**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not exercise reasonable care for the protection of the resident's property from loss or theft. Specifically, for 1 out of 50 sampled residents, a resident who was missing a personal item did not have the missing item located or replaced in a timely manner. Resident identifier: 65. Findings included: Resident 65 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, chronic respiratory failure with hypoxia, malignant neoplasm of larynx, emphysema, hypertensive heart disease with heart failure, major depressive disorder, generalized anxiety disorder, chronic pain syndrome, tracheostomy status, and acquired absence of larynx. On 6/24/24 at 3:03 PM, an interview was conducted with resident 65. Resident 65 stated that he had an issue with the housekeeping staff coming into his room and stuff would go missing. Resident 65 stated that he had a jacket that went missing and other items but resident 65 could not remember what other items had gone missing. Resident 65 stated that his personal papers had been put in the trash by the housekeeping staff. Resident 65's medical record was reviewed on 6/25/24. The Grievance Log was reviewed from February 2024 to current. There were no lost items or grievances filed by resident 65. An Inventory List was unable to be located for resident 65. On 6/27/24 at 12:03 PM, an interview was conducted with the Resident Advocate (RA). The RA stated if a resident was missing an item the process would usually depend on the item that was missing. The RA stated that she would look in the laundry room and the laundry room lost and found for the missing item. The RA stated that she also had a lost and found in her office for items that were found around the facility with no name on them. The RA stated that a grievance form could be filled out if the missing item was not found. The RA stated the facility would replace the missing item but it would depend on what the missing item was. The RA stated the Certified Nursing Assistants (CNA) would complete an inventory list for the residents upon admission. The RA stated that she would check the resident's inventory list to see if the missing item was on the list. The RA stated that resident 65 had reported that he was missing a zip up jacket. The RA stated that resident 65 told the prior Administrator about the missing item and it was passed to her. The RA stated that herself and the prior Administrator were trying to figure out if resident 65's missing item was actually at the facility. The RA stated that herself and the prior Administrator were discussing if they were going to replace resident 65's missing item. The RA stated that resident 65's missing jacket was at a stand still with the new Administrator starting at the facility a few weeks ago. On 6/27/24 at 12:40 PM, a interview was conducted with resident 65. Resident 65 stated that when the jacket went missing he had reported it to the laundry staff but they did not do anything. Resident 65 stated the laundry staff had looked for the jacket for a while and then gave up. Resident 65 stated the laundry staff were trying to tell him that it was a cheap windbreaker jacket that he had lost. Resident 65 stated the laundry staff told him to tell the Administrator. Resident 65 stated that it was the prior Administrator that he reported the missing jacket to. Resident 65 stated that he could not remember an exact date when he reported the missing jacket but it was a long long time ago. On 6/27/24 at 1:21 PM, a follow up interview was conducted with the RA. The RA stated that a grievance form was not completed for resident 65's missing item because the missing item was discussed in the morning meeting and everyone was working on looking for the missing item. The RA stated usually the CNA would have the resident complete a grievance form for a missing item if the RA was not available or if the missing item was not immediately found. The RA stated that sometimes she was present when the missing item was reported and she would just go find the item. The RA stated with resident 65 she believed they were all looking for the item and completing a grievance form just slipped her mind. On 6/27/24 at 1:47 PM, an interview was conducted with the Housekeeping and Laundry Supervisor. The Housekeeping and Laundry Supervisor stated that if there was a missing item the resident would usually give laundry a description of the item and the laundry staff would start looking for the item. The Housekeeping and Laundry Supervisor stated there was a room within the laundry room where items without names were stored. The Housekeeping and Laundry Supervisor stated if the resident's lost item could not be found the laundry staff would start looking in resident rooms with similar names. The Housekeeping and Laundry Supervisor stated if the resident's lost item was not found after two or three weeks she would get with the RA to replace the item. The Housekeeping and Laundry Supervisor stated that resident 65 had reported to her that he was missing a jacket. The Housekeeping and Laundry Supervisor stated that resident 65's jacket was reported missing maybe two or three weeks after resident 65 admitted to the facility. The Housekeeping and Laundry Supervisor stated that resident 65 was on the A hall at the time the jacket was reported missing. The Housekeeping and Laundry Supervisor stated that after resident 65 reported the missing jacket to her she went to the A hall and started asking the CNAs that admitted resident 65 if they had seen resident 65 in a jacket or seen the jacket. The Housekeeping and Laundry Supervisor stated that she was told by the CNAs that resident 65 would not let them do an inventory list. The Housekeeping and Laundry Supervisor stated that she was told by the CNAs that they had never seen resident 65 with any jacket like resident 65 had described. The Housekeeping and Laundry Supervisor stated that maybe three or four weeks after looking for the jacket resident 65 came to the laundry room and asked if the jacket was found and the Housekeeping and Laundry Supervisor stated that she told resident 65 they had not seen the jacket. The Housekeeping and Laundry Supervisor stated that she reported resident 65's missing jacket to the RA and was told by the RA that maybe they would replace the jacket. The Housekeeping and Laundry Supervisor stated this all happened with the prior Administrator. On 6/27/24 at 3:25 PM, an interview was conducted with the Administrator. The Administrator stated if a resident was missing an item we would get together and discuss it in the Interdisciplinary Team meeting, look in the resident rooms, laundry, and forward the missing item to the RA. The Administrator stated that he was aware of resident 65's missing jacket. The Administrator stated that resident 65 refused to fill out an inventory list upon admission. The Administrator stated he had contacted the facility that resident 65 was at prior to see if they had an inventory list and resident 65 refused to complete a list at the prior facility also. On 7/1/24 at 12:26 PM, an interview was conducted with the RA. The RA stated that she found out that resident 65's jacket was missing on 3/12/24, and she started to look into the missing jacket. The RA stated that resident 65 had refused to complete the inventory list upon admission. The RA stated that resident 65 had changed the missing jacked from a zip up jacket to a winter jacket. The RA stated they kept trying to get resident 65 to complete an inventory list. The RA stated on 4/16/24, she noted to replace the jacket and talk with the prior Administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the Centers for Medicare & Medicaid Services (CMS) system within 14 days of completing a resident's assessment. Specifically, for 1 out of 50 sampled residents, the facility did not transmit a resident's completed discharge MDS assessment to CMS. Resident Identifier: 95. Findings Included: Resident 95 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including end stage renal disease, type 2 diabetes mellitus with diabetic chronic kidney disease, chronic obstructive pulmonary disease, and acute and chronic respiratory failure with hypoxia. Resident 95's medical record was reviewed from 6/24/24 through 7/2/24. A Death in Facility MDS assessment was completed on 3/8/24. Question A0140 of the assessment had the response, Unit is neither Medicare nor Medicaid certified and MDS data is not required by the State. The assessment submission information stated, Do not submit to CMS. On 6/26/24 at 10:20 AM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that the MDS assessment for resident 95 should have been transmitted to CMS, but the option for the assessment to be transmitted had not been selected in the electronic medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals preferences. Specifically, for 1 out of 50 sampled residents, a resident was observed to complain about pain and pain medications were not available. Resident identifier: 9. Findings included: Resident 9 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included paraplegia, cirrhosis of liver, hepatic encephalopathy, psychosis, and hypertension. On 6/24/24 at 1:58 PM, an interview was conducted with resident 9. Resident 9 stated that he was in pain and that he did not want to complete the interview because he was in a lot of pain. Resident 9 was observed to have rested his head in the palm of his hand. Resident 9 was observed to have facial grimacing. On 6/27/24 at 8:11 AM, an observation was conducted of resident 9. Resident 9 was observed at the medication cart waiting for the Medication Technician to prepare the medications. Resident 9 was observed to have facial grimacing, was crying, and was rubbing his right leg. Resident 9's medical record was reviewed on 7/1/24. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed resident 9 had scheduled and as needed pain medication for the previous five days. There were no non-medical interventions used. The MDS assessment revealed resident 9 reported pain almost constantly. In addition, resident 9 reported pain effected his sleep and day-to-day activities. The MDS assessment revealed resident 9 had intensity of a pain level of 10 out of 10. A care plan dated 9/14/22, revealed [Resident 9] has acute/chronic pain r/t [related to] left femur fx [fracture], chronic pain syndrome, neuropathy, muscle spasm, mood d/o [disorder]. The goal was Will not have an interruption in normal activities due to pain through the review date. The interventions included Administer analgesia medication as per orders. Give 1/2 hour before treatments or care; Anticipate need for pain relief and respond immediately to any complaint of pain; Follow the pain scale to medicate as ordered; Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician; Monitor/record pain characteristics: Quality (e.g. sharp, burning); Severity (1 to 10 scale); Anatomical location; Onset; Duration (e.g., continuous, intermittent); Aggravating factors; Relieving factors; and Monitor/record/report to Nurse any s/sx [signs and symptoms] of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). A physician's order dated 3/26/24, revealed Cyclobenzaprine HCl [hydrochloride] tablet. Give 5 mg [milligrams] by mouth at bedtime for pain. The progress notes revealed on 6/27/24 at 7:52 PM, 6/28/24 at 7:06 PM, 6/29/24 at 7:15 PM, and 6/30/24 at 7:15 PM, Cyclobenzaprine HCl Oral Tablet. Give 5 mg by mouth at bedtime for Pain. Waiting on medication from pharmacy. On 7/2/24 at 9:43 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated if medications were unavailable, it depended on the medication and if the medication was in the emergency supply. RN 1 stated if it was an antibiotic or pain medication that could be used from the emergency medication supply, then the emergency supply was used. RN 1 stated when a resident was out of medications the nurse was to call the pharmacy, notify the resident's physician, and get guidance from the physician. RN 1 stated nurses should never write the medication was not available because the resident needed their medication, so the nurse needed to follow up. On 7/2/24 at 11:00 AM, a follow-up interview was conducted with RN 1. RN 1 was observed to review resident 9's Medication Administrator Record. RN 1 stated resident 9 was not administered the muscle relaxer on 6/27/24 through 6/30/24. RN 1 stated a resident could have increased pain if the pain was coming from tense muscles. RN 1 stated resident 9 was up and down with his pain from moment to moment. RN 1 stated resident 9 was usually at his medication cart at 6:00 AM, for his medication but had not been recently. RN 1 stated resident 9 had been experiencing a decline and the physician was aware. RN 1 stated resident 9 had not been waking up until about 10:00 AM, because mornings had been harder for him. RN 1 stated resident 9 maybe in a little more pain in the morning but there were other psychological issues and a recent urinary tract infection that was contributing to it. On 7/2/24 at 11:05 AM, an interview was conducted with the Director of Nursing (DON). The DON stated if a resident did not have medications available, the nurse was to contact the pharmacy. The DON stated there was a direct order system to the pharmacy through the medical record system. The DON stated she would need to check into resident 9's medications. On 7/2/24 at 1:06 PM, a follow-up interview was conducted with the DON. The DON stated medications should be re-ordered three to four days prior to when the medications were going to run out. The DON stated resident 9 was not administered the Cyclobenzaprine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 111 was admitted to the facility on [DATE] with the diagnoses of amyotrophic lateral sclerosis, acute respiratory failure with hypoxia, type 1 diabetes mellitus without complications, post-traumatic stress disorder, interstitial emphysema, anxiety disorder, mild neurocognitive disorder due to known physiological condition with behavioral disturbance, and mood disorder due to known physiological condition with depressive features. Resident 111's medical record was reviewed on 7/2/24. A physician's order with a start date of 5/17/24, documented QUEtiapine Fumarate Oral Tablet 25 MG (Quetiapine Fumarate). Give 25 mg enterally two times a day for psychoses, frontal temporal dementia. On 6/17/24 at 6:44 AM, an electronic (e)Mar- Medication Administration Note documented, QUEtiapine Fumarate Oral Tablet 25 MG. Give 25 mg enterally two times a day for psychoses, frontal temporal dementia. out of medication - will notify hospice On 6/17/24 at 7:46 PM, an eMar- Medication Administration Note documented, QUEtiapine Fumarate Oral Tablet 25 MG. Give 25 mg enterally two times a day for psychoses, frontal temporal dementia. Reordered, not received. Will administer when available/delivered. On 6/18/24 at 9:29 AM, an eMar- Medication Administration Note documented, QUEtiapine Fumarate Oral Tablet 25 MG. Give 25 mg enterally two times a day for psychoses, frontal temporal dementia. med [medication] unavailable, ordered. On 6/18/24 at 9:03 PM, an eMar- Medication Administration Note documented, QUEtiapine Fumarate Oral Tablet 25 MG. Give 25 mg enterally two times a day for psychoses, frontal temporal dementia. medication unavailable, reordered and not delivered at this time. It should be noted resident 111 did not receive their quetiapine for two days. On 7/2/24 at 11:21 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated if a medication supply was noticed to be low, the nurse in charge reordered it in the computer. LPN 1 stated they had multiple ways to reorder medication. LPN 1 stated they were also able to pull the sticker off the medication card and faxed it to the pharmacy but that was the old way of doing it. LPN 1 stated staff were flagged to reorder medication when the remaining pills were in the blue section of the medication card. LPN 1 stated how fast medication was delivered depended on the pharmacy in use. LPN 1 stated they use to get medication delivered the same day but it had slowed down a bit. LPN 1 stated they had two medication deliveries a day. LPN 1 stated if they had not received the medication by the first delivery then they called the pharmacy and notified them. LPN 1 stated the provider was notified if a resident was unable to receive the ordered medication and a progress note was written. On 7/2/24 at 11:26 AM, an interview was conducted with LPN 2. LPN 2 stated the computer system sent a notification when it believed it was time to reorder more medication. LPN 2 stated there were multiple ways to reorder medication. LPN 2 stated the electronic way was clicking the reorder button that popped up next to the medication. LPN 2 stated they also ordered medication by printing the prescription and sending it to the pharmacy. LPN 2 stated another way to reorder medication was to pull off the tab from the medication card and send it to the pharmacy. LPN 2 stated depending on when the medication was reordered, it normally arrived by the evening or the next day. LPN 2 stated the pharmacy was called if they knew they did not have the morning dose of the medication. LPN 2 stated a progress note was written if a medication was unavailable. LPN 2 stated if a medication was not available, first they notified the pharmacy and then the provider was notified. LPN 2 stated the provider was notified through a secure conversation and was asked for further instructions on the unavailable medication. LPN 2 stated if the provider replied the resident was fine to miss a dose, then they tried to write a progress note. LPN 2 stated if a medication was ordered, then it needed to be given as ordered by the provider. On 7/2/24 at 11:38 AM, an interview was conducted with the DON. The DON stated staff were able to reorder medication from the computer when it was due. The DON stated they were also able to fax a request to the pharmacy. The DON stated if the nurse had ordered the medication and noticed they had not received the medication then they needed to call the pharmacy. The DON stated if the nurse did not have the medication available when it was time to be given then they needed to notify the provider. The DON stated provider notification was documented in either the progress notes or the MAR. The DON stated they had two to three pharmacy deliveries a day. The DON stated if a medication had been reordered then it was expected to be here the same day or the following day at the latest. On 7/2/24 at 12:45 PM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated based on the pharmacy medication order status, the medication order was submitted on 6/18/24 at 7:08 AM. UM 1 stated it did not look like the medication had been reordered on 6/17/24. Based on observation, interview, and record review, the facility did not provide pharmaceutical services which included procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident. Specifically, for 2 out of 50 sampled residents, a resident did not have Cyclobenzaprine available and another resident did not have Seroquel available for administration. Resident identifiers: 9 and 111. Findings included: 1. Resident 9 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included paraplegia, cirrhosis of liver, hepatic encephalopathy, psychosis, and hypertension. On 6/24/24 at 1:58 PM, an interview was conducted with resident 9. Resident 9 stated that he was in pain and that he did not want to complete the interview because he was in a lot of pain. Resident 9 was observed to have rested his head in the palm of his hand. Resident 9 was observed to have facial grimacing. On 6/27/24 at 8:11 AM, an observation was conducted of resident 9. Resident 9 was observed at the medication cart waiting for the Medication Technician to prepare the medications. Resident 9 was observed to have facial grimacing, was crying, and was rubbing his right leg. A quarterly Minimum Data Set assessment dated [DATE], revealed resident 9 had scheduled and as needed pain medication for the previous five days. There were no non-medical interventions used. A care plan dated 9/14/22, revealed [Resident 9] has acute/chronic pain r/t [related to] left femur fx [fracture], chronic pain syndrome, neuropathy, muscle spasm, mood d/o [disorder]. The goal was Will not have an interruption in normal activities due to pain through the review date. The interventions included Administer analgesia medication as per orders. Give 1/2 hour before treatments or care; Anticipate need for pain relief and respond immediately to any complaint of pain; Follow the pain scale to medicate as ordered; Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician; Monitor/record pain characteristics: Quality (e.g. sharp, burning); Severity (1 to 10 scale); Anatomical location; Onset; Duration (e.g., continuous, intermittent); Aggravating factors; Relieving factors; and Monitor/record/report to Nurse any s/sx [signs and symptoms] of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). A physician's order dated 3/26/24, revealed Cyclobenzaprine HCl [hydrochloride] tablet. Give 5 mg [milligrams] by mouth at bedtime for pain. The progress notes revealed on 6/27/24 at 7:52 PM, 6/28/24 at 7:06 PM, 6/29/24 at 7:15 PM, and 6/30/24 at 7:15 PM, Cyclobenzaprine HCl Oral Tablet. Give 5 mg by mouth at bedtime for Pain. Waiting on medication from pharmacy. The June 2024 Medication Administrator Record (MAR) revealed Cyclobenzaprine was not administered on 6/27/24, 6/28/24, 6/29/24, and 6/30/24. On 7/2/24 at 9:43 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated if medications were unavailable, an emergency medication supply was available. RN 1 stated when a resident was out of medications the nurse was to call the pharmacy, notify the resident's physician, and get guidance from the physician. RN 1 stated nurses should never write the medication was not available because the resident needed their medication, so the nurse needed to follow up. On 7/2/24 at 11:00 AM, a follow-up interview was conducted with RN 1. RN 1 was observed to review resident 9's MAR. RN 1 stated resident 9 did not have the muscle relaxer available. RN 1 stated a resident could have increased pain if the pain was coming from tense muscles. RN 1 stated resident 9 was up and down with his pain from moment to moment. RN 1 stated resident 9 was usually at the medication cart at 6:00 AM, for his medication but has not been recently. RN 1 stated resident 9 had been experiencing a decline and the physician was aware. RN 1 stated resident 9 had not been waking up until about 10:00 AM, because mornings had been harder for him. RN 1 stated resident 9 was maybe in a little more pain in the morning but there were other psychological issues and a recent urinary tract infection that was contributing to it. On 7/2/24 at 11:05 AM, an interview was conducted with the Director of Nursing (DON). The DON stated if a resident did not have medications available, the nurse was to contact the pharmacy. The DON stated there was a direct order system to the pharmacy through the medical record system. The DON stated she would need to check into resident 9's medication. On 7/2/24 at 1:06 PM, a follow-up interview was conducted with the DON. The DON stated medications should re-ordered three to four days prior to when the medications were going to run out. The DON stated Medicaid provided 120 pills for the whole month and a lot of times the facility paid out of pocket when the payer source was long term Medicaid. The DON stated depending on which Medicaid program the resident had, the doctors had to order certain medications that were on the formulary provided. The DON stated that February was the only time that the medications lasted the whole month. The DON stated depending on what type of medications were on the formulary, the physician had to submit information. The DON stated usually the medication ordering process could be delayed because of the Medicaid system. The DON stated resident 9 was not administered the Cyclobenzaprine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is 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 indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 2 out of 50 sampled residents, resident's receiving blood pressure support medication for hypotension did not have the medication held when the systolic blood pressure (SBP) was outside of the physician's ordered parameters. In addition, a resident receiving insulin did not have the medication held when the blood sugar was below the physician's ordered parameters. Resident identifiers: 35 and 65. Findings included: 1. Resident 35 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, cerebral infarction, end stage renal disease, type 2 diabetes mellitus, hypertensive chronic kidney disease with stage 5 chronic kidney disease, major depressive disorder, generalized anxiety disorder, dependence on renal dialysis, epilepsy, hepatitis A without hepatic coma, hypotension, low back pain, and insomnia. Resident 35's medical record was reviewed on 7/1/24. On 1/8/24, a physician's order documented Midodrine HCl [hydrochloride] Oral Tablet (Midodrine HCl) Give 10 mg [milligrams] by mouth three times a day for Hypotension Given if SBP is < [less than] 90. The physician's order documented administration times were 7:00 AM to 9:00 AM, 11:00 AM to 1:00 PM, and 8:00 PM to 10:00 PM. A review of the June 2024 Medication Administration Record (MAR) documented when the SBP was greater than 90 and the Midodrine was administered to resident 35 when it should have been held according to the physician's order. a. On 6/2/24 at 7:00 AM to 9:00 AM, 103. b. On 6/2/24 at 11:00 AM to 1:00 PM, 103. c. On 6/2/24 at 8:00 PM to 10:00 PM, 99. d. On 6/3/24 at 11:00 AM to 1:00 PM, 110. e. On 6/3/24 at 8:00 PM to 10:00 PM, 104. f. On 6/5/24 at 7:00 AM to 9:00 AM, 95. g. On 6/6/24 at 11:00 AM to 1:00 PM, 142. h. On 6/8/24 at 7:00 AM to 9:00 AM, 98. i. On 6/8/24 at 11:00 AM to 1:00 PM, 98. j. On 6/9/24 at 7:00 AM to 9:00 AM, 97. k. On 6/9/24 at 11:00 AM to 1:00 PM, 97. l. On 6/19/24 at 7:00 AM to 9:00 AM, 101. m. On 6/19/24 at 11:00 AM to 1:00 PM, 101. n. On 6/20/24 at 7:00 AM to 9:00 AM, 101. o. On 6/21/24 at 7:00 AM to 9:00 AM, 99. p. On 6/21/24 at 11:00 AM to 1:00 PM, 99. q. On 6/22/24 at 7:00 AM to 9:00 AM, 99. r. On 6/22/24 at 11:00 AM to 1:00 PM, 99. s. On 6/26/24 at 7:00 AM to 9:00 AM, 106. t. On 6/26/24 at 11:00 AM to 1:00 PM, 106. u. On 6/28/24 at 7:00 AM to 9:00 AM, 99. v. On 6/28/24 at 11:00 AM to 1:00 PM, 99. On 1/19/24, a physician's order documented NovoLOG Injection Solution 100 UNIT/ML [milliliters] (Insulin Aspart) Inject 8 unit subcutaneously with meals related to TYPE 2 DIABETES MELLITUS WITH DIABETIC CHRONIC KIDNEY DISEASE; TYPE 2 DIABETES MELLITUS WITH MODERATE NONPROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, BILATERAL Hold insulin if blood sugar below 120. A review of the June 2024 MAR documented when the blood sugar was below 120 and the Novolog was administered to resident 35 when it should have been held according to the physician's order. a. On 6/3/24 at 8:00 AM, 93. b. On 6/4/24 at 8:00 AM, 108. c. On 6/11/24 at 8:00 AM, 112. d. On 6/13/24 at 8:00 AM, 119. e. On 6/24/24 at 8:00 AM, 119. f. On 6/25/24 at 8:00 AM, 119. On 7/1/24 at 1:28 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 35 would get one Midodrine in the morning before dialysis and resident 35 would take the noon Midodrine with her to dialysis and the dialysis nurse would determine if resident 35 got the noon dose or not. RN 1 stated that dialysis should have the same parameters as the physician's order. RN 1 stated that he would give the scheduled dose of Midodrine and if the Midodrine was not scheduled he would give the as needed (PRN) dose. RN 1 stated the Certified Nursing Assistant's would check resident 35's vital signs at 3:00 PM, when swing shift started. RN 1 stated the PRN Midodrine was available if resident 35 needed it. RN 1 stated the PRN Midodrine parameters were to give if the SBP was less than 100. RN 1 stated the scheduled medications could be given an hour before or an hour after the scheduled time and the PRN medication should be given outside of those times. On 7/2/24 at 10:03 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 35 was on dialysis and if staff were to hold the Midodrine resident 35's blood pressure would drop. The DON stated that resident 35 received dialysis five days a week. The DON stated it was hard to maintain resident 35's blood pressure when dialysis was pulling off water five days a week. The DON stated that resident 35 received regular scheduled vital signs. The DON stated if resident 35 was complaining of symptoms resident 35 could ask for the PRN Midodrine. The DON stated if resident 35 was in dialysis and was dropping, dialysis could call the staff for an extra dose of the Midodrine. On 7/2/24 at 1:03 PM, an interview was conducted with RN 1. RN 1 stated that resident 35's Novolog had hold parameters but RN 1 had never noticed resident 35's blood sugar being low. RN 1 stated that resident 35 would refuse the Novolog if her blood sugar was below 150. RN 1 stated that staff should hold the Novolog if resident 35's blood sugar was below 120. RN 1 stated that resident 35 knew how close to meals she was or what she had eaten prior to the administration of the Novolog. 2. Resident 65 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, chronic respiratory failure with hypoxia, malignant neoplasm of larynx, emphysema, hypertensive heart disease with heart failure, major depressive disorder, generalized anxiety disorder, chronic pain syndrome, tracheostomy status, and acquired absence of larynx. Resident 65's medical record was reviewed on 6/25/24. On 4/10/24, a physician's order documented Midodrine HCl Oral Tablet (Midodrine HCl) Give 2.5 mg by mouth two times a day for Hypotension ***HOLD for SBP > [greater than] 90. A review of the June 2024 MAR documented when the SBP was greater than 90 and the Midodrine was administered to resident 65 when it should have been held according to the physician's order. a. On 6/6/24 at 7:00 AM, 128. b. On 6/21/24 at 7:00 AM, 118. c. On 6/26/24 at 7:00 AM, 92. d. On 6/28/24 at 7:00 AM, 92. e. On 6/29/24 at 7:00 AM, 92. On 7/2/24 at 1:06 PM, an interview was conducted with RN 1. RN 1 stated that resident 65 would refuse the Midodrine almost every single morning. RN 1 stated staff would check vital signs around 5:00 AM or 5:30 AM, and today resident 65 was 80/50. RN 1 stated that resident 65 had refused the Midodrine from the night nurse. RN 1 stated that he had rechecked resident 65's blood pressure and it was 92/53. RN 1 stated that he eventually talked resident 65 into taking the Midodrine. RN 1 stated that he was unaware if resident 65's Midodrine even had hold parameters. RN 1 stated that resident 65 would usually run low on his blood pressure. RN 1 stated that he would hold the Midodrine if it was below the ordered parameters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not provide or obtain timely laboratory services to meet the needs of the residents. Specifically, for 1 out of 50 sampled residents, a Depakote lab was not obtained or followed-up on for 10 days and a Complete Blood Count (CBC) was not obtained or followed-up on for seven days. Resident identifier: 55. Findings included: Resident 55 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included a fracture of the right femur, hypertension, hypothyroidism, depression, hyperlipidemia, dementia, pain right leg, dysphagia, right artificial hip joint, cognitive communication deficit, benign prostatic hyperplasia, thrombocytosis, and anemia. Resident 55's medical record was reviewed from 6/24/24 through 7/2/24. On 5/6/24, resident 55's physician ordered a Depakote level. On 5/8/24, resident 55's physician ordered a CBC. Review of the laboratory results revealed the following: a. On 5/6/24, the lab report documented, A plasma specimen was received with no test indicated. The report documented that the sample was received on 5/7/24 and reported on 5/9/24. On 5/6/24, the Valproic Acid (Depakote) test documented, Test not performed. Gel barrier tube unsuitable for test ordered. The report documented that the specimen was received on 5/7/24 and reported on 5/20/24. The report had a hand written note that documented that the sample was drawn again on 5/21/24. b. On 5/9/24, the lab report documented that the CBC with differential was not performed due to Insufficient specimen to perform or complete. The report documented that the sample was received on 5/10/24 and reported on 5/17/24. On 7/1/24 at 8:38 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the specimen for the Depakote test was sent on 5/6/24, and the lab responded back with no test indicated. The DON stated that the facility responded to the requisition regarding what test was ordered and the lab did not redo the test. The DON stated that the facility responded to the lab on 5/10/24, with the test that was indicated. The DON stated that the lab then replied back on 5/20/24, that the test was not performed because the gel barrier was unsuitable. The DON stated that the sample was collected again on 5/21/24, and the results were received on 5/22/24. The DON stated that initially they were going to draw the sample again, but the lab informed them that they could still run the old sample. The DON stated she would have to talk to Unit Manager (UM) 1 to see what caused the delay in following up with the lab. The DON stated that UM 1 should have followed up within three days after the sample was sent to the lab. The DON stated that the CBC collected on 5/9/24, was redrawn on 5/16/24, because the facility did not have the results. The DON stated that the facility was informed of the insufficient sample with the original specimen on 5/17/24. The DON stated that the process was for staff to check lab results daily, and if they did not see a result they should call the lab after three days.

Based on observation and interview, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 5 out of 50 sampled residents, a Certified Nursing Assistant (CNA) assisted multiple residents with dining and hand hygiene was not performed when environmental surfaces and resident objects were touched. Resident identifiers: 21, 24, 40, 63, and 84. Findings included: On 6/26/24, a dining observation was made for the breakfast meal on the D hallway. On 6/26/24 at 8:08 AM, CNA 6 was observed to serve a bite of food to resident 84. CNA 6 then handed a stool over the top of the table to another CNA. The stool was passed over resident 24's meal. CNA 6 then cleaned spilled milk off the floor. CNA 6 did not perform hand hygiene. On 6/26/24 at 8:13 AM, CNA 6 assisted resident 40, resident 24, and resident 63 with a bite of food. CNA 6 then provided resident 21 with a drink of a beverage while touching the straw and area that came into contact with resident 21's mouth. CNA 6 did not perform hand hygiene. On 6/26/24 at 8:21 AM, CNA 6 provided multiple bites of food to resident 84, resident 40, and resident 21 without sanitizing their hands in between. CNA 6 was observed to touch her eyeglasses repeatedly, pushing them up onto her nose, while assisting the residents with their meal. On 6/26/24 at 9:03 AM, an interview was conducted with CNA 8. CNA 8 stated that they should be performing hand hygiene in between passing meal trays and in between feeding different residents. On 6/27/24 at 7:20 AM, an interview was conducted with the CNA Coordinator. The CNA Coordinator stated that staff should perform hand hygiene when they were serving food if they touched any environmental surfaces that could cross contaminate. CNA 6 stated that the CNAs should wash their hands if they touched a resident's straw that came into contact with the resident's mouth before moving on with assisting another resident with dining.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation was made if the events that cause the allegation involve abuse or result in serious bodily injury. Specifically, for 3 out of 50 sampled residents, the facility did not report an allegation of mental/verbal abuse until seven days after the incident occurred, the facility did not report an allegation of sexual abuse until five days after the incident occurred, and the facility did not report an additional allegation of sexual abuse to Adult Protective Services (APS) or the police within two hours of the allegation being made. Resident Identifiers: 21, 63, 85, and 167. Findings Included: 1. Resident 85 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unspecified dementia of unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. On 3/17/24 at 10:28 AM,a facility initial notification, form 358, was submitted to the State Survey Agency (SSA). The form documented an incident of sexual abuse. The form documented that staff had become aware of the incident on 3/17/24 at 8:00 AM. The form documented that the incident was reported by Certified Nursing Assistant (CNA) 13 to Registered Nurse (RN) 7 that another resident had reached inside resident 85's shirt. Documentation shows that APS was notified on 3/20/24, that police were notified on 3/18/24 at 8:30 AM, and the Ombudsman was notified on 3/19/24, and again on 3/22/24. On 6/26/24 at 2:59 PM, a telephone interview was conducted with RN 7. RN 7 stated that the CNA reported the incident to her right away. RN 7 stated that she immediately messaged the Director of Nursing, the Administrator, and the Unit Manager. RN 7 stated the facility went over abuse training at every staff meeting with all of the staff, nurses meetings, and twice a month. 2. Resident 21 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included of Alzheimer's Disease, dementia, cerebral infarction, dysphagia, type 2 diabetes mellitus, chronic kidney disease, and mood disorder. On 12/27/23 at 12:04 PM, a facility initial notification, form 358, was submitted to the SSA. The form documented an incident of mental/verbal abuse. The form documented that staff had become aware of the incident on 12/20/23 at 12:00 PM. The form documented that it was reported by CNA 10 that resident 21 had asked CNA 12 to stop showering him and CNA 12 replied back in Spanish, No porque paeta a mierda which translates to no because you stink like poop. It should be noted that the initial SSA notification occurred seven days after the incident occurred. No documentation could be found to indicate that APS was notified of the allegation of abuse. 3. Resident 63 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, dementia, mood disorder, anxiety disorder, chronic pain, lumbar region intervertebral disc degeneration, and dysphagia. a. On 2/16/24 at 6:46 PM, the facility initial notification, form 358, was submitted to the SSA. The form documented an incident of sexual abuse. The form documented that staff had become aware of the incident on 2/11/24 at 3:00 PM. The form documented that it was reported by CNA 2 that they had witnessed resident 167 kissing resident 63 on the couch and that resident 167 had his hand down resident 63's pants. On 2/16/24 at 6:44 PM, the Report of Suspected Dependent Adult/Elder Abuse report was submitted to APS. It should be noted that the initial SSA and APS notification occurred over five days after the incident had occurred. b. On 2/25/24 at 3:32 PM, the facility initial notification, form 358, was submitted to the SSA. The form documented an incident of attempt at Physical affection/contact. The form documented that staff became aware of the incident on 2/24/24 at 2:30 PM. The form documented that RN 3 witnessed resident 167 put his hands down the top of resident 63's pants on her back side. It should be noted that the initial SSA notification occurred over 24 hours after the incident occurred. No documentation could be found to indicate that APS was notified of the allegation of abuse. On 6/26/24 at 11:28 AM, an interview was conducted with CNA 13. CNA 13 stated that the Administrator was the abuse coordinator. CNA 13 stated the facility provided training about abuse. CNA 13 stated abuse training came up during meetings, and staff were to report abuse to the Administrator within an hour or two so the Administrator could do the paperwork within the timeline. CNA 13 stated that most often anything we see would be reported to the nurse directly. CNA 13 stated she had not gone to the Administrator herself. On 7/1/24 at 9:51 AM, a telephone interview was conducted with the Previous Administrator (PADM). The PADM stated that the goal was to report to the SSA and APS within two hours of all allegations of abuse. The PADM stated that all the staff were aware of the timeframe for reporting and knew to report to him. The PADM stated that they had conducted extensive education on abuse with the types of abuse and the timeframe for reporting.

Based on observation, interview and record review, the facility did not provide food that was palatable, attractive, and at a safe and appetizing temperature. Specifically, for 5 out of 50 sampled residents, residents complained about the food being served cold, the resident council minutes had concerns documented regarding food being served cold, and the food items on the test tray were cold. Resident identifiers: 25, 37, 72, 268, and 274. Findings included: 1. On 6/24/24 at 10:17 AM, an interview was conducted with resident 37. Resident 37 stated that the food was not always as warm as it should be. Resident 37 stated the staff would start passing meal in the dining room and then at the end of the hall. Resident 37 stated that she was almost the last to get her meal but she understood. 2. On 6/24/24 at 10:32 AM, an interview was conducted with resident 274. Resident 274 stated the food was cold when it was served and the food was not that good. 3. On 6/24/24 at 12:11 PM, an interview was conducted with resident 25. Resident 25 stated that sometimes the food was cold by the time it got to the hallway. 4. On 6/25/24 at 8:37 AM, an interview was conducted with resident 72. Resident 72 stated that sometimes the food was cold. Resident 72 stated sometimes the food was good and sometimes it was not. 5. On 6/25/24 at 9:08 AM, an interview was conducted with resident 268. Resident 268 stated that sometimes the food was cold by the time it reached him at the end of the hallway. 6. Resident council notes were reviewed between 6/24/24 and 7/2/24. Repeated concerns included: a. On 12/6/23, New business included, Food not always hot on hall carts. A response dated 1/3/24, revealed Will continue to monitor time/temp [temperature]. b. On 1/3/24, Old business included, Food not always hot on hall trays. This item was marked, not resolved. c. On 4/10/24, new business included, Food is not always served hot. Action taken revealed, Assure all thermal insulators being used and spot temp. Old business included, Food trays are sitting too long in the C & D dining room before getting served. Action taken was, resolved. d. On 5/9/24, old business included, Food is not always served hot. Action taken revealed, kitchen and marked as resolved. e. On 6/24/24, new business included, Food not always being served hot. 7. On 6/27/24 at 12:42 PM, a test tray was requested. At 12:46 PM, the meal cart left the kitchen for the A hallway. At 1:17 PM, the last resident meal was taken from the meal cart and served to the resident. The test tray was taken from the meal cart, temperatures were obtained, and the food was sampled: a. Barbeque chicken was 89 degrees Fahrenheit. The chicken was moist, had a good flavor, and was easy to chew. b. Pasta salad was 67.5 degrees Fahrenheit. The pasta salad was colorful, had a good flavor with a variety of ingredients. c. Mushroom salad was 64.4 degrees Fahrenheit. The mushroom salad did not look appetizing, and was not very flavorful. d. Ice cream was 21.2 degrees Fahrenheit. The strawberry ice cream was partially melted. On 6/27/24 at 3: 12 PM, an interview was conducted with the Registered Dietitian (RD). The RD stated she did an audit of the kitchen every other month. The RD stated the audit included watching tray line, checking food temperatures, and tasting the food. On 7/2/24 at 11:00 AM, an interview was conducted with the Dietary Manager (DM). The DM stated she attended resident council meetings when invited. The DM stated the RD was in the kitchen frequently and if she saw something that needed to be corrected she would notify the DM. The DM stated the RD completed audits quarterly that included tray audits. The DM stated the RD also ate at the facility so she was aware of the taste and temperature of the food. The DM stated to address resident concerns about cold food she had started doing more batch cooking. The DM also stated dietary aids were using plate warmers to ensure food was hot. The DM stated she had tested the temperature of the food and sometimes it is not the hottest, but it is still palatable.

Based on observation and interview, the facility did not distribute and serve food in accordance with the professional standards of food service safety. Specifically, food items in the dry storage room, walk in refrigerator and walk in freezer were open to air, the kitchen was not clean, and there were broken tiles in the kitchen. Findings included: On 6/24/24 at 8:26 AM, an initial walkthrough of the kitchen was conducted. In the dry storage room, bulk storage bins were open to air and were not labeled. These included oats, chocolate powder, sugar, flour, cake mix, and potato chips. In the walk-in refrigerator, a box containing bacon was open to air. In the walk-in freezer, a box containing biscuit dough and a box of beef patties were open to air. The floor under and behind the grill was dirty and along the base of the wall, with what appeared to be food pieces under the grill. A tile near the ice cream freezer had a hole in it with what appeared to be dirt and dried food particles in it. On 6/27/24 at 12:40 PM, an observation was conducted of the kitchen. Tiles between two ovens were observed to be broken. The floors under and behind the ovens had food bits on the floor, and the baseboard area appeared to be encrusted with crumbs and debris. On 7/2/24 at 9:09 AM, a second walkthrough was conducted in the kitchen. The walk-in refrigerator contained a box of gluten free sausage links that was open to air. The walk-in freezer contained a box of frozen peas that was open to air, a box of frozen vegetables that was open to air, tilapia filets in a box were open to air, and a box of sausage links was open to air. Broken tiles between two ovens were observed. The bins in the dry storage room were covered, however, the flour bin, a bin containing a yellow powder, and the potato chips were not labeled. Also a box of gluten free elbow pasta was open to air. On 6/27/24 at 3:12 PM, an interview was conducted with the Registered Dietitian (RD). The RD stated she was auditing the kitchen. The RD stated that kitchen audits included sanitation, tray line, food temperature, and taste. The RD stated she conducted the audits every other month and was available for questions throughout the day. The RD stated after she completed an audit, the information went to the Dietary Manager (DM) and the Administrator (ADM). On 7/2/24 at 11:00 AM, an interview was conducted with the DM. The DM stated there were cleaning logs for each shift and many of the tasks needed to be done weekly, so they would be checked off once per week. The DM stated kitchen staff were cleaning behind the ovens once per month. The DM stated floors were mopped throughout the day, and a thorough mopping at the end of each day. The DM stated spills were cleaned up whenever they happened. The DM stated she was not aware of the broken tiles between the ovens. The DM stated if tiles were broken or other maintenance needs were discovered, a request was put into the TELLS system for maintenance. The DM stated maintenance staff were usually very quick to fix things, and within a few days. The DM stated the RD was frequently in the kitchen and would alert her if she observed something that needed to be corrected. The DM stated the RD completed quarterly audits of the kitchen, including tray audits. The DM stated her expectation when food was returned to the refrigerator or freezer would be that food remaining in the box would be wrapped and sealed. The DM stated if the food item was out of the box it should be labeled and dated. The DM stated food items being returned to the refrigerator or freezer could become contaminated or get freezer burn if not wrapped and sealed appropriately. The DM stated the bulk storage bins in the dry food storage room should be labeled and dated. The DM stated that the stickers came off easily. The DM stated that lids to these bins should be labeled with the name of the item and the use-by date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined, in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility failed to have evidence that all alleged violations were thoroughly investigated. Specifically, for 6 out of 13 sampled residents, the facility did not thoroughly investigate resident to resident altercations, a resident with an injury of unknown origin, and a family to resident altercation. Resident Identifiers: 2, 3, 4, 5, 8 and 10. Findings included: 1. Resident 2 was admitted to the facility on [DATE] with diagnosis which included Alzheimer's disease, dementia, stage 3 chronic kidney disease, type 2 diabetes mellitus, and mood disorder. Resident 2's medical record was reviewed on 10/23/23. On 3/13/23, an annual Minimum Data Set (MDS) documented resident 2 had a Brief Interview for Mental Status (BIMS) score of 1 which indicated severe cognitive impairment. A care plan initiated on 5/9/23 documented, [Resident 2] has potential for a behavior problem r/t [related to] confusion and memory loss. Some of the interventions initiated on 5/9/23 included: a. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. b. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. On 2/22/23 at 11:38 AM, a nursing progress note documented, Resident having increased number of agitated and aggressive episodes. Attempting to use w/c [wheelchair] as weapon and ram other residents and staff. Staff intervenes quickly . On 2/23/23 at 10:00 AM, a nursing progress note documented, This nurse heard screaming from resident's room. When I ran in there this Pt [patient] had another female Pt in the corner of his room by his closet and was forcefully pushing his FWW [front wheeled walker] into her. Residents were removed from the situation and assessed for injuries. No injuries sustained to this resident. He was given a snack and soda. Pt is now sitting in his room pleasant and calm. Therapy notified of incident. Per PT [physical therapy], FWW will be removed and therapy is working on purchasing Pt new diabetic shoes. Administrator, DON [Director of Nursing], UM [Unit Manager], SW [Social Worker], Family notified. On 2/23/23 at 10:55 PM, a nursing progress note documented, No further interaction with female peer involved in res/res [resident to resident] this shift. No aggression this shift. Agitated a couple of times. Required redirecting from staff as he was going into several different bedrooms. Staff quick to redirect. Several snacks given. On 2/24/23 at 3:16 PM, a nursing progress note documented, No new res/res incidents noted this shift. Pt continues to be agitated c [with] peers however no physical aggression noted this shift. On 2/24/23 at 7:48 PM, an incident note documented, Resident was assessed post resident to resident incident from 2/23/23, he is alert and oriented x 1 [person], he communicates his needs, and is able to answer simple questions, he is forgetful and confused and needs redirecting and reminding from staff. Resident is a Spanish speaker and communicates better in Spanish. Resident is unable to state or remember what led to incident but is aware that the female resident goes into rooms and takes objects. Resident is walking on his own, with a steady gait and is doing well without his walker. Resident is able to move all extremities with ROM [range of motion] and no [sic] stating new pain. Resident has not showed aggression towards the female resident, he will get upset at times but will be redirected by staff. No other new behaviors or changes in mood noted . Action Taken: Residents were removed from the situation and assessed for injuries. No injuries sustained to this resident. He was given a snack and soda. Pt is now sitting in his room pleasant and calm. Therapy notified of incident. Per PT, FWW will be removed and therapy is working on purchasing Pt new diabetic shoes. Administrator, DON, UM, SW, Family notified. NP [nurse practitioner] was notified of incident on 2/23/23, NP ordered to start on Wellbutrin and Hydroxyzine, she ordered a UA [urinalysis] for resident, and a UA was sent out on 2/23/23. Physical Therapy assessed resident and he is able to self ambulate without his walker with a steady gait and felt it is better for resident to use walker since he uses as it weapon and not to assist with walking . Resident 3 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia, insomnia, and cachexia. Resident 3's medical record was reviewed on 10/23/23. On 2/6/23, a Quarterly MDS documented resident 3 had a BIMS score of 0 which indicated severe cognitive impairment. A care plan initiated on 11/20/22 documented, [Resident 3] has potential for a behavior problem r/t hoarding items d/t dementia. One identified intervention documented, Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. On 2/23/23 at 10:12 AM, a nursing progress note documented, This nurse heard screaming from other resident's room. When I ran in there another Pt had resident 3 in the corner of his room by his closet and was forcefully pushing his FWW into her. Residents were removed from the situation and assessed for injuries. Bruise noted to her right shin. She was given a snack and taken to watch a movie. Pt is now sitting in a chair pleasant and calm. Administrator, DON, UM, SW, Family notified. On 2/23/23 at 11:03 PM, a nursing progress note documented, No further interaction with male peer involved in res/res. Resident continues to wander into other resident's rooms. Requires much redirection from staff. No s/sx [signs/symptoms] distress or anxiety R/T [related to] incident . On 2/24/23 at 7:39 PM, an incident note documented, Resident was assessed post resident to resident incident from 2/23/23, she is alert and oriented x self only, she is confused and forgetful, will state short phrases or words only. Resident is unable to state what led to incident. Resident a wanderer on the unit and goes into other resident's room and will attempts to take their belongings or just wander into room and walk out. Resident is able to self ambulate and have ambulating with a very good gait, no issues noted with ROM to extremities. Resident shows slight swelling to her right shin. No other injuries noted a this time. Resident is constantly redirected by staff. Resident shows no changes in behaviors, or mood, no behaviors noted towards other residents or the male resident, no distress noted. Resident is redirected by staff . Action Taken: Residents were removed from the situation and assessed for injuries. Bruise noted to her right shin. She was given a snack and taken to watch a movie. Pt is now sitting in a chair pleasant and calm. Administrator, DON, UM, SW, Family notified. NP was notified of incident on 2/23/23, no new orders at that time. On 2/24/23 at 11:06 PM, a nursing progress note documented, No interaction with male peer involved in res/res incident this shift. Resident continues to wander into other resident's rooms. Requires much redirection from staff. No s/sx distress or anxiety R/T incident . On 2/25/23 at 11:03 PM, a nursing progress note documented, Resident continues to wander into other resident's rooms. Attempted to go into the room of peer involved in res/res several times this shift. Requires much redirection from staff. No s/sx distress or anxiety R/T incident. The Facility Incident reports, Exhibit 358 and Exhibit 359 Sample Forms for Facility Reported Incidents were reviewed and documented the following additional information: a. The incident report provided for resident 3 had no additional information about the resident to resident altercation. [Note: An incident report for resident 2 was not provided.] b. On 2/23/23, Exhibit form 358 documented that an allegation of physical abuse was made between residents 2 and 3. Resident 2 was identified as the alleged perpetrator and described that he had backed resident 3 into a corner of his room after resident 3 had wandered into the room. After the incident resident 3 presented with a small bruise to the right shin. It documented that both residents were separated after the incident and they were unable to answer any questions about what had happened between them due to residing in the memory care unit. Identified actions taken by the facility to protect the residents included the removal of resident 2's walker. c. On 3/2/23, Exhibit form 359 documented the incident between resident 2 and resident 3 was unprovoked. Resident 2 was in a bad mood that day and did not want to associate with anyone. The results of the investigation determined that abuse was unsubstantiated. [Note: It stated that staff were interviewed but did not specify who was interviewed and what was asked/documented in the interview.] On 10/24/23 at 10:52 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated resident 2 was very confused. RN 2 stated resident 2 got agitated with some of the residents. RN 2 stated resident 2 established his personal space by using his walker. RN 2 stated resident 2 had tried to use his walker as a weapon in the past but he could not swing/lift up the walker. RN 2 stated when resident 2 became agitated with other residents, they redirected him. RN 2 stated there was an incident between resident 2 and resident 3 but they were unable to remember the exact details. RN 2 stated they were unsure if resident 2's walker made any contact with resident 3 but it did hit a nightstand. RN 2 stated when a resident to resident altercation happened, they notified the social worker and the abuse coordinator. RN 2 stated they were unsure if they were interviewed about the resident to resident altercation between resident 2 and resident 3. RN 2 stated sometimes during the investigations, they were interviewed about what they saw but stated being interviewed by the administration did not happen all the time. 2. Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include schizoaffective disorder, Alzheimer's disease, dementia, polyneuropathy, hypothyroidism, anxiety disorder, kidney disease, osteoarthritis, unsteadiness on feet, difficulty in walking, atherosclerotic heart disease, mild cognitive impairment, hyperlipidemia, dermatitis, insomnia, and GERD. Resident 4 was discharged on 8/23/23. Resident 4's medical record was reviewed on 10/23/23. On 7/24/23, a Quarterly MDS documented resident 4 had a BIMS score of 10, which indicated moderate cognitive impairment. A document titled [Name of facility] Progress Notes dated 10/24/23 was reviewed. a. A Note Text from 5/16/23 at 8:47 PM documented, This nurse was outside of the dining room and noticed that resident [4] had slight redness and purple around her left eye, mostly on the inner part of her eye. This nurse asked her what had happened and she stated That guy hit me he was swinging his arms around and accidentally hit me in the eye. This nurse asked her if it was intentional or on accident and she stated it was on accident. Resident shows no open areas, slight bruising only, no increased swelling noted, no pain stated to area, no other injuries noted. This nurse asked her when it occurred and she stated it was about 1-2 weeks ago, bruising looks fairly new. Resident shows no new distress noted, no new issues noted. Resident statement: 'that guy hit me' 'it was on accident'. Action taken: Resident [4] was assessment, NP was notified, SW and Administrator notified. DON notified. Resident's daughter notified, voice message left for resident. b. A Note Text from 5/17/23 at 5:58 PM documented, Resident was assessment post incident 5/16/23, he is alert and oriented x2 [person and place], she is forgetful and confused at times and needs redirecting and reminding of current situation. Resident stated she was on the hall in her wheelchair, and the male resident was walking and walked past her and was moving his hands and hit her on the eye, she stated that the incident was on accident. Resident has slight redness, and purple colored bruising to left eye, she stated no pain to left eye. Resident shows no other new injuries. Resident is able to move around in her wheelchair on her own, she can self transfer and self reposition. Resident shows no changes to behaviors, or mood, she shows no distress, no upset mood. Resident stated no new issues. Nurse on Unit description: This nurse was outside of the dining room and noticed that resident had slight redness and purple around her left eye, mostly on the inner part of her eye. This nurse asked her what had happened and she stated, 'That guy hit me' he was swinging his arms around and accidentally hit me in the eye. This nurse asked her if it was intentional or on accident and she stated it was on accident. Resident shows no open areas, slight bruising only, no increased swelling noted, no pain stated to area, no other injuries noted. This nurse asked her when it occurred and she stated it was about 1-2 weeks ago, bruising look fairly new. Resident shows no new distress noted, no new issues noted .Administration and SW were notified 5/16/23, a report was sent in. Staff to continue to monitor resident's behaviors and any changes in mood. Resident 5 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, alcohol dependence, morbid obesity, chronic kidney disease, hypothyroidism, bilateral primary osteoarthritis, dementia, aphasia, hypopituitarism, chronic pain, hyperlipidemia, acute kidney failure, edema, and glaucoma. Resident 5 was discharged on 9/14/23. On 8/7/23, a Quarterly MDS documented resident 5 had a BIMS score of 1, which indicated severe cognitive impairment. The Quarterly MDS revealed that resident 5 had physical behavioral symptoms directed towards others 4 to 6 days. And Other behavioral symptoms not directed towards other 1 to 3 days. A care plan initiated 8/17/23 documented, [Resident 5] has potential for a behavioral problem r/t combative w/ cares, refusing cares, attempting to remove clothes, combative w/ peers d/t sequelae cerebral infarction, ETOH [alcohol] dependence with dementia, dementia w/ anxiety and aggressive features. The goal stated, Will have fewer episodes of behaviors by review date. Some of the interventions initiated on 8/17/23 included; A. Anticipate and meet needs. B. Approach in a calm manner. Due to blindness to left eye, do not approach [resident 5] from the side. C. Document behaviors, and resident response to interventions. D. Intervene as necessary to protect the rights and safety of others. E. Maintain other residents out of reach of this [resident 5]. The Facility Incident reports, Exhibit 358 and Exhibit 359 Sample Forms for Facility Reported Incidents were reviewed and documented the following additional information: a. On 5/16/23, Exhibit 358 documented an allegation type as physical abuse, identifying the alleged victim as resident 4 and the alleged perpetrator as resident 5. Under the section that stated provide all steps taken immediately to ensure resident(s) are protected Exhibit 358 documented, Residents will be monitored. Upon initial questioning of resident [4]. She said 'that guy [resident 5] hit me'. She was on the hall in her WC [wheelchair] and he was swinging his arms and accidentally hit her left eye. Staff asked if it was on purpose or accident and she said on accident, not intentinal [sic]. No signs of distress and cannot remember when it happened, she said it was about 1-2 weeks ago, but it appears fairly new (today). The document reported no witnesses. b. Exhibit 359 documented steps taken to investigate the allegation as, [Resident 4] was interviewed and she stated that 'that guy hit me' and pointed to [resident 5]. Staff asked her if [it] was intentional, she stated it was on accident. That [resident 5] was just swinging his arms and accidentally hit her. [Resident 4] stated it happened about a week ago, but it appeared new. [Resident 5] does not remember incident. Both [resident 5] and [resident 4] reside in the memory care unit. The allegation of abuse was unsubstantiated, and the correction actions taken stated, [Resident 4] was asked to inform staff if anything happens again, she agreed. [It should be noted that the investigation did not include interviews with other residents who may have had contact with the alleged perpetrator, or interviews with staff responsible for oversight and supervision of the location where the alleged victim and perpetrator reside.] On 10/23/23 at 11:35 AM, an interview with RN 1 was conducted. RN 1 stated that she conducted the investigation for the incident between resident 4 and resident 5. RN 1 stated that resident 5 was often aggressive with cares. RN 1 stated that resident 5 would often use the hand rail to propel himself in this wheelchair and he would swing his other arm out in front of him. RN 1 stated that she asked another nurse if they saw what had happened and the nurse reported that they did not witness anything. [It should be noted that the investigation report did not include interviews with other staff members]. RN 1 stated that she reported the incident to the NP, the daughter of resident 4, and the administrator. 3. Resident 10 was admitted to the facility on [DATE] with diagnoses which included calculus of gallbladder, type 2 diabetes mellitus, atherosclerotic heart disease, heart failure, sick sinus syndrome, chronic atrial fibrillation, hyperlipidemia, muscle weakness, unsteadiness on feet, edema, cardiac pacemaker, and long term use of anticoagulants. Resident 10 was discharged from the facility on 9/18/23. Resident 10's medical record was reviewed. On 9/14/23, an admission MDS documented resident 10 had a BIMS score of 6, which indicated moderate cognitive impairment. Resident 10's progress notes were reviewed. A progress note from 9/8/23 at 12:09 AM revealed, Heard commotion and then a big thump coming from resident's room. This nurse ran to check what happened and [resident 10] was on the floor by the heater/AC. Son-in-law states he was trying to help [resident 10] when [resident 10] got combative and hit him. After [resident 10] swung, he fell and hit his head and back on the heater/AC. No injuries noted to resident's head. Abrasions noted to L [left] scapula and R [right] side mid back. 3 skin tears noted to R forearm near elbow. Daughter was in the facility at the time of the fall. Neuro checksinitiated [sic]. A progress note from 9/8/23 at 4:25 PM revealed, This nurse assessed resident post fall on 9/7/23. Resident appears to be alert and oriented X [times] 1-2 with some confusion and forgetfulness. Resident is pleasant and cooperative with post fall assessment, appears to be adjusting well to facility. Resident currently denies any pain or injuries r/t fall. Skin tears to right elbow sustained r/t fall . No s/s infection to site noted. Wound care nurse notified of skin alterations. Neurological checks started at time of fall, all vital signs remain within normal limits .Concerns noted after reports of son-in-law pushing resident a little bit in 'self defense'. Concern reported DON, Administrator and SSW and was reported to APS per facilityprotocol [sic]. Daughter reports resident had been combative during his hospital stay. Resident attempting to pack bags and leave upon admission and required frequent reorientation and redirection throughout the NOC [night shift]. Resident agreed to stay the night and eventually fell asleep. Daughter refused all interventions for a secure unit and wander guard for elopement risk and any pharmacological interventions. NP was notified at time fall, no new orders. All staff are frequently monitoring and redirecting as needed. Nursing Description: Heard commotion between [resident 10] and son-in-law and then a big thump coming from resident's room. This nurse ran to check what happened and [resident 10] was on the floor by the heater/AC. Son-in-law states he was trying to help [resident 10] when [resident 10] got combative and hit him. After [resident 10] swung, he fell and hit his head and back on the heater/AC. No injuries noted to resident's head. Abrasions noted to L [left] scapula and R [right] side mid back. 3 skin tears noted to R forearm near elbow. Daughter was in the facility at the time of the fall. CNA [Certified Nursing Assistant] reported that he told her he pushed him a little in self-defense. Resident Description: Resident says son-in-law was trying to hit him so he swung back and son-in-law pushed him and he lost his balance. Description of action taken: Vital signs taken. Neuros initiated. Skin tears cleaned and dressed. Care plan updated: Orient to environment and redirect as needed. A progress note from 9/11/23 at 2:48 PM documented, Social Service Summary: [Resident 10] is a recent admit. He is alert and oriented to name with frequent confusion. He is verbally able to communicate his wants/needs. He is pleasant and cooperative with staff. He has a son and daughter who live close by and help take care of him. He states staff have been kind and has no concerns. Exhibit 359 documented additional/updated information related to the reported incident as, On 9/8/23 RN heard a thump from [resident 10's] room. When she entered his room he was on the floor by the AC. Steps taken to investigate the allegation were documented as, [Resident 10's] Son in Law (SIL) was in the room and sated [sic] that he was trying to help [resident 10], during which [resident 10] became combative and tried to hit the SIL. SIL states that [resident 10] swung, and he fell and hit his head. [Resident 10] stated that he got in a [NAME] with his son in law and he got pushed into the bedside table. Nurse did an assessment and there was an abrasion to his R [right] elbow. Son in law stated that when [resident 10] got aggressive, he tried to prevent [resident 10] from hitting and as a result [resident 10] lost his balance. [Resident 10] was pleasant afterwards. He has a history of sundowning. [Resident 10] states he is ok with his SIL still visiting. The conclusion documented that the abuse allegation was unsubstantiated. The facility investigator was identified as the Resident Advocate (RA). [It should be noted that the investigation did not include interviews with other residents who may have had contact with the alleged perpetrator, or interviews with staff responsible for oversight and supervision of the location where the alleged victim resided].4. Resident 8 was admitted to the facility on [DATE], 10/3/23 and passed away 10/15/23 with diagnoses which include diabetes mellitus, vascular dementia, chronic obstructive pulmonary disease, major depressive disorder and palliative care. A form titled exhibit 358 revealed resident 8 had an injury of unknown source. The form revealed resident 8 had a large bruise and goose egg was noted on [resident 8's] left forehead. A form titled exhibit 359 revealed the Unit Manager did an assessment and there was bruising was purple but no open areas. The form revealed when resident 8 was asked what had happened, he did not know. Resident 8 was asked if anyone hurt him and he stated nope. Resident 8 was asked if he had fallen and he stated nope. The staff were interviewed and no one saw resident 8 fall or any incident. Resident 8 was unsteady on his feet and he used a walker and had a history of falls. Resident 8 also had dementia and was forgetful. The staff reminded him to use his walker and staff to intervene when he forgot. The abuse was unsubstantiated. There was no corrective action. The exhibit 359 was submitted by the Administrator. Resident 8's medical record was reviewed 10/24/23. A quarterly MDS dated [DATE] revealed resident 8 had a BIMS of 00 which revealed resident was severely cognitively impaired. The MDS revealed resident 8 required supervision with bed mobility, transfers, walk in room walk in corridor, locomotion on and off the unit, dressing, eating, toilet use. The MDS further revealed resident 8 was steady at all times when moving from seated to standing position, walking, turning around and facing opposite direction while walking, moving on and off the toilet, surface to surface transfer. Resident 8 used a walker for mobility. On 8/30/23 at 5:56 AM, A large bruise and goose egg was noted on pt's left forehead. Pt doesn't know what happened. He states 'it was short and sweet'. NP, UM notified. will continue to monitor. An incident note dated 8/30/23 at 7:43 PM revealed, Resident was assessed post incident from 8/30/23, where he was found to have bruising noted to his left side of his forehead. Bruising is noted to be purple in color, he stated no new pain, slightly raised, no open areas noted. Resident was asked if he had fallen and he stated 'nope', he was asked if someone had hit him and he stated 'nope', he was asked if he bumped his head and he stated 'nope'. Resident appears in no distress, no sadness, no anger, no agitation. He is calm sitting on his bed and is cooperative. He shows no issues with other residents. Resident has a clear path in room, his mattress is well positioned and fitting correctly on his bed. Resident is wearing his shoes, he has his walker with him, he shows a slow steady walk with his walker. Resident is able to move his extremities with ROM at baseline. Resident stated no new pain. He shows no other injuries or bruising, old scabbing to his right knee. Resident is alert and oriented x 2 per baseline. Has been joining smoking breaks as per usual, and will ambulate the unit as per his norm. Nurse on unit Description: A large bruise and goose egg was noted on pt's left forehead. Pt doesn't know what happened. He states 'it was short and sweet'. NP, UM notified. will continue to monitor. Resident's Description: Pt doesn't know what happened. He states 'it was short and sweet'. Action Taken: Resident was assessed post injury for any other injuries. NP was notified of incident on 8/30/23, no new orders. Administrator, DON, and SW were notified on 8/30/23, a report was sent in. Staff to continue to monitor resident for any changes in mood, behaviors or changes in cognition. Continue to monitor for any changes in physical well being. There was no additional information located that revealed a thorough investigation completed. On 10/24/23 at 11:20 AM, an interview was conducted with the RA and the Administrator (Admin). The RA stated they had problems with the exhibit 359 form at the beginning and stated that was why staff used both the old and new forms interchangeably. The RA stated they tried to submit the new exhibit 359 form when they could. The Admin stated during an abuse investigation they were making sure they were doing 3 random interviews with both staff and residents. The Admin stated the nurse in the memory care unit was the one responsible for interviewing the residents right away and documenting the interview in the medical record. The Admin stated that the abuse investigation was started with the incident report. The Admin stated they relied on the department heads to help with the different staff and resident interviews about an incident. The Admin stated that there was a lot of chatter about what had happened with resident 10. The Admin stated that staff were trying to sift though all the information. The Admin stated he thought interviews were completed but was unable to find the interviews. The Admin stated he was unable to find interviews completed with staff for the incidents with resident 8, resident 2 and resident 3, and resident 4 and resident 5. On 10/24/23 at approximately 1:00 PM, an interview was conducted with the DON. The DON stated the nursing team always did their own in-depth abuse investigation apart from the Administrator's investigation. The DON stated the Unit Managers were the ones to do the interviews. The DON stated the follow up to the investigation included asking nursing what occurred and updating the resident care plans. On 10/24/23 at 1:30 PM, a follow up interview was conducted with the Admin. The Admin stated they do not conduct interviews if an incident was witnessed. The Admin stated they used the documented progress note about the incident to guide them in determining if the incident was intentional or unintentional.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined, the facility did not immediately consult with the resident's physician when there was a need to alter treatment significantly. Specifically, for 1 out of 36 sampled residents, the facility nursing staff did not notify the provider when a resident's blood sugar (BS) was lower than 60 and greater than 400 as ordered by the physician. Resident identifier: 53. Findings included: Resident 53 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, Type 1 diabetes mellitus, obstructive sleep apnea, and iron deficiency anemia. On 11/7/22 at 10:22 AM, an interview was conducted with resident 53. Resident 53 stated he had been a type 1 diabetic since he was 18. Resident 53 stated that the staff checked his blood sugars four times a day and the staff gave him insulin. Resident 53 stated the he was being undermedicated on his insulin. Resident 53 stated that he had asked various nurses for more insulin but the nurses told him he could not get more. Resident 53 stated he did not have the usual symptoms when his blood sugar was low. Resident 53's medical record was reviewed on 11/9/22. Resident 53's care plan was reviewed and revealed a care area for type 1 diabetes mellitus. Interventions were identified and included: 1. Diabetes medications as ordered by provider and to monitor/ document for side effects and effectiveness. 2. Monitor/Document/Report to provider signs and symptoms of hypoglycemia and hyperglycemia. The care plan was initiated on 6/1/20. A physician's order dated 7/8/22, documented Insulin Lispro Solution: Inject as per sliding scale. Notify provider if blood sugar was less than 60 for further instructions. Notify provider if blood sugar was greater than 400 for further instructions. A review of the daily blood sugar summary for the months of September and October 2022 revealed the following blood sugars: a. On 9/2/22, BS 52 b. On 9/8/22, BS 49 c. On 9/11/22, BS 54 d. On 10/22/22, BS 48 e. On 10/24/22, BS 40 and BS 511 f. On 10/25/22, BS 452 No documentation could be located indicating that the provider had been notified when the BS was below and above the physician ordered parameters. On 11/9/22 at 12:59 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated there was a protocol in place when resident 53's blood sugar was below 80. LPN 1 stated if resident 53 was conscious with a low blood sugar, the staff had resident 53 eat and drink; but if resident 53 was unconscious with a low blood sugar, the staff gave resident 53 glucagon. LPN 1 stated if resident 53's blood sugar was above the indicated amount for sliding scale, the staff notified the provider through tiger text. LPN 1 stated that some nurses added a progress note stating the provider was notified and other nurses did not. LPN 1 was unable to find any documentation where the provider was notified of resident 53's blood sugars for the month of October 2022. On 11/14/22 at 10:56 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that the staff had protocols in place when resident 53's blood sugar was either below 60 or above 400. RN 2 stated that when resident 53's blood sugars were below 60, the staff gave glucagon first and then notified the provider through their text message system. RN 2 stated that the staff rechecked resident 53's blood sugar 15 minutes after resident 53 had received the glucagon to make sure resident 53's blood sugar had increased. RN 2 stated after the provider had been notified through tiger text, the staff generally wrote a progress note indicating they had notified the provider and what new orders were received at that time. RN 2 was unable to find any progress notes where the provider was notified of resident 53's low and high blood sugars for the months of September and October 2022. On 11/14/22 at 11:45 AM, an interview was conducted with the Unit Manager (UM). The UM stated that if a nurse notified the provider, there should be a progress note that stated the provider was notified and what orders were received. On 11/14/22 at 1:20 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that nurses notified providers through a system called tiger text but the facility had switched over to a new system. The DON stated that she only had access to tiger text messages for 14 days once the message had been sent. The DON stated that when a provider was notified, it was best practice for the nurses to include a progress note stating the provider was notified and what new orders were received. The DON stated that sometimes the providers did not want to be notified if they had orders in place. The DON stated that the nurses were following orders as indicated. The DON was unable to find documentation where the provider was notified for resident 53's blood sugars for the months of September and October 2022. On 11/15/2022 at 9:59 AM, an interview was conducted with the Nurse Practitioner (NP). The NP stated that resident 53's diabetes was well managed because resident 53's hemoglobin A1C was 5.1. [Note: Hemoglobin A1C was a test that shows the average glucose levels for the past three months.] The NP stated the nurses notified her every time resident 53's blood sugar was above 400 or below 60. The NP stated that the nurses use to communicate with her through tiger text but they had switched over to a new system. The NP was unable to show documentation that she was notified of resident 53's blood sugars on 9/2/22, 9/8/22, 9/11/22, 10/22/22, 10/24/22, and 10/25/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined, the facility did not develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental, and psychosocial needs. Specifically, for 1 out of 36 sampled residents, a resident's Activities of Daily Living (ADL) care plan was not revised after the resident sustained an injury during a Hoyer lift transfer. Furthermore, the care plan did not have a focus area that addressed the resident's scrotal laceration with identified interventions. Resident identifier: 77. Finding included: Resident 77 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, quadriplegia Cervical (C) 5 through C7 incomplete, type 2 diabetes mellitus, dysphagia, reduced mobility, anemia, mood disorder with depressive features, anxiety disorder, epilepsy, metabolic encephalopathy, hypotension, chronic respiratory failure, pressure ulcer of right buttocks stage 4, pressure ulcer of back, buttocks and hip stage 4, pressure-induced deep tissue damage of right heel, traumatic brain injury, and tracheostomy status. On 11/7/22 at 12:22 PM, an interview was conducted with resident 77. Resident 77 stated that approximately three months ago a Hoyer lift ripped his scrotum open and he had to have surgery to repair it. Resident 77 stated that the sling was not the correct sling for the Hoyer lift. Resident 77 stated that the sling was too tight and that was why it ripped his scrotum open. Resident 77 stated this was why he did not like to take showers or get up in his wheelchair because he was afraid of the Hoyer lift sling. On 11/7/22, resident 77's medical record was reviewed. On 8/14/22 at 6:30 PM, an incident report documented that it was reported to the nurse that the resident's scrotum did not look right. The nurse assessed the skin and discovered that resident 77's right testicle was exposed, and the sectoral layer over the right teste had been torn apart. The CNA [Certified Nursing Assistant] reported that they noticed the skin alteration after transferring him into bed using the crisscross sling and pulling his clothes down. A dry sterile bandage was placed on the right testicle to protect it. The report documented that resident 77 believed that the crisscross sling caused the injury and that resident 77 did not want to be transferred using that sling anymore. On 8/14/22 at 11:06 PM, a progress note documented, At approximately 1850 [6:50 PM], right after being transferred into bed by the CNAs via the mechanical lift, it was reported to this nurse that resident was bleeding from his right testicle. This nurse went to assess him and discovered that the top layer of the scrotal sac was torn and exposing his right testicle. VS [vital signs]: [blood pressure] 103/64, p [pulse] 70, rr [respiratory rate] 14, t [temperature] 97.3, SpO2 [oxygen saturation] 94% on room air. He denied pain to this right testicle and after being cleaned was no longer bleeding. A dry sterile dressing was placed on the right testicle to protect it. The MD [medical doctor] on call was notified of this even (sic) and ordered to have this resident see a urologist tomorrow (8/15/2022) and to continue protecting the right testicle with a dry sterile dressing. No distress noted from resident. UM [Unit Manager] and DON [Director of Nursing] were also notified. He is currently laying quietly in bed with his eyes closed and call light within reach. Review of resident 77's care plan revealed a care area for ADL self care deficit related to quadriplegia. Interventions identified included: Restorative Nurse Assistant and CNA would assist with transfers and positioning in power wheelchair as tolerated (initiated 7/29/22), and Requires Hoyer lift two person physical assistance with transferring (initiated on 4/20/22). No care plan could be found for the scrotal laceration that required surgical repair or any identified interventions to prevent the accident from reoccurring. On 11/15/22 at 9:37 AM, an interview was conducted with the DON. The DON stated that resident 77 was in his wheelchair and when the staff transferred him back to bed they found blood in the scrotal area. The DON stated that the nurse immediately assessed the injury and notified the MD. The DON stated that the nurse placed a wet to dry dressing on the wound. The DON stated that resident 77 did not know he was injured. The DON stated that at the time of the incident resident 77 was wearing clothing, that the injury was related to the transfer, but they could not determine the exact cause. The DON stated that resident 77 believed that the injury was caused by the Hoyer lift sling. The DON stated that the staff did not use the crisscross sling with resident 77 anymore. The DON stated that resident 77 did not know how the injury occurred. The DON stated that it could have been resident 77's clothes or brief that caused it, or it could have been a combination of the sling and clothes. It should be noted that resident 77 did not wear a brief. The DON stated that care plans were updated with any resident transfers for any reason. The DON stated that she would look in the ADL care plan to see if it was updated to show the type of sling to be used with resident 77's transfers. The DON was observed to check resident 77's care plan and stated that they would update the care plan. The DON stated that the [NAME] documented that resident 77 should be transferred with a Hoyer lift, but did not specify the type of sling to use. The DON confirmed that the [NAME] was how resident care information was communicated to the CNAs. The DON stated that resident 77 would tell the CNAs what his care needs were and the staff communicated with each other. The DON stated that they would update the care plan so that it stated which sling was to be utilized with resident 77's transfers.

**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 a resident who needed respiratory care was provided such care, consistent with professional standards of practice. Specifically, for 1 out of 36 sampled residents, facility staff did not have a process implemented on how often an oxymask needed to be changed. Resident identifier: 53 Findings included: Resident 53 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, Type 1 diabetes mellitus, obstructive sleep apnea, and iron deficiency anemia. On 11/7/22 at 10:22 AM, an observation was made of resident 53's oxygen mask that appeared very used due to an off yellow coloring and flimsy material. An interview was immediately conducted with resident 53. Resident 53 stated the staff did not change his oxygen mask often and was unable to give a date when it was last changed. Resident 53's medical record was reviewed on 11/9/22. A quarterly Minimum Data Set assessment dated [DATE], documented that resident 53 had a Brief Interview for Mental Status (BIMS) score of 13. A BIMS score of 13 to 15 suggests the resident was cognitively intact. No physician's orders were found on how often the oxymask needed to be changed. No documentation was found on the Medication Administration Record or the Treatment Administration Record (TAR) indicating when the oxymask was last replaced. A daily skilled note dated 9/14/22, documented that resident 53 received oxygen via nasal cannula. No other documentation was located on when resident 53 was placed on the oxymask. On 11/9/22 at 1:17 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 53 had an oxymask since he did not want to use a nasal cannula. LPN 1 stated that oxygen tubing was changed every Sunday and respiratory therapy had to changed that mask since it was a special-order item. LPN 1 stated she was unsure how long resident 53 had that mask but believed it had been less than two weeks since he was given the oxymask. LPN 1 was unable to find any documentation on when the mask was last changed. On 11/9/22 at 3:05 PM, an interview was conducted with the Directory of Respiratory Therapy (DORT). The DORT stated that resident 53 had an oxymask and the oxymask helped mouth breathers get air. The DORT stated the oxymask was disposable and that she had a couple on hand. The DORT stated the mask lasted two weeks unless it was visibly soiled and at that point it would be changed. On 11/14/22 at 11:00 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated they changed resident 53's mask every two weeks and as needed if it appeared soiled. RN 2 stated she was unsure when his mask was last changed. RN 2 was unable to find any orders on how often the mask needed to be changed or when it was last changed. RN 2 stated there was no order to change resident 53's mask. On 11/14/22 at 11:15 AM, an interview was conducted with the Unit Manager (UM). The UM stated they just learned the oxymask was changed every two weeks. The UM stated that they believed the oxymask was changed the same time as oxygen tubing. [Note: Upon reviewing resident 53's TAR, the oxygen tubing was changed on 11/13/22. while the oxymask was changed on 11/12/22.] On 11/17/22 at 3:46 PM, the facility provided additional information in the form of a typed statement and documentation. In the additional documentation, the oxymask manufacture guidelines stated the oxymask needed to be changed every 30 days if being used occasionally. The DORT stated that the oxymask was changed every two weeks at the facility. A respiratory equipment log inventory documented that resident 53 was given the oxymask on October 28, 2022, and it was replaced on November 12, 2022.

**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 the resident's drug regimen was 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 indicated the dose should be reduced or discontinued; or any combination of the reasons stated in this section. Specifically, for 2 out of 36 sampled residents, a Certified Nurse Assistant (CNA) administered a medication to a resident that was obtained from inside the resident's backpack, and a Registered Nurse (RN) connected an intravenous antibiotic to a resident's peripherally inserted central catheter (PICC) and did not start the antibiotic infusion for sixty minutes after connecting the antibiotic. Resident identifiers: 77 and 218. Findings included: 1. Resident 77 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, quadriplegia Cervical (C) 5 through C7 incomplete, type 2 diabetes mellitus, dysphagia, reduced mobility, anemia, mood disorder with depressive features, anxiety disorder, epilepsy, metabolic encephalopathy, hypotension, chronic respiratory failure, pressure ulcer of right buttocks stage 4, pressure ulcer of back, buttocks and hip stage 4, pressure-induced deep tissue damage of right heel, traumatic brain injury, and tracheostomy status. On 11/7/22, resident 77's medical record was reviewed. On 12/4/21 at 5:55 PM, the incident report documented that the CNA reported to the nurse that resident 77 asked the CNA to give him a pill out of his backpack and she did. He took Ivermectin, and antiparasitic, experimentally used to treat COVID [Coronavirus disease]. Resident 77 reported that he did not feel good that day and was worried about getting COVID. The resident stated that the medication was prescribed by a doctor and that they were expensive. The nurse assessed resident 77 and determined that the medication was obtained by a doctor online. The medication was confiscated, and resident 77 was reminded of the facilty policy on self-administering medications. The Medical Director was notified on 12/4/21 at 6:00 PM. The report documented that the Director of Nursing (DON) provided education to the Nursing Assistants and CNAs and instructed then that they may not give medications to residents. The DON further educated that if they found medications in a resident's room they were to be turned over to the nurse. On 12/4/21 at 6:02 PM, the nursing progress note documented, At 1730 [5:30 PM] this nurse was notified by a CNA that the resident had asked her to give him a pill out of his backpack and that she did. He took Ivermectin, and antiparasitic, experimentally used to treat COVID. This nurse immediately assessed resident, he stated that he got the medication prescribed by a doctor online. The medications were confiscated, the resident was reminded of our policy on self-administering medications, the provider and UM [unit manager] on call were notified.' Resident 77's physician's orders were reviewed and did not reveal any orders that stated resident 77 may self-administer medications. The orders for Milk [NAME] one capsule by mouth every 24 hours as needed and Tumeric Capsule 500 milligrams by mouth every 24 hours as needed did not indicate that they may be stored at resident 77's bedside. On 11/14/22 at 9:13 AM, an interview was conducted with CNA 2. CNA 2 stated that resident 77 was a total dependence for cares and needed assistance with dining. CNA 2 stated that resident 77 was able to move his hands and could use his computer independently. CNA 2 stated that the resident had never asked her to give him any medications from his room. CNA 2 stated that resident 77 did not have any medications stored inside his room. CNA 2 stated that if resident 77 were to ask her to administer a medication she would inform the nurse. On 11/14/22 at 9:31 AM, an interview was conducted with RN 1. RN 1 stated that resident 77 was a maximum assist with total dependence. RN 1 stated that resident 77 had some range of motion in the arms but fine motor skills in the fingers was not good. RN 1 stated that in the past resident 77 had stored supplements in the room. RN 1 stated that they had talked to the provider to see if it was appropriate, and they had an order to keep the Milk [NAME] Capsule and Tumeric Capsule at the bedside. RN 1 stated that no prescription medications were kept at the bedside. RN 1 stated that at one time resident 77 had Ivermectin stored in his room. RN 1 stated that the medication was not prescribed by their provider and was removed by the staff. RN 1 stated she believed he asked a staff member to administer the medication to him. RN 1 stated she was not sure if the staff administered the medication, but she did not believe so. RN 1 stated that she thinks that a CNA gave resident 77 the medication. On 11/15/22 at 10:56 AM, an interview was conducted with the DON. The DON stated that resident 77 had asked the CNA to give him medication from his backpack and she gave it. The DON stated that they conducted an investigation and determined that it was Ivermectin. The DON stated that they educated the CNA. The DON stated that resident 77 could be intimidating and threatening. The DON stated that as soon as the CNA gave resident 77 the medication she informed the nurse, but at that point he had already taken it. The DON stated that the CNA involved in the incident was CNA 5, and was still employed at the facility. The DON stated that she informed CNA 5 that she was not allowed to give medications to a resident and if she knew he had stuff like that to notify the nurse. The DON stated that they did not have any Medication Technicians at the facility. The DON stated that the CNA should have had prior knowledge that she was not allowed to administer medication per her certification guidelines and education. The DON stated that the Ivermectin medication was obtained from an online order and provider. The DON stated that resident 77 did not have any orders that the resident could have medications at bedside and could self administer. The DON stated that she was not aware if resident 77 was capable of self administration of medications. 2. Resident 218 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, osteomyelitis, sepsis, methicillin resistant staphylococcus aureus (MRSA) infection, and paraplegia. On 11/8/22 at 10:09 AM, an interview was conducted with resident 218. Resident 218 stated that he was getting an intravenous (IV) antibiotic for the MRSA infection in his left leg. An observation was made of a bag of Vancomycin 200 milliliter (ml) that was hung and attached to resident 218's left PICC line. The infusion pump was not infusing the IV medication and the pump was not turned on. RN 3 entered the resident room a short time later to address resident 218's alarming tube feed pump. RN 3 was asked about the IV antibiotic and why the pump was not infusing. RN 3 stated that she thought she had started the infusion and that it had been running. RN 3 stated she would flush the PICC line again since it was not infusing. RN 3 cleaned the PICC line hub with an alcohol swab and flushed the line with 10 ml normal saline. RN 3 then started the IV infusion at a rate of 100 ml per hour. It should be noted that the total fluid volume was 200 ml and with the rate of infusion it would finish in two hours. After RN 3 exited the room, resident 218 stated that the infusion was hooked up at 8:20 AM. Resident 218 stated that he knew it was exactly that time because RN 3 had fixed the time on the clock because it was running fast. Resident 218 stated that was the last time the PICC line was flushed also. Resident 218's physician's orders revealed an order for Vancomycin solution, 1000 milligrams (mg) intravenously two times a day for MRSA. The medication was scheduled to be administered at 9:30 AM and at 9:30 PM. The order was initiated on 11/4/22, and discontinued on 11/9/22. On 11/9/22, the Vancomycin solution was increased to 1250 mg two times a day. On 11/8/22 at 9:03 AM, the November 2022 Medication Administration Record documented that the Vancomycin was administered by RN 3. On 11/8/22 at 10:30 AM, a progress note documented, NP [Nurse Practitioner] notified of IV vanco [Vancomycin] starting 55 min [minutes] after being hung, requested to continue for the morning, and continue as scheduled. On 11/15/22 at 11:12 AM, a follow-up interview was conducted with RN 3. RN 3 stated that when she notified the NP of the delayed medication administration the NP had stated to continue with the same dose and maintain the next scheduled dose. Review of the Lippincott Nursing Procedures documented under the Implementation of IV Pump Use to Confirm that the IV pump's display screen displays the right information . Observe the IV pump for 1 to 2 minutes to make sure it's delivering the infusion at the proper rate. Wolters Kluwer. Lippincott Nursing Procedures. Ninth Edition, Philadelphia, PA. (2023), pp. 505. On 11/17/22 at 10:30 AM, the facility provided additional information in the form of a typed statement. In the additional information the facility documented that the nurse began preparation for the Vancomycin at 9:30 AM, but did not start the infusion. The statement documented that the nurse went back to the resident's room at 10:23 AM, to assist the resident with care and started the Vancomycin at 10:25 AM.

Based on observation, interview, and record review, it was determined, the facility must store all drugs and biologicals under proper temperature controls. Specifically, medications were not stored at the proper temperature according to manufacturer's recommendations. Findings included: On 11/9/22 at 11:36 AM, an observation of the medication refrigerator located in the medication storage room on Hall A was conducted. The thermometer located on the top shelf of the refrigerator read 32 degrees Fahrenheit (F). The freezer was located directly above the top shelf where the medications were stored. The following medications were observed located on top shelf of the refrigerator: a. Trulicity Pen 45 milligrams/0.5 milliliter (ml) b. Prevnar 13 syringe 0.5 ml c. NovoLog 100 unit/ml FlexPen The Refrigerator and Freezer Temperature Log was reviewed for October and November 2022. The log had documented temperatures and staff initials for each day the refrigerator temperature had been checked. The following dates were noted to be out of range of manufacturer's recommendations. a. On 10/9/22, 33 degrees F. b. On 10/21/22, 34 degrees F. c. On 10/26/22, 30 degrees F. d. On 10/30/22, 35 degrees F. e. 11/2/22, 34 degrees F. f. 11/5/22, 32 degrees F. g. 11/6/22, 34 degrees F. On 11/9/22 at 1:03 PM, an interview was conducted with Registered Nurse (RN 2). RN 2 verified the temperature of the thermometer, on the top shelf of the refrigerator, on the Hall A. RN 2 verified the temperature was 32 degrees F. RN 2 was asked what the temperature of the medication refrigerator should be at, RN 2 referred to the Refrigerator and Freezer Temperature Log taped on the front door of medication refrigerator. The bottom of the log sheet documented Refrigerator range 44° [degrees] F or below. A second thermometer was observed on the bottom shelf of the medication refrigerator. RN 2 verified the temperature was 40 degrees F. RN 2 stated that the night shift documented the temperatures on the log sheet. On 11/9/22 at 2:04 PM, an interview was conducted with the Director of Nursing (DON). The DON verified the temperature of the thermometer on the top shelf of the medication refrigerator at 34 degrees F. The DON was asked what temperature medications should be stored at. The DON was observed to grab the medication Prevnar 13, located on the top shelf of the medication refrigerator, and looked at the packaging. The DON pointed out on the packaging and stated the medication should be stored between 36 degrees F to 46 degrees F. A review of the Trulicity Pen manufacturer's recommendations according to the website, https://uspl.lilly.com/trulicity/trulicity.html#ug, documented to store medication in the refrigerator between temperatures of 36 degrees F to 46 degrees F. A review of the Prevnar 13 manufacturer's recommendations according to the website, https://labeling.pfizer.com/showlabeling.aspx?id=501#section-14, documented Upon receipt, store refrigerated at 2°C [Celsius] to 8°C [36 degrees F to 46 degrees F]. A review of the NovoLog Flexpen manufacturer's recommendations according to the website, https://www.mynovoinsulin.com/insulin-products/novolog/taking-novolog.html, documented to store unused NovoLog pens in the refrigerator at 36 degrees F to 46 degrees F until expiration.

Based on interview and record review, it was determined, the facility did not ensure the Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of correction to correct identified quality deficiencies. Specifically, the facility was found to be in non-compliance with F880, which was cited within the facility's 2019 and 2021 recertification survey. Findings included: A standard recertification survey was completed on 2/21/2019. During the survey deficiencies F684, F688, F710, F761, F810, F812, and F880 were cited. A standard recertification survey was completed on 4/8/2021. During the survey deficiencies F584, F600, F607, F842, F880, and F924 were cited. Based on observation, interview, and record review, it was determined, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 1 out of 36 sampled residents, observations were made of cross contamination, gloves not changed, and hand hygiene not performed during a dressing change. Resident identifier: 77. [Cross reference F880] On 11/15/22 at 3:20 AM, an interview was conducted with the Administrator. The Administrator stated the facility held a QAA meeting monthly, and the Administrator ensured the Medical Director (MD) was there at least quarterly, but the Administrator would try to get the MD to attend as much as he could. The Administrator stated that most all of the department heads would attend the monthly meetings. The Administrator stated the last QAA quarterly meeting was held on 9/23/22. The Administrator stated they had stand up meetings daily where the department heads met to discuss issues and concerns that arose in the QAA meeting. The Administrator stated he would have each department bring issues to the QAA meeting and the team would use discussion, graphs, and audits to come up with a plan to solve the issue at the root of the problem. The Administrator stated staff meetings, education, and trainings were used to improve care for the residents. The Administrator stated the nursing department had specific trainings directed toward falls, infections, wound care and other resident care areas. The Administrator stated he felt the QAA meetings were effective.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 1 out of 36 sampled residents, observations were made of cross contamination, gloves not changed, and hand hygiene not performed during a dressing change. Resident identifier: 77. Findings included: Resident 77 was admitted to the facility on [DATE] with diagnoses which included but were not limited to quadriplegia Cervical (C) 5 through C7 incomplete, type 2 diabetes mellitus, dysphagia, reduced mobility, anemia, mood disorder with depressive features, anxiety disorder, epilepsy, metabolic encephalopathy, hypotension, chronic respiratory failure, pressure ulcer of right buttocks stage 4, pressure ulcer of back, buttocks and hip stage 4, pressure-induced deep tissue damage of right heel, traumatic brain injury, and tracheostomy status. On 11/7/22, resident 77's medical record was reviewed. Review of resident 77's physician's orders revealed the following: a. Bilateral Buttocks/Right hip: 10 minute Dakins soak, pat dry, apply skin prep to periwound, Calmoseptine mixed with small amount of A & D to intact skin, apply collagen sheet to wound beds (open areas), apply calcium alginate over wound beds as needed for excessive drainage, cover with abdominal (ABD), every day shift and as needed replace dressing if soiled, loose, or dislodged. The order was initiated on 9/20/22. b. Bilateral Buttocks/Right hip: replace ABDs and calcium alginate every night shift and as needed due to excessive drainage every night shift and as needed. The order was initiated on 9/7/22. c. Soak Buttocks with Dakins moistened gauze for 10 minutes prior to dressing change every day shift. The order was initiated on 8/10/22. Resident 77's care plans were reviewed and revealed a care area for had pressure ulcers and had the potential to develop pressure ulcers. The care plan identified moisture associated skin damage to the buttocks, right inferior hip, right hip, and right lower buttocks. Interventions were identified and included to administer treatments as ordered and monitor for effectiveness. The care plan was initiated on 4/20/21 and was revised on 11/11/22. On 11/14/22 at 9:31 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 77 was a maximum assistance with total dependence. RN 1 stated resident 77 had open wounds on the left and right buttocks, and the left side was almost healed. RN 1 stated that the right buttocks still had two open wounds, but nothing that required a vacuum dressing. RN 1 stated that the plan was to perform a skin graft this week. RN 1 stated that resident 77 was on antibiotics last month for an infection in the buttocks wound. RN 1 stated that the dressings were completed two times a day. RN 1 stated that resident 77 would often refuse the nighttime dressing change, but generally did not refuse the morning dressing change. RN 1 stated that they soaked the wounds with Dakins for 10 minutes, cleansed with normal saline, and then placed collagen and calcium alginate over the wound. RN 1 stated that they applied Calmoseptine mixed with A & D cream to the surrounding wound area and then applied an ABD pad over the top. On 11/14/22 at 10:16 AM, an observation was made of resident 77's wound care completed by RN 1 and assisted by Certified Nurse Assistant (CNA) 2. RN 1 and CNA 2 donned gloves. RN 1 and CNA 2 positioned resident 77 on the left lateral side. CNA 2 maintained the position while RN 1 provided the wound care. RN 1 removed the soiled dressing from resident 77's buttocks and discarded into the trash receptacle. Multiple ABD pads were observed overlapping on both buttocks and were secured to the resident's skin with tape. RN 1 stated that there was minimum to moderate drainage on the soiled ABD pads. The skin on resident 77's buttocks was macerated. On the right buttocks were two open areas, the wounds were not measured. On the left buttocks was one open area, the wound was not measured. RN 1 was observed to apply multiple soaked gauze dressing to the entire buttocks that were contained within a disposable plastic cup. RN 1 stated that the Dakins solution was applied to the gauze in the resident room prior to application. RN 1 did not change her gloves or perform hand hygiene between removal of the old dressing and application of the Dakins soaked gauze to the wound bed. RN 1 doffed the dirty gloves and performed hand hygiene with alcohol based hand rub (ABHR) upon completion of the gauze application. On 11/14/22 at 10:41 AM, RN 1 was observed to mix Calmoseptine and A & D ointment in a medication cup. RN 1 mixed the two creams using a tongue depressor obtained from the medication cart bulk stock. RN 1 placed gauze 4 by 4 pad soaked with normal saline (NS) in a disposable plastic cup. RN 1 obtained scissors obtained from her pocket and cleaned with Microkill, germicidal wipes. RN 1 then placed the cleaned scissors on top of the medication cart. RN 1 performed hand hygiene with ABHR. The dressing items were placed on the bedside table. RN 1 exited the residents room. At 10:58 AM, RN 1 returned to the resident's room. CNA 2 was at resident 77's bedside. RN 1 performed hand hygiene and donned new gloves. RN 1 was observed to move resident 77's cup on the bedside table with gloved hands. The scissors were placed on top of the alginate wound dressing package. RN 1 removed resident 77's bed covers. RN 1 was observed to handle resident 77's ventilator tubing and absorbent chuck pad. RN 1 then removed the Dakins gauze from the wound bed. RN 1 doffed the soiled gloves and donned new gloves. No hand hygiene was performed between glove application. RN 1 cleansed the wounds with the NS soaked gauze working from the center outward. RN 1 was observed to position resident 77 in a more left lateral position by pushing the residents hip with the left gloved hand. RN 1 opened the collagen dressing package and placed four collagen pads on the wound bed. It should be noted that RN 1's left hand was used for the application of the collagen dressing. RN 1 then applied the mixed A & D cream with Calmoseptine cream to her gloved right hand with the tongue depressor. The cream was spread over the peri wound of the right buttocks and all over the left buttocks with the gloved hand. RN 1 doffed the soiled gloves and new gloves were donned. No hand hygiene was performed between glove application. RN 1 then cut the alginate with the scissors. At this point the observation was completed. On 11/14/22 at 1:24 PM, a follow-up interview was conducted with RN 1. RN 1 stated that hand hygiene should be completed prior to removing an old dressing. RN 1 stated that the gloves should be changed and hand hygiene should be performed before applying any new dressing, and if any environmental surfaces were touched. On 11/15/22 at 9:37 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that gloves should be changed and hand hygiene performed when removing a dirty dressing and before applying a clean dressing. The DON stated that if environmental surfaces were touched during a dressing change then gloves should be doffed, hand hygiene performed, and new gloves applied. The DON stated that when creams were mixed the applicator that was used to apply the cream to the wound bed should be from a package.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 of 50 sampled residents, that the facility did not ensure that all residents were free from abuse, neglect, misappropriation of residential property and exploitation. Specifically, staff observed a resident to resident abuse from resident 72 directed to resident 47. Resident 72 also admitted to resident abuse and agitation towards resident 47. Resident identifiers: 47 and 72. Findings include: Resident 72 was admitted to the facility on [DATE] with diagnoses which included but not limited to a history of cerebral infarction, major depression, hypothyroidism, bipolar disorder, morbid obesity, epilepsy, osteoarthritis, dysphagia, insomnia, and obstructive sleep disorder. On 4/8/2021 at 10:43 AM, an interview was conducted with Resident 72. Resident 72 stated he did not get along with his roommate, resident 47. Resident 72 stated that resident 47 frequently moaned and answered for him which resident 72 stated was annoying. Resident 72 stated that because of this, he would yell at resident 47. Resident 72 stated that he would sometimes do things to agitate and annoy resident 47 like slap on his own arm, and would call resident 47 names. Resident 72 stated there was no physical contact between himself and resident 47. Resident 72 stated that he liked to annoy resident 47. On 04/8/2021 at 10:52 AM, an interview was conducted with Certified Nurse Assistant (CNA) 11. CNA 11 stated that she had witnessed resident 72 yelling at resident 47 frequently. CNA 11 stated that she separated the residents and reported the altercation to the on duty nurse when it happened. CNA 11 stated that resident 72 was frequently triggered by resident 47's moaning. On 4/8/2021 at 10:55 AM, an interview was conducted with CNA 12. CNA 12 stated that she had heard resident 72 yell at resident 47 occasionally. CNA 12 could not recall the exact phrases used by resident 72, but stated that there were good days and bad days. CNA 12 stated that when this happened, she separated the residents, tried to de-escalate the situation, and then reported the incident to the Registered Nurse on duty. On 4/8/2021 at 12:09 PM, a follow-up interview was conducted with CNA 12. CNA 12 stated that resident 72 frequently called resident 47 the B word. CNA 12 stated that this happened almost every day, and multiple times a day. CNA 12 stated that she knew who to report abuse to, which was the administrator. CNA 12 stated that if she were in resident 47's shoes that she would consider that treatment abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined for, 2 of 50 sampled residents, that the facility did not implement policies to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours. Specifically, nursing staff did not report a witnessed incident of resident to resident verbal abuse. Resident identifiers: 47 and 72. Findings include: Resident 72 was admitted to the facility on [DATE] with diagnoses which included but not limited to a history of cerebral infarction, major depression, hypothyroidism, bipolar disorder, morbid obesity, epilepsy, osteoarthritis, dysphagia, insomnia, and obstructive sleep disorder. Review of the facility Policy and Procedure for Abuse documented that all allegations or suspicions of abuse was to be reported to the administrator immediately. Review of the facility training records for abuse revealed Abuse training was provided on 2/10/2021. Logs showed that Certified Nursing Assistant (CNA) 11, CNA 12, and Registered Nurse (RN) 6 all attended this training. On 4/8/2021 at 10:52 AM, an interview was conducted with CNA 11. CNA 11 stated that she had witnessed resident 72 yelling at resident 47 frequently. CNA 11 stated that she separated the residents and reported the altercation to the on duty nurse when it happened. CNA 11 stated that resident 72 was frequently triggered by resident 47's moaning. On 4/8/2021 at 10:55 AM, an interview was conducted with CNA 12. CNA 12 stated that she had heard resident 72 yell at resident 47 occasionally. CNA 12 could not recall the exact phrases used by resident 72, but stated that there were good days and bad days. CNA 12 stated that when this happened, she separated the residents, tried to de-escalate the situation, and then reported the incident to the RN on duty. On 4/8/2021 at 11:01 AM, an interview was conducted with RN 6. When RN 6 was asked about the altercations between resident 72 and resident 47, RN 6 stated that she had not noticed any yelling or incidents. RN 6, also stated that she did not recall any notifications by CNA's of any incidents. On 4/8/2021 at 1130 AM, an interview was conducted with the Resident Advocate (RA). The RA stated that she was unaware of any allegations of abuse or resident to resident interactions with resident 72 and resident 47. On 4/8/2021 at 12:09 PM, a follow-up interview was conducted with CNA 12. CNA 12 stated that resident 72 frequently called resident 47 the B word. CNA 12 stated that this happened almost every day, and multiple times a day. CNA 12 stated that she knew who to report abuse to, which was the administrator. CNA 12 stated that if she were in resident 47's shoes that she would consider that treatment abuse. On 4/8/2021 at 12:20 PM, an interview was conducted with the Administrator. The Administrator stated that he was just informed of the situation between resident 72 and resident 47. The administrator stated that he was currently working on fixing the situation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined the facility did not maintain medical records on each resident that were complete and readily accessible. Additionally, the facility did not keep confidential all information contained in the resident's records, regardless of the form of storage method of the records. Specifically, for 1 of 50 sampled residents, physician visit notes including an evaluation of the resident's condition and total program of care were not included in the medical record. Additionally, on four separate occasions the facility did not safeguard medical record information. Resident identifier: 17 and 73. Findings include: 1. Resident 73 was admitted to the facility on [DATE] with diagnoses which included but not limited to bilateral osteoarthritis of hip, pre-diabetes, muscle weakness, reduced mobility, glaucoma, dorsalgia, essential hypertension, history of falling, and other specified symptoms and signs involving the circulatory and respiratory systems. Resident 73's medical record was reviewed on 4/6/2021. During the medical record review the last physician or provider visit note was documented on 12/29/2020. On 4/7/2021 at approximately 2:00 PM, an interview was conducted with the Medical Records Director (MRD). The MRD was asked if additional physician visit notes were available after 12/29/2020. The MRD stated she was relatively new at the position and was backlogged on getting records into the system. The MRD stated that she would look for resident 73's records and get back to this surveyor. On 4/8/2021 at approximately 8:30 AM, the Administrator provided Nurse Practitioner (NP) notes dated 2/10/2021, 3/23/2021, 3/25/2021, 3/29/2021, and 4/1/2021. The Administrator stated the NP notes were faxed to the facility on 4/7/2021. On 4/8/2021 at approximately 11:20 AM, an interview was conducted with the MRD regarding the process for obtaining physician visit notes. The MRD was asked who was in charge of obtaining visit notes from the medical providers. The MRD stated she had a binder with a list of residents who need to be seen by the physician and when. The MRD stated the physician would check the residents off the list if they were seen during the visit to the facility. The MRD stated the physician would bring the completed documentation to the facility on the following visit and place the documentation on her desk. The MRD stated the documentation would be returned to the facility usually within a week. The MRD was asked what was done if the documentation was not returned at the next visit by the physician. The MRD stated she had each physician and medical provider's personal cell phone number and she would call them and remind them of the documents that need to be returned. The MRD was asked what action would be taken if the documents still did not come back. The MRD stated she would keep hounding them until they were brought into the office. The MRD stated the facility had one NP that came to the facility Monday through Friday, one physician that came to the facility every Thursday, and one physician that came to the facility every other week. The MRD stated the facility also had an additional NP and two physician assistants that came to the facility when needed. The MRD was asked how she knew if a physician was asked to see a resident by a nurse that may not be on the schedule. The MRD stated the physician or medical provider would come to her office, they all have a key, and write-in the resident on the schedule for that day. The MRD was asked specifically about resident 73's physician visit notes and why the physician visit notes were not in resident 73's medical record. The MRD stated she was unsure why resident 73's physician visit notes were not at the facility. The MRD stated sometimes they get behind on notes and so then they'll bring in a big stack of them all at one time. The MRD was asked how laboratory and x-ray results were put into the medical record. The MRD stated the notes were loaded directly from the lab or the x-ray provider. The MRD also stated if resident medical records were faxed to the facility someone would print them off for the physician to sign, but she did not know who. 2. On 4/5/2021 at 2: 53 PM, an observation was made of resident 17 sitting behind the nurses' station talking on the desk phone. The nurses' station was observed to have paperwork sitting face up with resident protected health information (PHI) visible. The computer at the nurses' station was also observed to be open to the facility electronic charting system. Resident 17 was able to view all of the resident PHI that was left open and uncovered. On 4/5/2021 at 3:10 PM, an observation was made of the resident vital sign record sheet face up on the vital's cart, and visible to anyone who passed by. On 4/6/2021 at 10:21 AM, an observation was made of Registered Nurse (RN) 3. RN 3 was observed to leave the nurses' cart with the computer screen open to resident PHI, which was visible to anyone that passed by. RN 3 returned at 10:24 AM, and locked the computer screen. On 4/7/2021 at 11:43 AM, an interview was conducted with Certified Nursing Assistant (CNA) 5. CNA 5 stated that all papers with resident information should always be face down or covered. On 4/7/2021 at 11:45 AM, an interview was conducted with RN 2. RN 2 stated that all private resident information had to be covered up and all computer screens locked. RN 2 stated that they did allow residents to sit at the nurses' station to use the phone, but any visible resident information should be covered. On 4/7/2021 at 11:51 AM, an interview was conducted with CNA 4. CNA 4 stated that all resident information had to be covered or placed in a cabinet to keep it protected. On 4/8/2021 at 10:28 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that staff should lock their computer screens any time they walked away from them, and all paperwork should also be turned over. The DON stated if a resident was using the phone at the nurses' station, then there should not be any visible PHI that the resident could see.

Based on observation, interview, and record review, it was determined the facility did not provide a safe, clean, comfortable, and homelike environment. Specifically, observations were made of residents smoking in close proximity to the facility creating smoking odors in the resident hallways. Findings include: On 4/5/2021 at 10:56 AM, an observation was conducted of residents smoking outside the D hall exit door on the patio. Residents were observed smoking near the No Smoking sign, which was located within 25 feet of the doorway. A vertical ashtray was located next to the No Smoking sign. A Smoking Permitted sign was around the corner on the patio with a fire extinguisher hanging underneath the sign. Residents were supervised by staff. On 4/6/2021 at 10:36 AM, an observation was conducted of 4 residents smoking outside the D hall exit door on the patio near the No Smoking. Residents were supervised by staff. On 4/6/2021 at 10:40 AM, an observation was conducted of 2 residents that came inside the facility after smoking on the D hall patio. Cigarette smoke could be smelled inside the facility. Residents were supervised by staff. On 4/6/2021 at 10:42 AM, it was observed that there was a strong cigarette smoke smell in the day room on the D hall while 2 residents were smoking near the exit door on the patio in the No Smoking area. Residents were supervised by staff. On 4/7/2021 at 10:50 AM, it was observed that residents on the D hall were directed to the area of the Smoking Permitted sign by staff. A vertical ashtray was located by the No Smoking sign and exit door. A resident in the D hall shouted you don't want to go down there, it stinks. The smoke smell was observed to still be present inside the facility at this time. Residents were supervised by staff. On 4/7/2021 at 2:44 PM, an observation was conducted of the D hall residents smoking by the No Smoking sign. A vertical ashtray was moved to the smoking area. Residents were supervised by staff. On 4/7/2021 at 2:55 PM, an observation was conducted of the C hall residents smoking within 25 feet of the exit door to the smoking patio. Cigarette smoke could be smelled in C hall. Residents were supervised by staff. On 4/7/2021 at 3:00 PM, in an interview with the Director of Nursing (DON). The DON stated that the expectation of the smoking concierge was that they would direct any unsafe smoking practices, which would include smoking in the appropriate areas. The DON stated the smoking areas were indicated by the Smoking Signs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined, that the facility did not ensure that all handrails in the facility were secured on each side of the hallways. Findings include: On 4/7/2021 at approximately 10:00 AM, it was observed that loose handrails were found at the following locations: a. C Hall between rooms [ROOM NUMBERS]. b. C Hall between the hallway lavatory and room [ROOM NUMBER]. c. D Hall near the nurses station. d. D Hall next to the smoking patio. e. Main Hall in the middle of hallway. f. Main hall next to Heritage Square. On 4/7/2021 at 2:40 PM, an interview was conducted with the Maintenance Staff Member (MSM). The MSM stated that requests for maintenance come through the computer system which prioritizes work orders. The MSM stated that he was unaware of any handrails which were loose, and that staff must not have been reporting them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 12 of 50 sampled residents, that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, observations were made of a staff reconnecting a ventilator tubing to a resident's tracheostomy connector barehanded after it had fallen to the floor, new admissions were not quarantined and isolated on contact/droplet precautions, a resident exposed to a positive COVID-19 infection was not quarantined and isolated on contact/droplet precautions, a hoyer lift used in a contact precautions isolation room was not disinfected prior to use with another resident, vital sign equipment was not disinfected between resident use, dialysis staff were observed not wearing a face mask, hand hygiene was not performed during a dressing change, hand hygiene was not performed during meal tray delivery, hand hygiene was not performed between residents that required assistance during dining, meals were delivered uncovered and open to air, and meal items were delivered to residents with bare handed contact with the food item. Resident identifiers: 9, 29, 33, 49, 58, 69, 75, 160, 162, 408, 409, and 509. Findings include: 1. Resident 509 was admitted to the facility on [DATE] with diagnoses which included acute respiratory distress syndrome, acute respiratory failure, tracheostomy status, end stage renal disease, dependence on renal dialysis, other specified diseases of upper respiratory tract, and history of COVID-19. Review of resident 509's physician's orders revealed the following: a. Meropenem 500 milligrams (mg) intravenously (IV) in the afternoon for elevated [NAME] Blood Cells (WBC's) for 14 days. Start medication once Peripherally Inserted Central Catheter (PICC) line was placed. The order was initiated on 4/7/2021. b. Vancoymcin 125 mg, use 750 mg/milliliter IV one time a day every Monday through Friday for increased WBC. Administer 750 mg Vanco after Dialysis. The order was initiated on 4/7/2021. c. Mobile IV team to place PICC line. The order was initiated on 4/6/2021. d. Tracheostomy care every shift and as needed, rinse with normal saline (NS) and pat dry. The order was initiated on 4/2/2021. e. Change Ventilator circuit as needed to include valved tee adaptor the first of every month. The order was initiated on 4/2/2021. f. Maintain Ambu bag and spare trach available for emergency. The order was initiated on 4/2/2021. g. Change trach (size 6) cuffed every 30 days and as needed for dislodgement/cuff failure. The order was initiated on 4/2/2021. h. Change trach inner cannula (size 6) every day and as needed. The order was initiated on 4/3/2021. Review of progress notes on 4/6/2021 at 10:10 AM, revealed Resident post covid tx (treatment), acute respiratory failure, acute kidney failure, PNA (pneumonia) d/t (due to) coronavirus; droplet precautions: acinetobacter Baumannii Complex sputum. Resident tolerating Interventions well. No other progress notes dated 4/6/2021 documented care provided by Respiratory Therapist (RT) 1. Review of resident 509's Respiratory Therapy (RT) Administration Record for 4/6/2021, revealed that RT 1 documented that the Ambu bag and spare trach was available for emergency use. On 4/2/2021, the discharge instructions from the transferring facility documented Droplet and Contact Precautions: Other Viral Respiratory Infection: Acinetobacter Baumannii Complex SPUTUM. Personal Protective Equipment (PPE) upon entering, contain all soiled wastes and linens before leaving room. Use specific patient blood pressure cuff and stethoscope; leave at bedside. Use purple top disinfectant wipe to clean any equipment that leaves the room (thermometers, sat monitors, cough assist, etc .). On 4/5/2021 at 11:17 AM, an observation was made of resident 509's room. A sign was located on the door that stated new admission preventative quarantine with admit date of 4/2/2021, day 7 of 4/9/2021, and day 14 end quarantine end date on 4/16/2021. No stop sign was observed on the door directing visitors to see the nurse, nor the type of precautions to be implemented. A PPE cart was located outside the resident room and contained reusable cloth gowns and disinfecting wipes. Gloves were observed inside the resident room near the door. On 4/6/2021 at 10:25 AM, an observation was made of resident 509 transferring back to his room from dialysis in a recliner/chair. Resident 509 was being pulled by RT 1 and pushed by dialysis staff (DS) 2. Resident 509 was observed wearing a surgical face mask. RT 1 and DS 2 were observed wearing a surgical mask and face shield. An observation was made of resident 509's ventilator tubing disconnecting from the trach connector and falling to the floor. The end of the tubing was observed to make contact with the floor. RT 1 stated to DS 2 to pick it up. RT 1 was then observed to pick the tubing up off the floor and re-connect it to resident 509's trach, barehanded. The observation occurred on the B hallway next to the nurse's station and the RT supply cart. RT 1 was observed to push resident 509 into the doorway of his room and donn a reusable cloth gown. RT 1 was observed to ask a passing staff member to obtain more gloves for resident 509's room. On 4/7/2021 at 7:37 AM, an interview was conducted with RT 2. RT 2 stated that they change the connecter to the trach one time per week and as needed. The circuit or tubing was changed one time per month or as needed. RT 2 stated that if the connection to the trach were to fall to the ground it would need to be changed, and it should not be reconnected to the resident. On 4/7/2021 at 7:42 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 509 was on Transmission Based Precautions (TBP) due to Acinetobacter bacteria in the sputum. RN 1 stated that resident 509 was on droplet precautions and staff should donn PPE of a mask, face shield, gown, and gloves when entering resident 509's room. RN 1 stated that the universal PPE required inside the facility was a mask and eye protection. RN 1 stated that the ventilator was a contained system and resident 509 would wear a face mask while outside the room on either the face or over the trach. RN 1 stated that staff have not been wearing a gown or gloves during transfer of resident 509 to and from dialysis. RN 1 stated that resident 509 was not quarantining for new admission as he was status post COVID positive on 2/25/2021. On 4/7/2021 at 11:37 AM, an observation was made of two staff members entering resident 509's room without donning a gown and gloves. One staff member was observed to move a sealed surgical kit from resident 509's bedside table and placed it on the top of the dirty gown bin. An immediate interview was conducted with RT 3. RT 3 stated that the staff that entered resident 509's room were with the mobile PICC line team. On 4/7/2021 at 11:50 AM, two PICC line team members were observed in resident 509's room without gowns and gloves. The staff were observed to exit the room and obtain an item from their bag which was located in the hallway and re-enter the room without donning additional PPE. On 4/7/2021 at 12:04 PM, an follow-up interview was conducted with RN 1. RN 1 stated again that the PPE required for any staff entering resident 509's room was a mask, eye protection, gown, and gloves. RN 1 stated that the PICC team was informed of precautions by the door sign and she would let them know about the TBP. RN 1 also stated that when the order was called into the mobile team and they would ask about TBP. RN 1 stated that when the mobile PICC team arrived she informed them that resident 509 was on isolation precautions, but did not specify droplet. RN 1 stated that resident 509 should have a blue precautions sign on the door that says stop and see the nurse. RN 1 confirmed that resident 509 did not have a blue precautions stop sign on the door to alert visitors. RN 1 stated that she observed the two PICC line team members in the room with sterile gowns donned for the procedure. RN 1 stated that the staff did not have an isolation gown donned under the sterile gown. RN 1 stated that she was going to place a stop sign on the door now stating that the resident was on droplet precautions. On 4/7/2021 at 12:52 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that in resident rooms with droplet precautions staff should donn upon entrance a gown and gloves in addition to the universally worn surgical mask and eye protection. The DON stated that resident 509 was on a ventilator and all droplets were contained within the vent as it was a closed system. The DON stated that until the resident was determined to be resistant to or colonized with a bacterial infection they should be isolated with contact/droplet precautions and the staff would need to donn a surgical mask and face shield. The DON stated that during respiratory treatments the staff would use a higher level mask, gown, and gloves. The DON stated that during a situation with the trach tubing coming off the staff would need to ensure that the life saving ventilator was in place and maybe that was what had happened. The DON stated that resident 509's WBC were elevated and he was having a midline central catheter placed today to receive IV antibiotics. On 4/8/2021 at 8:02 AM, a follow-up interview was conducted with RT 2. RT 2 stated that the storage/medication cart at the nurse's station had supplies such as tubing connectors for the ventilator, nasal cannula tubing, and nebulizer supplies. RT 2 stated that every resident ventilator had an Ambu bag attached to it in the event of an emergency such as ventilator malfunction or disconnection. RT 2 stated that whenever a resident was transferred the Ambu bag goes with them. 2. Resident 49 was admitted to the facility on [DATE] with diagnoses which included neurogenic bladder, alcohol abuse, type 2 diabetes, hypertension, major depressive disorder, hyperlipidemia, insomnia, and gastro-esophageal reflux disease. On 4/5/2021 at 12:56 PM, resident 49 was observed to ambulate on hall A, while wearing a mask. Resident 49 stated that he was just coming back from lunch in the dining room. On 4/8/2021 at 7:56 AM, resident 49 was observed ambulating on hall A. Resident 49 was wearing a mask. On 4/5/2021, resident 49's medical record was reviewed. A progress note on 3/29/2021 at 2:16 PM, documented .Resident was reviewed by IDT (interdisciplinary team) for skill in place waiver d/t prolonged exposure to COVID-19 positive individual and ongoing monitoring for s/s (signs and symptoms) of COVID-19. Resident was exposed to a positive staff member [Certified Nursing Assistant] who provided direct care on 3/22/21 who was confirmed positive on 3/27/21. Another progress note on 3/30/2021 at 6:00 PM, documented COVID-19 Note: Evaluation is being completed due to: Close personal exposure to COVID-19 positive individual necessitating quarantine period of transmission based precautions and elevated monitoring and evaluation. A review of resident 49's physician's orders revealed no orders for resident 49 to be on any type of isolation precautions following his staff exposure on 3/22/2021. Resident 49's immunization record was reviewed and showed that resident 49 declined the Covid-19 vaccine. Additionally, resident 49 had not been diagnosed with Covid-19 in the previous 90 days. On 4/8/2021 at 7:51 AM, an interview was conducted with RN 5. RN 5 stated that staff were doing Covid exposure charting for resident 49, which consisted of monitoring and documenting symptoms. On 4/8/2021 at 7:57 AM, an interview was conducted with Certified Nursing Assistant (CNA) 13. CNA 13 stated that if a resident was exposed to Covid-19, then the resident would be placed on isolation precautions for 14 days. CNA 13 stated the staff would don a gown, gloves, mask, and goggles to enter the resident room, and the resident was not allowed to leave their room unless for smoke breaks or for necessary appointments. CNA 13 stated she had not been notified that resident 49 had been exposed to Covid-19. On 4/8/2021 at 9:44 AM, an interview was conducted with Physical Therapist (PT) 1. PT 1 stated that if a resident was exposed to Covid-19, then the resident would be placed on a 14 day isolation and monitored for signs and symptoms of Covid-19. PT 1 stated that the resident would still be allowed to leave for therapy starting on day 7, just like new admits were. On 4/8/2021 at 10:06 AM, an interview was conducted with the DON. The DON stated that if a resident were exposed to Covid-19, staff did increased monitoring and charting for 14 days. The DON stated that resident 49 should have been placed on isolation following his 3/22/2021 exposure. The DON stated that when a resident was placed on isolation, staff were notified of a need for isolation precautions for a resident by a sign on the resident's door and a PPE cart outside the resident room. The DON stated that a physician order for isolation would also be entered into the electronic charting system. A review of the Centers for Disease Control and Prevention guidelines found at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html stated Residents who have had close contact with someone with SARS-CoV-2 infection should be placed in quarantine for 14 days after their exposure. 3. Resident 409 was admitted to the facility on [DATE] with a diagnoses of dementia. On 4/5/2021 at 10:38 AM, an observation was made of resident 409's room. Resident 409's room was observed to have an isolation cart outside by the door and a sign on the door which stated Droplet precautions/isolation day 1-7. All therapy and meals in room. limit staff entering room Day 7- 4/2/21 May come out of room after hand washing, wearing mask and accompanied by therapy/nursing. End quarantine 4/9/21. On 4/5/2021 at 12:18 PM, an observation was made of a CNA asking resident 409 if she wanted to eat in the dining room or in her room. Resident 409 stated that she wanted to eat in the dining room. An observation was made of resident 409 leaving her room without a mask or hand hygiene; resident 409 walked to the dining room and sat next to another resident to eat lunch. On 4/5/2021 at 3:19 PM, an observation was made of resident 409 outside of her room without a mask, gown, or gloves. On 4/6/2021 at 8:47 AM, an observation was made of resident 409 eating in the main dining room on D hall, while other residents were eating within six feet of resident 409. On 4/6/2021 at 9:40 AM, an observation was made of resident 409 in room [ROOM NUMBER] which was not her room. Resident 409 did not have a mask or gown on. A housekeeper was present and tried to direct resident 409 out of room [ROOM NUMBER]. On 4/7/2021 at 8:51 AM, an observation was made of CNA 10. CNA 10 entered resident 409's room to collect her breakfast tray. CNA 10 did not don any PPE beyond the mask and goggles the CNA was already wearing. CNA 10 was observed to exit resident 409's room and entered room [ROOM NUMBER] without performing hand hygiene. On 4/8/2021 at 8:09 AM, an observation was made of resident 409 in the dining room for breakfast. On 4/5/2021, resident 409's medical record was reviewed. Resident 409 was admitted 10 days prior to the first observation, on 3/26/2021. Resident 409's electronic immunization record revealed that resident 409 had not been vaccinated for Covid-19. Further review revealed that resident 409 had not been diagnosed with Covid-19 in the previous 90 days. A physician's order, initiated on 3/26/2021 and scheduled to be completed on 4/9/2021, documented Isolation Precautions: droplet May resolve associated diagnoses . at the conclusion of these precautions Additionally, another physician's order was initiated on 3/27/2021, and documented Document Temp (temperature) and monitor for the following symptoms: Fever, Cough, New shortness of breath or difficulty breathing, Chills, Repeated shaking with chills, Muscle pain, Headache, Sore throat, New loss of taste or smell, Congestion, Runny Nose. GI (gastro-intestinal) Symptoms: Diarrhea/Nausea/ Vomiting every day shift A review of resident 409's Treatment Administration Record revealed that on 3/31/2021, there was no documentation that resident 409 was monitored for signs and symptoms of Covid-19 per the physician's order. A review of resident 409's progress notes documented: a. On 3/28/2021 at 11:25 PM, Resident alert and oriented to self only. Ambulating with steady gait. Wandering into peers' room's requiring much redirection. b. On 3/30/2021 at 12:42 PM, . Delusions of use of objects and their use. Wanders hall with her hands full of things. c. On 3/30/2021 at 11:39 PM, Resident alert and oriented to self only. Ambulating with steady gait. Wandering into peers' room's requiring much redirection. d. On 3/31/2021 at 12:42 PM, . Cognitive symptoms described as resident able to follow simple directions. knows who she is. is able to locate her room most of the time but will often be found in other rooms. e. On 3/31/2021 at 11:30 PM, Resident continues to wander into peers' rooms' requiring much redirecting. Staff show her to her room about 12 times a shift but she still continues to wander out as soon as she gets in it. f. On 4/1/2021 at 12:42 PM, . Delusions of use of objects and their use. Wanders hall with her hands full of things. g. On 4/2/2021 at 12:42 PM, . Delusions of use of objects and their use. Wanders hall with her hands full of things. h. On 4/3/2021 at 12:42 PM, . Delusions of use of objects and their use. Wanders hall with her hands full of things. Resident 409's eating assistance needs were reviewed from 3/26/2021 to 4/7/2021, and documented that resident 409 was INDEPENDENT - No help or staff oversight at any time 19 of the 37 meals documented for resident 409. Resident 409 was documented to be SUPERVISION - Oversight, encouragement or cueing 17 of the 37 meals documented for resident 409. On 4/5/2021 at 11:04 AM, an interview was conducted with RN 5. RN 5 stated that staff tried to encourage the residents to wear a face mask, but that the residents usually did not keep them on. On 4/5/2021 at 2:42 PM, a follow up interview was conducted with RN 5. RN 5 stated that resident 409 was supposed to be on 14 day isolation due to being a new admission. RN 5 stated that staff were supposed to wear a gown, gloves, mask, and goggles any time they entered resident 409's room. RN 5 stated that resident 409 left her room sometimes but that staff tried to direct her back to her room. RN 5 stated that after 7 days on isolation then resident 409 was allowed to leave her room for therapy if she wore her mask. On 4/5/2021 at 2:46 PM, an interview was conducted with CNA 8. CNA 8 stated that resident 409 was still on her 14 day quarantine because she was a new admission. CNA 8 stated that staff had to wear a gown, gloves, mask, and face shield when they entered resident 409's room. CNA 8 stated that resident 409 was allowed to leave her room and go sit in the main dining room to eat with the other residents. CNA 8 stated that staff had to wear full PPE when they entered resident 409's room, but the CNA did not know what PPE resident 409 was supposed to wear when she came out of her room. On 4/7/2021 at 9:32 AM, an interview was conducted with CNA 5. CNA 5 stated that staff wore gloves and a gown when they entered resident 409's room, in addition to their regular mask and face shield which they wore all day. CNA 5 stated that staff tried to keep resident 409 in her room as much as possible, but that resident 409 normally came down to the dining room for lunch and dinner. CNA 5 stated that resident 409 had been eating her meals in the dining room with the other residents since her admission on [DATE]. On 4/7/2021 at 9:36 AM, an interview was conducted with CNA 10. CNA 10 stated that staff were supposed to wear full PPE when they entered resident 409's room. CNA 10 stated that he should have donned PPE when he entered resident 409's room to collect her meal tray. On 4/7/2021 at 9:41 AM, an interview was conducted with RN 2. RN 2 stated that staff were supposed to be performing contact and droplet precautions when they entered resident 409's room. RN 2 stated that the new facility admission protocol was for all new admits to be on contact and droplet precautions for 14 days after admission. RN 2 stated that even after day 7, the resident still could not go down to the dining room to eat. On 4/8/2021 at 8:11 AM, an additional follow up interview was conducted with RN 5. RN 5 stated that residents on isolation were allowed to come out of their rooms, after 7 days from admission date, for therapy or smoking if they were wearing a mask. RN 5 stated that it was too hard for the therapists to always do therapy in the resident rooms. On 4/8/2021 at 9:40 PM, an interview was conducted with PT 1. PT 1 stated that new admissions were not isolated if they had been fully vaccinated or if they had been diagnosed with Covid-19 in the previous 90 days. PT 1 stated that if a resident was on isolation then the therapy staff did therapy in the resident room for the first 7 days, while wearing full PPE. PT 1 stated that after the 7 days then the resident could come out of their rooms to do therapy while wearing a mask. On 4/8/2021 at 9:53 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that her records showed that resident 409 was to eat her meals in the dining room. The DM stated that newly admitted residents were allowed to eat in the dining room if they were fully vaccinated against Covid-19, or if they had been diagnosed with Covid-19 in the previous 90 days. The DM stated that the CNA's or the nurses were the ones that notified the kitchen staff if a resident could eat in the dining room, or if the resident had to eat in their room. On 4/8/2021 at 10:04 AM, an interview was conducted with the DON. The DON stated that new admits were isolated for 14 days and were only allowed out for one-on-one smoke breaks, and doctor appointments. The DON stated that residents on isolation should not be going to meals in the dining room. The DON stated that resident 409 required help to eat due to her severe dementia, which might have been why the resident was going down to the dinning room. The DON stated that there would be some concern with resident 409 being a new admit and not being isolated, which could have possibly spread Covid-19. [Note: documentation showed that resident 409 did not require help with eating.] 4. Resident 162 was admitted to the facility on [DATE] with diagnoses which included cerebral palsy, muscle weakness, and injury of sciatic nerve. On 4/5/2021 at approximately 1:00 PM, an observation was made of resident 162's room. A sign was observed on resident 162's door which stated that resident 162 was admitted to the facility on [DATE] and was on isolation precautions. On 4/6/2021, a further observation was made of resident 162, between approximately 1:00 PM and 2:30 PM, in which resident 162 ambulated in his wheelchair in the A hall with Occupational Therapist (OT) 1. On 4/6/2021 at 10:16 AM, an observation was made of resident 162. Resident 162 was observed in his wheelchair ambulating with the therapist to the therapy gym. On 4/6/2021 at 11:20 AM, resident 162 was observed in the hallway working with the therapist. On 4/6/2021 at 11:30 AM, resident 162 was observed wheeling himself back to his room. On 4/6/2021 at 11:30 AM, an interview was conducted with resident 162. Resident 162 stated that he had not ever had Covid-19 and that he had not yet been immunized. Resident 162 stated that he requested the immunization but had not received it yet. On 4/7/2021, resident 162's medical record was reviewed. A review of resident 162's immunization record revealed no facility record that resident 162 had received the Covid-19 vaccine. A review of resident 162's medical history revealed no past diagnosis of Covid-19. A physician's order, initiated on 3/29/2021 and scheduled to be completed 4/12/2021, stated Isolation Precautions: droplet May resolve associated diagnoses . at the conclusion of these precautions. On 4/5/2021 at 3:20 PM, an interview was conducted with OT 1. OT 1 stated that after a resident was at the facility for 7 day, the resident was able to leave their room as long as they performed hand hygiene and wore a mask. OT 1 stated that 14 days after admit the resident was able to come off of isolation precautions. On 4/8/2021 at 7:52 AM, an interview was conducted with RN 5. RN 5 stated that they did not know why resident 162 was coming out of his room. RN 5 stated that resident 162 was supposed to be on a 14 day new admit isolation precautions; which included a gown, gloves, mask, and goggles every time a staff member entered resident 162's room. RN 5 stated that he thought residents were allowed to leave their room for therapy after 7 days, so long as they wore a mask. On 4/8/2021 at 7:59 AM, an interview was conducted with CNA 13. CNA 13 stated that resident 162 was supposed to be on isolation precautions because he was a new admit. CNA 13 stated that resident 162 was only supposed to be allowed out of his room for showers. On 4/8/2021 at 9:09 AM, an interview was conducted with CNA 7. CNA 7 stated that new admit residents were supposed to be on isolation and only leave their room for showers. CNA 7 stated that staff were supposed to wear gowns, gloves, mask, and goggles any time they entered the resident room. On 4/8/2021 at 9:47 AM, an interview was conducted with PT 1. PT 1 stated that resident 162 was allowed out of his room with therapy staff because it had been more than 7 days since his admission. PT 1 stated that she did not know why facility policy allowed the resident's out after day 7, since most other facilities required a full 14 day isolation. On 4/8/2021 at 10:06 AM, an interview was conducted with the DON. The DON stated that 7 days after a resident was admitted to the facility, the resident was allowed out one-on-one with therapy but they should not be in the therapy gym or common areas. The DON stated that all residents were tested for Covid-19 prior to admission to the facility plus weekly while at the facility. The DON stated that she did not know why resident 162 was out of his room and in common areas with the therapist. A copy of an all staff in-service dated 2/10/2021 was provided by the DON, and documented: .3. Isolation Types: Contact, Droplet a. Sign, Cart at door. New admits x 14 days b. PPE: Change gown each time, place in bin. Take down to laundry during your shift. A review of the Centers for Disease Control and Prevention guidelines found at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html stated . In general, all other new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission. 5. On 4/5/2021 at 12:25 PM, an observation was made of CNA 2 and Concierge 1 donning a gown and gloves and entering room [ROOM NUMBER] with a hoyer lift. room [ROOM NUMBER] had a stop sign located on the door and a PPE cart outside the door. An immediate interview was conducted with RN 1. RN 1 stated that the resident in room [ROOM NUMBER] was on contact precautions due to a Methicillin-resistant Staphylococcus aureus (MRSA) infection in the coccyx wound. At 12:39 PM, CNA 2 exited room [ROOM NUMBER] with the hoyer lift. The hoyer lift was placed in the hallway outside of the room. At 12:42 PM, the hoyer lift was taken into room [ROOM NUMBER] by Concierge 1 and CNA 2. No observation was made of cleaning the hoyer lift after it exited the TBP room [ROOM NUMBER]. On 4/5/2021 at 12:58 PM, an observation was made of CNA 3 placing the hoyer lift in the communal shower room across from the nurse's station. An immediate interview was conducted with CNA 3. CNA 3 stated that the shower room was where the resident care equipment was stored. On 4/5/2021 at 1:28 PM, an interview was conducted with CNA 2. CNA 2 stated that the resident care equipment was cleaned once a shift, and was not sure how often hoyer lifts were cleaned. CNA 2 stated that the cleaning process was to clean the hoyer lifts with a bleach wipe after use and before using with another resident. CNA 2 stated that she did not clean the hoyer lift between resident use in the TBP room [ROOM NUMBER] and room [ROOM NUMBER]. Review of the facility Policy and Procedures for Transmission Based Precautions and Isolation documented under Multi-drug Resistant Organisms (MDRO) such as MRSA that Dedicated use of non-critical care equipment (i.e., sphygmomanometer, stethoscope and thermometer) will be provided to MDRO resident(s), when available. This equipment should be disinfected after each use whether dedicated to MDRO resident or shared. The policy was last revised on 9/29/2017. On 4/8/2021 at 10:03 AM, an interview was conducted with the DON. The DON stated that shared resident equipment should be cleaned after use with a bleach or disinfecting wipe. The DON stated that hand hygiene should be performed after entering and exiting rooms, during meal times with tray delivery, and anytime staff are touching a resident or providing resident care. 6. On 4/5/2021 at 3:01 PM, an observation was made of a CNA taking the Hoyer lift out of room [ROOM NUMBER] on the D hall, after using it to transfer a resident. The CNA was observed to take the Hoyer lift to the shower room and leave it there. The CNA did not clean the Hoyer lift after use. On 4/5/2021 at 3:04 PM, an observation was made of CNA 8. Between 3:04 PM and 3:11 PM, CNA 8 was observed to take three different resident's vital signs. CNA 8 did not clean the vital sign equipment in-between residents. On 4/5/2021 at 3:14 PM, an observation was made of CNA 9. Between 3:14 PM and 3:28 PM, CNA 9 was observed to take five different resident's vital signs. CNA 9 did not clean the vital sign equipment in-between residents. CNA 9 was also not observed to perform hand hygiene in-between different residents. On 4/6/2021 at 9:02 AM, a CNA was observed to enter room [ROOM NUMBER] with the sit-to-stand lift, the CNA was observed to exit the room at 9:09 AM with the lift. The CNA was then observed to take the lift to the shower room and leave it there. The CNA did not clean the lift after use. On 4/6/2021 at 10:21 AM, an observation was made of a CNA ta[TRUNCATED]