**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 37 sampled residents, that the facility failed to ensure that a resident with urinary incontinence, based on the resident's comprehensive assessment received appropriate treatment and services to restore continence to the extent possible. Specifically, a resident who was incontinent of bladder and was assessed to be a likely candidate for a toileting program was not provided treatment and services to achieve as much normal bladder function as possible. Resident identifier: 10. Findings include: Resident 10 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which included diabetes mellitus type 2, congestive heart failure, chronic kidney disease, respiratory failure with hypoxia, atrial flutter, major depressive disorder, and right leg below the knee amputation. On 1/23/24 at 10:16 AM, an interview was conducted with resident 10. Resident 10 stated she used a brief for bladder incontinence and that she wished she was on a bladder training program. Resident 10 stated she was on dialysis but that she did make urine and had urine frequency. Resident 10 stated the facility had done nothing for bladder training and that the facility had not talked with her about bladder training. Resident 10's medical record was reviewed from 1/22/24 through 1/29/24. The MDS (Minimum Date Set) Quarterly assessment dated [DATE] revealed resident 10 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated a cognitive status of an intact cognition. The MDS quarterly assessment dated [DATE], indicated that a trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) had not been attempted on admission/entry or reentry or since urinary incontinence was noted in the facility. It further indicated that resident 10 was always incontinent of urine. The Bowel and Bladder Evaluation dated 1/2/24 at 10:18 AM indicated that resident 10 was a likely candidate with a score of 8. A score of 8 indicated, Likely candidate for Bowel and Bladder re-training (LC). It further indicated resident 10 was evaluated to have, Behavior/Attitude. Shows initiative and Willingness. On 1/25/24 at 2:34 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated the bowel and bladder evaluation was completed when a resident was first admitted , quarterly, and when a change of condition occurred. LPN 1 stated she did not think resident 10 was on a bowel and bladder program. On 1/29/24 at 11:18 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the bowel and bladder assessment was to be completed every quarter. The DON stated resident 10 had episodes of urinary incontinence and was on a check and change program. The DON stated that if a resident was a likely candidate for the bowel and bladder program that they would have been added to a bathroom upon rise program. The DON further stated that based on how a resident responded to the bathroom upon rise program, along with being cognitively able, the resident would then be a candidate for a prompt and void program. The DON stated resident 10 was cognitively capable and that she would have been a likely candidate for the bowel and bladder program. On 1/8/24 at 9:07 AM, an interview was conducted with resident 5 who stated she had a concern that one of the providers had changed her medication without

Based on interview and observation, the facility did not ensure that the resident environment remained as free of accidents as possible. Specifically, the laundry room was left open with no staff present; the laundry room was observed to have various chemicals inside. Findings include: On 1/29/24 at 10:43 AM, an observation was made of the first floor laundry room. The laundry room door was cracked open and no staff were located inside the laundry room. An observation was made of several chemicals located on the clean side of the laundry room which included: 4 containers of Febreeze fabric refresher, 7 containers of Comet disinfecting sanitizing bathroom cleaner, 2 bottles of broad range quaternary sanitizer and 2 containers of disinfecting all purpose spray and glass cleaner. Several of the warning labels located on the containers stated to keep out of reach of children and may be harmful if swallowed. Another observation of the door between the clean and dirty laundry room was made. The door had a sign which read this door must not be propped open. That door was found to be propped open and more chemicals were located inside the dirty side of the laundry. Those chemicals consisted of a 5 gallon container of tide whiteness enhancer, 5 gallon container of Tide laundry detergent, 5 gallon container of Clorox bleach, 9 boxes of tide stain removal treatment powder, 6 bottles of tide rust stain remover, and 5 one gallon containers of germicidal ultra bleach. On 1/29/24 at 10:53 AM, an interview was conducted with Housekeeping (HK). The HK stated the laundry room door was always closed when no one was in there. The HK stated the door remained closed so residents were not able to come in unattended. The HK stated residents knocked on the door when they needed to look through the lost and found. The HK stated only staff had access to the laundry room when they were not in here. The HK stated residents were not allowed to be in the laundry room unattended. On 1/29/24 at 12:17 PM, an interview was conducted with the Maintenance Director (MD). The MD stated residents were not allowed in the laundry room by themselves due to the chemicals located inside. The MD stated due to resident safety, the laundry door was always kept shut to prevent residents from having access to the chemicals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 2 of 23 sample resident, the facility did not provide the right for residents to choose medical treatment. Specifically, residents Physicians Orders for Life Sustaining Treatment (POLST) forms were not filled out timely after the residents were admitted to the facility. Resident identifiers: 8 and 30. Findings include: 1. Resident 8 was admitted to the facility on [DATE] with diagnoses which included heart failure, type II diabetes, chronic gastritis, hypertension, fibromyalgia, irritable bowel syndrome, carpel tunnel and hypothyroidism. On [DATE] a review of resident 8's medical record was conducted. Resident 8's POLST was not signed by the resident until [DATE] and signed by a medical provider on [DATE]. This was 84 days after admission. 2. Resident 30 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included gastro-esophageal reflux disease with esophagitis, peptic ulcer, anemia, chronic kidney disease stage 5, schizophrenia, chronic obstructive pulmonary disease, and dysphagia. On [DATE] a review of resident 30's medical record was conducted. Resident 30's POLST was not signed by the resident until [DATE] and signed by a medical provider on [DATE]. This was 61 days after admission. On [DATE] at 2:16 PM, an interview with Registered Nurse (RN) 3. RN 3 stated if a resident had an emergency she would find the information for treatment on her shift sheet, if it was there, if not RN 3 stated she would look in the POLST book. If no information was found the resident would be considered a Full Code. On [DATE] at 10:26 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the POLST needed to be signed within 24 hours of resident's admission to the facility. The DON stated if the POLST was not completed we would assume the resident was a full code and do cardiorespiratory resuscitation (CPR). The DON stated if that resident was a Do Not Resuscitate (DNR) and CPR was performed that would be a big problem. The DON stated the system on how the POLST forms had been completed was ineffective and was on the forefront of the facilities recovery effort for ineffective systems.

Based on observation and interview, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, the two showers in the third floor shower room were in disrepair. Findings included: On 5/2/22 at 10:27 AM, an interview was conducted with resident 19. Resident 19 stated the showers had black stuff in the corners, the Certified Nursing Assistant's (CNA) went in after each person and washed it down after each person showered. On 5/4/22 at 3:07 PM, an observation was made of the shower room on the third floor. The following observations were made: a. Shower A had orange rust stains that ran down the tiled wall to the floor. b. Shower A faucet continuously dripped from the end of the hand held shower nozzle. c. Shower A paint peeled along the top of the shower, where the tile met the pain in two locations. d. Shower A had caulk missing around the base of the shower. e. Shower A had multiple tiles with reminents of adhesive residue on the walls. f. Shower A had fauset base pulled out from wall. g. Shower A had multiple quarter sized rust stains on the tile floor. h. Shower B had missing caulk around the base of the tiled shower, there was a black substance around the bottom of the shower. i. Shower B soap holder with corrosion on the side and top of the holder. j. Shower B had the tip of a latex glove, in the same location on the tiled floor on 5/4/22 and 5/5/22. k. Shower B had a plastic razor cap, in the same location on the tiled floor on 5/4/22 and 5/5/22. On 5/4/22 at 3:20 PM, an interview was conducted with Certified Nurses Assistant (CNA) 3. CNA 3 stated the showers were cleaned in between each shower. CNA 3 stated the showers were sprayed with disinfectant, then wiped down after the disinfectant sat for one minute then, we can shower another resident. CNA 3 stated we try to keep the showers clean for the residents. On 5/5/22 at 10:15 AM an interview was conducted with Maintenance Director (MD). The MD stated housekeeping cleaned the showers everyday, they wash them and clean the floors. The MD stated before he came they changed the caulk in the showers and put in the wrong caulk. The MD stated the black on the caulk was from the paint. The MD was observed pointing to the wall that was painted white in color. The MD stated the metal soap dispenser was placed over a metal screw and there was a leak behind that caused the rust to run down the wall and the faucet to leak. The MD stated the showers needed to have some things fixed in them so they were better for the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 4 of 23 sample residents, that in response to an allegation of abuse, neglect, exploitation or mistreatment, the facility did not ensure that all alleged violations were report no later than 2 hours after the allegation was made and the results of all investigations were reported within 5 working days of the incident. Specifically, two resident to resident altercations were not reported within 2 hours to the state survey agency. Resident identifiers: 9, 31, 33 and 89. Findings include: 1. Resident 33 was admitted to the facility on [DATE] with diagnoses which included dementia without behavioral disturbance, major depressive disorder, personal history of transient ischemic attack, diabetes, and cerebral infarction. On 5/2/22 at 9:11 AM, an interview was conducted with resident 33. Resident 33 stated the roommate tried to kill her. Resident 33 stated that her roommate told her that she was going to stab her. Resident 33 stated she was unable to sleep at night. Resident 33 stated that her roommate was not at the facility very long. Resident 33's medical record was reviewed on 5/3/22. There were no progress notes located in resident 33's medical record regarding any concerns with her roommate. Resident 89 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia without behavioral disturbance, bipolar disorder, major depressive disorder, anxiety disorder, cognitive communication deficit and unsteadiness on feet. Resident 89's medical record was reviewed on 5/3/22. Resident 89's History and Physical prior to admission dated 3/24/22 revealed She becomes agitated and may hit, kick, scream or grab. The form further revealed Familiar people are not recognized or misidentified. Resident 89's progress notes revealed the following entries: a. On 4/14/22 at 5:12 PM, Registered Nurse (RN) 3 documented Staff member went into patients room to get the covid test done. Patient told her that she would not let her do that. Staff member asked her why and patient told her that she was thinking about murder and that she was thinking about doing this to the staff member. Staff member left the room and did not perform the test. Will notify social services. b. On 4/15/22 the Nurse Practitioner (NP) documented Seen due to agitation and aggression. Threatened to stab roommate last night. When laboratory analysis without acute normalizites. Coordinate transfer back to [mental health facility]. c. On 4/15/22 at 8:35 PM, resident 89 was picked up and transported to the mental health facility about 8:35 PM. A review of facility reported incidents to the State Survey agency revealed no reported information regarding the incident. On 5/5/22 at 9:52 AM, a follow up interview was conducted with resident 33. Resident 33 stated that her roommate kept talking about killing. Resident 33 stated that her roommate told resident 33 to call the cops because she had already hurt someone. Resident 33 stated she told a nurse and a couple of Certified Nursing Assistant's (CNA) about resident 89's comments. Resident 33 stated that after the roommate told her that she already hurt someone, resident 33 stated that she was afraid that the resident would stab her. Resident 33 stated she was concerned the roommate was a threat to other people if she came back to the facility. Resident 33 stated she did not feel safe with the roommate in her room. Resident 33 stated she did not remember if the NP, doctor or Administrator talked to her about feeling safe. Resident 33 stated if she had been asked if she felt safe would have said no. Resident 33 stated I just felt like she was crazy. Resident 33 stated she was unable to sleep about 4 night because she was scared of her roommate. Resident 33 stated her roommate did not talk much but was able to get herself up and walk to the bathroom and walk to the door. Resident 33 stated as soon as the roommate left, she was not scared anymore. Resident 33 stated she would be afraid if her roommate was readmitted to the facility. On 5/5/22 at 10:24 AM, an interview was conducted with CNA 2. CNA 2 stated she worked with residents on the 3rd floor three days a week where resident 33 and resident 89 resided. CNA 2 stated there was a incident with resident 33 who had a roommate, resident 89. CNA 2 stated when went in to help resident 33, resident 89 told CNA 2 that she committed a murder and she asked who she had murdered and she said she had not done it yet but was going to and pointed to resident 33. CNA 2 stated she reported the incident to the nurse but could not remember who the nurse was and might have been a agency nurse. CNA 2 stated she talked to resident 33 and asked her how she felt. CNA 2 stated she asked resident 33 if she was afraid and she said no, but her roommate was just crazy. CNA 2 stated she thought resident 89 was transported to a mental health facility the same day. CNA 2 stated she heard from another CNA that resident 89 was thinking about murdering that CNA too. CNA 2 stated she reported the threat to the nurse because it was a form of abuse and did not think resident 33 should be in the same room with resident 89 because she could use utensils or something to hurt resident 33. CNA 2 stated she looked in the room to make sure that resident 89 did not have anything she could hurt resident 33 with. CNA 2 stated she felt like it could be a threat or abuse that's why she reported it to the agency nurse. On 5/4/22 at 3:12 PM, an interview was conducted with CNA 3. CNA 3 stated that resident 89 said some not so nice things to her. CNA 3 stated she was helping resident 33 and resident 89 looked at CNA 3 and said that B gets all the help and she wanted to kill her. CNA 3 stated she helped resident 33 back to bed to get her safe. CNA 3 stated then she went to resident 89 and asked her what she needed. CNA 3 stated that resident 89 stated she was fine. CNA 3 stated other staff heard resident 89 say she wanted to kill resident 33 at different times. CNA 3 stated it happened about the middle of April 2022. CNA 3 stated that she reported it to an agency nurse. CNA 3 stated she hoped that the nurse documented something. CNA 3 stated she randomly check in there for safety reasons. CNA 3 stated the same day resident 89 was transferred out of the facility. CNA 3 stated staff were randomly checking the room through out the day. CNA 3 stated resident 33 did not say anything about feeling unsafe. On 5/4/11 at 3:28 pm, an interview was conducted with RN 3. RN 3 stated resident 33's roommate was paranoid and was having some issues. RN 3 stated resident 89 threatened staff and then threatened her roommate because she was not in her right mind. RN 3 stated resident 33 sat out with us at the nurses station because the roommate was not coming out of her room. RN 3 stated she was told from a staff member that roommate had threatened resident 33. RN 3 stated she did not remember the exact words. RN 3 stated that she talked to resident 33 after the incident and she told the nurse that her roommate was crazy and did not want another roommate. RN 3 stated Yes, absolutely it would be reported as possible abuse. RN 3 stated she talked to the Director of Nursing and the Administrator about it being abuse. RN 3 stated that she was educated that a threat needed to be handled the same as an abuse case. RN 3 stated that the DON educated everyone about that. RN 3 stated that the note on 4/14/22 that she wrote, it was something about not letting resident 89 get the COVID test and resident 89 stated that she was thinking about murder. RN 3 stated she notified people and let them know resident 89 was unstable and that's when management started to get her transferred. RN 3 resident 89 had threatened the staff member not the roommate on 4/14/22. RN 3 stated that resident 89 just told her that she was thinking about murder. RN 3 stated on 4/15/22 resident 89 threatened resident 33 and a CNA reported it to her. RN 3 stated she should have taken it more seriously on 4/14/22 but did not and had since been education about it. RN 3 stated she was educated by 4/16/22 about it being abuse possibly. On 5/4/22 at 3:45 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated resident 89 was was not at the facility very long. The ADON stated she discharged to a mental health facility on 4/15/22 at about 8:35 PM. The ADON stated she did not remember any additional information about why resident 89 was admitted to the mental health facility. The ADON stated resident 89 was discussed in the morning meeting but did not recall what day or what was discussed. On 5/4/22 at 3:45 PM, an interview was conducted with CRN 1. CRN 1 stated the NP caught him in the parking lot on the way into work on 4/15/22. CRN 1 stated resident 89 came from a mental health facility because of homicidal comments. CRN 1 stated resident 89 had homicidal comments toward staff so the NP had staff obtain labs. CRN 1 stated there was nothing acute wrong with resident 89, so resident 89 was sent back to the mental health facility. CRN 1 stated nothing had been reported about threats toward another resident. CRN 1 stated as far as he knew that staff member was told by resident 89 that she was going to kill her. On 5/4/22 at 3:58 PM, an interview was conducted with the Operations Manager (OM). The OM stated there was a resident that was making threats but not to a specific person. The OM stated he did not know if there was an investigation into it. The OM stated that he was the abuse coordinator. The OM stated he tried to get all of the initial information in the first hour or 2. The OM stated that an investigation was started by interviewing the resident, staff involved, investigate and then get that all typed up and sent in within the 5 days to the State Survey Agency. The OM stated he reported to Adult Protective Services (APS) and or the police also. The OM stated the only thing he heard was that it was not a threat to a particular staff or resident. The OM stated the resident was homicidal but not to a specific person. The OM stated he did not write anything down, but did ask if anyone heard anything. On 5/5/22 at 9:03 AM, an interview was conducted with the NP. The NP stated he was notified about residents by staff through a secured texting system. The NP stated that he was able to text back to the staff and that the messages deleted within 5-7 days. The NP stated he cared for resident 89 at the mental health facility prior to her admission to the facility. The NP stated when he was made aware of the incident he contacted the mental health facility and readmitted resident 89 there. The NP stated the morning resident 89 was readmitted to the mental health facility he could not remember 100% of the details. The NP stated he knew resident 89 threatened to harm her roommate. The NP stated he had was notified and then transferred her out the same day. The NP stated he had not been notified of any other times resident 89 had made threatening statements. The NP stated resident 89 was ambulatory but needed a walker. The NP stated resident 89 was able to walk across her room but not much further. The NP stated resident 89 was not very independent or able to get around very far by herself. The NP stated it was safer to get her back to the mental health facility for a change in an environment and see if anything could be done with her medications. The NP stated he did not think resident 89 was going to really hurt anyone at the facility. The NP stated that resident 89 spent a majority of the time in her bed while she was at the facility. The NP stated he instructed staff to monitor her and get blood work. The NP stated he talked to CRN 1 and the ADON about the incident. The NP stated that the DON was moving residents around on the 3rd floor the same day resident 89 made the threatening statements. CRN 1 stated the DON was trying to separate multiple people that day. The NP stated he did not recall if resident 89 had specifically threatened a person. The NP stated he thought he talked to the roommate (resident 33) the morning of 4/15/22. The NP stated that he through resident 33 stated everything was fine. The NP stated that resident 33 was fairly mobile. 2. Resident 9 was admitted to the facility on [DATE] with diagnoses which included epilepsy, encephalitis, traumatic brain injury, and major depressive disorder. Resident 9's progress notes were reviewed and revealed on 4/15/22 at 4:32 AM, Staffing heard screaming, abusive language and resident 9's roommate screaming, 'why did you hit me in the arm!' CNA intervened and separated resident 9, after he was threatening roommate that he will kill him. Resident 31 was admitted to the facility on [DATE] with diagnoses which included streptococcal infection, protein-calorie malnutrition, cerebral infarction, and diabetes mellitus. Resident 31's progress notes were reviewed and revealed On 4/15/22 at 4:40 AM, Staff heard loud voices fighting, abusive language, and verbal threats coming from residents room. Staffing intervened and resident stated roommate had hit him in the arm for no reason. CNA separated roommate and redirected. No injuries to resident upon assessment shall continue to monitor. A Facility Reported Incident (FRI) revealed the State Survey Agency was contacted on 4/15/22 at 11:04 AM. The report revealed on 4/15/22 at 4:30 AM resident 31 reported that resident 9 hit his arm. The residents were separated and assessments of resident 31 was completed. Labs were also ordered for resident 9. APS and Physician were notified. On 5/4/22 at 3:41 PM, an interview was conducted with the DON. The DON stated there had been one incident and she was not the one that reported it. The DON stated the incident was between resident 9 and resident 11. The DON stated she was not at the facility when the incident occurred. On 5/5/22 at 10:36 AM, an interview was conducted with CRN 1. CRN 1 stated there was a resident to resident incident that was reported to the state. CRN 1 stated it was between resident 9 and resident 31. CRN 1 stated from what he remembered one resident was struck another resident on the arm. CRN 1 stated it was reported up the chain of command but it was reported late. CRN 1 stated since the incident was not immediately reported it triggered management to to do abuse education with all staff. CRN 1 stated that agency staff had a binder at each nurses station with the abuse policy and procedure. CRN 1 was observed to look through the binders titled Nurse Quick Guide Reference and was unable to find information on abuse. On 5/5/22 at 1:45 PM, an interview was conducted with the Operations Manager (OM). The OM stated the incident between resident 31 and resident 9, took place early into the day, like early in the morning. The OM stated that he was informed about it between 8:00 to 9:00 AM. The OM stated the incident needed to be reported within 2 hours to the State Survey Agency and was not. A review of the facility Abuse policy and procedure revealed, Policy: It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to, Facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends, or other individuals. Mental Abuse - This includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation. Verbal Abuse: The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their representatives, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Procedures: In response to allegations of abuse, neglect, exploitation, or mistreatment, the Facility will: 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 (2) hours after the allegation is made if the events that cause the allegation involved abuse or results in serious bodily injury. Not later than twenty-four (24) hours if the events that cause the allegation does not involved abuse and does not result in serious bodily injury. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to: The Administrator of the Facility The State Survey Agency Adult Protective Services (as appropriate) Ensures that, after receipt of a report of possible abuse, neglect, mistreatment, exploitation, or misappropriation of resident property, steps are immediately taken to protect the identified resident (s). Ensure that the results of all investigations are reported within five (5) working days of the incident: The Administrator The State Survey Agency .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 of 23 sample residents, that in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility did not have evidence that all alleged violations were thoroughly investigated. Specifically, a resident threatened another resident and there was no investigation. Resident identifiers: 33 and 89. Findings include: Resident 33 was admitted to the facility on [DATE] with diagnoses which included dementia without behavioral disturbance, major depressive disorder, personal history of transient ischemic attack, diabetes, and cerebral infarction. On 5/2/22 at 9:11 AM, an interview was conducted with resident 33. Resident 33 stated the roommate tried to kill her. Resident 33 stated that her roommate told her that she was going to stab her. Resident 33 stated she was unable to sleep at night. Resident 33 stated that her roommate was not at the facility very long. Resident 33's medical record was reviewed on 5/3/22. There were no progress notes located in resident 33's medical record regarding any concerns with her roommate. Resident 89 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia without behavioral disturbance, bipolar disorder, major depressive disorder, anxiety disorder, cognitive communication deficit and unsteadiness on feet. Resident 89's medical record was reviewed on 5/3/22. A History and Physical from 3/24/22 revealed She becomes agitated and may hit, kick, scream or grab. The form further revealed Familiar people are not recognized or misidentified. Resident 89's progress notes revealed the following entries: a. On 4/14/22 at 5:12 PM, Registered Nurse (RN) 3 documented Staff member went into patients room to get the covid test done. Patient told her that she would not let her do that. Staff member asked her why and patient told her that she was thinking about murder and that she was thinking about doing this to the staff member. Staff member left the room and did not perform the test. Will notify social services. b. On 4/15/22 the Nurse Practitioner (NP) documented Seen due to agitation and aggression. Threatened to stab roommate last night. When laboratory analysis without acute normalizites. Coordinate transfer back to [mental health facility]. c. On 4/15/22 at 8:35 PM, resident 89 was picked up and transported to the mental health facility about 8:35 PM. A review of facility reported incidents to the State Survey agency revealed no reported information regarding the incident. On 5/5/22 at 9:52 AM, a follow up interview was conducted with resident 33. Resident 33 stated that her roommate kept talking about killing. Resident 33 stated that her roommate told resident 33 to call the cops because she had already hurt someone. Resident 33 stated she told a nurse and a couple of Certified Nursing Assistant's (CNA). Resident 33 stated that after the roommate told her that she already hurt someone, resident 33 stated that she was afraid that the resident would stab her. Resident 33 stated she was concerned the roommate was a threat to other people if she came back to the facility. Resident 33 stated she did not feel safe with the roommate in her room. Resident 33 stated she did not if the NP, doctor or Administrator talked to her about feeling safe. Resident 33 stated if had been asked if she felt safe would have said no. Resident 33 stated I just felt like she was crazy. Resident 33 stated she was unable to sleep about 4 night because she was scared of her roommate. Resident 33 stated her roommate did not talk much but was able to get herself up and walk to the bathroom and walk to the door. Resident 33 stated as soon as the roommate left, she was not scared anymore. Resident 33 stated she would be afraid if her roommate was readmitted to the facility. On 5/5/22 at 10:24 AM, an interview was conducted with CNA 2. CNA 2 stated she worked with residents on the 3rd floor three days a week. CNA 2 stated there was a incident with resident 33 who had a roommate resident 89. CNA 2 sated when went in to help resident 33, resident 89 told CNA 2 that she committed a murder and she asked who she had murdered and she said she had not done it yet but was going to and pointed to resident 33. CNA 2 stated she reported the incident to the nurse but could not remember who the nurse was and might have been a agency nurse. CNA 2 stated she talked to resident 33 and asked her how she felt. CNA 2 stated she asked resident 33 if she was afraid and she said no, but her roommate was just crazy. CNA 2 stated she though resident 89 was transported to a mental health facility the same day. CNA 2 stated she was not aware of comments made prior to that day. CNA 2 stated she heard from another CNA that resident 89 was thinking about murdering that CNA too. CNA 2 stated she reported to the treat to the nurse because it was a form of abuse and did not think resident 33 should be in the same room with resident 89 because she could use utensils or something to hurt resident 33. CNA 2 stated she looked in room to make sure that she did not have anything she could hurt resident 33 with. CNA 2 stated she felt like it could be a threat or abuse that's why she reported it to the agency nurse. On 5/4/22 at 3:12 PM, an interview was conducted with CNA 3. CNA 3 stated resident 33's roommate was here for a short time. CNA 3 stated that resident 89 said some not so nice things to her. CNA 3 stated she was helping resident 33 and resident 89 looked at CNA 3 and said that B gets all the help and she wanted to kill her. CNA 3 stated she helped resident 33 back to bed to get her safe. CNA 3 stated then she went to resident 89 and asked her what she needed. CNA 3 stated that resident 89 stated she was fine. CNA 3 stated other staff heard resident 89 say she wanted to kill resident 33 at different times. CNA 3 stated it happened about the middle of April 2022. CNA 3 stated that she reported it to an agency nurse. CNA 3 stated she hoped that the nurse documented something. CNA 3 stated she randomly check in there for safety reasons. CNA 3 stated the same day resident 89 was transferred out of the facility. CNA 3 stated staff were randomly checking the room through out the day. CNA 3 stated resident 33 did not say anything about feeling unsafe. On 5/4/11 at 3:28 pm, an interview was conducted with RN 3. RN 3 stated resident 33's roommate was paranoid and was having some issues. RN 3 stated resident 89 threatened staff and then threatened her roommate because she was not in her right mind. RN 3 stated resident 33 sat out with us at the nurses station because the roommate was not coming out of her room. RN 3 stated she was told from a staff member that resident 89 had threatened resident 33. RN 3 stated she did not remember the exact words. RN 3 stated that she talked to resident 33 after the incident and she told the nurse that her roommate was crazy and did not want another roommate. RN 3 stated Yes, absolutely it would be reported as possible abuse. RN 3 stated she talked to the Director of Nursing (DON) and the Operations Manager (OM) about it being abuse. RN 3 stated that she was educated that a threat needed to be handled the same as an abuse case. RN 3 stated that the DON educated everyone about that. RN 3 stated that the note on 4/14/22 that she wrote, it was something about not letting resident 89 get the COVID-19 test and resident 89 stated that she was thinking about murder. RN 3 stated she notified people and let them know resident 89 was unstable and that's when management started to get her transferred. RN 3 resident 89 had threatened the staff member not the roommate on 4/14/22. RN 3 stated that resident 89 just told her that she was thinking about murder. RN 3 stated on 4/15/22 resident 89 threatened resident 33 and a CNA reported it to her. RN 3 stated she should have taken it more seriously on 4/14/22 but did not and had since been education about it. RN 3 stated she was educated by 4/16/22 about it being possible abuse. On 5/4/22 at 3:41 PM, an interview was conducted with the DON. The DON stated that she did not remember an incident between resident 33 and resident 89. The DON stated that resident 89 discharged to a mental health facility and returned to the facility on 5/3/22. The DON stated she was gone when the incident happened and the Assistant Director of Nursing (ADON) and Corporate Resource Nurse (CRN) 1 took care of it. On 5/4/22 at 3:45 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated resident 89 was was not at the facility very long. The ADON stated she discharged to a mental health facility on 4/15/22 at about 8:35 PM. The ADON stated she did not remember any additional information about why resident 89 was admitted to the mental health facility. The ADON stated resident 89 was discussed in the morning meeting but did not recall what day or what was discussed. On 5/4/22 at 3:45 PM, an interview was conducted with CRN 1. CRN 1 stated the NP caught him in the parking lot on the way into work on 4/15/22. CRN 1 stated resident 89 came from a mental health facility because of homicidal comments. CRN 1 stated nothing had been reported about threats toward another resident. CRN 1 stated as far as he knew that staff member was told by resident 89 that she was going to kill her. On 5/4/22 at 3:58 PM, an interview was conducted with the Operations Manager (OM). The OM stated there was a resident that was making threats but not to a specific person. The OM stated he did not know if there was an investigation into it. The OM stated that he was the abuse coordinator. The OM stated if there was an allegation of abuse, he tried to get all of the initial information in the first hour or 2. The OM stated that an investigation was started by interviewing the resident, staff involved, investigate and then get that all typed up and sent to the State Survey Agency within the 5 days. The OM stated he reported to Adult Protective Services and or the police. The OM stated the only thing he heard was that it was not any threat to a particular staff or resident. The OM stated the resident was homicidal but not to a specific person. The OM stated he did not write anything down, but did ask if anyone heard anything. A review of the facility Abuse policy and procedure revealed, Policy: It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to, Facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends, or other individuals. Mental Abuse - This includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation. Verbal Abuse: The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their representatives, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Procedures: In response to allegations of abuse, neglect, exploitation, or mistreatment, the Facility will: 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 (2) hours after the allegation is made if the events that cause the allegation involves abuse or results in serious bodily injury. Not later than 23 hours if the events that cause the allegation does not involved abuse and does not result in serious bodily injury. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to : The Administrator of the Facility The State Survey Agency Adult Protective Services (as appropriate) Ensures that, after receipt of a report of possible abuse, neglect, mistreatment, exploitation, or misappropriation of resident property, steps are immediately taken to protect the identified resident (s). Ensure that the results of all investigations are reported within five (5) working days of the incident: The Administrator The State Survey Agency .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 1 of 23 sample residents, the facility did not ensure that the residents' environment remained as free of accident hazards as was possible or that each resident received adequate supervision to prevent accidents. Specifically, a resident had access to hazardous chemicals and there was a hallway rug outside of a resident's room which a resident tripped over when using a walker. Resident identifier: 194 Findings include: Resident 194 was admitted to the facility on [DATE] with diagnoses which included left knee derangement of patella, bipolar disorder, current episode manic without psychotic features, borderline personality disorder, muscle weakness and unsteadiness on feet. 1. On 5/2/22 at 12:08 PM, an observation was made of resident 194. Resident 194 was observed to ask house keeping for a broom and dust pan so resident could clean behind the door. House keeper was observed to give resident 194 the supplies requested and proceeded to tell the resident to return the broom and pan back to the house keeping closet and gave resident 194 the code to the closest. On 5/4/22 at 10:49 AM, an observation of the housekeeping closet was conducted. Several hazardous containers were located including Clorox, Peroxide multi surface cleaner, liquid hand sanitizer, Multiple bags of keystone multi-quat sanitizer and glass cleaners. Warning labels on the containers stated hazardous to humans and domestic animals. Resident's 194 medical record was reviewed on 5/4/22 Care plan dated 4/14/22 revealed a Focus of The resident is at risk for falls r/t (related to) L (left) patellar fx (fixture) / hardware removal, WBAT (weight bearing as tolerated) to LLE (left lower extremity). The goal developed was The resident will not sustain serious injury through the next review date. Interventions developed were, Therapy evaluation and treatment per physician orders, educate resident/family/caregivers about safety reminders and what to do if a fall occurs. On 5/4/22 at 10:54 AM, an interview was conducted with Housekeeper 1. Housekeeper 1 stated housekeeping were the only ones aware what the code was to the housekeeping closet and residents were not allowed to borrow any kind of supplies from them nor were residents allowed in the housekeeping closest. Housekeeper 1 stated if a resident needs something cleaned or picked up house keeping did it. On 5/5/22 at 10:14 AM, an interview was conducted with the Director of Nursing (DON). The DON stated hazardous chemicals were stored in the maintenance closet and they had a biohazard room (housekeeping closet) with some sprays in it that was locked. The DON stated the only staff that was aware of the code and who had access to the closets were the maintenance worker and housekeeping. The DON stated the codes were not given out to residents. The DON then stated if a resident did have access to any of the closets, they would be concerned about ingestion of the hazardous material, especially pertaining to resident 194. The DON stated that resident 194 was not mentally stable to be around hazardous material and worried that resident 194 may ingest the chemicals or spray another resident/staff since resident 194 was vindictive. The DON since resident 194 knew the code, they were immediately changing the code. 2. On 5/3/22 at 09:02 AM, an observation was made of resident 194. Resident 194 was observed to get the left front end of their walker stuck on an entry rug located outside resident's 194 room. Resident 194's medical record was reviewed on 5/4/22. Care plan dated 4/19/22 revealed a Focus of The resident has potential to demonstrate verbally abusive behaviors r/t (related to) Mental/ Emotional illness. The goal developed was The resident will demonstrate effective coping skills through the review date. Intervention developed were, Assess and anticipate resident's needs, assess resident's coping skills and support system, assess resident's understanding of the situation. Allow time for the resident to express self and feelings toward the situation. Give as many choices as possible about care and activities. Progress notes revealed the following entries: a. Nursing note on 4/16 at 14:54 revealed resident 194 was put on a behavior contract due to aggression. b. Behavior note on 4/19 at 12:46 revealed that resident 194 was identified as a fall risk by staff. Behavior note stated Res did not have brace applied to leg. Res ambulates without socks placed to feet. c. Daily skilled nursing note on 4/23 revealed resident 194 was independent with walker and knee brace d. Daily skilled note on 5/2 at 14:58 signed by DON, read, Discussed with resident the importance of wearing non-skid footwear while ambulating in the halls to prevent skipping or falls. Resident has been non-compliant with footwear and when redirected, has melt-downs. Staff and the resident have been educated on proper communication and presentation. Resident was admitted to the facility for rehab stay post-surgery on her Left Knee. Physical therapy discharge summary on 5/2/22 revealed resident 194 was discharged due to achieving the highest practical level. Interventions reviewed by PT included safety precautions and use of assistive device(s) in order to improve safety and independence with functional mobility. On 5/4/22 at 11:18 AM, an interview was conducted with License Practical Nurse 1 (LPN). LPN 1 stated that resident 194 needed more help than she let on. LPN 1 stated resident 194 needed a walker to get around but was unsure if resident was compliant with it at all times. On 5/4/22 at 11:57 AM, an interview was conducted with resident 194. Resident 194 stated they trip on the rug all the time but have not fallen yet. Resident 194 stated staff had not been notified but stated staff had witnessed them trip on the rug and had made comments about resident 194 tripping. On 5/4/22 at 3:07 PM, an interview was conducted with the DON. The DON stated they have not been made aware by staff about resident 194 tripping on the rug located outside resident 194's room. The DON agreed that the rug would be considered a tripping hazard especially since resident 194's walker continually got stuck on it. On 5/5/22 at 10:23 AM, an interview was conducted with the Physical Therapist (PT). PT stated they were working with resident 194 due to a left patellar fracture and they were working on increasing her strength on the left leg. Resident 194 was recently discharged from their care due to reaching their goal of being able to walk short house hold distances. PT stated while resident 194 was under the supervision of PT, resident 194 was instructed to wear a left leg immobilizer and use a walker anytime they were going to bear weight on the left leg. PT stated additionally at that time, rugs were not identified as a barrier for resident 194 while using a walker. Resident 194 had been instructed on how to use a walker properly per PT. PT stated that when a resident discharged to the community, PT reviewed safe at practices and safety hazards including how to correctly position their body within the walker, how to watch transitions around doorways to avoid falls and watch for throw rug as they could potentially be a fall hazard. PT stated that resident 194 has been compliant with PT instructions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility did not label all drugs and biologicals used in the facility in accordance with currently accepted professional principles, and did not include appropriate accessory instructions and the expiration date when applicable. Specifically, insulins were not labeled with an open date and administered to residents. The medication cart was not locked when the nurse was not by it. Resident identifier: 8, 19, and 194. Findings included: 1. Resident 19 was admitted to the facility on [DATE] with diagnoses which included type II diabetes, asthma, macular degeneration, suicidal ideation's, hypertension, major depressive disorder, panic disorder, post traumatic disorder, bipolar disorder and anxiety. On 5/3/22 at 7:10 AM, an observation was made of Registered Nurse (RN) 6. RN 6 was observed to obtain a Humulin 70/30 Kwikpen Insulin pen from the medication cart. The insulin pen did not have an open date written on the label. RN 6 stated, We don't know when it was opened because no one wrote the date on it. But insulin is good for 30 something days after it is opened, so it is fine to give. RN 6 was then observed to administer the insulin pen to resident 19. RN 6 then placed the insulin pen back in the medication cart, no date was written on the insulin pen. 2. Resident 8 was admitted to the facility on [DATE] with diagnoses which included heart failure, type II diabetes, chronic gastritis, hypertension, fibromyalgia, irritable bowel syndrome, carpel tunnel and hypothyroidism. On 5/3/22 at 7:22 AM, an observation was made of RN 6 obtaining Humulin 30/100 unit/ml vial for resident 8 from the medication cart. RN 6 stated resident 8 had received the insulin that morning. The vials of insulin in the medication cart had a yellow tag on them that stated when opened date no open dated was written on the vial of insulin for resident 8. An immediate interview was conducted, RN 6 stated, we probably messed up on that one, and yes we will give the insulin to the residents if the insulin is in the medication cart. 3. On 5/3/22 at 7:55 AM, an observation was made of a report sheet with resident information face up on the counter of the nurses desk with residents in hallway. On 5/3/22 at 7:40 AM, an observation was made of RN 2. RN 2 walked away from the medication cart and left a bottle of aspirin on the top. Residents were observed in the hallway. On 5/3/22 at 8:05 AM, an observation was made of RN 2. RN 2 walked away from the medication cart to go down the hallway into room [ROOM NUMBER] and left the medication cart unlocked. On 5/3/22 at 8:15 AM, an observation was made of RN 2. RN 2 left the medication cart unlocked to walk down the hallway. Resident 194 was sitting next to the medication cart. On 5/3/22 at 8:22 AM, an interview was conducted with RN 2. RN 2 stated the medication cart should always be locked and the medications be put away if the nurse was not directly by the cart. On 5/05/22 at 10:29 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the nurses are to label the medications when they open them. The DON stated insulin is good for 28 days after being opened. The DON stated she would want the nurses to look at the date the pharmacy delivered the medication and use that date on the insulin as the opened date, if the date of the insulin being used is within a couple of days of the delivery date then the nurses are good to use the insulin. The DON stated the insulin should have been labeled. The DON stated if the insulin is not marked and the nurse does not check the pharmacy date then the resident could be given insulin that has gone past the 28 days and that is not appropriate. The DON stated the medication cart should be locked, and the screens should be locked and all information should be covered for the residents privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 23 sampled residents, the facility did not obtain laboratory (lab) services to meet the needs of the residents. Specifically, a resident had physician's orders to obtain a glycated hemoglobin (A1C), Phosphorous (Phos), Complete Metabolic Panel (CMP), C-reactive protein (CRP), and Pre-Albumin for medical monitoring and the labs were not completed timely as ordered. Resident identifiers: 30. Findings included: Resident 30 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included gastro-esophageal reflux disease with esophagitis, peptic ulcer, anemia, chronic kidney disease stage 5, schizophrenia, chronic obstructive pulmonary disease, and dysphagia. On 5/3/22 resident 30's medical record was reviewed. A Registered Dietitian Note dated 4/15/22 revealed a recommendation of follow up labs of A1C, Phos, CMP, CRP and prealbumin. A Nurse Practitioner/Physician Assistant (NP/PA) Progress note dated 4/18/22 revealed to monitor labs as needed. A Physician's order dated 4/28/22 revealed, a A1C, Phos, CMP, CRP and Pre-Albumin needed to be drawn on 4/29/22 and was marked as completed. A Nursing Progress note dated 4/28/22 revealed, Provider ordered to dc (discontinue) mvi (multivitamin) with minerals, start on renal mvi with minerals, juven 1 packet BID (twice daily), vit (Vitamin) c qd (daily), Zinc 220 mgqd x 14 days, thiamine 100 mg x 10 days and A1c, Phos, CMP, CRP, prealbumin. Resident was educated on new orders. The April Medication Administration Record (MAR) revealed the A1C, Phos, CMP, CRP and Pre-Albumin were ordered for 4/29/22 but not drawn. No progress notes found in the medical record for lab draw being performed on 4/28/22. A Physician's order dated 5/1/22 revealed, an A1C, Phos, CMP, CRP, and Pre-Albumin needed to be drawn on 5/2/22. The May 2022 MAR revealed the A1C, Phos, CMP, CRP and Pre-Albumin were drawn on 5/2/22. A Nursing Progress note dated 5/2/22 revealed, Attempted to draw labs with no success, will attempt again tomorrow. Lab results revealed labs were collected in 5/4/22 and reported to the facility on 5/5/22. It should be noted this was 6 days after the original order to draw the labs. On 5/4/22 at 1:30 PM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated the order for labs was put in the book by the nurses, then a progress note was written in the medical record. RN 3 stated when the results came back the nurses reviewed them. RN 3 stated if we had not gotten the labs back the same day they were drawn, then it was passed on in report to the next shift. RN 3 stated when drawing labs it was customary to attempt the draw twice and then let management know if unsuccessful. RN 3 stated if we just can not get the labs draw then we make the provider aware and they can bring someone else in if needed. On 5/4/22 at 1:47 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated she reviewed the orders, put a note in the medical record and notify the provider, then marked the labs as reviewed and follow through with any new orders. The ADON stated the nurses on the floor put a lab form in a binder for the physician and the physician reviewed them and gave orders based off of the labs. On 5/4/22 at 2:08 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that labs were the facilities weak spot. The DON stated these labs were not drawn by the staff on shift and management was not made aware of the unsuccessful attempt(s). The DON stated that herself and the ADON looked at the labs every day but we were unable to see all the messages in the medical record and it had been a very hard thing to clear up. The DON stated immediate (STAT) labs and the medical record were the main areas they were focused on fixing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 23 sample residents, that the facility did not promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fell outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders. Specifically, a resident's urine culture and sensitivity was not reported to the physician. Resident identifier: 38. Findings include: Resident 38 was admitted to the facility on [DATE] with diagnoses which included urinary tract infection, acute respiratory failure, wedge compression fractures, diabetes mellitus, and asthma. Resident 38's medical record was reviewed on 5/4/22. A physician's order dated 4/7/22 revealed Urine Analysis (UA) with reflux culture patient was having urine retention and may perform straight catheter to obtain culture. The urine analysis and culture were not located in resident 38's medical record. The Assistant Director of Nursing (ADON) provided the UA with reflux culture dated 4/7/22. The form was flagged as abnormal. Resident 38's progress notes were reviewed and revealed the following: a. On 4/6/2022 at 6:22 PM, Received labs results on labs drawn 4/5/22. Sent abnormal lab values to the medical provider. The most concerning value is the TSH (thyroid stimulating hormone). No new orders have been given at this time. b. On 4/7/22 at 2:59 PM, Resident had foley catheter removed, noted to have 390 mLs (milliliters) urine post residual, RN (Registered Nurse) spoke with NP (Nurse Practitioner), received orders to replace foley catheter with dx (diagnoses) of obstructive uropathy and to refer resident to urology. Informed floor nurse, placed orders, resident educated, notified transportation. c. On 4/7/22 at 11:07 PM, . foley catheter inserted as per new order received for dx. of urinary obstruction. Procedure was without complication, cloudy dark yellow urine draining well into catheter drainage bag. Bag placed at lowest position of bed. Wctm (Will continue to monitor). d. On 4/8/22 at 4:44 PM, 300mls dark yellow/clear urine seen @ 0945 (9:45 AM). Foley care done. It should be noted that there was no progress note regarding the physician notification. On 5/4/22 at 2:25 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the facility were in a transition with the laboratory draws and results. The DON stated that the process was currently for the (ADON) to look at the results, download the results and then send the results to the physician. The DON stated the ADON then wrote a progress notes in the medical record that results were received and that the physician had been notified. The DON stated then laboratory results were placed in the results tab of the electronic medical record. The DON stated resident 38 had retention so a urine analysis was obtained. The DON stated that the process just shifted and nurses were taking over the laboratory draws and notification to the physician. The DON was observed to review resident 38's urine analysis and culture. The DON stated resident 38 should have been treated because the urine was dark, had blood and some bacteria according to the UA. On 5/5/22 at 9:03 AM, an interview was conducted with the Nurse Practitioner (NP). The NP stated that staff notified him through phone calls or a secured text messaging system that automatically delete after 7 days. The NP stated he was able to respond back to nursing staff through the messaging system. The NP stated the messaging can be sent through a specific resident. The NP stated he was able to obtain laboratory results that way as well.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of communicable diseases and infections. Specifically, appropriated signage was not placed outside resident rooms identifying the need for transmission-based precautions (TBP), staff were observed in a patient's isolation room without personal protective equipment (PPE) and unvaccinated COVID-19 newly admitted residents were not put on TBP. In addition, staff did not wear appropriate eye protection (goggles or face shields) when interacting with residents and visitors were observed to enter the facility through a back entrance on the second floor and walk down a hallway past residents prior to performing the COVID-19 screening process. Resident Identifiers: 88, 138 and 193. Findings include: 1. Resident 193 was admitted to the facility on [DATE] with diagnoses of clostridium difficile (c-diff), sepsis, essential hypertension, gout, and hypothyroidism. On 5/2/22 at 9:30 AM, resident 193's room was observed. Located outside the room in the hallway was a cart containing PPE. A white sign stating stop and the resident's name was located on the door. The stop sign had a date 5/6/22. On 5/3/22 at 8:49 AM, Certified nursing assistant (CNA) 1 was observed to enter resident 193 without the appropriate PPE. An interview was immediately conducted with CNA 1 when they exited resident 193's room. CNA 1 stated that PPE must be worn at all times when going into resident 193's room. Resident 193's medical record was reviewed on 5/3/22. Resident 193 developed c-diff in the hospital prior to arriving to the facility. Resident 193 had been on antibiotics to treat his infection and the course of treatment ended on 5/6/22. On 5/2/22 at 9:32 AM, Registered Nurse (RN) 1 was interviewed. RN 1 stated they normally he did not work here and needed to look a report sheet to see why there was a sign on resident 193's door. RN 1 then stated that resident 193 had the sign outside their door due to being on intravenous (IV) fluids and receiving a bag of normal saline. [Note: RN 1 did not know resident 193 was on contact precautions due to c-diff.] On 5/2/22 at 12:11 PM, an interview and observation was made of RN 1. RN 1 stated that resident 193 had a stop sign on his door because he was getting IV fluids. RN 1 was observed to enter resident 193's room without PPE. RN 1 was observed to walk next to resident 193 and touch his IV fluid bag. RN 1 was observed to exit the room and hand hygiene was not performed. On 5/3/22 at 8:47 AM, RN 2 was interviewed. RN 2 stated that resident 193 was precautions for either two reasons, c-diff or because he was a new admit and probably was not vaccinated for COVID-19. RN 2 stated that it was most likely because of the vaccination that resident 193 was on precautions. On 5/4/22 at 12:15 PM, Licensed Practical Nurse (LPN) 1 was interviewed. LPN 1 stated that resident 193 was on standard contact precautions due to c-diff. LPN 1 stated that PPE must be worn when coming in contact with the resident. 3. Resident 138 was admitted to the facility on [DATE] no medical diagnoses were found in resident 90's medical record. Resident 138 was not vaccinated against COVID-19. On 5/2/22 at 9:00 AM, an observation was made of room [ROOM NUMBER] door open, no signage or isolation cart outside of room. On 5/3/22 at 7:10 AM, an observation was made of room [ROOM NUMBER] door open, no signage or isolation cart outside of room. On 5/04/22 at 11:22 AM, an interview was conducted with RN 3. RN 3 stated for those residents who are not vaccinated, they are isolated for 14 days, the facility could administer the COVID-19 vaccination if they want it. RN 3 stated there should be a sign that said to see the nurse before entering and a cart with PPE outside the residents door. On 5/5/22 at 2:49 PM, an interview was conducted with the DON. The DON stated resident 138 was not COVID-19 vaccinated and isolation was to continue until 5/10/22. The DON stated resident 138 was able to test for COVID-19 on 5/6/22 and if it was negative was able to discontinue isolation. On 5/05/22 at 10:09 AM, an interview was conducted with the Nurse Practitioner (NP). The NP stated when a resident was in isolation staff must wear gown goggles, mask, and gloves. The NP stated unvaccinated residents should be in isolation for 5-10 days then they can be retested at 7 days to see if they were positive or if isolation could be discontinued. The NP stated vaccinated residents did not need to be isolated. 4. PPE usage On 5/3/22 at 7:38 AM, an observation was made of RN 2 not wearing eye protection during morning medication pass. On 5/03/22 at 7:35 AM, an observation was made of the Maintenance Director (MD). The MD wore his eye protection on top of his head while on the 3rd floor. On 5/03/22 at 8:11 AM, an observation was made of the MD. The MD wore his eye protection on top of his head while on the 3rd floor. On 5/03/22 at 8:30 AM, an observation was made of the MD. The MD wore his eye protection on top of his head while on the 3rd floor. On 5/2/22 at 12:57 PM, an observation was made of CNA 4. CNA 4 was observed with his nose and mouth exposed in the hallway outside room [ROOM NUMBER]. CNA 4 was observed to enter room [ROOM NUMBER] with his nose and mouth exposed. On 5/4/22 at 10:47 AM, an observation was made in the 300 hallway. A Dentist and Dental Assistant were observed with residents without eye protection. An observation was made of the Dentist and Dental assisting within 6 feet of residents without eye protection. According to the Utah Department of Health Personal Protective Equipment (PPE) Requirements for Long-Term Care Facility Staff updated 3/21/22 surgical masks and eye protection were to be worn by staff in resident rooms and resident common areas by staff when the community transmission rate was high. 5. Visitor Screening: On 5/3/22 at 8:00 AM, an observation was made of the Corporate Resource Nurse (CRN) 1 and CRN 2 standing next to the North outside entrance on the 2nd floor. A visitor was observed to come to the door. CRN 2 opened the door and asked what the visitor needed. The visitor stated she was there to see her son. CRN 2 asked the visitor if she had a mask, the visitor reached into her bag and placed a surgical mask on her face. The visitor then entered the facility and walked directly to her son's room. On 5/3/22 at 8:10 AM, an interview was conducted with the visitor. The visitor stated she came in the front entrance a couple of times at the beginning of her son's stay at the facility, but since being there for a while they know me and I come in the side entrance. The visitor stated she was vaccinated and wore a mask. The visitor stated she did not screen today at the front entrance. On 5/03/22 at 8:10 AM, an interview was conducted with CRN 1 and CRN 2 who stated they did let the visitor in through the 2nd floor side entrance. CRN 2 stated the visitor screened at the nurses pod on the 2nd floor. The visitor was not observed to come to the nurses station as this surveyor was standing there doing medication pass with the nurse on duty. CRN 1 stated the visitor would have had to walk down the 2nd floor resident hallway, past residents to screen in at the nurses pod on the 2nd floor. On 5/3/22 at 8:15 AM, an interview conducted with DON. The DON stated screening was done at the front entrance. The DON stated all visitors screened at the front entrance. The DON stated they came in on the second floor but there was no screening done on the second floor. The DON stated there was a sign on the 2nd floor entrance that directed all visitors to come to the first floor for them to screen. The DON stated the doors on 2nd floor were locked. The DON stated if a visitor entered through the 2nd floor entrance they were directed to the 1st floor to screen in at the front of the building to screen. The DON stated the staff were to wear goggles and masks and visitors were to wear masks. 2. Resident 88 was admitted to the facility on [DATE] with diagnoses which included left tibia fracture, epilepsy, hypertension, muscle weakness, and unvaccinated for COVID-19. On 5/2/22 at 9:00 AM, an observation was made of a 3 drawer container outside resident 88's room. There was no signage on the door. Resident 88's medical record was reviewed on 5/3/22. A physician's order dated 4/22/22 revealed Isolation Precautions-contact. droplet. May resolved associated diagnoses U07.1 and/or R09.89 at the conclusion of these precautions every shift. There was no end date. It should be noted day 10 since admission was 5/2/22. On 5/2/22 at 11:53 AM, an observation was made of RN 5. RN 5 was observed to enter resident 88's room with surgical mask and eye protection. RN 5 was interviewed. RN 5 stated he was called in to help out and was not aware of any residents that required isolation precautions on the 200 hallway. RN 5 stated that RN 1 was the nurse for the hall and he knew who was on isolation precautions. On 5/2/22 at 12:11 PM, RN 1 was interviewed. RN 1 stated that there was one resident on isolation precautions in the 200 hallway. RN 1 stated that resident 88 was not on isolation precautions. On 5/2/22 at 12:19 PM, an observation was made of CNA 5. CNA 5 was observed to enter resident 88's room. CNA 5 was observed to wear a surgical mask and eye protection into resident 88's room. CNA 5 was not observed to change her mask or eye protection and did not add additional PPE. On 5/2/22 at 12:21 PM, CNA 4 was interviewed. CNA 4 stated if a resident was on isolation precautions there was usually a 3 drawer compartment outside their room. CNA 4 stated resident 88 did not have a stop sign. On 5/3/22 at 8:16 AM, an interview was conducted with resident 88. Resident 88 stated she was not vaccinated for COVID-19. Resident 88 stated that staff wore yellow gowns, gloves, eye protection and masks into her room. Resident 88 stated she was told her isolation was discontinued yesterday. On 5/5/22 at 2:00 PM, the Director of Nursing (DON) was interviewed. The DON stated that residents unvaccinated for COVID-19 required isolation precautions for 10 days after admission. The DON stated if a resident tested negative for COVID-19 on day 7, then isolation precautions were discontinued. The DON stated that resident 29 had been in isolation but there was no signage to notify staff until 5/5/22. The DON stated she removed resident 29 from the dining room on 5/2/22 and told resident 29 she was on isolation and not allowed in the dining room. The DON stated there were orders in resident's electronic medical record for staff, Sadly who knows with agency (staff where they) look regarding isolation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 5 out of 6 sampled staff, that the facility did not conduct testing based on parameters set forth by the Secretary. Specifically, routine testing of unvaccinated staff members, based on community transmission, was not completed. Findings include: On 5/5/22, the Operations Manager (OM) provided the vaccination status of facility staff. Staff member (SM) 1, SM 2, SM 3, SM 4, SM 5 and SM 6. SM 1, SM 3, SM 4, SM 5, and SM 6 had Religious Objections to the COVID-19 vaccination. SM 2 did not have an exemption. The county transmission rate provided by the facility revealed the following: a. 4/4/22 rate was 3.27% indicating weekly COVID-19 testing, b. 4/11/22 rate was 4.07% indicating weekly COVID-19 testing, c. 4/18/22 rate was 5.36% indicating weekly COVID-19 testing, d. 4/25/22 rate was 6.63% indicating twice weekly COVID-19 testing, e. 5/2/22 rate was 11.28% indicating twice weekly COVID-19 testing. COVID-19 testing was reviewed and SM 1 was tested on [DATE], 4/13/22, 4/22/22, 4/29/22, 4/26/22 and 5/3/22. There were no COVID-19 testing results for SM 2, SM 3, SM 4, SM 5 and SM 6 from 4/4/22 through 5/5/22. The facility COVID-19 Vaccine Policies and Procedures with no date, stated additional precautions and contingency plans for unvaccinated staff included, requiring at least weekly testing for exempt staff, and staff who have not completed their primary vaccination series . On 5/5/22 at 2:19 PM, an interview was done with the Director of nursing (DON). The DON stated that the Human Resource (HR) staff member had COVID-19 testing and documentation. The DON stated that the (HR) staff member was unavailable. On 5/5/22 at 2:49 PM, a follow up interview was conducted with the DON. The DON stated SM 2 was a fairly new employee and she was not sure if SM 2 was vaccinated or not. On 5/24/22 at 2:26 PM, a follow up interview was conducted the OM. The OM stated that not all COVID-19 testing was being completed for unvaccinated staff.

Based on observation, interview and record review, it was determined the facility did not develop and implement policies and procedures to ensure that all staff were fully vaccinated for Coronavirus Disease-2019 (COVID-19). The facility did not ensure that the policies and procedures applied to individuals who provided care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement. Also, the facility did not implement policies and procedures that included, at a minimum, a process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who were not fully vaccinated for COVID-19. Specifically, the facility was unaware and did not keep documentation of the vaccination status for their contracted staff. In addition, an unvaccinated staff member was not wearing the appropriate personal protective equipment according to the facility's policy and procedures. Findings include: On 5/4/22 at 3:04 PM, an observation was made of Staff member (SM) 3. SM 3 was observed to be wearing a surgical mask with eye protection in resident care areas. On 5/5/22 Operations Manager (OM) provided 3 agency staff vaccination records. The facility COVID-19 Vaccine Policies and Procedures with no date, stated additional precautions and contingency plans for unvaccinated staff included, requiring at least weekly testing for exempt staff, and staff who have not completed their primary vaccination series . Requiring staff who have not completed their primary vaccination series to use a NIOSH approved N95 or equivalent or higher-level respirator for source control, regardless of whether they are providing direct care to or otherwise interacting with patients. The facility staff vaccination matrix revealed staff members (SM) 1, SM 2, SM 3, SM 4, SM 5, and SM 6 had religious objections for the COVID-19 vaccination. On 5/24/22 the facility's COVID-19 testing plan implementation and documentation was reviewed and revealed that only staff member 1 had been doing the required weekly testing as per facility policy and guidelines. No documentation regarding COVID-19 testing was found regarding staff members 2,3,4,5,6 through the month of March and April. On 5/5/22 at 1:16 PM, an interview was done with the Operations Manager (OM). The OM stated that the facility did not have contracted employee vaccine status including hospice and agency staff. On 5/5/22 at 2:19 PM, an interview was done with the Director of Nursing (DON). The DON stated that Human Resource (HR) staff member had COVID-19 testing and documenting for staff. The DON stated the HR staff member was unavailable and other staff were unable to locate the testing. It should be noted testing was sent to surveyors on 5/23/22. On 5/24/22 at 2:26 PM, a follow up interview was conducted the OM. The OM stated that not all COVID-19 testing was being completed for unvaccinated staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, it was determined that the facility did not notify the resident's physician for 1 of 23 sampled residents. Specifically, the facility nursing staff did not notify the Medical Doctor (MD) of abnormal blood glucose (BG) levels per physician's standing order. Resident identifier: 23. Findings include: Resident 23 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus (DM), chronic congestive heart failure, chronic kidney disease, anxiety and major depressive disorder. Resident 23's medical record was reviewed on 11/6/19 at 12:59 PM. A review of resident 23's physician's orders dated 6/6/19, documented Humalog Solution 100 unit/ milliliter (ml) (Insulin Lispro), inject as per sliding scale: 401-450=18; call MD for BG greater than 400, subcutaneously before meals and at bed time for DM II. [Note: this order was discontinued on 10/7/19.] A review of resident 23's physician's orders dated 10/7/19, documented Humalog Solution 100 unit/ ml (Insulin Lispro), inject as per sliding scale: 401+=13; call MD for BG greater than 400, subcutaneously before meals and at bed time for DM II. A review of resident 23's August, September, October, and November 2019 Medication Administration Record (MAR)/ Treatment Administration Record (TAR) documented that resident 23's BG levels were greater than 400 on the following dates. a. On 8/2/19, 445. b. On 8/14/19, 401. c. 9/2/19 (468), 9/4/19 (434 and 450), 9/11/19 (406), 9/12/19 (450), 9/16/19 (443), 9/21/19 (402), 9/22/19 (437), 9/24/19 (407), 9/26/19 (406), 9/29/19 (441), 10/6/19 (404), 10/14/19 (467), 10/31/19 (489) and 11/4/19 (492). There was no documentation that resident 23's MD was notified of these BG values. On 11/6/19 at 10:07 AM the Corporate Resource Nurse (CRN) was interviewed. The CRN stated that if there was an order for any kind of monitoring, notifying the MD or the family, the staff were supposed to follow that order. The CRN stated that if staff notified MD about anything, they were supposed to document that under nursing progress notes. The CRN stated that she was not able to find any documents regarding MD notification about resident 23's BG levels greater than 400. The CRN stated that she was not sure if staff called the MD and did not document it or or if they did not call at all. On 11/6/19 at 11:19 AM Licensed Practical Nurse (LPN) 1 was interviewed. LPN 1 stated that if there was an order for calling the MD, then he called and documented that under nursing progress notes and on the MAR. LPN 1 stated that if resident had BG higher than 400 he administered ordered insulin per the MD order and notified MD as well. On 11/6/19 at 11:53 AM LPN 2 was interviewed. LPN 2 stated that if there was an order to call MD over someone's BG greater than 400, she called the MD as soon as she administered insulin per physician order. LPN 2 stated that every time she called the MD, she documented that under nursing progress notes. On 11/6/19 at 11:55 AM, Registered Nurse (RN) 1 was interviewed. RN 1 stated that all physician orders were strictly followed. RN 1 stated that if there was an order to call MD on greater than 400 BG levels, she called the MD and administered insulin per physician order. RN 1 stated that she documented MD notification under nursing progress notes. On 11/6/19 at 12:09 PM The Director of Nursing (DON) was interviewed. The DON stated that they educated their staff regarding medications administration, proper ordering, monitoring and MD notification few months ago. The DON stated that if there was an order to notify the MD the staff were educated to do this as soon as possible. The DON stated that they strictly followed all physician orders. The DON stated that each MD notification/ medications and treatments administration was documented on the eMAR/ eTAR and under nursing progress notes. The DON stated that she was not sure if her nurses notified the MD regarding resident 23's above 400 BG levels.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, it was determined that for 2 of 23 sampled residents, the facility did not provide routine and emergency drugs and biological's to its residents. Specifically, medications were not available for administration. Residents identifier: 13 and 25. Findings include: On 11/4/19, the facility provided medication administration times sheet. Per this sheet, the facility did morning medication administration to their residents from 7:00 AM to 9:00 AM. On 11/6/19 at 7:20 AM, medication administration was observed. It was observed that Licensed Practical Nurse (LPN) 1 prepared medications for resident 25. LPN 1 did not have Metformin 500 milligrams (mg) tablet available to administer. LPN 1 stated that pharmacy did not deliver this medication on time. LPN 1 stated that resident 25 usually received his morning medications between 7:00 AM and 9:00 AM. LPN 1 took available medications and a cup of water to resident 25 and told resident 25 that he did not have his Metformin available at the time. On 11/6/19 at 7:30 AM LPN 1 prepared medications for resident 13. LPN 1 stated that he did not have Divalproex 250 mg tablet available to administer. LPN 1 stated that resident 13 received his morning medications between 7:00 AM and 9:00 AM. LPN 1 administered the rest of medication to resident 13 and said to resident 13 that he did not have Divalproex available at the time. On 11/6/19 at approximately 10:00 AM, resident 13 and 25's medical records were reviewed and documented following: 1. Resident 25 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, major depressive disorder, chronic obstructive pulmonary disease (COPD), neuropathy and chronic pain. Records revealed that among other medications, on 9/5/19, resident 25's physician ordered Metformin 500 mg to be given every day. The Medication Administration Review (MAR) revealed that this medication was scheduled to be given at 7:00 AM. 2. Resident 13 was admitted to the facility on [DATE] with diagnoses which included Alzheimers disease, muscle weakness, type 2 diabetes mellitus, history of traumatic brain injury and dementia with aggressive behaviors. Records revealed that among other medications, on 5/24/19, resident 13's physician ordered Divalproex 250 mg to be given every day for Dementia with aggressive behavior. The MAR revealed that administration of this medication was scheduled for 7:00 AM. On 11/6/19 at 11:19 AM, LPN 1 stated that he received Metformin from the pharmacy and not Divalproex. LPN 1 was observed to administer Metformin to resident 25 at 11:25 AM. LPN 1 was interviewed. LPN 1 stated that as he did medications administration, if he noticed that resident was low on medication, he pulled the sticker from the medication dispensing card, placed sticker on the fax sheet and faxed that sheet to the pharmacy as soon as he was done with medication administration. LPN 1 stated that he received the fax confirmation page when the pharmacy received his order. LPN 1 stated that the pharmacy delivered ordered medications within the same day. LPN 1 stated that the staff were not supposed to wait until there was only one tablet left and that they ordered medication if there was about 5 to 7 tablets left on the medication dispensing card. LPN 1 stated that he did daily follow up his orders until he received them from the pharmacy. LPN 1 stated that Metformin and Divalproex were not ordered on time and that the nurse did not order these two medications or did not do proper follow up with the pharmacy. On 11/6/19 at 11:53 AM LPN 2, was interviewed. LPN 2 stated that when she had less than week worth of medications, she ordered them from the pharmacy. LPN 2 stated that the staff were trained not to wait to have only one tablet available before they ordered more medications. LPN 2 stated that when she needed to order more medications, she pulled the sticker from the medication dispensing card, placed the sticker on the fax sheet and faxed it to the pharmacy. LPN 2 stated that if she needed something immediately, then she called the pharmacy. LPN 2 stated that the pharmacy delivered ordered medications within few hours. On 11/6/19 at 11:55 AM, registered nurse (RN) 1 was interviewed. RN 1 stated that when she administered medications she always looked how many she still had available. RN 1 stated that she made sure that there was enough tablets to last for few days before they received new batch from the pharmacy. RN 1 stated that when ready to order more medications, she pulled the sticker from the medication dispensing card, placed the sticker on the fax sheet and faxed it to the pharmacy. RN 1 stated that if she needed medication sooner, she usually called the pharmacy. RN 1 stated that pharmacy delivered ordered medications within few hours. RN 1 stated that situations with medications not available happened because someone failed to order these medications on time or did not follow up with the pharmacy. On 11/6/19 at 12:09 PM, the Director of Nursing (DON) was interviewed. The DON stated that they educated their staff regarding medications administration and ordering few weeks ago. The DON stated that if there was no medication available, the staff were educated to reschedule the order, notify MD, and pharmacy to deliver medication as soon as possible. The DON stated that the staff were educated to call pharmacy as soon as they noticed that they did not have medication on stock and not to wait until they finished medication administration to all residents on the floor. The DON stated that if there was less than week worth of supply, the staff were educated to fax the pharmacy about it. The DON stated that if there was no confirmation page received from the pharmacy that they received their order, the staff were educated to re-order or to call the pharmacy to check on ordered medication. The DON stated that if there were some issues with the medications, such as out of stock, or waiting for the insurance approval, then the communication between the pharmacy and the staff was supposed to be documented and resident, physician and/or the family were supposed to be informed about the issue. The DON stated that she did not know why they did not have these 2 medications available. The DON stated that probably nurses did not order these medications on time. The DON stated that if her nurses were busy and not able to order medications, they notified her and then she did follow up with the pharmacy. On 11/6/19 at 12:37 PM, the DON approached LPN 1 and stated that Divalproex 250 mg was scheduled to be delivered at 2:00 PM. The Medication Pass Observation protocol was provided by the facility on 11/7/19. Per this protocol, under The Six Rights of Medication Pass the facility listed that Times and frequencies need to be consistent with the physician order and All medications should be available. If not, proper procedures must be followed to obtain medication. In-service Attendance Record dated 10/3/19 was attached to this protocol and revealed that the facility staff were trained on what to do when medication was not available, on narcotic sign out log, and the MAR documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 of 23 sampled residents, that the facility did not maintain accurate documentation of medical records for each resident. Specifically, residents' Medication Administration Records (MARs) and Narcotic Record Logs did not match. Residents identifier: 23 and 46. Findings include: 1. Resident 23 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus (DM), chronic congestive heart failure, chronic kidney disease, anxiety and major depressive disorder. Resident 23's medical record was reviewed on 11/6/19 at 12:59 PM. Resident 23's physicians orders revealed the following: a. On 4/29/19, Oxycodone HCL 5 mg (milligrams) [1] tab (tablet) PO (oral) Q (every) 4 hr (hours) PRN (as needed) for pain 7/10 (7 out of ten on the scale 1 to 10). b. On 6/28/19, Tramadol HCL 50 mg tab PO Q 6 hr PRN for severe pain. Review of the Narcotic Record Log entries with the corresponding MAR for Oxycodone 5 mg tab Q 4 hr PRN revealed that the medication was documented as signed out on the Narcotic Record Log, but the medication was not documented on the MAR as being administered on the following dates: a. 8/3/19 at 5:10 PM; b. 8/4/19 at 10:15 AM; c. 8/7/19 at 11:30 AM; d. 8/15/19 at 8:30 PM; e. 8/20/19 at 1:00 PM; f. 9/7/19 at 9:00 PM; g. 9/12/19 at 9:00 PM; h. 9/16/19 at 8:50 AM; i. 9/18/19 at 10:40 PM; j. 9/20/19 at 7:00 AM; k. 10/13/19 at 11:50 AM; l. 10/15/19 at 5:00 AM, 8:30 AM, and 6:45 PM; m. 10/16/19 at 1:00 PM; n. 10/18/19 at 11:00 AM; o. 10/20/19 at 2:20 AM and 7:10 PM; p. 10/21/19 at 8:00 PM; q. 10/22/19 at 2:30 PM; r. 10/24/19 at 3:20 AM; s. 10/27/19 at 7:00 PM; t. 11/1/19 at 11:55 AM; u. 11/4/19 at 10:10 PM; and v. 11/5/19 at 4:30 AM. Review of the Narcotic Record Log entries with the corresponding MAR for Oxycodone 5 mg tab Q 4 hr PRN revealed that the medication was documented on the MAR as being administered, but not signed out on the Narcotic Record Log on following dates: a. 9/13/19 at 4:56 AM and 8:28 PM; b. 9/22/19 at 7:28 PM; and c. 10/14/19 at 10:04 PM. Review of the Narcotic Record Log entries with the corresponding MAR for Tramadol HCL 50 mg tab PO Q 6 hr PRN for severe pain revealed that medication was documented as signed out on the Narcotic Record Log, but the medication was not documented on the MAR as being administered on following dates: a. 8/17/19 at 1:05 AM; b. 8/18/19 at 1:15 AM; c. 8/24/19 at 4:40 PM; d. 8/27/19 at 9:00 AM and 1:00 PM; e. 8/28/19 at 1:15 PM; f. 8/29/19 at 9:45 AM; g. 8/30/19 at 1:00 AM; h. 8/31/19 at 6:00 PM; i. 9/4/19 at 2:45 AM; j. 9/7/19 at 10:00 PM; k. 9/8/19 at 8:00 AM; l. 9/10/19 at 6:30 PM; m. 9/12/19 at 8:35 PM; n. 9/14/19 at 2:50 AM and 6:53 PM; o. 9/18/19 at 2:00 PM and 7:40 PM; p. 9/24/19 at 2:45 PM; q. 9/26/19 at 8:00 PM; r. 9/28/19 at 2:00 AM; s. 10/2/19 at 7:00 AM; t. 10/7/19 at 3:00 PM; u. 10/8/19 at 1:00 PM; v. 10/26/19 at 12:00 PM; and w. 10/29/19 at 4:30 PM. Review of the Narcotic Record Log entries with the corresponding MAR for Tramadol HCL 50 mg tab PO Q 6 hr PRN for severe pain revealed that the medication was documented on the MAR as being administered, but not signed out on the Narcotic Record Log on a. 8/25/19 at 4:06 PM and b. 9/8/19 at 2:17 PM. 2. Resident 46 was admitted to the facility on [DATE] with diagnoses which included generalized anxiety disorder, Type 2 Diabetes Mellitus, major depressive disorder, Dementia, bipolar and encephalopathy. Resident 46's medical record was reviewed on 11/6/19 at 2:19 PM. Medical records revealed that resident 46 was on hospice since 9/28/18. Resident 46's physicians orders revealed the following: a. On 2/4/19, Morphine Sulfate Solution 20 mg/ milliliter (ml), 0.5 ml PO Q 1 hr PRN for mild pain/ air hunger. b. On 2/4/19, Morphine Sulfate Solution 20 mg/ml, 1 ml PO Q 1 hr PRN for severe pain/ air hunger. c. On 10/29/18, Oxycodone HCL 5 mg tab, 1 tablet PO Q 8 hr PRN for pain. Review of the Narcotic Record Log entries with the corresponding MAR for Morphine Sulfate Solution 20 mg/ ml, 0.5 ml PO Q 1 hr PRN for mild pain/ air hunger revealed that the medication was documented as signed out on the Narcotic Record Log, but not documented on the MAR as being administered on 8/17/19 at 10:31 AM. Review of the Narcotic Record Log entries with the corresponding MAR for Morphine Sulfate Solution 20 mg/ ml, 1 ml PO Q 1 hr PRN for severe pain/ air hunger revealed that the medication was documented as signed out on the Narcotic Record Log, but not documented on the MAR as being administered on following dates: a. 8/8/19 at 11:45 AM and at 8:00 PM; b. 9/13/19 at 8:30 AM; c. 9/14/19 at 4:30 AM and 10:10 AM; d. 9/16/19 at 7:10 PM; e. 9/18/19 at 3:00 AM; f. 9/21/19 at 2:00 PM; g. 9/26/19 at 1:40 AM; h. 9/27/19 at 6:00 PM; i. 9/28/19 at 8:05 PM; j. 10/13/19 at 3:00 PM; k. 10/23/19 at 10:30 AM; and l. 10/26/19 at 3:30 AM. Review of the Narcotic Record Log entries with the corresponding MAR for Morphine Sulfate Solution 20 mg/ ml, 1 ml PO Q 1 hr PRN for severe pain/ air hunger revealed that the medication was documented on the MAR as being administered, but not signed out on the Narcotic Record Log on: a. 9/5/19 at 10:14 AM and b. 10/13/19 at 7:27 PM. Review of the Narcotic Record Log entries with the corresponding MAR for Oxycodone HCL 5 mg, 1 tab PO Q 8 hr PRN for pain revealed that the medication was documented as signed out on the Narcotic Record Log, but not documented on the MAR as being administered on following dates: a. 8/9/19 at 3:15 PM; b. 8/15/19 at 10:33 AM; c. 8/18/19 at 10:00 PM; d. 8/21/19 at 9:20 PM; e. 8/24/19 at 8:05 AM; f. 9/4/19 at 7:34 PM; g. 9/15/19 at 8:00 PM; h. 10/21/19 at 9:00 PM; and i. 10/31/19 at 6:00 AM and 4:00 PM. On 11/6/19 at 11:19 AM, Licensed Practical Nurse (LPN) 1 was interviewed. LPN 1 stated that if there was an order for narcotic and resident requested one or was scheduled to receive narcotic, every time the medication was pulled out of the narcotic drawer, the Narcotic Administration Log had to be signed and administration had to be documented on the MAR. LPN 1 stated that the Narcotic Administration Log and the MAR had to match. On 11/6/19 at 11:53, AM LPN 2 was interviewed. LPN 2 stated that narcotic administration had to be documented on the MAR. LPN 2 stated that when narcotic was pulled out of the narcotic drawer, then she signed the Narcotic Administration Log. LPN 2 stated that the Narcotic Administration Log and the MAR had to match. On 11/6/19 at 11:55 AM, Registered Nurse (RN) 1 was interviewed. RN 1 stated that all physician orders, including pain medication orders were strictly followed. RN 1 stated that if there was an order for narcotic to be administered, she pulled the narcotic out of the narcotic drawer, documented that on the Narcotic Administration Log and on the MAR. RN 1 stated that the MAR and the Narcotic Administration Log had to match. On 11/6/19 at 12:09 PM, the Director of Nursing (DON) was interviewed. The DON stated that they educated their staff regarding medications administration, narcotic sign out log and the MAR documentation on 10/3/19. The DON stated that her expectation from the staff was to document Narcotic Administration Log every time the narcotic was pulled out of the narcotic drawer. The DON stated that Narcotic Administration Log had to match with the MAR. The DON stated that nurse assessed pain levels before narcotic was administered and after and that the pain levels were documented on the MAR/TAR. The Medication Pass Observation protocol and the Medication Administration Policy were provided by the facility on 11/7/19. Per Medication Pass Observation protocol, section I, the facility listed that PRN medications must be used according to the order and documented appropriately. Per Medication Administration Policy, section 6, the facility listed following:When a controlled medication is administered, the licensed nurse administering the medication, immediately enters all following information on the accountability record: a. Date and time of administration b. Amount administered c. Signature of the nurse administering the dose, completed after the medication is actually administered.