conducted with CNA 15. CNA 15 stated if a resident did not get showered due to a refusal or the CNA was not able to get to the resident then the resident became a priority shower. CNA 15 stated if the resident was highlighted or starred on the Daily Shower Sheet the resident was a priority to be showered. CNA 15 stated if the resident was a priority to be showered the resident would be the first person the shower CNA would speak with. CNA 15 stated she would talk to the priority residents when she started her shift and would come up with a plan for their shower. CNA 15 stated that some residents refuse to be showered by agency. CNA 15 stated the facility was short staffed and it would all depend on the day if tasks were completed. On 8/3/22 at 7:44 AM, an interview was conducted with CNA 16. CNA 16 stated it would depend on the day if there were enough CNAs. CNA 16 stated that most of the time agency staff were assigned to be the shower CNA. CNA 16 stated that agency do not do much but show up for a pay check. CNA 16 stated that two agency CNAs were amazing. CNA 16 stated if the agency CNA did not shower the resident then the resident did not get showered or the resident would become a priority shower. CNA 16 stated that he would try to call out the agency CNA staff when they were not caring for the residents but it would become a shouting match and that was not productive. On 8/3/22 at 8:30 AM, an interview with CNA 2 was conducted. CNA 2 stated that the facility was sometimes short staffed. CNA 2 stated that she was able to get her work done except for the days when the facility was short staffed. On 8/3/22 at 8:35 AM, an interview with Licensed Practical Nurse (LPN) 1 was conducted. LPN 1 stated that she felt like the CNA's were understaffed. LPN 1 stated that sometimes resident showers were missed due to the facility being short on CNA's. On 8/3/22 at 9:09 AM, an interview was conducted with CNA 10. CNA 10 stated she was an agency CNA and came to the facility a lot. CNA 10 stated she mostly worked the day shift and had worked on both sides of the building. CNA 10 stated orientation and training for agency staff was provided by another agency staff member. On 8/3/22 at 9:24 AM, an interview was conducted with Unit Manager (UM) 2. UM 2 stated the Assistant Director of Nursing (ADON), scheduling staff and unit managers worked together to come up with a plan regarding how many staff were needed to care for the resident census. UM 2 stated the ADON did a lot of the agency outreach for staffing. UM 2 stated if the facility was short on CNAs, the unit managers would get out on the floors to help. UM 2 stated agencies had a lot of staff because they pay a little better. UM 2 stated the facility has had a decent amount of staff from agency. UM 2 stated agency staff trained with other agency staff, or the CNA coordinator would train them over a few days. On 8/3/22 at 9:42 AM, an interview was conducted with CNA 4. CNA 4 stated she was responsible for 9 to 15 or 16 residents when working the day shift and 12 to 18 residents when working the night shift. CNA 4 stated when fully staffed she felt she had enough time to complete her tasks. CNA 4 stated it was less frequent that the facility was fully staffed as they had a lot of staff leave within the last 2 weeks. CNA 4 also stated that sometimes the staff coming for the next shift would come in late so she had to stay late to provide her report. CNA 4 stated she had not been asked to extend her shift. CNA 4 stated that some of her tasks included taking vital signs, providing ice water to residents, helping with transfers, providing activities of daily living (ADL's), passing meal trays, and occasionally taking residents outside if they were dependent and requested to go outside. CNA 4 stated she did not have enough time to complete the tasks she was responsible for if there was not a shower CNA to do showers. CNA 4 stated if a resident asked for a shower or told her they did not get one on their last shower day she had to make giving the shower a priority. CNA 4 stated that residents who were supposed to get a shower sometimes had to wait. 4. On 8/1/22 at 1:00 PM, an interview with resident 52's family member was conducted. Resident' 52's family member stated that he came to visit almost every day. Resident 52's family member stated that the facility was not properly staffed. Resident 52's family member stated that he had witnessed call lights taking 30 to 45 minutes to get answered. 5. On 8/1/22 at 1:20 PM, an interview with resident 121 was conducted. Resident 121 stated that it often felt like the facility was short staffed. Resident 121 stated that it sometimes would take facility staff an hour to answer call lights. 6. On 8/1/22 at 2:38 PM, an interview was conducted with resident 54. Resident 54 stated they did not get a shower last week. Resident 54 stated that the facility did not have enough staff, specifically Certified Nursing Assistants (CNAs), and she has had to wait for 2 hours for toileting assistance. Resident 54 stated that she had a bowel movement and sat in it for 2 hours, date and time unknown. [Cross Reference F677] On 8/4/22 at 9:00 AM, an interview was conducted with CNA 5. CNA stated that resident 54 was a one person assist for transfers and showers. CNA 5 stated that resident 54 required standby assistance to the bathroom, and that the resident wore a brief. CNA 5 stated that resident 54 was not on any toileting program, and would inform them if she wanted to go to the toilet. CNA 5 stated that resident 54 was incontinent of urine and stool. Based on observation, interview, and record review, it was determined, the facility did not have sufficient nursing staff with the appropriate competencies and skill set to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessment and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Specifically, for 6 out of 37 sampled residents, resident showers were not being completed due to staffing, complaints from residents regarding staffing and not receiving cares, and long call light times were observed. Resident identifiers: 7, 32, 40, 52, 54, and 121. Findings included: 1. On 8/1/22 at 9:08 AM, an interview was conducted with resident 7. Resident 7 stated the facility was short staffed at night. Resident 7 stated there were three staff for the entire facility. On 8/1/22 at 12:41 PM, a follow up interview was conducted with resident 7. Resident 7 stated that the facility did not always have this much help. Resident 7 stated the staff had increased because survey was in the facility. [Cross Reference F677] 2. On 8/1/22 at 9:20 AM an interview with resident 40 was conducted. Resident 40 stated that staff took an hour or longer to answer her call light. Resident 40 stated that she has had to wait on the toilet for an hour for a staff member to answer the call light and help her get up from the toilet and back to bed. Resident 40 stated that call lights were not being answered timely due to the facility being short staffed. 3. On 8/1/22 at 12:11 PM, an interview was conducted with resident 32. Resident 32 stated that if she pushed the call light button and fell asleep while waiting for staff to respond, the staff would just come in and turn off the call light without waking her to see what she needed. Resident 32 stated that her roommate and herself were not getting their showers. Resident 32 stated that they were not bathed on this past Friday, 7/29/22. Resident 32 stated they were not getting their showers because there was not enough staff. [Cross Reference F677]

Based on interview and record review, it was determined, the facility did not ensure that the Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of action to correct identified quality deficiencies. Specifically, the facility was found to be in non-compliance with F584, and F880 which were cited within the facility's 2020 recertification survey. In addition, the facility was found to be in non-compliance with F758 and F761 which were cited within the facility's 2017, 2019, and 2020 recertification survey. Findings included: An annual recertification survey was completed on 10/16/17. The following deficiencies included, but not limited to, F329 (F758) and F431 (F761). An annual recertification survey was completed on 1/10/19. The following deficiencies included, but not limited to, F758 and F761. An annual recertification survey was completed on 2/10/20. The following deficiencies included, but not limited to, F584, F758, F761, and F880. 1. Based on observation and interview, it was determined, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, for 5 out of 37 sampled residents, resident rooms were observed to be unclean with debris on the floor. In addition, Hoyer lifts for resident care were observed to be soiled. Resident identifiers: 7, 19, 26, 62, and 80. [Cross Reference F584] 2. Based on interview and record review, it was determined, the facility did not ensure that a resident who used psychotropic drugs was not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. Residents who use psychotropic drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Specifically, for 1 out of 37 sampled residents, a resident received one GDR on an antipsychotic medication for bipolar disorder that was initiated by the facility on 9/1/21. Resident identifier: 7. [Cross Reference F758] 3. Based on observation and interview, it was determined, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with accepted professional principles, included the accessory and cautionary instructions and the expiration date when applicable, and were stored in locked compartments. Specifically, observations were made of medications left unattended on top of the medication cart and a medication was found available for use without an expiration date or dosage visible. [Cross Reference F761] 4. Based on observation and interview, it was determined, the facility did not maintain an infection prevention and control program to help prevent the development and transmission of communicable disease and infections. Specifically, for 1 out of 37 sampled residents, facility staff were observed entering resident rooms on transmission based precautions without donning the appropriate personal protective equipment (PPE) and hand sanitizing. In addition, facility staff were observed using a vital signs machine for multiple residents without sanitizing it between uses. Resident identifiers: 59. [Cross Reference F880] On 8/9/22 at 8:48 AM, an interview was conducted with the Administrator. The Administrator stated the QAA committee members included the Medical Director (MD), the MD for the Ventilator Tracheostomy unit, Administrator, Director Of Nursing, Assistant Director Of Nursing, nurse managers, Minimum Data Set coordinator, activities, Certified Dietary Manager, social workers, maintenance directors, Director of Rehabilitation, Certified Nursing Assistant coordinator and staff development, and medical records. The Administrator stated the facility was a data driven Quality Assurance and Performance Improvement team. The Administrator stated that concerns were identified through quality measures, hospital rates, infection rates, falls, qualitative feedback from customer service, resident council, and the grievance log. The Administrator stated the team would watch for anything that was trending to the negative or identified areas that they could make improvements. The Administrator stated that the team would review the previous months minutes and identity the top three priorities month to month.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. On 8/1/22 at 9:07 AM, observations were made of CNA 7 obtaining vital signs on residents. CNA 7 was observed to not sanitize the vital signs machine or perform hand hygiene before she entered room [ROOM NUMBER]. CNA 7 was observed to obtain vital signs from both residents in room [ROOM NUMBER] but did not sanitize the vital signs machine or perform hand hygiene between resident use. CNA 7 was observed to not sanitize the vital signs machine or perform hand hygiene prior to or after exiting room [ROOM NUMBER]. CNA 7 was observed to not sanitize the vital signs machine or perform hand hygiene before she entered room [ROOM NUMBER]. CNA 7 was observed to obtain vital signs from both residents in room [ROOM NUMBER] but did not sanitize the vital signs machine or perform hand hygiene between resident use. CNA 7 was observed to not sanitize the vital signs machine or perform hand hygiene prior to or after exiting room [ROOM NUMBER]. CNA 7 was observed to not sanitize the vital signs machine or perform hand hygiene before she entered room [ROOM NUMBER]. CNA 7 was observed to obtain vital signs from both residents in room [ROOM NUMBER] but did not sanitize the vital signs machine or perform hand hygiene between resident use. CNA 7 was observed to not sanitize the vital signs machine or perform hand hygiene prior to or after exiting room [ROOM NUMBER]. On 8/1/22 at 9:25 AM, an interview was conducted with CNA 7. CNA 7 stated she was from an agency and today was her first day at the facility. CNA 7 stated she was notified when she arrived at the facility that she was required to wear eye protection and a N95 mask. CNA 7 stated she did not know why she was required to wear the PPE she was instructed to wear. CNA 7 stated to prevent the spread of infection she always washed her hands, sanitized equipment between every resident interaction, wore a mask, and used standard precautions. On 8/9/22 at 10:21 AM, an interview was conducted with CNA 9. CNA 9 stated she worked for an agency and was here to do resident showers. CNA 9 stated she did not know when the equipment used by the residents (vital signs machine, Hoyer lift, shower chair) needed to be sanitized. On 8/9/22 at 10:23 AM, an interview was conducted with CNA 5. CNA 5 stated she sanitized the equipment used by the residents after she finished assisting the residents. CNA 5 stated that for example, she sanitized the vital signs machine after she finished obtaining the vital signs for all her residents. On 8/9/22 at 10:26 AM, an interview was conducted with CNA 8. CNA 8 stated she obtained all the vital signs for all her assigned residents then when she was finished, she wiped down the vital signs machine with a sanitizing wipe before she plugged it in to charge. Based on observation and interview, it was determined, the facility did not maintain an infection prevention and control program to help prevent the development and transmission of communicable disease and infections. Specifically, for 1 out of 37 sampled residents, facility staff were observed entering resident rooms on transmission based precautions without donning the appropriate personal protective equipment (PPE) and hand sanitizing. In addition, facility staff were observed using a vital signs machine for multiple residents without sanitizing it between uses. Resident identifiers: 59. Findings include: 1. Resident 59 was admitted to the facility on [DATE] with diagnoses which included polyneuropathy, lymphedema, type 2 diabetes mellitus, major depressive disorder, anxiety disorder, hypothyroidism, peripheral vascular disease, and essential hypertension. On 8/1/22, resident 59's medical record was reviewed. A progress note dated 7/25/22, documented by nursing staff revealed that resident 59 tested positive for Coronavirus Disease 2019 on 7/25/22. The progress note documented, Resident going to room [ROOM NUMBER] for droplet isolation precautions per facility protocol. On 8/1/22 at 12:30 PM, an observation was conducted of the door to resident 59's room. The door was closed and had signed which documented Droplet Precaution with information on the PPE required to enter the room. The sign documented that a mask, glove, a gown, and eye protection were necessary to enter the room. On 8/1/22 at 12:50 PM, an observation was conducted of Certified Nursing Assistant (CNA) 1 entering resident 59's room. CNA 1 entered resident 59's room with eye protect and a N95 face mask on, however CNA 1 did not put on gloves or a gown. On 8/1/22 at 12:53 PM, CNA 1 was observed to exit resident 59's room and CNA 1 sanitized her hands. On 8//1/22 at 12:54 PM, an interview with CNA 1 was conducted. CNA 1 stated that she did not know why resident 59 was on droplet isolation precautions. CNA 1 stated that if a person wanted to enter resident 59's room, they would need eye protection, a mask, and gloves. 2. On 8/1/22 at 8:59 AM, an observation was made of Registered Nurse (RN) 1 and Nursing Student (NS) 1 exiting resident room [ROOM NUMBER] which had signage on the door indicating the resident was on droplet precautions. Door signage also included instructions for donning appropriate PPE and doffing PPE. Both nurses were observed not to sanitize their eye protection after exiting the room. An interview was conducted with RN 1. RN 1 stated that Centers for Disease Control and Prevention guidelines, for residents on quarantine, required staff to don a mask, eye protection, a gown, and gloves before entering a room, and doff the gown and gloves when exiting the room. RN 1 also stated staff should perform hand hygiene after exiting and sanitize the eye protection. RN 1 stated both staff should have sanitized their eye protection and they did not. 3. On 8/2/22 at 9:28 AM, CNA 1 was observed to enter resident room [ROOM NUMBER], where the resident was on contact precautions for a multi-drug resistant organism wound. CNA 1 was observed to sanitize her hands before entering the resident's room, assisted the resident from her wheelchair to her bed while holding the resident's gown closed, and helped the resident position herself in bed. CNA 1 then exited the room and sanitized her hands. An interview was conducted with CNA 1. CNA 1 stated contact precautions required a gown and gloves while changing briefs. CNA 1 also stated that if she was just assisting the resident, she only needed to sanitize her hands. 4. On 8/2/22 at 12:59 PM, CNA 1 was observed entering resident room [ROOM NUMBER], where the resident was newly admitted and on droplet precautions. CNA 1 was wearing a N95 mask and eye protection. CNA 1 donned a gown and gloves and entered the room. At 1:06 PM, CNA 1 exited the room with the resident's meal tray. CNA 1 had doffed the gown and gloves inside the resident's room. CNA 1 was observed not to sanitize her hands or eye protection after exiting the resident's room. 5. On 8/3/22 at 8:28 AM, an observation was made of UM 3 entering resident room [ROOM NUMBER], where the resident was newly admitted and on droplet precautions. UM 3 was wearing a N95 mask and eye protection before donning a gown and gloves and entering the room. At 8:42 AM, an observation was made of UM 3 exiting room [ROOM NUMBER] carrying a bag that appeared to contain PPE in it, a bag that appeared to contain a soiled brief, and the resident's meal tray. UM 3 was observed not to sanitize his hands or his eye protection upon exiting the resident's room. 6. On 8/8/22 at 11:29 AM, an observation was made of RN 4 entering resident room [ROOM NUMBER], where the resident was newly admitted and on droplet precautions due to not having an updated vaccination status. Nursing Student (NS) 1 was observed to already be in the resident's room trying to assist the resident. RN 4 was observed to be wearing a N95 mask and eye protection but did not don a gown and gloves prior to entering the room. At 11:30 AM, RN 4 was observed to walk back to the doorway of the resident's room and obtain a gown and gloves to don while in the resident's room. On 8/2/22 at 9:19 AM, an interview was conducted with Unit Manager (UM) 2. UM 2 stated when a resident was no longer on isolation, the signs were removed from the doors and staff would then know that additional PPE was no longer needed. UM 2 also stated management had to constantly educate agency staff about who is on what, regarding the type of precautions different residents were isolating under. On 8/3/22 at 8:04 AM, an interview was conducted with UM 2. UM 2 stated for residents on contact precautions, staff were only required to put on gown and gloves if they had significant contact with the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 1 of 45 sampled residents, that the facility did not determine that the right to self-administer medications was safe and clinically appropriate. Specifically, a resident was observed to self administer insulin incorrectly and the entire dose was not dispensed. Resident identifier: 7. Findings include: Resident 7 was admitted to the facility on [DATE] with diagnoses which included urinary tract infection, altered mental status, acute kidney failure, type 2 diabetes mellitus, metabolic encephalopathy, and gastro-esophageal reflux disease. On 2/6/20 at 9:15 AM, Registered Nurse (RN) 5 was observed to prepare and administer medications to resident 7. RN 5 obtained resident 7's Lantus insulin pen from the medication cart. RN 5 dialed the pen to dispense 65 units and then gave the pen to resident 7 to self administer. Resident 7 was observed to press the tip of the pen to the abdomen while pressing the plunger of the pen. Resident 7's hands were observed to shake during the self administration of the insulin. Upon completion of the medication administration resident 7's abdomen was observed wet with liquid on it. On 2/6/20 at approximately 9:20 AM, an interview was conducted with RN 5. RN 5 stated that resident 7 did not administer the full dose of insulin, and that she had wiped a lot of the medication away on the skin. RN 5 stated that the injection was not completely given due to resident 7's hands shaking. RN 5 stated that resident 7 would need to be re-evaluated for self administration of the medication, and that she was not sure if resident 7 had the evaluation in place currently. RN 5 was observed to check resident 7's orders and stated that resident 7 did not have an order to self administer medications. RN 5 further stated that there was no documentation of an evaluation to self administer medications. Resident 7's medical record was reviewed and the medications were reconciled. A physician order initiated on 8/9/19, documented that resident 7 was to receive Insulin Glargine (Lantus), inject 65 units subcutaneous daily in the morning. The order did not document self administration of the medication by resident 7. Resident 7's assessments and care plans were reviewed and no documentation could be found of a self administration evaluation. Review of the facility policy and procedure for Medication Pass Protocol stated, 19. Self Administration of drugs is permitted when the resident is able to successfully pass the Self Administration Assessment, an order is obtained by the physician and proper storage of medications is provided. On 2/6/20 at 12:05 PM, a follow-up interview was conducted with RN 5. RN 5 stated that she contacted resident 7's physician and the physician stated that resident 7 should not administer her own insulin. On 2/6/20 at 12:36 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that she was not aware that resident 7 was self administering the insulin. The DON stated that resident 7 did not have a self administration evaluation for medications. The DON stated that the evaluations were completed initially when the resident requested to self administer and were reviewed quarterly or as needed. The DON stated that the evaluation would be located under the Evaluation/Forms tab and would say self medication evaluation. The DON stated that the care plan would be updated to reflect a self administration evaluation and would be specific to medication that the resident was administering. The DON stated that the medication order would also state self administration and that resident 7's order did not state to self administer.

Based on observation, interview, and record review, it was determined the facility did not provide a safe, clean, comfortable, and homelike environment. Specifically, residents complained of smoking odors and observations were made of residents smoking in close proximity to the facility. Findings include: On 2/4/20 at approximately 10:15 AM, an interview was conducted with a resident whose room was located on the 300 hallway. The resident stated it smells smoky in here and the facility was working on moving her to a different room. The resident further stated she wore a surgical mask because the facility smelled of cigarette smoke. On 2/4/20 at 1:47 PM, an observation was made in the television area located at the intersection of the 100 and 200 hallways. A resident was observed smoking directly outside of the door leading from the television area to the outdoor courtyard. On 2/4/20 at 2:40 PM, the 300 hallway was observed to smell of cigarette smoke. The Social Services Director (SSD) was observed walking down the 300 hallway and was immediately interviewed. The SSD stated it smells smoky in here. The SSD further stated designated smoking areas were outside a few different doors. On 2/4/20 at 2:51 PM, the 300 hallway was observed to continue smelling of cigarette smoke. On 2/6/20 at 8:46 AM, the 300 hallway was observed to smell of cigarette smoke. A resident was subsequently observed smoking outside of the door located on the 300 hallway that lead to the outdoor courtyard. The resident was observed smoking directly alongside the facility. The facility's Smoking policy, dated 10/24/17, was reviewed and documented the following information: PURPOSE: The facility has been designated a smoke-free facility; however, the rights of those who choose to smoke will be respected . 1. Smoking is permitted only outside of the facility and in areas where it is labeled by a Designated Smoking Area sign. Smoking is prohibited in all other areas both inside and outside of the building, this includes within 25 feet of an entrance or accessible window of the building . On 2/6/20 at 12:49 PM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated the designated smoking areas were out front on the south side of the building and in the center of the outdoor courtyard away from the doors. CNA 2 further stated there were occasional issues with residents smoking odors inside the building, and residents who wander were only able to smoke within the courtyard. On 2/6/20 at 1:02 PM, an interview was conducted with CNA 1. CNA 1 stated the designated smoking area was in the center of the outdoor courtyard, and there had been issues with residents smoking too close to the building. CNA 1 further stated residents complained about smoke getting into the building. On 2/6/20 at 2:04 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated the designated smoking area was out by the shed off of the 100 hallway, and she was unsure whether or not residents were able to still smoke in the courtyard due to complaints from residents about smoking odors inside the facility. On 2/10/20 at 8:13 AM, an interview was conducted with RN 2. RN 2 stated the designated smoking area was the inner courtyard. RN 2 further stated residents were not supposed to smoke on the sidewalk along the perimeter of the courtyard because there were complaints from residents about smoking odors if the residents who smoke were too close to the windows. On 2/10/20 at 1:53 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the designated smoking area was out by the shed and residents have been encouraged not to smoke in the outdoor courtyard. The DON further stated there was a problem with residents smoking in the courtyard because residents complained of smoking odors in the building.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined, for 2 of 45 sampled residents, the facility did not make prompt efforts to resolve grievances the residents may have. Specifically, grievances filed by the residents were not addressed by the facility in a timely manner. Resident identifiers: 6 and 112. Findings include: 1. Resident 6 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, pain, insomnia, major depressive disorder, hypertension, dysphagia, anoxic brain damage, and dystonia. On 2/4/20 at 10:35 AM, an interview was conducted with resident 6. Resident 6 stated she had several personal items that were missing and she notified facility staff. Resident 6 further stated her laptop went missing two weeks prior, and more and more jewelry was missing every day. Resident 6 further stated her missing items had not been replaced and the facility had not followed up with her about her missing items. The facility's grievance binder was reviewed and documented the following grievances filed by resident 6: a. The Concern Log for December 2019, documented that resident 6 filed a grievance on 12/4/19 related to Missing Jewlry (sic). The log further documented that the grievance had not yet been resolved. [Note: There was not a Concern Form associated with this grievance.] b. A Concern Form, dated 1/8/20, documented that resident 6 filed a grievance related to Missing laptop. The form further documented that the grievance had not yet been resolved. c. A Concern Form, dated 1/9/20, documented that resident 6 filed a grievance related to missing her 'Alexa'. The form further documented that the grievance not not yet been resolved. The facility's Grievances policy, dated 11/28/16, was reviewed and documented the following information: PURPOSE: The facility will investigate all grievances and complaints filed within the facility . 6. Upon the receipt of the a Grievance/Complaint Report, the grievance office will begin an investigation into the allegations . 8. The resident, or person filing the grievance and/ or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problemsuponrequest (sic) . On 2/6/20 at 12:49 PM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated if a resident voiced a grievance, she would have the resident speak to the nurse and fill out a concern form. CNA 2 stated the form was given to the unit manager. On 2/6/20 at 1:02 PM, an interview was conducted with CNA 1. CNA 1 stated if a resident voiced a grievance, the resident was provided with a concern form to fill out. CNA 1 further stated the form was given to the Director of Nursing (DON) or Administrator, and management followed upon on the complaint. On 2/6/20 at 1:21 PM, an interview was conducted with CNA 3. CNA 3 stated if a resident voiced a grievance, there was a concern form the resident filled out. CNA 3 stated resident 6 was missing an iPad, not a laptop, and it had gone missing a few weeks prior. On 2/6/20 at 1:38 PM, an interview was conducted with CNA 4. CNA 4 stated if a resident voiced a grievance and it was not something she could solve herself, she spoke with the Social Services Worker (SSW). On 2/6/20 at 1:52 PM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated if a resident was missing a personal item, there was a lost items report sheet that was completed and given to the social services department. On 2/6/20 at 2:04 PM, an interview was conducted with RN 4. RN 4 stated if a resident was missing a personal item, a missing item report was completed and staff checked the resident's room to try to locate the item. RN 4 further stated if staff were unable to locate the item, the social services department would be notified. On 2/10/20 at 8:56 AM, an interview was conducted with the SSW. The SSW stated grievances were reported to the nurse or herself, and a grievance form was completed. The SSW stated blank copies of the form were located at the nurses stations and in the activity rooms, and the grievances were communicated to staff and discussed at morning meetings. The SSW further stated she worked on grievances right away and tried to solve grievances within a week. The SSW further stated she was working on resident 6's concerns and several of her personal items had gone missing. The SSW further stated resident 6's tablet had gone missing, which resident 6 referred to as a laptop, and she had not had a chance to check resident 6's inventory to see if she admitted to the facility with a laptop. The SSW further stated she was unaware that resident 6 was missing any other personal items. On 2/10/20 at 1:53 PM, an interview was conducted with the DON. The DON stated she completed the concern form related to the missing laptop and gave the form to the social services department, and the social services department was supposed to follow up with resident 6. The DON further stated if the facility was determined to be responsible for missing items, the items needed to be replaced. 2. Resident 112 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, bipolar, disorder, hypertension, pain, Wernicke's encephalopathy, and acute respiratory failure. On 2/4/20 at 9:45 AM, an interview was conducted with resident 112. Resident 112 stated she filed a grievance because there was a nurse who made her wait for her medications, and she was very angry and upset about it. Resident 112 further stated there was no follow up related to her grievance. A Concern Form, dated 1/17/20, documented that resident 112 filed a grievance related to delayed medication administration. The form further documented that the grievance had not yet been resolved. On 2/6/20 at 9:04 AM, a follow up interview was conducted with resident 112. Resident 112 stated there was still no follow up related to her grievance, and had continued concerns with the nurse involved in the initial grievance. On 2/10/20 at 8:13 AM, an interview was conducted with RN 2. RN 2 stated if a resident voiced a grievance, a concern form was completed and given to the unit manager and DON. RN 2 stated resident 112 voiced concerns related to a nurse who worked at the facility, and alleged that the nurse did not administer her medications on time. On 2/10/20 at 8:52 AM, a follow up interview was conducted with resident 112. Resident 112 stated nothing had been done about her grievance still and she was becoming very frustrated. On 2/10/20 at 8:56 AM, an interview was conducted with the SSW. The SSW stated resident 112 filed a grievance related to medication administration, and she had not had a chance to follow up on that grievance yet. The SSW stated resident 112 was upset that it took a while to receive her medications. On 2/10/20 at 3:49 PM, an interview was conducted with the DON. The DON stated resident 112's grievance had not been followed up on because the SSW verbally notified the unit manager, and the expectation was that a paper copy of the grievance was provided to the unit manager to follow up on grievances involving staff members.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 9 was admitted to the facility on [DATE] with diagnoses which included congenital deformity of spine, congenital malformation syndromes predominantly affecting facial appearance, anorexia, anxiety disorder, bipolar disorder, borderline personality disorder, major depressive disorder, cachexia, [NAME]-Danlos syndrome, and pain. On 2/4/20, resident 9's medical record was reviewed. Review of resident 9's PASRR Level II documented an assessment start date of June 24, 2019. The Mental Health/Substance Abuse Diagnostic Summary Impression, Section 7, listed diagnoses of borderline personality disorder; major depression; post-traumatic stress disorder; narcissistic personality disorder; and generalized anxiety disorder. Recommendations were provided for mental health treatment. Review of resident 9's admission MDS Assessment with an Assessment Reference Date of 11/11/19, documented No to question A1500 is the resident currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition? On 2/5/20 at 1:10 PM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that the PASRR information was provided to him by the Social Service Worker (SSW) for the completion of the MDS Assessment. The MDS Coordinator stated that the SSW would verify if a PASRR Level II was completed and depending on when this information was provided to him he would sometimes have to modify and resubmit the assessment. The MDS Coordinator stated that he was not aware that resident 9 had a PASRR Level II. The MDS Coordinator stated that he would complete a modification to the assessment and retransmit the assessment now, Basically I will put a data entry error as the reason to resubmit and modify the MDS Assessment. On 2/10/20 at 8:56, AM an interview was conducted with the SSW. The SSW stated that when a resident was admitted she would look for a mental health diagnosis on the PASRR Level I. The SSW stated that if the resident resided in the facility for more than 30 days she would initiate a Level II assessment or obtain a copy of the assessment if it had been previously completed. The SSW stated that when the Level II was obtained a copy of the determination letter along with portions of the Level II Assessment would be provided to the MDS Coordinator. The SSW stated that this documentation was provided to the MDS Coordinator for resident 9 on 11/5/19. Based on interview and record review it was determined, for 2 of 45 sampled residents, that the facility assessment did not accurately reflect the resident's status. Specifically, a resident who did not require an anticoagulant medication was coded as receiving anticoagulants. In addition, a resident with a Preadmission Screening Resident Review (PASRR) Level II was coded as currently not considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. Resident identifiers: 9 and 64. Findings include: 1. Resident 64 was admitted to the facility on [DATE] with diagnoses which included acute respiratory failure with hypoxia, dysphagia, chronic obstructive pulmonary disease, diabetes mellitus type 2, bipolar disorder, and epilepsy. On 2/4/20 at 12:28 PM, an interview was conducted with resident 64. Resident 64 was asked if she had received her blood thinning medication as ordered by the physician and in a timely manner by staff. Resident 64 stated that she was not on an anticoagulant medication and she had never been on an anticoagulant medication. Resident 64's medical record was reviewed on 2/10/20. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], documented that resident 64 had received an anticoagulant medication on 7 occasions during the last 7 days. A review of resident 64's Order Summary Report from admission to current revealed no physician's orders for an anticoagulant medication. On 2/10/20 at 3:26 PM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that he was responsible for completing and submitting the resident MDS assessments. The MDS Coordinator stated that resident 64 was not on an anticoagulant medication. The MDS Coordinator stated that resident 64's MDS assessment was coded in error.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 1 of 45 sampled residents, that the facility did not ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, a resident with a contracture did not receive range of motion services in order to prevent further decrease in range of motion. Resident identifier: 80. Findings include: Resident 80 was admitted to the facility on [DATE] with diagnoses which included disorientation, pain, hypertension, bipolar disorder, major depressive disorder, encephalopathy, dysphagia, and anxiety disorder. On 2/4/20 at 1:26 PM, an observation was made of resident 80. Resident 80 was observed laying in bed, and her right hand was contracted into a closed position. Furthermore, resident 80 was not observed to have a splint, brace, or other device in place. On 2/4/20 at 2:53 PM, a follow up observation was made of resident 80. Resident 80 was observed laying in bed, and her right hand was contracted into a closed position. Furthermore, resident 80 was not observed to have a splint, brace, or other device in place. A review of resident 80's medical record was completed on 2/10/20. Resident 80's physician's orders were reviewed. The orders documented that starting on 10/5/19, the skin on her right hand and fingers was to be monitored two times per day. Resident 80's care plans were reviewed. There was no care plan related to resident 80's contracture, range of motion, or restorative therapies. Resident 80's progress notes, documented by the hospice company involved in her care, were reviewed and documented the following information related to resident 80's contracture: a. On 10/29/19, . Over the last benefit period she developed a contracture in her right hand with swelling. Due to the contracture her rings had to be cut off her fingers. She requires scheduled hydromorphone due to nonverbal s/s (signs and symptoms) of pain with ADL (activities of daily living) cares and moaning out when her right had (sic) is touched . b. On 12/31/19, . 6 month ago the patient developed a contracture in her right hand. The staff is no longer able to open her hand to clean and perform cares . c. On 1/23/20, . 6 month ago the patient developed a contracture in her right hand. The staff is no longer able to open her hand to clean and perform cares . On 2/6/20 at 9:18 AM, a follow up observation was made of resident 80. Resident 80 was observed laying in bed, and her right hand was contracted into a closed position. Furthermore, resident 80 was not observed to have a splint, brace, or other device in place. On 2/6/20 at 1:21 PM, an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated she tried to make sure resident 80's hand remained clean, and resident 80's hand was really painful. CNA 3 further stated resident 80 was not able to extend her hand and she was unsure if resident 80 received restorative therapy services. CNA 3 further stated resident 80's hand became swollen and closed a few months prior, and resident 80's rings had to be removed because her hand was so swollen. On 2/6/20 at 1:38 PM, an interview was conducted with CNA 4. CNA 4 stated resident 80 was unable to verbally communicate her feelings to staff. CNA 4 further stated resident 80 received restorative therapy services. On 2/6/20 at 1:52 PM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated resident 80 developed a contracture in her right hand this past year and the contracture was monitored for cleanliness and any skin issues. RN 3 further stated the contracture was painful for resident 80, and she had not received restorative therapy services. RN 3 further stated she referred residents to restorative therapy services if she noticed a decline or increased weakness, and sometimes residents with contractures were referred as well. On 2/6/20 at 2:38 PM, a follow up interview was conducted with RN 3. RN 3 stated she spoke with the Restorative Therapy Aide (RTA), who informed her that resident 80 had been on and off services in the past. RN 3 further stated resident 80 was getting put back onto services after she informed the RTA that resident 80 developed a contracture. On 2/10/20 at 8:39 AM, an interview was conducted with the RTA. The RTA stated she received referrals from her supervisor, the therapy department, and nursing staff if they notice that a resident exhibited decline. The RTA further stated if she noticed a resident had declined, she would pick them up as well. The RTA further stated she worked with residents with contractures on a daily basis, and she was unaware that resident 80 had a contracture. The RTA stated she worked with residents who also received hospice services, and resident 80's contracture was something we overlooked. The RTA further stated now that she was aware of resident 80's contracture, resident 80 was going to begin receiving restorative therapy services. On 2/10/20 at 9:15 AM, a follow up observation was made of resident 80. Resident 80 was observed laying in bed while a CNA assisted her with breakfast, and her right hand was contracted into a closed position. Furthermore, resident 80 was not observed to have a splint, brace, or other device in place. On 2/10/20 at 1:53 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the restorative therapy team conducted a long term care meeting on a weekly basis and discussed residents who would benefit from restorative therapy services. The DON further stated the nursing staff was educated to notify the restorative team if a contracture worsened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 2 of 45 sampled residents, that the facility did not ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Specifically, one resident was not provided with assistance and interventions to prevent falls in accordance with her plan of care and a second resident was burned by a steam table located in the dining room. Resident identifiers: 6 and 112. Findings include: 1. Resident 6 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, pain, insomnia, major depressive disorder, hypertension, dysphagia, anoxic brain damage, and dystonia. On 2/4/20 at 10:35 AM, an interview was conducted with resident 6. Resident 6 stated she fell many times since admitting to the facility, and most recently fell in the bathroom. Resident 6 further stated the facility had not put anything in place to keep her from falling. Resident 6 further stated she had issues with her knee locking up, which caused her to fall often. A review of resident 6's medical record was completed on 2/10/20. Resident 6's care plans were reviewed and documented the following care plan, initiated on 11/25/19, related to resident 6's risk of falling: a. Outcomes: i. [Resident 6] is at risk for falls due to weakness and mental status ii. [Resident 6] will have no unaddressed fall TNR (through next review) iii. refer to PT (physical therapy) as needed for loss of strength iv. Education to not reach for items without adaptive equip (equipment) 1/27 b. Interventions: i. Morse Fall Risk Standard Precautions [Note: This intervention was initiated on 1/13/19.] ii. [Resident 6] has orders for PT/OT (occupation therapy) to eval (evaluate) and tx (treat) [Note: This intervention was initiated on 1/13/19.] iii. [Resident 6] assistive devices will be evaluated for strength and safety [Note: This intervention was initiated on 1/13/19.] iv. Lock wheelchair breaks before transferring or leaning forward fall [Note: This intervention was initiated on 1/29/19.] v. Knee block transfer with transfers due to weakness fall [Note: This intervention was initiated on 3/4/19.] vi. where possible two person staff assist with transfers [Note: This intervention was initiated on 8/27/19.] vii. [Resident 6] will utilize knee block transfers due to knee weakness [Note: This intervention was initiated on 9/4/19.] viii. provide resident with proper footwear when out of bed [Note: This intervention was initiated on 9/11/19.] ix. toileting to be offered at regular intervals [Note: This intervention was initiated on 9/12/19.] x. Staff education completed in staff meeting 11/8/19 on proper transfers [Note: This intervention was initiated on 11/7/19.] xi. declutter pathways and remove unneeded furnit (furniture) [Note: This intervention was initiated on 11/8/19.] xii. provide [resident 6] a reacher for things out of reac (sic) [Note: This intervention was initiated on 12/4/19.] xiii. [Resident 6] not to be unattended when toileting [Note: This intervention was initiated on 1/6/20.] xiv. 2 person assist for transfers [Note: This intervention was initiated on 1/8/20.] Resident 6's incident reports and progress notes were reviewed from February 2019 through February 2020. The incident reports and progress notes documented that resident 6 experienced falls on the following occasions: a. On 7/8/19, an incident report documented that resident 6 fell to the floor while staff assisted her with transferring. According to the report, interventions included frequent toileting and a PT evaluation, and the care plan was updated. [Note: The care plan was not updated at this time.] b. On 8/23/19, an incident report documented that resident 6 fell to the floor while staff assisted her with transferring. According to the report, interventions included frequent checks and staff interaction when passing resident 6. c. On 9/3/19, an incident report documented that resident 6 fell to the floor while staff assisted her with transferring. According to the report, interventions included utilizing a knee block for transfers and socks to be provided to resident 6. d. On 9/10/19, an incident report documented that resident 6 slid out of her wheelchair and fell to the floor. According to the report, interventions included encouraging resident 6 to call for assistance and appropriate footwear to be provided to resident 6 when out of bed. e. On 9/11/19, an incident report documented that resident 6 slid out of her wheelchair and fell to the floor. According to the report, interventions included encouraging resident 6 to call for assistance, frequent checks by staff, frequent toileting breaks, and assisting resident 6 to bed when not engaged in activity or eating. f. On 11/5/19, an incident report documented that resident 6 fell to the floor while staff assisted her with transferring. According to the report, intervention included staff education related to proper transferring technique. g. On 11/7/19, a Progress Note - Nurse documented that resident 6 was found on the floor next to her wheelchair. The note further documented that resident 6 slipped out of her wheelchair while reaching for something on the ground, and she was reminded to ask for help when trying to reach for items that were out of reach. [Note: There was not an incident report associated with this fall.] h. On 12/3/19, an incident report documented that resident 6 was found on the floor. The report further documented that resident 6 fell as a result of reaching for a hair elastic on the floor. According to the report, interventions included encouraging resident 6 to call for assistance and providing her with a reacher to avoid leaning in her wheelchair. i. On 12/31/19, an incident report documented that resident 6 was found on the floor after being left on side of toilet. According to the report, interventions included staff education to not leave resident 6 alone in the bathroom and to use the call light for additional staff assistance. [Note: A Minimum Data Set assessment, dated 11/1/19, documented that resident 6 required extensive, one-person physical assistance with toileting.] j. On 1/6/20, an incident report documented that documented that resident 6 fell to the floor while staff assisted her with transferring. The report further documented that one aide was present at the time of resident 6's fall. According to the report, interventions included frequent check by staff, utilizing a knee block for transfers, and having two staff members assist resident 6 with transfers. [Note: Resident 6's care plan documented that she required two staff members to assist her with transfers since 8/27/19.] k. On 1/24/20, an incident report documented that resident 6 was found on the floor. The report further documented that resident 6 fell as a result of reaching for something on the floor. According to the report, interventions included frequent checks by staff and a low bed. On 2/6/20 at 8:39 AM, a follow up interview was conducted with resident 6. Resident 6 stated the facility never provided her with a reacher, and she was always left in the bathroom by herself. [Note: Resident 6's care plan documented that she was to be provided with a reacher starting on 12/4/19. Additionally, the care plan documented that she was not to be left unattended while toileting starting on 1/6/20.] On 2/6/20 at 12:49 PM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated residents' fall interventions were verbally communicated by the nurses to the CNAs. On 2/6/20 at 1:02 PM, an interview was conducted with CNA 1. CNA 1 stated residents' fall interventions were documented in the care plans, and she followed up with the nurse on duty to ask about fall interventions. On 2/6/20 at 1:21 PM, an interview was conducted with CNA 3. CNA 3 stated resident 6 required the assistance of two people when toileting and transferring. CNA 3 further stated resident 6 was sometimes left in the bathroom while toileting and she knew to pull the call light when she was done. CNA 3 further stated resident 6 was a fall risk and she likes to reach down for items. CNA 3 further stated she thought resident 6 was provided with a reacher, and she was reminded to use her call light for assistance. CNA 3 further stated new CNAs were verbally informed of fall interventions in order to keep an extra eye on those residents. On 2/6/20 at 1:38 PM, an interview was conducted with CNA 4. CNA 4 stated resident 6 fell when a CNA left her on the toilet, which was not usually something we do. CNA 4 stated the CNA was from a staffing agency and did not know resident 6 well, and resident 6 required extensive assistance and should not have been left in the bathroom by herself. CNA 4 further stated she was pretty sure resident 6 had a reacher. In addition, CNA 4 further stated the CNAs' charting program included fall interventions for each resident. Resident 6's fall interventions documented within the CNAs' charting program were reviewed with CNA 4. CNA 4 stated resident 6's fall interventions included assistance from 1-2 people with transferring, frequent checks, and verbal cues while transferring. [Note: The CNAs' charting program did not include all fall interventions in accordance with resident 6's care plan.] On 2/6/20 at 1:52 PM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated resident 6 required extensive assistance from 1-2 staff members while transferring and toileting. RN 3 further stated resident 6 had weakness in her knees, which caused her to fall while transferring. RN 3 further stated residents' care plans included fall interventions, and the interventions were verbally communicated to the CNAs. RN 3 further stated she thought residents' fall interventions were also documented within the CNAs' charting program. On 2/6/20 at 2:04 PM, an interview was conducted with RN 1. RN 1 stated residents' care plans included fall interventions, and the interventions were communicated to the CNAs verbally and documented within the CNAs' charting program. On 2/10/20 at 1:53 PM, an interview was conducted with the Director of Nursing (DON). The DON stated residents' care plans were used to communicate fall interventions among the nursing staff and CNAs. The DON further stated resident 6 required assistance from one person while transferring and toileting, and her assistance level was recently increased to requiring assistance from two people. The DON further stated resident 6 fell after being left in the bathroom, and it was not okay for her to be left alone in the bathroom. The DON further stated if resident 6 said she was not provided with a reacher, then she must not have been provided with a reacher in accordance with her care plan. On 2/10/20 at 3:30 PM, a follow up interview was conducted with RN 3. RN 3 stated the brain was also used to communicate residents' fall interventions among the nursing staff and CNAs. [Note: The 300 Hall Report Sheet, referred to by RN 3 as the brain was reviewed and did not include information related to resident 6's fall interventions.] 2. Resident 112 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, bipolar, disorder, hypertension, pain, Wernicke's encephalopathy, and acute respiratory failure. On 2/4/20 at 12:01 PM, observations were made throughout lunch service in the dining room located within the long term care unit. A resident was observed to walk into the kitchen unaccompanied, fill a cup with ice using an ice machine located inside the kitchen door, eat the ice, and continue to fill the cup with ice. [Note: The resident was observed to walk in an erratic manner and staff guided her out of the kitchen.] A review of resident 112's medical record was completed on 2/10/20. Resident 112's progress notes were reviewed and documented the following entries: a. On 2/2/20, a Progress Note - Nurse documented that resident 112 . accidentally burned her wrist. The patient stated that she rested her wrist on one of the kitchen's hot pots and burned her wrist . The wrist looks like a first degree burn with a mild reddish pink tinge to the skin at the burn site. The patient reports a slight stinging feeling . b. On 2/3/20, a Progress Note - Physician documented that . Patient reports sustaining a minor burn on her right arm over the weekend. She burned it on steam when she reached for a lid on the warmer. she (sic) reports mild pain and redness, improving . Burn of first degree of right upper arm . PLAN . Minor burn Steam from heating plate Very minor No open skin, blisters . On 2/6/20 at 9:04 AM, an interview was conducted with resident 112. Resident 112 stated there used to be an ice machine off of the dining room alongside the soda machines, but now the only ice machine for residents was located inside the kitchen. Resident 112 further stated residents wandered back there all the time to get ice from the kitchen. Resident 112 further stated she went to the kitchen to get ice and on her way out of the kitchen, approached the steam table located in the dining room outside of the hallway leading to the kitchen. Resident 112 further stated she lifted the lid to one of the compartments of the steam table and the steam burned her arm. Resident 112 further stated the steam table was usually left on all day. On 2/6/20 at 9:13 AM, an observation was made of the steam table located in the dining room within the long term care unit. All four compartment of the steam table remained on with visible steam emitting from the steam table, and there was no barrier surrounding the steam table. On 2/10/20 at 8:08 AM, an interview was conducted with the Dietary Manager (DM). The DM stated residents exited the kitchen on the opposite side of the hallway where the steam table was located, and they usually knocked on the door of the kitchen to get ice. On 2/10/20 at 8:12 AM, an interview was conducted with CNA 5. CNA 5 stated if a resident wanted ice, the resident went to the kitchen to get ice. CNA 5 further stated if a resident was confused, staff remained with the resident on the way to and from the kitchen. On 2/10/20 at 8:13 AM, an interview was conducted with RN 2. RN 2 stated if a resident wanted ice, there was a cooler located at the nurses' station with ice or it was obtained from the kitchen. RN 2 further stated sometimes residents wheeled back to the kitchen to request ice. RN 2 further stated the steam table usually had a tray in front of it so the residents knew to exit the kitchen on the opposite side of the hallway where the steam table was located. On 2/10/20 at 9:13 AM, an observation was made of the steam table located in the dining room within the long term care unit. All four compartment of the steam table remained on with visible steam emitting from the steam table, and there was no barrier surrounding the steam table. On 2/10/20 at 1:36 PM, a follow up interview was conducted with the DM. The DM stated the steam table was usually turned off between meals, and turned on approximately an hour or half an hour before meals to heat up. The DM further stated the CNAs kept eyes on residents who wandered back to the kitchen for ice. The DM further stated she was not aware of the burn incident involving resident 112. On 2/10/20 at 1:53 PM, an interview was conducted with the DON. The DON stated she was not aware of the burn incident involving resident 112, and there was not a barrier to protect residents from the steam table. On 2/10/20 at 3:35 PM, an observation was made of the steam table located in the dining room within the long term care unit. Three out of the four compartment of the steam table remained on with visible steam emitting from the steam table, and there was no barrier surrounding the steam table.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 1 of 45 sampled residents, that the facility did not ensure that the licensed nurses had the specific competencies and skill set necessary to care for the residents' needs. Specifically, an observation was made of Licensed Practical Nurse (LPN) 1 administering intravenous (IV) medications improperly and the LPN did not have the credentials that documented competency in IV infusions. Resident identifier: 330. Findings include: Resident 330 was admitted to the facility on [DATE] with diagnoses which included quadriplegia C1-C4 complete, stage 3 pressure ulcer, hypertension, mood disorder, and pain. On 2/6/20 at 8:30 AM, an observation was made of LPN 1 during morning medication administration. LPN 1 was observed to prepare an IV infusion of piperacillin-tazobactam (Zosyn) 3.375 grams (gm). The vial of powdered Zosyn was reconstituted into a bag of Normal Saline 100 milliliters (ml). LPN 1 was observed to attach the IV tubing to the reconstituted bag of Zosyn and the tubing line was primed to the end of the tubing. No excess liquid medication was expelled from the tubing. LPN 1 was then observed to connect the IV tubing to resident 330's Peripherally Inserted Central Catheter (PICC) line located in the right upper extremity. The tubing was then placed into the infusion pump and the rate was set at 200 ml/hr (hour) to infuse the 100 ml Zosyn within 30 minutes. LPN 1 then stepped away from resident 330 and prepared to exit the resident room. The IV tubing line was then observed by this surveyor. The portion of the IV tubing that was exiting the infusion pump and leading to resident 330 was inspected. The tubing was observed with 2 large air bubbles in the line. An immediate interview was conducted with LPN 1. LPN 1 was asked what, if anything, he would do about the two observed air bubbles. LPN 1 stated that he would flick the line to break up the bubbles and proceeded to do so. The line was inspected again and the air bubbles were observed to coalescence back together to form one large bubble. LPN 1 stated that he did not want to give the resident a pulmonary embolism but thought that the amount of air in the line was okay. LPN 1 was then observed to stop the infusion with 81 ml remaining of the original 100 ml. The tubing was removed from the pump, disconnected from resident 330, and the line was primed into the garbage can to expel the air bubbles. The amount of antibiotic that was wasted was unable to be determined. The tubing was reconnected to resident 330 and the antibiotic infusion was restarted. On 2/6/20, resident 330's medical record was reviewed. Review of the physician's order revealed an order for piperacillin-tazobactam 3.375 gm, IV piggyback every 6 hours. The order was initiated on 2/5/20, and the first dose was administered on 2/6/20 at 8:30 AM. Review of resident 330's progress notes revealed the following: a. On 2/3/20 at 8:30 PM, a physician note stated, PT (patient) sent to ED (Emergency Department) last night for hematuria. Nurse noticed this and apparently sent him out. Pt also has a HA (headache). States today he is doing fine. Says he felt some vague pressure in his abdomen that is now resolved. A new diagnosis of Urinary Tract Infection was documented with an onset date of 2/3/20. b. On 2/4/20 at 12:48 PM, a nursing note stated, Resident was started on cefdinir 300 mg (milligrams) 1 capsule by mouth twice a day for ten days. c. On 2/5/20 at 2:45 PM, a nursing note stated, New orders per [name redacted] ID (infectious disease) consult Zosyn 3.375 gm q (every) 6hr x (times) 10 days, Vancomycin 20 mg/kg (kilogram) q12 hr x 10 days . d. On 2/8/20 at 11:18 AM, a physician note stated, .2/7 Received call about positive blood cultures from the ED, MRSA (Methicillin-resistant Staphylococcus aureus). Started on Vanc (Vancomycin) and Zosyn, PICC line placed yesterday. Final cultures pending. A new diagnosis of Bacteremia was documented with an onset date of 2/7/20. LPN 1's personnel file was reviewed. No documentation could be found that IV Certification training was completed by LPN 1. LPN 1's license was verified and was active. On 2/6/20 at 10:39 AM, an interview was conducted with the Director of Nursing (DON) and the Corporate Resource Nurse (CRN). The CRN stated that LPN 1 had passed competency training based on corporate policy on medication administration. The CRN stated that LPN 1 had passed off the competency skills in a registered nurse program and upon hire to the facility was passed off on a skills test for IV administration. The CRN stated that she would obtain LPN 1's credentials. On 2/6/20 at 10:52 AM, a follow-up interview was conducted with the CRN. The CRN stated that LPN 1 had been at the facility for 4 years and that they did not have any training specific to IV medications for LPN 1. The CRN stated that the DON believed that since LPN 1 had completed the associates degree courses for a Registered Nurse that he met the competency requirements, even though he had not taken the National Council Licensure Examination yet. The CRN stated that the facility policy did not cover scope of practice for LPN IV certification. The CRN stated that LPN 1 did not receive any training on IV administration of medications or pass off skills at the facility. The CRN stated that the DON did not have any documentation verifying LPN 1's status or completion of an associates degree nursing program. On 2/6/20 at 12:36 PM, a follow-up interview was conducted with the DON. The DON stated that they had been trying to establish a new system to conduct competency skills testing at the facility. The DON stated that they would be transitioning to a new pharmacy service next month and they would provide IV certification training to the facility staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 of 45 sampled residents, that the facility did not establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and determine that all drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled. Specifically, the facility did not have a narcotics reconciliation process in place and the Narcotic Record Log did not match the Medication Administration Records (MAR). Resident identifiers: 31 and 50. Findings include: 1. Resident 31 was admitted to the facility on [DATE] with diagnoses which included paraplegia, anxiety, orthostatic hypotension, unstable burst fracture, rib fracture, depressive disorder, mono-neuropathy, and chronic pain. On 2/5/20 at 1:45 PM, resident 31 was interviewed. Resident 31 stated that he had chronic back pain and that he received multiple pain medications for pain control. Resident 31 stated that his pain was always present and that the medications only helped with severity. On 2/5/20 at 2:27 PM, resident 31's medical record was reviewed. Record revealed that among other medications, on 12/4/19, resident 31's physician ordered the following medications: a. Clonazepam 0.5 milligram (mg) tablet to administer daily, b. Oxycodone 5 mg tablet, to administer 1 to 2 tablets every (Q) 4 hours (hr) as needed (PRN), c. Morphine 15 mg tablet to administer Q 12 hr. Resident 31's MAR and Narcotic Record Log for December 2019, January 2020, and February 2020 were reviewed. Resident 31's Narcotic Record Log revealed that Clonazepam was pulled out of the narcotic drawer and documented on the Narcotic Record Log on 12/13/19 at 9:07 AM and 8:35 PM. The administration from 8:35 PM was not documented on the MAR. The Narcotic Record Log further revealed that Clonazepam was pulled out of the narcotic drawer and documented on the Narcotic Record Log on 12/18/19 at 8:47 AM and 10:30 PM. The administration from 10:30 PM was not documented on the MAR. [Note: Clonazepam order was to administer Clonazepam 0.5 mg tablet once per day and not twice per day.] The Narcotic Record Log revealed that Oxycodone 5 mg tablets were pulled out of the narcotic drawer, but not documented on the MAR on 28 following occasions: a. 12/5/19 at 2:17 PM, b. 12/6/19 at 3:08 PM, c. 12/8/19 at 2:05 PM, d. 12/9/19 at 1:40 PM, e. 12/10/19 at 10:13 AM and 4:30 PM, f. 12/12/19 at 12:12 PM and 4:39 PM, g. 12/13/19 at 10:41 AM, h. 12/15/19 at 11:03 AM and 3:07 PM, i. 12/18/19 at 7:55 PM, j. 12/19/19 at 12:30 AM, k. 12/20/19 at 12:30 PM and 5:00 PM, l. 12/24/19 at 7:50 PM, m. 12/25/19 at 7:37 PM, n. 1/7/20 at 6:00 AM and 12:41 PM, o. 1/10/20 at 5:55 PM, p. 1/11/20 at 5:50 PM and 9:08 PM, q. 1/18/20 at 4:01 PM, r. 1/19/20 at 10:50 AM, s. 1/2/20 at 2:00 PM, t. 1/26/20 at 11:50 AM, u. 1/29/20 at 5:55 PM, and v. 2/1/20 at 9:44 PM. The Narcotic Record Log revealed that Morphine 15 mg tablet was pulled out of the narcotic drawer, but not documented on the MAR on 1/11/20 at 10:45 PM. 2. Resident 50 was admitted to the facility on [DATE] with diagnoses which included dementia, rheumatoid arthritis, osteoporosis, chronic pain, anxiety, mood disorder, and muscle spasm. On 2/5/20 at 2:16 PM, resident 50 was interviewed. Resident 50 was confused, but when questioned about the pain, she showed her hips and lower back. On 2/6/20 at 8:32 AM, resident 50's medical record was reviewed. Medical record revealed that among other medications, resident 50's physician, on 12/12/19, ordered Hydrocodone-Acetaminophen 10-325 mg tablet to be administered Q 4 hr PRN for pain and Lorazepam 0.5 mg tablet to be administered three times a day. Resident 50's MAR and Narcotic Record Log for December 2019, January 2020, and February 2020 were reviewed. Resident 50's Narcotic Record Log revealed that Lorazepam was pulled out of the narcotic drawer and documented on the Narcotic Record Log, but not on the MAR on 8 following occasions: a. 12/6/19 at 12:50 PM, b. 1/13/20 at 8:47 AM, c. 1/18/20 at 8:00 AM, d. 1/22/20 at 12:00 PM, e. 1/26/20 at 12:30 PM and 6:30 PM, f. 1/31/20 at 4:15 PM, and g. 2/1/20 at 9:55 AM. Resident 50's Narcotic Record Log revealed that Hydrocodone was pulled out of the narcotic drawer and documented on the Narcotic Record Log, but not on the MAR on 16 following occasions: a. 12/10/19 at 8:38 AM, b. 12/11/19 at 7:37 PM, c. 12/12/19 at 8:08 AM and 1:48 PM, d. 12/16/19 at 12:50 PM, e. 12/26/19 at 6:45 AM, f. 1/5/20 at 7:10 PM, g. 1/6/20 at 12:00 PM, h. 1/8/20 at 7:12 AM, i. 1/22/20 at 7:20 AM and 12:00 PM, j. 1/26/20 at 12:30 PM, k. 1/31/20 at 7:20 AM, l. 2/1/20 at 4:55 AM and 2:00 PM, and m. 2/5/20 at 7:15 AM. An interview with Registered Nurse (RN) 3 was conducted on 2/10/20 at 12:15 PM. RN 3 stated that every time the narcotic medication was pulled out of the narcotic drawer, she would sign the Narcotic Record Log at the medication cart. RN 3 stated that she also documented narcotic administration on specific resident MAR. RN 3 stated that the MAR and the Narcotic Record Log had to match. RN 3 stated that all discrepancies with the Narcotic log and the MAR she reported to the Unit Manager or to the Director of Nursing (DON). An interview with RN 4 was conducted on 2/10/20 at 12:30 PM. RN 4 stated that before she administer any pain medication, she assessed resident for pain. RN 4 stated that when she pulled the pain medication or narcotic out of the narcotic drawer, she signed the Narcotic Record Log and also documented the administration on resident's MAR. RN 4 stated that if narcotic was pain medication, she assessed pain level after medication administration. RN 4 stated that the Narcotic Record Log and the MAR had to match. RN 4 stated that at the end of the shift, the nurses ensure that all narcotics were properly counted. RN 4 stated that inconsistencies were reported to the Unit Managers or the DON. An interview with the DON was conducted on 2/10/20 at 12:57 PM. The DON stated that her expectation from nurses was to document properly on the Narcotic Record Log and on the MAR. The DON stated that regardless to type of medication, proper medication administration and monitoring was every nurse job expectation. The DON stated that the nurses usually reported to her if they noticed any discrepancies with medications. The DON stated that the current pharmacy did not do medication reconciliation timely and appropriately and that was one of the reason why, as of March 1 2020, the facility switched pharmacy services to another pharmacy. An interview with the Corporate Resource Nurse (CRN) was conducted on 2/10/20 at 1:02 PM. The CRN stated that they noticed this issue with reconciliation process in other facilities and that they started to do audits on the corporate level a few weeks ago. The CRN stated that their current pharmacy did not do medication reconciliation timely and appropriately, and as of March 1, 2020, they switched the pharmacy services to another pharmacy company. The CRN stated that the nurses were expected to document Narcotics administration on the Narcotic Record Log and on the MAR. The CRN stated that these two documents had to match. The CRN stated that they had Medication Pass Protocol but that they did not have specific protocol or policy regarding the narcotic administration. On 2/10/20 at 1:30 PM, the Medication Pass Protocol was reviewed. Section 11 of this protocol noted that Medications must be charted immediately following the administration by the person administering the drugs. The date, time administered, dosage, etc. must be entered in the medical record and signed by the person entering the data.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility did not ensure that as needed (PRN) psychotropic drugs are limited to 14 days except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond the 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. Specifically, for 1 of 45 sampled residents, an anti-anxiety drug was not limited to 14 days and the resident's record did not document a rationale for use including a duration for the order. Resident identifier: 112. Findings include: Resident 112 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, bipolar, disorder, hypertension, pain, Wernicke's encephalopathy, and acute respiratory failure. A review of resident 112's medical record was completed on 2/10/20. Resident 112's physician's orders were reviewed. The orders documented that resident 112 was prescribed Lorazepam, an anti-anxiety medication, on 12/26/19 on a PRN basis for anxiety. [Note: This order did not include a duration of use and remained active.] Resident 112's Medication Administration Record documented that resident 112 received Lorazepam on 73 occasions from 12/26/19 through 2/10/20. Resident 112's Progress Notes - Physician were reviewed from December 2019 through February 2020. The notes did not document a rationale for use including a duration for the order. On 2/6/20 at 2:04 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated PRN psychotropic medications had 14-day time frames, and required follow up monitoring to assess efficacy. RN 1 further stated psychotropic meetings were held on a monthly basis and were attended by the unit managers, Director of Nursing (DON), psychiatrist, and social services department. On 2/10/20 at 8:13 AM, an interview was conducted with RN 2. RN 2 stated PRN psychotropic medications were automatically inputted into the electronic medical record with a 14-day time frame, and the system prompted staff to input a time frame. RN 2 stated there was not a time frame for resident 112's Lorazepam, and the order would have normally included a stop date. On 2/10/20 at 1:53 PM, an interview was conducted with the DON. The DON stated PRN psychotropic medications were ordered for 14 days, and the provider completed a new order if the medication was continued after the 14 days. The DON further stated resident 112's Lorazepam, ordered on 12/26/19, did not have a stop date for reassessment. On 2/10/20 at 3:19 PM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN stated resident 112's PRN Lorazepam was evaluated by the physician on 12/18/19, and resident 112's medications were scheduled to be reviewed during the next quarterly psychotropic review meeting. [Note: The physician's note, dated 12/18/19, did not document a rationale for use including a duration for the order.]

Based on observation and interview, it was determined that the facility did not label all drugs in accordance with professional standards and with the expiration date, and all drugs and biologicals were not stored under proper temperature controls. Specifically, an opened vial of insulin was not labeled with an expiration date and a medication fridge was not registering within the temperature control range for the stored medication. Findings include: 1. On 2/6/20 at 11:27 AM, the medication cart on the 700 hallway was inspected. An open vial of Admelog (Lispro) insulin 100 units/milliliter vial was documented with a date of 2/3/20. The vial did not document if the date was an open date or an expiration date. An immediate interview was conducted with Registered Nurse (RN) 6. RN 6 stated that she would consider the date an expiration date based on the bottle being half empty. RN 6 stated that it was not possible to verify if the date was for open or expiration. RN 6 stated she would discard the medication and obtain a new vial. 2. On 2/6/20 at 11:46 AM, the medication fridge on the 500 hallway was inspected with Licensed Practical Nurse (LPN) 1. The thermometer was located under the freezer compartment next to 2 vials of Hepatitis B vaccine. The thermometer registered 22 degrees Fahrenheit. On 2/6/20 at 1:36 PM, an interview was conducted with LPN 1 and RN 7. LPN 1 stated he was not sure if they gave the Hepatitis B vaccine at the facility. LPN 1 stated that the Hepatitis B vaccine should be stored at a temperature of 36-46 degrees Fahrenheit. RN 7 stated that the fridge temperature was adjusted, and the Hepatitis B vaccines should be discarded. RN 7 stated that the vaccine was available upon resident request. On 2/6/20 at 1:55 PM, the medication fridge on the 500 hallway was inspected again with RN 7 and Unit Manager (UM) 1. The fridge was observed empty. UM 1 stated that the fridge was registering too warm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined, for 1 of 45 sampled residents, that the facility did not maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections. Specifically, facility staff were observed to bare handed touch medication during medication preparation. Resident identifier: 54. Findings include: Resident 54 was admitted to the facility on [DATE] with diagnoses which included adjustment disorder with mixed anxiety and depressed mood, major depressive disorder, and Schizophrenia. On 2/6/20 at 10:00 AM, Student Nurse (SN) 1 was observed to prepare and dispense medications for resident 54. SN 1 was not observed to perform hand hygiene prior to dispensing the medication. SN 1 dispensed Lorazepam 1 milligram (mg) tablet into the palm of her hand and then picked it up with three fingers and placed it into a medication cup. SN 1 then dispensed Seroquel 150 mg, 3 tablets into the palm of her hand. One tablet fell into the opened medication cart drawer and the other two tablets were placed into the medication cup with the Lorazepam. Registered Nurse (RN) 5 was not supervising SN 1 at the time of medication preparation. RN 5 approached the medication cart in the 200 hallway after SN 1 had finished dispensing the Seroquel medication. RN 5 was observed to provide SN 1 with education and stated that the medication should not be touched with the bare hands. RN 5 separated the Lorazepam into a second medication cup. An immediate interview was conducted with RN 5. RN 5 stated that she was going to discard the 3 Seroquel tablets and dispense the medication again because SN 1 had touched the medication with her bare hands. RN 5 stated she would administer the Lorazepam along with the remainder of resident 54's scheduled medication. RN 5 stated she did not verify that the Lorazepam had not been touched also. RN 5 was informed of the observation of the Lorazepam preparation with bare handed contact. On 2/6/20 at 12:36 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that nursing staff should not be touching the medication with their bare hands during preparation and administration. The DON stated that it was an infection control issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 3 of 45 sampled residents, that the facility did not ensure that the medication error rate was not 5 percent or greater. Specifically, 4 medication errors were observed out of 31 observations with a medication error rate of 12.9%. Resident identifiers: 7, 99, and 330. Findings include: 1. Resident 330 was admitted to the facility on [DATE] with diagnoses which included quadriplegia C1-C4 complete, stage 3 pressure ulcer, hypertension, mood disorder, and pain. On 2/6/20 at 8:30 AM, Licensed Practical Nurse (LPN) 1 was observed to prepare and administer medications to resident 330. LPN 1 was observed to prepare an intravenous (IV) infusion of piperacillin-tazobactam (Zosyn) 3.375 grams (gm). The vial of powdered Zosyn was reconstituted into a bag of Normal Saline 100 milliliters (ml). LPN 1 was observed to attach the IV tubing to the reconstituted bag of Zosyn and the tubing line was primed to the end of the tubing. No excess liquid medication was expelled from the tubing. LPN 1 was then observed to connect the IV tubing to resident 330's Peripherally Inserted Central Catheter line located in the right upper extremity. The tubing was then placed into the infusion pump and the rate was set at 200 ml/hour to infuse the 100 ml Zosyn within 30 minutes. LPN 1 then stepped away from resident 330 and prepared to exit the resident room. The portion of the IV tubing that was exiting the infusion pump and leading to resident 330 was inspected. The tubing was observed with 2 large air bubbles in the line. The medication was then reconciled with resident 330's medical record. A physician order initiated on 2/5/20, documented piperacillin-tazobactam 3.375 gm, IV piggyback every 6 hours. On 2/6/20 at approximately 8:40 AM, an interview was conducted with LPN 1. LPN 1 was asked what, if anything, he would do about the two observed air bubbles. LPN 1 stated he would flick the line to break up he bubbles and proceeded to do so. The line was inspected again and the air bubbles were observed to coalescence back together to form one large bubble. LPN 1 stated that he did not want to give the resident a pulmonary embolism but thought that the amount of air in the line was okay. LPN 1 was then observed to stop the infusion with 81 ml remaining of the original 100 ml. The tubing was removed from the pump, disconnected from resident 330, and the line was primed into the garbage can to expel the air bubbles. The amount of antibiotic that was wasted was unable to be determined. The tubing was reconnected to the resident and the antibiotic infusion was restarted. 2. Resident 7 was admitted to the facility on [DATE] with diagnoses which included urinary tract infection, altered mental status, acute kidney failure, type 2 diabetes mellitus, metabolic encephalopathy, and gastro-esophageal reflux disease. On 2/6/20 at 9:15 AM, Registered Nurse (RN) 5 was observed to prepare and administer medications to resident 7. RN 5 administered the following medications which were then reconciled with resident 7's medical record: a. Pantoprazole 80 milligram (mg) tablet. A physician's order initiated on 7/11/19, documented that resident 7 was to receive Pantoprazole 80 mg tablet daily on an empty stomach. b. Lantus insulin pen 65 units. RN 5 dialed the pen to dispense 65 units and then gave the pen to resident 7 to self administer. Resident 7 was observed to press the tip of the pen to the abdomen while pressing the plunger of the pen. Resident 7's hands were observed to shake during the self administration of the insulin. Upon completion of the medication administration resident 7's abdomen was observed wet with liquid on it. A physician's order initiated on 8/9/19, documented that resident 7 was to receive Insulin Glargine (Lantus), inject 65 units subcutaneous daily in the morning. On 2/6/20 at approximately 9:20 AM, an interview was conducted with RN 5. RN 5 stated that resident 7 did not administer the full dose of insulin, and that she had wiped a lot of the medication away on the skin. RN 5 stated that the injection was not completely given due to resident 7's hands shaking. RN 5 stated that the Pantoprazole should have been administered before breakfast. RN 5 stated that she was late administering the morning medications because she did not usually work on this hallway. 3. Resident 99 was admitted to the facility on [DATE] with diagnoses which included gastro-esophageal reflux disease, polyosteoarthritis, dementia, major depressive disorder, anxiety disorder, and pain. On 2/6/20 at 9:30 AM, RN 5 was observed to prepare and administer medications to resident 99. RN 5 administered Pantoprazole 40 mg tablet which was then reconciled with resident 99's medical record. A physician's order initiated on 1/8/20, documented that resident 99 was to receive Pantoprazole 40 mg tablet daily at 7:00 AM. On 2/6/20 at 9:25 AM, an interview was conducted with RN 5. RN 5 stated that resident 99's Pantoprazole should have been administered at 7:00 AM before breakfast. On 2/6/20 at 12:36 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that she was not aware that resident 7 was self administering the insulin. The DON stated that resident 7 had not been evaluated to self administer the insulin.