**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 5 was admitted to the facility on [DATE] with diagnoses which included dementia, major depressive disorder, severe intellectual disabilities, dysphagia, and schizoaffective disorder. On 3/3/25 at 12:19 PM and 3/4/25 at 12:10 PM, observations were made of the resident 5. Resident 5 was observed to be sitting at a table by himself drinking thin liquids and coughing after each sip. Resident 5's medical record was reviewed 3/3/25 through 3/5/25. A physician's order dated 1/17/24 revealed regular, diet easy to chew textures, thin/regular liquids consistency. A nursing progress note dated 12/24/24 at 12:02 PM revealed, Patient was given a cupcake today during a Christmas activity. Patient began to choke on the cupcake. He got up and went to his room, CNA followed. Patient was struggling to breath. CNA performed the Heimlich maneuver, patient began coughing up and vomiting saliva. Patient began breathing normal, and wanted to lie down in bed. PA [Physician's Assistant] ., assessed lung sounds. Lung sounds are congested at this time. Patient breathing normal. Vital signs all within normal ranges for patient's baseline. Family notified of incident. The incident was not reported to the State Survey Agency. On 3/5/25 at 3:32 PM, an interview was conducted with the ADM. The ADM stated the incident with resident 5 chocking on the plastic ring was not reported to the SSA because there was no suspicion of abuse or neglect because they knew what happened. Based on interview, and record review, for 3 of 24 residents sampled, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency. Specifically, a resident had an assisted fall out of bed during cares, the same resident had a fall which resulted in a bilateral femur fractures, a resident threatened another resident with physical harm, and a resident choked on a plastic ring and the State Survey Agency was not notified after the allegation was identified. Resident identifiers: 5, 28, 35, Findings include: 1. Resident 35 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease with late onset, lymphedema, morbid obesity, abnormalities of gait and mobility, chronic pain, and epilepsy. Resident 35's medical record was reviewed 3/4/25 through 3/5/25. An incident report dated 1/12/25 documented, [Resident 35] was turned on her left side in bed for CNA [certified nursing assistant] to change her chuck, as the CNA was pulling on the chuck, her right leg moved forward towards the edge of the bed. CNA was able to go to the other side of the bed and hold her legs until assistance arrived to assist [resident 35] to the floor. She was placed in sling and lifted via hoyer lift back into bed. Only her legs were coming off the bed. Due to her weight it was safer for [resident 35] and staff to lower her to the floor and put her back in bed with the hoyer lift. My leg slipped. No injuries were documented on the incident report. An incident report dated 1/17/25 documented, [Resident 35] was calling out for help, when aide entered the room she was on her knees at the side of the bed holding onto the and position bar. She had a bowel movement and urinated. Additional staff came in to assist her to the floor. She was layed down on the hoyer sling and assisted back into bed. On 3/4/25 a review of resident 35's physician progress note dated 1/18/25 revealed the following, patient with fall from bed, yesterday, during cares. subsequently sent to the ER [emergency room] for evaluation where she was found to have bilateral femoral fractures . There was no additional information regarding the incident or an investigation into the incident provided. On 3/5/25 at 3:32 PM, an interview was conducted with the Administrator (ADM). The ADM stated he was the abuse coordinator for the facility and the staff reported allegations of abuse or neglect to the nurse and then it was reported to him. The ADM stated if there was not a signifiant injury then the allegation would not necessarily be reported to him. The ADM stated he would report any allegations of abuse or neglect to the State Survey Agency. The ADM stated with the assisted fall he would not have expected them to report it to him because they knew exactly what had happened and the CNA was with the resident. The ADM stated with the second fall, it was the exact same thing that happened with the first fall except staff were not in the room. The ADM stated resident 35 liked to be left alone, so the CNAs would place her on her side and leave the room. The ADM stated those who were in the room deem whether the incident would be reported to him or not, if it was reported to him then we talk about it. The ADM stated he did not think these incidents were reportable. The ADM stated we just knew there was not abuse or neglect because it was the way it had always been done. On 3/10/25 at 10:00 AM, a conference call was conducted with the ADM, Director of Nursing (DON), and the Regional Nurse Consultant (RNC). The RNC stated because there was a fracture it was reported to red cap and not to the State Survey Agency because it was not abuse. The ADM stated there was no cause for concern and they knew exactly what happened. The RNC stated within the investigation, if there was a concern, then they would report it. The RNC stated an investigation was completed for interventions but not to determine if there was abuse or neglect. The ADM stated the CNA's were interviewed on 3/6/25. It should be noted on 3/6/25 the CNA's were interviewed and the incident took place on 1/12/25 and 1/17/25. 2. Resident 28 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included intraductal carcinoma in situ of right breast, dysphagia, type 2 diabetes mellitus with diabetic neuropathy, aphasia, cerebral infarction, depression, acute kidney failure, and generalized anxiety disorder. Resident 28's medical record was reviewed 3/3/25 through 3/5/25. A Nurses Note, dated 3/2/25 at 5:30 PM, indicated, Pt [patient] threatened to throw a flower pot at another resident today in the dining hall during dinner. Staff intervened before any physical assault occurred. Residents were separated and taken back to their rooms. An annual Minimum Data Set (MDS) assessment, dated 2/13/25, indicated a Brief Interview for Mental Status (BIMS) score of 10. A BIMS score of 8-12 indicated a moderate cognitive impairment. Resident 6 was admitted to the facility on [DATE] with diagnoses which included generalized anxiety disorder, chronic kidney disease, major depressive disorder, hypertension, and intellectual disabilities. Resident 6's medical record was reviewed 3/3/25 through 3/5/25. A Nurses Note, dated 3/2/25 at 5:29 PM, indicated, Pt got into a verbal altercations [sic] with another pt in the dining hall where the other patient threatened to throw a flower pot at her. Pt stated 'go ahead'. Staff intervened before any physical assault occurred. Pt taken back to her room. A Quarterly MDS assessment, dated 1/29/25, indicated a BIMS score of 7. A BIMS score between 0-7 indicated severe cognitive impairment. On 3/5/25 at 11:24 AM, an interview was conducted with the Resident Advocate (RA). The RA stated that she was not aware of the incident that occurred between residents 28 and 6 and that it should have been reported to her but might have been reported to the DON. The RA stated that if it was reported to her she would have reviewed the care plans and make changes if needed. On 3/5/25 at 11:37 AM, an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated that she had heard about an incident that happened in the dining room where resident 28 got frustrated with resident 6 and that she picked up an object but that nothing happened and they were separated. On 3/5/25 at 12:11 PM, an interview was conducted with the DON. The DON stated it was reported to her that resident 6 was yelling a lot and resident 28 said that she was going to throw a centerpiece at resident 6, so staff separated them. The DON stated that is not typical behavior for resident 28 and seemed out of character. The DON stated she did not think anyone spoke to either of the residents after the altercation and that the RA should have followed up on that. The DON stated she would want to put an intervention into place after a resident-to-resident altercation to protect the resident. On 3/5/25 at 2:11 PM, a follow-up interview was conducted with the RA. The RA stated that if the resident-to-resident altercation was reported to her she would have met with both of the residents and make sure interventions were put into place to prevent any future incidents. On 3/5/25 at 2:58 PM, a follow-up interview was conducted with the DON. The DON stated that any suspicions of physical, sexual or verbal abuse, staff-to-resident or resident-to-resident needed to be reported to the Administrator immediately. On 3/5/25 at 3:47 PM, an interview was conducted with the Administrator (ADM). The ADM stated staff told him that resident 28 said that she was going to throw a vase at resident 6 and that staff separated them. The ADM stated he had first heard about the incident today. The ADM stated the staff that witnessed the incident deemed that this was not abuse and that he agreed so it did not need to be reported to the state agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, for 1 of 24 sampled residents, the facility did not develop and implement a comprehensive person-centered care plan consistent with the resident's rights that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, a resident who had multiple falls had repeated interventions implemented after falls and staff were not aware of the interventions that were on the care plan. Resident identifier: 29. Findings include: On 3/3/25 at 10:30 AM, an observation was made of resident 29 in his room. Resident 29 was observed to be in bed with his bed in a low position and the call light within reach. There was a call don't fall sign on his wall. Resident 29's medical record was reviewed 3/3/25 through 3/5/25. Resident 29 was admitted to the facility on [DATE] with diagnoses which included hemiplegia affecting right dominant side, epilepsy, major depressive disorder, dementia, and personal history of traumatic brain injury. A Quarterly Minimum Data Set (MDS) assessment, dated 12/4/24, indicated a Brief Interview for Mental Status (BIMS) score of 3. A BIMS score between 0-7 indicated severe cognitive impairment. It further indicated resident 29 required supervision or touching assistance to stand from a sitting position, substantial/maximal assistance to walk 10 feet, and used a manual wheelchair. A physician's order, dated 7/29/24, indicated, Keep resident in shorts if possible, to prevent him from tripping over long pants. The Care Plan dated 12/18/24 and resided on 2/28/25 indicated, RISK FOR FALLS I am at risk for falls r/t [related to] Gait and balance problems, Hx [history] of falls, Psychotropic drug use, R [right] hemiplegia 5/27/23:Un-witnessed Fall 6/9/23:Un-witnessed Fall 6/10/23:Witnessed Fall 6/16/23:Witnessed Fall 10/8/23:unwitnessed fall 10/19/23:Un-witnessed fall 10/31/23:unwitnessed fall 11/1/23:Un-witnessed fall 12/8/23:unwitnessed fall 1.12.24:unwitnessed fall 2.29.24Fall during staff assist 3/31/24:Witnessed Fall 4/1/24:Unwitnessed Fall 4/4/24:Witnessed Fall 4/5/24:Unwitnessed Fall 4/08/24:unwitnessed fall 4/23/24:witnessed fall 4/28/24:Witnessed fall 5/4/24:Witnessed fall 5/7/24:Unwitnessed fall 5/22/24:Unwitnessed fall 5/25/24:WF 7/12/24:WF 7/29/24:Unwitnessed fall 8.16.24:Unwitnessed fall 8/23/24:Staff Assisted Fall 9/4/24:WF 9/8/24:Unwitnessed fall 10/1/24:WF [witnessed fall] 11/19/24: WF 12/8/24:WF 12/17/24 WF 01/02/25: unwitnessed fall 02/09 02/21/25:WF 02/27/25- UNWITNESSED FALL. The goal revised on 10/7/24 was I will be free from falls during my stay. Interventions included: a. 1/12/24 Clothing inventory review to discard, replace, or hem pants that are too long. Date Initiated: 01/15/2024 b. 5/22/24: Personalize wheelchair with brightly colored tape to encourage resident use. c. 5/27/23 Unwitnessed Fall: Ankle brace fitted to patient to prevent rolling ankle when ambulating Date Initiated: 05/29/2023 d. 6/9/23: New task for CNA's [Certified Nursing Assistant] to ensure resident is wearing Right ankle brace during waking hours e. 7/29/24: Dress patient in shorts to eliminate trip hazard of pajama pants that may be too long. f. 10/31/23: encourage wearing ankle brace during ambulation On 3/5/25 at 10:42 AM, an interview was conducted with Certified Nursing Assistant (CNA) 5. CNA 5 stated resident 29 fell a lot and needed a lot of reminders to use his wheelchair. CNA 5 did not know if resident 29 had interventions about having to wear certain pants or shorts and stated he did not wear a brace on his ankle. On 3/5/25 at 11:12 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated resident 29 was a bit confused and struggled to remember to call for help before getting up. LPN 1 stated that resident 29 was a high risk for falling due to his unsteady gait. LPN 1 stated he tended to walk out of his room without his wheelchair to ask if he could be shaved tomorrow. LPN 1 was not sure if he had certain interventions concerning his pants or shorts. On 3/5/25 at 11:33 AM, an interview was conducted with CNA 3. CNA 3 stated resident 29 would get up on his own without his wheelchair and go to the bathroom. CNA 3 stated that he can stand up, but he should not be walking on his own. CNA 3 stated he continuously asked about shaving even when he was shaved the same day. CNA 3 stated she did not know why there was orange tape on the wheelchair and was not sure if he had certain interventions concerning his pants or shorts but that she did have to help him put his clothes on every day. CNA 3 stated he did not wear an ankle brace. On 3/5/25 at 11:57 AM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 29 had a brain injury that caused him to fixate on things and he wanted to shave every day and he felt like he needed to tell somebody. The DON stated that had caused a lot of falls because he would stick his head out of his room or walk to the nurse's station to let staff know that he needed to shave even if he had already shaved that day. The DON stated he cannot walk due to an unsteady gait and he could not remember to use his call light. The DON stated his wheelchair was wrapped with bright orange tape on the arms to draw his attention to the wheelchair and that he would occasionally get in his wheelchair. The DON stated that he had not worn an ankle brace since she had worked at the facility. The DON stated they had a lot of staff turnover, and the nurses were expected to read what was on the resident's care plan. The DON stated after each fall she ensured the nurse put the date of the fall on the care plan but the nurses were also expected to update the care plan with an intervention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 24 sampled residents, that the facility did not ensure that a resident who was continent of bladder on admission received services and assistance to maintain continence. Specifically, a resident was assessed a candidate for scheduled toileting and was not provided the services. Resident identifier: 25. Findings include: Resident 25 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following a cerebral infarction affecting non-dominate side. On 3/3/25 at 11:31 AM, an interview was conducted with resident 25. Resident 25 stated after she pushed her call light she wet her pants while waiting for staff. Resident 25 stated she was not on a toileting schedule but would like to be on one especially in the evenings and at night time because there were less staff to help her to the bathroom. Resident 25's medical record was reviewed 3/3/25 through 3/5/25. A quarterly Minimum Data Set (MDS) dated [DATE] revealed resident 25 was frequently incontinent. Resident 25 was not currently on a trial toileting program. There was no care plan regarding bowel and bladder incontinence. There was a care plan dated 7/27/24 with an admitting diagnosis of overactive bladder. Interventions included giving medications and treatments as ordered; by the Medical Doctor, dietary activities, Social Services and consultant visits; and therapies as ordered. A bowel and bladder program screener in the assessment section dated 11/4/24 revealed a score of 12 which indicated resident 25 was a candidate for scheduled toileting (timed voiding). A Long Term Care Evaluation dated 9/18/24 at 7:51 PM documented, resident 25 was incontinent of urine and was on a check and change program with a scheduled toileting program in place. Resident 25 used adult briefs with no new onset of incontinence. Resident 25 was frequently incontinent with 7 or more episodes of urinary incontinence, but at least one episode of continent voiding. Resident 25 voided via the toilet. A Long Term Care Evaluation progress note dated 1/22/25 at 11:37 PM, revealed resident 25 was incontinent of urine and used adult briefs. There was no new onset of incontinence and was always incontinent (no episodes of continent voiding). A Long Term Care Evaluation progress note dated 1/29/25 at 11:21 PM, revealed resident 25 was incontinent of urine and used adult briefs. In addition, there was no new onset of incontinence and resident was always continent. A Long Term Care Evaluation progress note dated 2/26/25 at 11:06 PM, revealed resident 25 was incontinent of urine and used adult briefs. In addition, no new onset incontinence and resident was always incontinent (no episodes of continent voiding). The CNA (Certified Nursing Assistant) documentation in the tasks section revealed frequent toileting/monitor for incontinence. There was a check mark documented 2 to 3 times per day. There was no specific timed voiding documented. It was documented that resident 25 was continent of bladder on 2/17/25, 2/24/25, 2/26/25 and 2/27/25. On 3/5/25 at 11:56 AM, an interview was conducted with CNA 7. CNA 7 stated she was not sure what a bowel and bladder program was. CNA 7 stated she completed rounds for all residents every 2 hours. CNA 7 stated resident 25 was not on a bladder program. On 3/5/25 at 12:00 PM, an interview was conducted with CNA 8. CNA 8 stated he would have to ask the nurse what a bowel and bladder program was. CNA 8 stated he was not aware of anyone on a bowel and bladder program. On 3/5/25 at 12:01 PM, an interview was conducted with CNA 3. CNA 3 stated she had not heard of a bowel and bladder program. CNA 3 stated there were residents that need to be checked on every 2 hours. CNA 3 stated resident 25 knew when she needed to use the restroom and used her call light. CNA 3 stated she checked on resident 25 every 2 hours or resident 25 used the call light if she needed assistance more often than 2 hours. CNA 3 stated resident 25 took water pills so she had to use the restroom more often. On 3/5/25 at 12:06 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated there was a bowel and bladder assessment the nurse completed to determine if the resident would be appropriate for a bowel and bladder retraining program. LPN 1 stated after filling out the assessment, he was not sure what happened. LPN 1 stated he was generally aware if a resident was continent or incontinent of bowel and bladder because the residents were at the facility long term. LPN 1 stated resident 25 was continent and staff used a hoyer lift to get her into the bathroom. LPN 1 stated resident 25 was very good about using her call light to ask staff to get her to the bathroom. LPN 1 stated if a resident was on frequent toileting, then he would expect staff to ask the resident if they needed to use the restroom more frequently than every 2 hours. On 3/5/25 at 11:11 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the facility had a bladder retraining program. The DON stated there was an assessment and if the resident was a candidate, then staff did that. The DON stated the program consisted of toileting residents every 2 hours to see if they had that urge to urinate. The DON stated the facility had a bladder scanner the staff used to find out how much urine a resident had. The DON stated the nurses managed the bladder retraining program. The DON stated the program was listed in the CNA's tasks section and was on the CNA report sheets. The DON stated frequent toileting was toileting a resident every 2 hours. At 3:15 PM, a follow up interview was conducted. The DON stated usually there was a physician's order for a retraining program. The DON stated resident 25 usually used a commode for toileting but sometime resident 25 did not want to get out of bed so a brief change was done by the CNA's. The facility provided a Behavioral Programs and Toileting Plans for Urinary Incontinence Policy and Procedure revised October 2010 that revealed the purpose of this procedure was to provide guidelines for the initiation and monitoring of behavioral interventions and/or a toileting plan for the resident with urinary incontinence. The preparation section revealed the following steps: the resident care plan was to be assessed for any special needs for the resident; a thorough assessment was to be completed; treatment and services to address factors that were potentially modifiable; monitor, record and evaluate information about the resident's bladder habits; and assess the resident for appropriateness of behavioral programs which promote urinary continence. The habit training/scheduled voiding was a technique that called for scheduled toileting at regular intervals on a planned basis to match the resident's voiding habits. There was no systemic effort to encourage the resident to delay voiding, included timed voiding with interval based on the resident's usual voiding schedule or patter, timed voiding was every three to four hours while awake and resident who could not self-toilet may be candidates for habits training or scheduled voiding programs. Staff were to document the results of the behavioral/toileting training in resident's medical record and if the resident responded then the program should continue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, for 1 of 24 residents, the facility did not ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, a resident did not have a physician order for the use of oxygen, and residents did not have properly labeled oxygen tubing. Resident identifiers: 20. Findings include: Resident 20 was admitted to the facility on [DATE] with diagnoses of pericardial effusion, chronic obstructive pulmonary disease, morbid obesity, chronic respiratory failure with hypoxia, interstitial pulmonary disease, chronic respiratory failure with hypercapnia, obstructive sleep apnea and chronic congestive heart failure. Resident 20's medical record was reviewed 3/4/25 through 3/5/25. On 3/4/25 at 9:31 AM, an interview was conducted with resident 20. Resident 20 stated his oxygen did not work when it was going through the humidifier. An observation was made of the oxygen concentrator. The oxygen tubing to the nasal cannula was connected directly to the concentrator and not through the humidifier. Resident 20 stated his concentrator had not been working for about 2 weeks. Resident 20 stated it felt like his nose was dry. On 3/4/25 at 11:47 AM, an observation was made of the humidifier bottle not being connected to the concentrator and the nasal cannula was attached directly to the concentrator. Another humidifier with tubing observed to be sitting on the night stand. Resident 20 was observed to have a nasal cannula in place and oxygen was flowing at 4 L (liters) per minute. On 3/5/25 at 9:10 AM, an interview was conducted with resident 20. The resident stated the humidifier on his concentrator did not seal so when they hooked it up it would leak and there was not enough pressure to supply him with the oxygen he needed. The resident stated when it is hooked up to the bubbler he would get shortness or breath, lightheaded, headaches, occasional bloody noses and it felt like everything was closing in on him. The resident stated it had been going on for a couple of weeks and the CNAs had tried to change it but it was just a bad batch from the manufacturer. The resident stated the staff change out the bubbler and oxygen cannula every Sunday. On 3/5/25 at 9:13 AM, an observation was made of the humidifier bottle not being connected to the concentrator and the NC was attached directly to the concentrator. The tubing that attaches to the concentrator is sticking straight up in the air. Another humidifier with tubing observed to be sitting on the night stand. The order dated 2/1/25 documented, Change O2 humidifier every month on first Sunday every night shift starting on the 1st and ending on the 1st every month. March 1st fell on Saturday and the progress notes documented, Will be changed Sunday night. The Medication Administration Record (MAR) documented that the humidifier had not been changed on the first Sunday of March. On 3/5/25 at 10:33 AM, an interview was conducted with CNA 3. The CNA stated that the oxygen supplies were changed every Sunday night. CNA 3 stated if the humidifier did not work she would try to fix it. CNA 3 stated if she could not get it to work she would tell the nurse to see if they could help. CNA 3 stated she did not know of any trouble with them. On 3/5/25 at 10:39 AM, an interview was conducted with the Certified Nursing Assistant Coordinator (CNAC). The CNAC stated that the oxygen supplies were changed every Sunday. The CNAC stated if they could not get the bubbler to work, they would need to reach out to the administration to see what needed to be done. The CNAC stated if the oxygen is humidified it dries out their nose, throat, can cause them to cough and from experience got CNAC stated the resident's nose can get so dried out they had nose bleeds. The CNAC stated he had not been notified about a humidifier that was not working. The CNAC stated he did not know of any problems with the humidifiers, they had been working pretty well lately. On 3/5/25 at 10:58 AM, an interview was conducted with CNA 1, who was the CNA working on resident 20's hallway. CNA 1 stated that as far as she knew it was a night shift thing to take care of changing the oxygen supplies. CNA 1 stated that each shift the CNAs are supposed to check the oxygen set up for the residents on oxygen to make sure the tubing had been updated and it is working correctly. CNA 1 stated she was unaware of any complaints that a humidifier was not working. CNA 1 stated that there was not humidifier on the 300 hallway that was not working today. CNA 1 stated if the oxygen was not working correctly she would get the nurse to help her. CNA 1 stated she did not know it would do to the resident if the humidification was not working correctly. On 3/5/25 at 11:13 AM, an interview was conducted with Registered Nurse (RN)1. RN 1 stated she had not been told that any of the residents on the 300 hallway that their oxygen was not working. RN 1 stated she would usually check the oxygen set up to make sure it was functioning correctly if a resident was on oxygen. An immediate observation was made of RN 1 enter resident 20's room and administer a medication. RN 1 was observed to walk past the oxygen concentrator and did not check it. On 3/5/25 at 11:16 AM, The CNAC accompanied this survey to resident 20's room. Resident 20 informed the CNAC that the humidifier was not working. The CNAC was observed to apply gloves and check the oxygen concentrator and humidifier. The CNAC stated the CNAs should check the oxygen set up when they did their rounds. Resident 20 informed the CNAC that the CNAs had hooked up 3 bottles in one night but it still did not work. The CNAC stated that the CNAs should have let me know or someone in administration so we could have done something about it. The CNAC stated that they had hired a few new CNAs at night and that he had not been told anything about it. The CNAC was observed to leave resident 20's room without correcting the issue with the humidifier. On 3/5/25 at 2:54 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that every Sunday the residents are given new oxygen tubing and humidifier bottle. The DON stated she would expect the CNAs to remove the equipment that was not functioning correctly with working equipment. The DON stated if the humidification was not functioning correctly then the resident could get a dry nose and possibly cause a bloody nose. The DON stated she was unaware that the humidifer bottles were not functioning correctly. On 3/5/25 at 3:25 PM, a follow up observation was made of resident 20's oxygen set up. The oxygen tubing to the nasal cannula was connected directly to the concentrator and not through the humidifier. A follow up interview with the DON was conducted on 3/5/25 at 3:40 PM, the DON stated it was not required to have a humidifier bottle on every oxygen administration. The DON stated humidification was used to help with the dryness. The DON was unaware that resident 20 had experienced bloody noses when he received the unhumidified oxygen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review it was determined, for 1 of 24 sampled residents, that the facility did not ensure residents who displayed or was diagnosed with mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. Specifically, a resident diagnosed with depression and anxiety who verbalized she wanted to die and was ready to die, refused medications, displayed crying episodes, and threatened another resident with physical harm was not offered or provided behavioral health services. Resident identifier: 28. Findings include: On 3/3/25 at 10:41 AM, an interview and observation was conducted with resident 28. Resident 28 was in her bed with her eyes closed. Resident 28 opened her eyes, she answered interview questions with one to two word answers. Resident 28 was withdrawn and displayed a flat affect throughout the interaction. On 3/3/25 at 11:11 AM, an observation was made of resident 28 in the dining room playing bingo. Resident 28 was observed to maintain a flat affect and had minimal interaction with other residents or staff. On 3/4/25 at 12:09 PM, an observation was made of resident 28 in the dining room eating lunch. Resident 28 was sitting next to two other residents, she did not interact with other residents or staff and stared blankly in the room with a flat affect while she ate lunch. A resident spoke to resident 28 and she looked at him and gave no verbal response, she had an annoyed facial expression. At 12:18 PM, resident 28 started coughing on her food, staff asked her if she was okay, and she nodded yes. At 12:24 PM, resident 28 had finished eating and was staring around the room with a flat affect. At 12:28 PM, a staff member took resident 28 to her room via wheelchair. Resident 28's medical record was reviewed 3/3/25 through 3/5/25. Resident 28 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included intraductal carcinoma in situ of right breast, dysphagia, type 2 diabetes mellitus with diabetic neuropathy, aphasia, cerebral infarction, depression, acute kidney failure, and generalized anxiety disorder. A Preadmission Screening Resident Review (PASRR) Level II, dated 2/10/23, indicated, Recommendation for Specialized Services for mental illness treatment: Please continue to monitor and assess mental health symptoms as well, especially if there are increased depressive symptoms. Please also continue to monitor and assess any possible cognitive concerns. An annual Minimum Data Set (MDS) assessment, dated 2/13/25, indicated a Brief Interview for Mental Status (BIMS) score of 10. A BIMS score of 8-12 indicated a moderate cognitive impairment. It further indicated resident 28 expressed little interest or pleasure in doing things 2-6 days (several days); felt down, depressed, or hopeless 2-6 days (several days); and displayed isolation sometimes. A Nurses Note, dated 10/2/24 at 12:51 PM, indicated, BIOPSY RESULTS: Biopsy results received from [health facility name redacted]. Final Diagnosis: 1- Lymph node, right axillary, core biopsy: Positive for metastatic carcinoma. 2- Breast, right, UQ MASS, CORE BIOPSY: Invasive grade 2 ductal carcinoma. [Physician Assistant name redacted] and [medical doctor name redacted] notified of results. A Nurses Note, dated 10/24/24 at 10:55 AM, indicated, Give [sic] pt [patient] AM meds. Pt laying in bed. Assist to sit up. Pt took 1/2 her pills, looked at the rest and started getting teary eyed and stated, 'She doesn't want to take pills anymore. She hates taking so many meds [medications]. She just wants to die. RN [Registered Nurse] sitting and talking to pt about her feelings. She states she's just tired and there's no point to being here. Pt talks about her family, parents sisters and children growing up in [state redacted] and moving to USA and eventually coming to [state redacted] with her family. Pt smiles and laughs when recalling memories of raising her children. Pt eventually took the rest of her meds. Turn on a show for her to watch while in bed. A Nurses Note, dated 10/24/24 at 3:42 PM, indicated, Attempted to give pt brown cow, prune juice and MOM [milk of magnesia]. Pt stated she didn't like it and wouldn't drink it. Educate pt it has been 4 days since last recorded BM [bowel movement] and she has been refusing suppositories at noc [night]. Pt states she doesn't like it and she hasn't been eating to have BM. Encourage ot [sic] to drink H2O [water] and rest. Alert social Worker of pt not wanting to take anymore meds, food and wanting to die. States she will talk to pt and family. The December 2024 Medication Administration Record (MAR) indicated resident had an order for Lexapro Oral Tablet 5 MG (Escitalopram Oxalate) Give 2.5 mg by mouth at bedtime for depression with a start date of 11/22/24 at 7:00 PM. The December 2024 Treatment Administration Record (TAR) indicated resident 28 verbalized sadness one time on the night of 12/1/24 and three times on the night of 12/7/24. A Psychotropic IDT (Interdisciplinary Treatment) note, dated 12/19/24 at 5:09 PM, indicated, Patient was reviewed during psychotropic meeting today. [Medical Doctor name redacted] ordered to increase Lexapro from 2.5mg [milligrams] to 5mg QHS [every hour of sleep] for depression. A Psychotropic IDT, dated 1/23/25 at 3:11 PM, indicated, Patient was reviewed during today's psychotropic meeting. In attendance: [name redacted], RA [Resident Advocate] [name redacted] DON [Director of Nursing] [Medical Doctor name redacted] [name redacted], Pharmacist -Decrease Lexapro to 2.5mg QD [every day] Will review again in February. The February 2025 Treatment Administration Record (TAR) indicated resident 28 verbalized sadness once on the night of 2/15/25, once during the day and once on the night of 2/18/25, once on the night of 2/22/25, once during the day of 2/23/25, and once during the day and once on the night of 2/27/25. It further indicated that monitoring numbers of verbalizations of sadness every shift was discontinued on 2/28/25 at 4:00 PM. An Activity Participation Note, dated 2/11/25 at 5:22 PM, indicated, .Resident became tearful while answering 'getting to know you questions' about her family. By the end of the conversation, Resident was smiling and had a more calm and content demeanor and expressed gratitude for someone listening to them . A Social Work Note, dated 2/14/25 at 11:45 AM, indicated, .Residents psychosocial well-being goal is continue to be more open about how her day is going or how she is feeling with staff. She see's that she usually just says she is fine regardless of how she is truly feeling, and wants to be more open and honest when answering questions like that. When asked about an IDT Resident expressed that she does not want to do an IDT this quarter, but would be more open to doing one next quarter. RA will follow up then. A Nurses Note, dated 2/28/25 at 1:55 PM, indicated, Nurse reported to DON that patient made a comment to the nurse that she 'no longer wants to take medications and is ready to die'. It should be noted that a Certified Nursing Assistant (CNA) Task-Behavior Symptoms document indicated no Frequent Crying or Rejection of Care was observed on 2/28/25. A Nurses Note, dated 2/28/25 at 2:04 PM, indicated, [Medical Doctor name redacted] was notified of situation. A Nurses Note, dated 2/28/25 at 3:49 PM, indicated, Patient has been struggling to take her medications. DON spoke with sister [name redacted] about the situation. Patient has been refusing medications and making comments that she doesn't want to take medications anymore and is 'ready to die'. Sister [name redacted] said she will come visit her tonight and talk about her medications and the need for them. DON notified Social worker/Resident Advocate of comments made by patient. A Psychotropic IDT, dated 2/28/25 at 3:56 PM, indicated, Patient was reviewed during this month's psychotropic meeting. In attendance: [name redacted], MD [Medical Doctor], [name redacted] PharmD [name redacted], LCSW [Licensed Clinical Social Worker] [name redacted], DON [name redacted], RA Patient is taking a 2.5mg dose of lexapro. MD ordered to DC [discontinue] medication. A Social Work Note, dated 2/28/25 at 4:07 PM, indicated, RA was informed by DON that patient had mentioned to nurse that she is 'ready to die'. RA and DON spoke with Resident about why she has been refusing meds as well as why she made that statement. Resident expressed that she feels frustrated about the fact that her meds are making her not enjoy food, as well as making it so food does not taste good. She continued that food is a big part of who she is and her culture, which is why she has been frustrated and refusing meds. Resident also expressed that her statement that she is 'ready to die' is not true and came out of the situational frustration. RA and DON told Resident that they could reach out to Facility Doctor about her medications. Resident seemed very happy about this and again confirmed that she did not truly mean that she is 'ready to die'. RA will continue to follow up with any further tracking of sadness or behaviors like these. DON sent message to facility Doctor. A Nurses Note, dated 3/2/25 at 5:30 PM, indicated, Pt threatened to throw a flower pot at another resident today in the dining hall during dinner. Staff intervened before any physical assault occurred. Residents were separated and taken back to their rooms. It should be noted that a CNA Task-Behavior Symptoms document indicated no Yelling/Screaming, Abusive Language or Threatening Behaviors were observed on 3/2/25. A Clinical Provider note dated 3/5/25 indicated, 3/3/25: Nurse was asked to inform family of her refusal of meds so that they are aware. Pt educations given. If continues, we will reach out to oncology for other med delivery methods. It further indicated, .Mood disorder due to known physiological condition with depressive features Mood stable Lexapro 2.5 milligrams daily Medications will be reviewed in monthly psychotropic meeting at least quarterly 3/3/25: decreased to 2.5 mg on 1/24/25 and discontinued in monthly psychotropic on 2/27/25. Pt is not stating depression today. The Care Plan Report indicated: a. Mood disorder- At times I become depressed Date Initiated: 02/26/2024 Revision on: 02/26/2024. With the Goals of: My depression will not worsen or interfere with my recovery Date Initiated: 02/26/2024 Revision on: 08/27/2024 Target Date: 05/26/2025 and I do not want my score to increase on the next PHQ-9 [Patient Health Questionnaire instrument used for measuring depression severity] Date Initiated: 02/26/2024 Revision on: 08/27/2024 Target Date: 05/26/2025. Interventions included: Help me decorate my room so it says something good about me and my life. Date Initiated: 02/26/2024 Invite me to activities I might enjoy Date Initiated: 02/26/2024 Referral made by [name redacted] CSW [Certified Social Worker], SWCS for therapeutic recreation activities. Date Initiated: 02/13/2025 Remind me to spend time out of my room and to eat my meals in the dining room Date Initiated: 02/26/2024 Review my antidepressant at least quarterly and ask Dr. to be sure that it is the best dose for me. Date Initiated: 02/26/2024 Speak to me each day, and use validation techniques to help me feel like I am being heard Date Initiated: 02/26/2024 b. Anxiety I get anxious sometimes Date Initiated: 05/13/2024. With the Goal of: I want you to help me calm down within 10 minutes of my becoming anxious Date Initiated: 05/13/2024 Revision on: 08/27/2024 Target Date: 05/26/2025. Interventions included: Even if I can't tell you what is wrong, use validation techniques that might help to feel safer and more relaxed Date Initiated: 05/13/2024 If I am too anxious to go to sleep, offer to play some soft music or give me a warm beverage like tea or hot chocolate. Date Initiated: 05/13/2024 Referral made by [name redacted] CSW, SWCS for therapeutic recreation activities. Date Initiated: 02/13/2025 When I do become anxious, please help me calm down by going with me to a low stimulus area to calm down, or offer me a beverage of my choice, or walk with me and talk gently with me. Date Initiated: 05/13/2024 c. PASSR - Resident has PASRR Level 2 d/t [due to] dx [diagnosis] of: Depression and Anxiety with an LTC [long term care] Determination. Date Initiated: 08/11/2023 Revision on: 01/02/2025. With the Goal of: Patient will be appropriately screened. Date Initiated: 08/11/2023 Revision on: 01/02/2025 Target Date: 05/26/2025. Interventions included: Level 2 Recommendations (Specify to each patient): Date Initiated: 08/11/2023 Revision on: 01/02/2025 [Resident 28] would benefit from skilled nursing therapies and rehabilitation that will help to strengthen her. She used to be very independent prior to her stroke and the loss of this independence has been very difficult for her. She would benefit also from socialization and group activities as her son reported that if she is alone and not engaging in something, she will tend to isolate and ruminate on worries. She would benefit from activities that she can do in her room to also help keep her mind active. Date Initiated: 08/11/2023 Revision on: 01/02/2025. d. Resident has actual psychotropic med use of high-risk medication lexapro. Date Initiated: 02/25/2025 Revision on: 02/25/2025. With the Goal of: The resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. Date Initiated: 02/25/2025 Target Date: 05/26/2025. Interventions included: Administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT [every shift]. Date Initiated: 02/25/2025 Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of antidepressants. Date Initiated: 02/25/2025 Revision on: 02/25/2025 Monitor/document/report PRN [as needed] adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL [activities of daily living] ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt [weight] loss, n/v [nausea/vomiting], dry mouth, dry eyes Date Initiated: 02/25/2025. e. Resident at risk for impaired psychosocial wellbeing r/t [related to] presence of depressive symptoms. Date Initiated: 02/25/2025 Revision on: 02/25/2025. With the Goal of: The resident will verbalize feelings related to emotional state by review date. Date Initiated: 02/25/2025 Target Date: 05/26/2025. Interventions included: Encourage participation from resident who depends on others to make own decisions. Date Initiated: 02/25/2025 Provide opportunities for the resident and family to participate in care. Date Initiated: 02/25/2025 When conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. Date Initiated: 02/25/2025 It should be noted that resident 28's care plan did not include refusing medication and was not revised on: a. 10/24/24 when the statement that she wanted to die was made; b. 11/22/24 when Lexapro was started at a 2.5 mg dose; c. 2/28/25 when the statement that she was ready to die was made and Lexapro was discontinued; or d. 3/2/25 when the resident threatened another resident. On 3/5/25 at 10:48 AM, an interview was conducted with CNA 5. CNA 5 stated that resident 28 used to cry a few months ago but was in a pretty good mood most of the time now and that she would get up and go to activities every day. On 3/5/25 at 11:08 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated resident 28 had recently started having difficulty taking her pills because she did not like taking her medications. LPN 1 stated he would explain what they are for and then she would take them. LPN 1 stated resident 28 had not expressed sadness to him and was not aware of statements she had made of wanting to die. On 3/5/25 at 11:24 AM, an interview was conducted with the RA. The RA stated that she was not aware of the resident-to-resident incident that occurred and that it should have been reported to her, but might have been reported to the DON. The RA stated that if it was reported to her she would have reviewed the care plans and made changes if needed. The RA stated she completed the PHQ-9 evaluations and residents who had a high score would be consulted with the LCSW, but resident 28 scored a 1 and 2. The RA stated the PHQ-9 score was not the only thing that would be used to determine a need for a referral to the LCSW. On 3/5/25 at 11:27 AM, an interview was conducted with CNA 3. CNA 3 stated she observed resident 28 cry, usually when she took her medications. On 3/5/25 at 12:11 PM, an interview was conducted with the DON. The DON stated a nurse reported to her that she was having a hard time getting resident 28 to take her medications and that resident 28 stated she was ready to die. The DON stated she immediately spoke with the RA and then they both went and talked with the resident. The DON stated the resident was remorseful for saying that and that she was just frustrated about having to take so many medications because it ruined the taste of her food. The DON stated that the Physician Assistant (PA) saw her and they are trying to get her off any unnecessary medications. The DON stated they talked to her family too and that her family was going to come in to discuss her taking medications or, possibly, a palliative approach because resident 28 was not currently seeking treatment for her cancer. The DON stated she was diagnosed with cancer in October when she had verbalized that she wanted to die. The DON stated resident 28 would sometimes cry, but if you asked her if she was okay, she would say she was fine and smile. The DON stated that resident 28 had not been sad but occasionally she would remember that she had cancer and she would cry for 10 seconds and then she would forget again and be fine. The DON stated resident 28 was reviewed in the psychotropic meeting recently and was taken off of her Lexapro and the treatment for her depression was that she was meeting with the RA. The DON stated when an antidepressant was discontinued, the behavioral symptom monitoring was discontinued too. The DON stated if the resident was becoming more depressed, it would be based off of what staff reported. The DON stated they were not expecting to see any changes once resident 28 was taken off of the Lexapro because she was on a super low dose. The DON stated resident 28 was not meeting with a therapist right now. The DON stated that the RA does the PHQ-9 evaluation quarterly and if the score is above a 10 she would be reviewed in the psychotropic meeting but that resident 28 scores very low. The DON stated if a resident was consistently high she would be referred to behavioral health. The DON stated she was notified of the resident-to-resident incident where resident 28 stated that she was going to throw a centerpiece at the other resident because she was yelling a lot. The DON stated that was not typical behavior for resident 28 and seemed out of character. The DON stated she did not think that anyone spoke with resident 28 about the altercation and that the RA should follow up on that. The DON stated whoever witnessed the altercation should have reported that to the RA and possibly have the doctor follow up with resident 28. On 3/5/25 at 2:11 PM, a follow-up interview was conducted with the RA. The RA stated that she had not consulted with the LCSW for resident 28 and that she would typically reach out to the consultant with circumstances where she did not have any experience. The RA stated the LCSW consultant did not go to the facility but that she did monthly audits. The RA stated she did not think there was any documentation of a review of resident 28. The RA stated that if she was made aware of the resident-to-resident altercation she would have consulted with the LCSW. On 3/5/25 at 3:47 PM, an interview was conducted with the Administrator (ADM). The ADM stated that he was not aware that resident 28 had made statements about wanting to die and that it would be warranted as something to look at. The ADM stated staff told him that resident 28 said that she was going to throw a vase at resident 6 and that staff separated them. The ADM stated he had first heard about the incident today. The ADM stated the staff that witnessed the incident deemed that this was not abuse.

**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 ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences which indicated that the dose should be reduced or discontinued. Specifically, resident's blood pressure (BP) support medication was administered outside of the physician's ordered parameters. Resident identifier: 20 and 238. Findings included: 1. Resident 20 was admitted to the facility on [DATE] with diagnoses of essential hypertension. Resident 20's medical record was reviewed 3/4/25 through 3/5/25. A physician's order dated 11/27/24 documented, Toprol XL (extended release)Tablet 24 Hour 25 MG (milligram) (Metoprolol Succinate ER (extended release) Give 1 tablet by mouth one time a day for HTN (hypertension) HOLD FOR SBP (systolic blood pressure)<(less than) 105 OR HR (heart rate) < 55. The January 2025 Medication Administration Record (MAR) was reviewed and revealed Toprol XL was held when it should have been administered on: a. 1/24/25 B/P 106/63 b. 1/27/25 B/P 109/64 c. 1/29/25 B/P 106/62 The January 2025 MAR revealed Toprol XL was administered and should have been held on the following date: a. 1/25/25 B/P 101/59 On 3/5/24 at 12:15 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated the nurses should always follow the doctors orders and administer or hold the blood pressure medication if it falls into those parameters. RN 1 stated it could cause the resident's blood pressure to increase or lower incorrectly if the parameters were not followed. On 3/5/35 at 2:50 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the nurses were expected to make sure to follow the physician ordered parameters and enter the vital signs of each resident into the medical record before administering the medication. 2. Resident 238 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included hypotension, disorder of kidney and ureter, and dementia. Resident 238's medical record was reviewed 3/3/25 through 3/5/25. A physician's order, dated 2/28/25, indicated, Midodrine HCl Oral tablet 2.5 MG (Midodrine HCl) Give 2.5 mg by mouth two times a day for HYPOtension HOLD for SBP greater than 110 or DPB [diastolic blood pressure] greater than 90. The February 2025 MAR was reviewed and indicated Midodrine HCl was administered when it should have been held on 2/28/25 with a blood pressure (B/P) of 145/68. The March 2025 MAR was reviewed and indicated Midodrine HCl was administered when it should have been held on: a. 3/3/25 B/P 138/76 b. 3/3/25 B/P 136/75 c. 3/4/25 B/P 132/69 On 3/5/25 at 2:40 PM, an interview was conducted with RN 1. RN 1 stated a check mark on the MAR indicated the resident was administered the medication. RN 1 stated the Midodrine should be held when the B/P was greater than 110 because the medication increases B/P. On 3/5/25 at 2:59 PM, an interview was conducted with the DON. The DON stated nurses were expected to follow the parameters and document the vitals that were required. The DON stated the Midodrine should have been held when the blood pressure was outside the ordered parameters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 2 out of 28 sampled residents, that the facility did not develop and implement a comprehensive person-centered care plan for each resident that included the services that were to be furnished to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, two resident's utilized a Continuous Positive Airway Pressure (CPAP) machine and did not have a care plan in place to address this aerosol generating procedure. Resident identifiers: 14 and 22. Findings included: 1. Resident 14 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, cerebral palsy, acute respiratory failure, obstructive sleep apnea, morbid obesity, atrial fibrillation, and hypertension. On 8/02/21 at 2:52 PM, an interview was conducted with resident 14. Resident 14 stated that he needed a new CPAP machine because his current one was on recall. Resident 14 stated that he operated the machine independently and cleaned the machine himself. Resident 14 stated that he filled up the water reservoir, and that he should receive new supplies soon. An observation was made of signs posted on resident 14's door that stated on droplet precautions during aerosolized procedure. Upon initiation of CPAP/Bilevel Positive Airway Pressure (BIPAP), during all duties and cares with CPAP, and for 30 minutes after removal of CPAP wear gloves, gown, N95, and face shield, and discard upon exiting room. The Personal Protective Equipment (PPE) was observed to be located inside the resident's room by the door hanging in a bag on the glove dispenser. The PPE bag contained disposable gowns, face shields, and N95 masks. On 8/3/21 resident 14's medical records were reviewed. On 3/8/21 resident 14's care plan revealed a focus area for altered respiratory status related to sleep apnea and shortness of breath (SOB) was initiated. The care plan interventions did not address the use of a CPAP machine. No documentation could be found of a care plan that addressed the use of the CPAP machine. 2. Resident 22 was admitted to the facility on [DATE] with diagnoses which included congestive heart failure (CHF), morbid obesity, major depressive disorder, history of transient ischemic attack, sciatica, restless leg syndrome, and hypothyroidism. On 8/02/21 at 1:39 PM, an interview was conducted with resident 22. Resident 22 stated that she had been using a CPAP machine for many years and could operate it independently. Resident 22 was observed seated at the bedside with 1.5 liters of supplemental oxygen being administered via a nasal cannula. The CPAP machine was observed on the bedside table with a gallon bottle of distilled water next to it. The water was labeled with an open date of 7/1/21, and was initialed by a staff member. An observation was made of signs posted on resident 22's door that stated on droplet precautions during aerosolized procedure. Upon Initiation of CPAP/BIPAP during all duties and cares with CPAP, and for 30 minutes after removal of CPAP wear gloves, gown, N95, face shield, and discard upon exiting room. The Personal Protective Equipment (PPE) was observed located inside the resident's room by the door hanging in a bag on the glove dispenser. The PPE bag contained disposable gowns, face shields, and N95 masks. On 8/3/21 resident 22's medical records were reviewed. On 7/2/21 resident 22's care plan for Oxygen Therapy related to CHF was initiated. The care plan interventions did not address the use of a CPAP machine. No documentation could be found of a care plan that addressed the use of the CPAP machine. On 8/05/21 at 9:04 AM, an interview was conducted with the Corporate Resource Nurse (CRN) who was also the acting Director of Nursing for the facility. The CRN stated that resident 14 and resident 22 should have a care plan that included the use of the CPAP machine. The CRN stated that the medical records were located in three different locations; the electronic medical records, the hard chart, and a folder in medical records. The CRN stated that she would check to see if any of these locations contained a care plan where the CPAP machine was addressed. No other additional information was provided by the CRN for the care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 2 out of 28 sampled residents, that the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, two residents who utilized a Continuous Positive Airway Pressure (CPAP) machine did not have orders for their CPAP equipment and treatment, and there was no resident monitoring for the use of the devices in place. Resident identifiers: 14 and 22. Findings included: 1. Resident 14 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, cerebral palsy, acute respiratory failure, obstructive sleep apnea (OSA), morbid obesity, atrial fibrillation, and hypertension. On 8/02/21 at 2:52 PM, an interview was conducted with resident 14. Resident 14 stated that he needed a new CPAP machine because his current one was on recall. Resident 14 stated that he operated the machine independently and cleaned the machine himself. Resident 14 stated that he filled up the water reservoir, and that he should receive new supplies soon. An observation was made of signs posted on resident 14's door that stated on droplet precautions during aerosolized procedure. Upon Initiation of CPAP/Bilevel Positive Airway Pressure (BIPAP), during all duties and cares with CPAP, and for 30 minutes after removal of CPAP wear gloves, gown, N95, face shield, and discard upon exiting the room. The Personal Protective Equipment (PPE) was observed located inside the resident room by the door hanging in a bag on the glove dispenser. The PPE bag contained disposable gowns, face shields, and N95 masks. On 8/3/21 resident 14's medical records were reviewed. Review of resident 14's physician orders revealed no order for the use of the CPAP machine, nor the equipment settings for the prescribed flow rate and pressure settings, when to use the equipment and the humidification level. Review of resident 14's July 2021 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no documentation for monitoring of the resident's response to CPAP therapy or monitoring of the therapy with the equipment settings. On 3/8/21 resident 14's care plan for a focus area for altered respiratory status related to sleep apnea and shortness of breath (SOB) was initiated. The care plan interventions did not address the use of a CPAP machine, the type of equipment and settings utilized, when to administer, and any required monitoring for complications. No documentation could be found of a care plan that addressed the use of the CPAP machine. Review of the facility Policy and Procedure for CPAP/BiPAP Support stated to document the following in the resident's medical record: 1. General assessment (including vital signs, oxygen saturation, respiratory, circulatory and gastrointestinal status) prior to procedure; 2. Time CPAP was started and duration of the therapy; 3. Mode and setting for the CPAP/IPAP/EPAP; 4. Oxygen concentration and flow, if used; 5. How the resident tolerated the procedure; and 6. Oxygen saturation during therapy. The policy also stated to notify the physician if the resident refused the procedure, experienced any adverse consequences, including (but not limited to) respiratory distress and marked change in vital signs. The policy was last revised in March 2015. On 8/05/21 at 9:04 AM, an interview was conducted with the Corporate Resource Nurse (CRN) who was also the acting Director of Nursing (DON). The CRN stated that there should be a physician order for the CPAP machine, and nursing should be monitoring the equipment. The CRN stated that the licensed nursing staff would document the monitoring on the TAR. 2. Resident 22 was admitted to the facility on [DATE] with diagnoses which included congestive heart failure (CHF), morbid obesity, major depressive disorder, history of transient ischemic attack, sciatica, restless leg syndrome, and hypothyroidism. On 8/02/21 at 1:39 PM, an interview was conducted with resident 22. Resident 22 stated that she had been using a CPAP machine for many years and could operate it independently. Resident 22 was observed seated at the bedside with 1.5 liters of supplemental oxygen being administered via a nasal cannula. The CPAP machine was observed on the bedside table with a gallon bottle of distilled water next to it. The water was labeled with an open date of 7/1/21, and was initialed by a staff member. An observation was made of signs posted on resident 22's door that stated on droplet precautions during aerosolized procedure. Upon Initiation of CPAP/BIPAP, during all duties and cares with CPAP, and for 30 minutes after removal of CPAP wear gloves, gown, N95, face shield, and discard upon exiting the room. The Personal Protective Equipment (PPE) was observed located inside the resident room by the door in a bag hanging on the glove dispenser. The PPE bag contained disposable gowns, face shields, and N95 masks. On 8/3/21 resident 22's medical records were reviewed. Review of resident 22's physician orders revealed an order that stated, CPAP at night per home regimen at bedtime for sleep apnea AND as needed for sleep apnea *while napping during the day*. The order was initiated on 3/10/19 and was discontinued on 4/30/2020. There was no current order for the CPAP equipment. Review of resident 22's July 2021 MAR and TAR revealed no documentation for monitoring of the resident's response to CPAP therapy or monitoring of the therapy with the equipment settings. On 7/2/21 resident 22's care plan for Oxygen Therapy related to CHF was initiated. The care plan interventions did not address the use of a CPAP machine, the type of equipment and settings utilized, when to administer, and any required monitoring for complications. No documentation could be found of a care plan that addressed the use of the CPAP machine. On 8/04/21 at 5:46 AM, an interview was conducted with Certified Nurse Assistant (CNA) 1. CNA 1 worked the night shift and stated that the resident had refused to wear her CPAP and had not ever used it since she had been at the facility. CNA 1 stated she had never assisted her with it. CNA 1 stated that the resident had told her that the machine did not work correctly and she did not want to use it. CNA 1 stated that she reported it to the nurse, but could not recall who as it was a long time ago. CNA 1 stated that they assisted the residents with applying the CPAP machine at nighttime. On 8/04/21 at 7:25 AM, an interview was conducted with the CRN. The CRN stated that she would check with the Physician's Assistant (PA) about the CPAP needing to be replaced. On 8/04/21 at 9:55 AM, observed the CRN to ask the Medical Director to assess resident 22's need for the CPAP and the possibility of discontinuing the order. The CRN stated that if the machine was broken she would obtain a new one for the resident. On 8/05/21 at 9:12 AM, a follow-up interview was conducted with the CRN. The CRN stated that the Medical Director reported that resident 22 wanted to keep the CPAP machine to utilize on an as needed (PRN) basis. The CRN stated that the resident reported that she did not like it but wanted to have it available should she choose to use it. The CRN stated that resident 22 having a roommate with an aerosol generating procedure was not a concern for them because neither residents were symptomatic, both were vaccinated, and the equipment was not currently being utilized.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 out of 28 sampled residents, that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any of these combinations. Specifically, medications were not administered per the physician ordered parameters and a resident was not monitored for complications associated with an anticoagulant use. Resident identifiers: 2 & 11. Findings included: 1. Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, essential hypertension, type 2 diabetes with hyperglycemia, dementia without behavioral disturbance, chronic kidney disease, gastro-esphageal reflux disease, generalized anxiety disorder,inerstitial cystitis, pain, nausea and vomiting. Review of resident 2's physician orders revealed the following: a. Lasix tablet 40 milligrams (mg), give 1 tablet by mouth one time a day for hypertension. Hold Lasix for (systolic blood pressure) SBP less than 105 and to hold the Potassium if the Lasix was held. The medication was initiated on 5/2/2020. b. Potassium Chloride (extended release) ER tablet 20 milliequivalents (meq), give 1 tablet by mouth one time a day for supplement with Lasix. The medication was initiated on 5/2/2020. Review of the July 2021 Medication Administration Record (MAR) revealed that the Lasix 40mg was documented as administered on 7/24/21. The Lasix should have been held per the physician ordered parameters to hold for a SBP of <105. On 7/24/21 resident 5's blood pressure (B/P) was recorded as 98/46. Review of the August 2021 MAR revealed that the Lasix 40mg was documented as held on 8/3/21, which was within the ordered parameters to hold for a SBP of <105. On 8/3/21 resident 5's blood pressure (B/P) recorded as 100/58. However, the Potassium 20 meq was documented as administered on 8/3/21. The Potassium should have been held per the physician ordered parameter to not administer the Potassium if the Lasix was held. On 8/3/21 resident B/P was recorded as 100/58. On 8/4/21at 8:55 AM, an interview was conducted with a licensed practical nurse (LPN)1. LPN1 stated before blood pressure medications were given a blood pressure must be taken and be within the parameters ordered by the medical doctor. The potassium should have been held on 8/3/21 and both lasix and potassium should have been held on 7/24/21. If a resident's blood pressure was too low the doctor should be informed. On 8/05/21 at 11:34 AM, an interview was conducted with the Corporate Resource Nurse (CRN) who was also the acting Director of Nursing for the facility. The CRN stated she had never seen an order where Lasix would be given in regards to blood pressure parameters. The CRN stated after reviewing the July and August MAR she had not ever seen an order like that in any facility and she could see how the nurses had missed it. The CRN stated the potassium order parameters are in the Lasix order and should not be there, if a medication had a parameter it should be on that specific medications order. 2. Resident 11 was admitted to the facility on [DATE] with diagnoses which included congestive heart failure, cirrhosis of liver, dysphagia, pnuemonitis, coronary artery bypass graft(s), atrial-fibrillation, hypertension, hyperlipidemia, nonrheaumatic tricuspid valve insufficiency, shortness of breath, edema, polyneuropathy, dysuria, osteoarthritis, cervicalgia, and cardiomegaly. On 8/03/21 at 9:38 AM, an interview was conducted with resident 11. Resident 11 was observed seated in a wheelchair at the bedside. A saturated bloody tissue was observed on the bedside table. Resident 11 stated that they had a nose bleed and it was from the Coumadin they were taking. Resident 11 stated that this happened when the Coumadin dosage was changed. On 8/3/21 resident 11's medical records were reviewed. Review of resident 11's physician orders revealed an order for Warfarin (Coumadin) Tablet, give 2.5 milligrams by mouth in the evening for anticoagulation. Review of the July 2021 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no documentation for monitoring for signs and symptoms of bleeding. On 8/04/21 at 12:47 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that with any resident that was receiving an anticoagulant they tracked any signs and symptoms of bleeding and documented it on the TAR. On 8/04/21 at 2:21 PM, an interview was conducted with RN 2. RN 2 stated that the Certified Nursing Assistanct (CNA) yesterday reported that resident 11 had a bloody nose. RN 2 stated that he monitored the resident for signs and symptoms of bleeding with the Coumadin medication, and that it was documented on the TAR. RN 2 proceeded to look up the documentation of monitoring for bleeding for resident 11 and stated that it was not located on the TAR. RN 2 stated that if it was not in there then he probably did not document any place else. RN 2 proceeded to look at other residents receiving anticoagulants and verified that they had orders in the TAR for monitoring for signs and symptoms of bleeding. On 8/05/21 at 8:23 AM, an interview was conducted with the CRN. The CRN stated that the licensed nursing staff should be monitoring for signs and symptoms of bleeding when a resident was taking an anticoagulant medication for potential complications of that medication. Bleeding could include nose bleeds, bleeding from the gums or blood in the urine. The CRN stated that the nurses should be documenting the monitoring every day or every shift and it should be located in the TAR. It should be documented somewhere.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 2 was admitted to the facility on [DATE] then readmitted on [DATE] with diagnoses which included but were not limited to, essential hypertension, type 2 diabetes with hyperglycemia, dementia without behavioral disturbance, chronic kidney disease, gastro-esophageal reflux disease, generalized anxiety disorder, interstitial cystitis, pain, nausea and vomiting. Resident 2's medical record was reviewed on 8/3/21. a. The Consultation Pharmacist's Medication Regimen Review (MRR) Report dated 4/13/21, documented that resident 2 was on Lantus and sliding scale insulin. The MRR revealed This resident takes Lantus 32 units daily and sliding scale insulin, the Lantus was increased last month from 25 units daily. A review of the MAR shows that the patient requires sliding scale insulin about 43% of the time, or an average of about 3 units per day (previously used 80% for average of 10 units daily, before Lantus increased). The most recent A1C in November was 6.3%, and the target for this patient based on age and comorbidities, is 8% or lower. Sliding scale Insulin is classified as a high risk in the elderly, due to high risk of hypoglycemia, and it requires expensive testing supplies, and significant nursing time. The lowest blood glucose on record in April was 100 (previously 104 before Lantus increase), and about 57% of measurements were below 150 (previously 7% before Lantus Increase), and most doses of sliding scale occur at dinner time. There are no oral agents on board, and the American Diabetes Association recommends utilizing three oral agents before the use of rapid acting insulin. This was discussed with the medical team and the following has been approved: Discontinuation of the sliding scale insulin and initiation of Metformin 500mg once daily at lunchtime was recommended. The form indicated that the medical director had signed the form and agreed with the Pharmacist recommendations but the recommendations were never executed. b. Review of resident 2's medication administration record (MAR) for May, June, July and August revealed no active order for Metformin and an active order to continue using the following sliding insulin scale: Novolog solution 100 unit/milliliter (ml), inject subcutaneously before meals as per sliding scale: if blood sugar (BS) 0-150 = 0 units, if <60 notify medical doctor (MD) and offer juice, protein, glucose tabs, recheck BS in 15 minutes; if resident unresponsive call 911. If BS 151-180 administer 2 units; if BS 181-200 administer 4 units; if BS 201-250 administer 6 units; if BS 251-300 administer 8 units; if BS 301-350 administer 10 units; if BS 351-400 administer 14 units; if BS 401 or greater administer 14 units and notify MD. On 8/3/21, during survey, the insulin sliding scale for resident 2 was discontinued by the Physician's Assistant (PA). On 8/5/21 at 9:15 AM, an interview was conducted with the acting director of nursing (DON/CRN). DON/CRN stated the signature that approved the initiation of Metformin and the discontinuation of the sliding scale on the 4/13/21 pharmacology review was that of the facility's medical director. DON/CRN stated she was also unable to find the Metformin in the MAR for May, June, July or August. On 8/05/21 at 12:26 PM, an interview was conducted with the DON/CRN. DON/CRN stated the Metformin order was never acted upon and put into place for resident 2. Based on interview and record review it was determined, for 3 out of 28 sampled residents, that the facility did not ensure that the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist, and any irregularities were reported to the attending physician, the facility's medical director and the Director of Nursing (DON) and these reports were acted upon. Additionally, the attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. Specifically, the pharmacist made recommendations to the attending physician that were not acted upon nor documented in the resident's medical record. Resident identifier: 2, 8, and 28. Findings included: 1. Resident 8 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type 2, adjustment disorder with depressed mood, pseudobulbar affect, morbid obesity, anxiety disorder, osteoarthritis, dry eye syndrome, protein-calorie malnutrition, interstitial pulmonary disease, muscle spasm, vascular dementia, hypertension, gastro-esophageal reflux disease, insomnia, and hyperlipidemia. On 8/03/21 resident 8's medical records were reviewed. Review of resident 8's Monthly Medication Review (MMR) by the licensed pharmacist revealed the following recommendations: a. February 2021 - Increase Lantus to 32 units every (Q) evening at bedtime (HS) (2 unit increase) and discontinue (DC) the sliding scale; or increase Lantus to 31 units (QHS) (1 unit increase) and DC the sliding scale; or DC the sliding scale. A check mark was noted next to Increase Lantus to 32 units QHS (2 unit increase) and the DC sliding scale was crossed off and initialed as noted, initials were not identified. The physician signed the recommendation on 2/17/21 and the form was also signed by the same individual who crossed off DC sliding scale. This unknown individual signed the form on 2/19/21. b. April 2021 - This resident takes Tradjenta 5 mg (milligram), Actos 45 mg daily, Lantus 32 units daily and sliding scale insulin. A review of the MAR (Medication Administration Record) shows that the patient requires sliding scale insulin about 30% of the time, for an average of almost 7 units per day, mostly due to several high doses given at lunch time in April. The most recent A1c in February was 5.6 % and the target for this patient, based on age and comorbidities, is 8% or lower. Sliding scale insulin is classified as a high risk in the elderly due to risk of hypoglycemia, and it requires expensive testing supplies, and significant nursing time. The lowest blood glucose on record in April was 85. This was discussed with the medical team, and the following has been approved: 1. DC sliding scale insulin. It should be noted that the Physician's Assistant (PA) signed the recommendation but did not indicate if they agreed or disagreed with the recommendation. c. August 2021 - Increase Lantus to 35 units daily and DC the sliding scale. The PA also documented in the response section to continue the morning fasting blood glucose level and discontinue all other checks. The recommendations were signed by the PA. On 8/04/21 at 11:37 AM, an interview was conducted with the Corporate Resource Nurse (CRN) who was also the acting DON. The CRN stated that the process for the monthly pharmacist review was that the pharmacist had already spoken with the physician prior to sending the recommendation to the facility. The CRN stated that the PA signed the August recommendation today. The CRN stated that the pharmacy reports were signed by the provider and sent to medical records to be scanned into each resident's miscellaneous section of the electronic medical records. The CRN stated that the previous Administrator was the person receiving the pharmacy recommendations and not the clinical staff. On 8/05/21 at 8:28 AM, a follow-up interview was conducted with the CRN. The CRN stated that if the provider signed the pharmacy recommendation then that meant they were agreeing to the recommendations. The CRN stated she was not aware of who the initials belonged to on the February 2021 recommendations next to the DC sliding scale that was crossed off. The CRN stated that it was not possible to identify if the physician or the unknown individual crossed off that portion of the recommendation. The CRN stated that she did not believe that the physician wanted the sliding scale discontinued because he liked ordering sliding scales for insulin. The CRN stated that the Lantus dose was increased per the pharmacist's recommendations. The CRN stated that the April 2021 had the same recommendation to discontinue the sliding scale for the insulin and based off her knowledge of the recommendation having a signature, the sliding scale should have been discontinued per the providers agreement with the recommendation. The CRN stated that the sliding scale was finally discontinued yesterday after the third recommendation was made in August 2021. 2. Resident 28 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type 2, dysphagia, dementia, localized edema, hyperlipidemia, retention of urine, left bundle branch block, metabolic encephalopathy, urinary tract infection, bradycardia, hypotension, zoster, chronic kidney disease, pneumonitis, hypokalemia, gastro-esophageal reflux disease, major depressive disorder, protein-calorie malnutrition, chronic pain, and hypertension. On 8/03/21 resident 28's medical records were reviewed. Review of resident 28's MMR by the licensed pharmacist revealed the following recommendations: a. March 2021 - Increase Lantus to 16 units daily and discontinue sliding scale insulin; or Increase Lantus to 15 units daily and discontinue sliding scale insulin; or Increase Lantus to 16 units daily and maintain sliding scale for now; or Increase Lantus to 15 units daily and maintain sliding scale for now; or Other; or No changes at this time. The form did not indicate the physician response to the recommendations and did not contain a physician or provider signature. b. April 2021 - Discontinue Pantoprazole; Start Famotidine 20 mg two times a day as needed for rebound reflux; Increase Lantus to 17 units daily; and discontinue the sliding scale insulin. The recommendations documented that this was discussed with the medical team for this facility and it was approved. A signature was noted on the recommendations with an Ok next to it. c. July 2021 - Discontinue Pantoprazole; Start Famotidine 20 mg two times a day as needed for rebound reflux; Increase Lantus to 17 units daily; and discontinue the sliding scale insulin. The recommendations documented that this was discussed with the medical team for this facility and it was approved. The PA response was signed on 7/6/21. It should be noted that this was the same recommendation that was made in April 2021. On 8/05/21 at 8:47 AM, an interview was conducted with the CRN. The CRN stated that the March 2021 recommendations that was implemented was that the Lantus was increased to 16 units daily on 3/11/21 and the sliding scale insulin was maintained. The CRN stated that the physician did not document the response to the recommendation on the form nor did he sign the recommendation form. The CRN stated that the recommendations in April 2021 was signed Ok by the Medical Director, but the recommendations were not implemented until July 2021 when the PA signed the recommendations again.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 4 out of 28 sampled residents, that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including SARS-CoV-2. Specifically, observations were made of staff entering rooms on Transmission Based Precautions (TBP) without determining if aerosolized generating procedures (AGP) were in use and the necessary Personal Protective Equipment (PPE) was not donned, resident's Continuous Positive Airway Pressure (CPAP) machines were not cleaned by staff, staff were observed not performing hand hygiene and changing gloves during wound care, and staff were observed not performing hand hygiene during meal delivery. Resident identifiers: 11, 14, 22, and 24. Findings included: 1. Resident 14 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, cerebral palsy, acute respiratory failure, obstructive sleep apnea (OSA), morbid obesity, atrial fibrillation, and hypertension. On 8/02/21 at 2:52 PM, an interview was conducted with resident 14. Resident 14 stated that he needed a new CPAP machine because his current one was on recall. Resident 14 stated that he operated the machine independently and cleaned the machine himself. Resident 14 stated that he filled up the water reservoir, and that he should receive new supplies soon. An observation was made of signs posted on resident 14's door that stated on droplet precautions during aerosolized procedure. Upon initiation of CPAP/Bilevel Positive Airway Pressure (BIPAP), during all duties and cares with CPAP, and for 30 minutes after removal of CPAP wear gloves, gown, N95, and face shield, and discard upon exiting room. The PPE was observed to be located inside the resident's room by the door hanging in a bag on the glove dispenser. The PPE bag contained disposable gowns, face shields, and N95 masks. On 8/3/21 resident 14's medical records were reviewed. Review of resident 14's July 2021 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no documentation for cleaning and care of the CPAP equipment. On 8/4/21 at approximately 4:15 AM a continuous observation was started outside of resident 14's room. No observations were made of the licensed nurses or Certified Nursing Assistants (CNA) from night shift entering the resident room. On 8/04/21 at 5:52 AM, an interview was conducted with CNA 1. CNA 1 stated that the day shift staff were responsible for cleaning the CPAP machines, but some residents were able to do this themselves. CNA 1 stated that for residents that had a CPAP machine running she would donn a gown, goggles, gloves, and N95 mask when she entered the room. CNA 1 stated that she would place a face shield over her goggles and then discard it afterwards. CNA 1 stated that the face shields were used one time only and then discarded, and that the facility had sufficient supply to do this. The CNA stated the PPE was located just inside the door of resident 14's room. On 8/04/21 at 6:18 AM, an observation was made of CNA 2 entering resident 14's room. CNA 2 was observed to donn a pair of gloves at the residents doorway and close the door. An immediate interview was conducted with the CNA 2 upon exit of resident 14's room. CNA 2 stated that the resident needed assistance to the restroom. The CNA stated that the resident was up and seated at the bedside when she entered. The CNA stated that the CPAP machine was not running when she entered the room, that the resident was independent with operating the machine, and he put it on and took it off independently. CNA 2 was observed wearing a surgical mask and goggles inside the resident room. On 8/04/21 at 6:29 AM, an observation was made of CNA 2 entering resident 14's room again to answer the call light. The CNA had a stack of clean linen with her when she entered the room, and no additional PPE was donned. CNA 2 was observed wearing a surgical mask and goggles inside the resident room. On 8/04/21 at 6:34 AM, an interview was conducted with CNA 2. CNA 2 stated that when she entered resident 14's room earlier for toileting assistance she only donned gloves and no other PPE. The CNA stated that she did not know when the resident had turned off the CPAP machine and she did not ask. The CNA stated that the nightshift staff were responsible for cleaning the CPAP equipment. On 8/04/21 at 6:38 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she was not sure of the process for cleaning the CPAP machine, but that the staff on the night shift should be doing it. On 8/04/21 at 6:40 AM, an interview was conducted with Registered Nurse (RN) 1 and CNA 3. RN 1 stated that resident 14 cleaned his own CPAP machine. CNA 3 stated that she filled the water reservoir on day shift and then wiped the machine down with a disinfecting wipe on the outside only. RN 1 stated that resident 14 was independently using his CPAP machine. RN 1 stated that she did not know when he had removed the machine this morning and she did not ask him. RN 1 stated that when the CPAP was running the staff were to wear an N95 mask, gown, gloves and goggles or face shields when it was operating and for 30 minutes afterwards. That's a good question. How do I know when he took it off? RN 1 stated that usually resident 14's door was closed when he was using the CPAP machine. RN 1 stated that by the time she entered the resident's room in the morning he had been up for awhile, because he was an early riser. On 8/04/21 at 6:47 AM, an interview was conducted with the Corporate Resource Nurse (CRN) who was also the acting Director of Nursing (DON). The CRN stated that she would print the facility process for cleaning the CPAP machines. On 8/04/21 at 7:25 AM, an interview was conducted with the CRN. The CRN stated that she had an email with the cleaning process for the CPAP machines and a policy for the cleaning process. The CRN stated that the CNAs were responsible for this task, probably the night shift, but should be the day shift. The CRN stated that she did not know where it was documented as completed or if it was even being documented at all. The CRN stated that for rooms on TBP for the CPAP machine and for 30 minutes after discontinuation of use staff should be asking the resident when they removed the CPAP to determine if the additional PPE was still required. The CRN stated that other residents nap during the day and use the CPAP during the day. The CRN stated that on the Long Term Care side the residents were very routine so the CNAs knew that by breakfast they were fine. Review of the CPAP cleaning recommendations contained in an email on 6/23/2020 from the CRN documented that the staff were to do the following: 1. Wipe off with a damp cloth (outside) 2. Change filter every 3 - 6 months 3. 1 x per week wash the reservoir, face mask and tubing with warm soapy (mild detergent) water. a. If it isn't coming clean you can use 1 part vinegar with 3 parts water to clean. b. Repeat with warm soapy water. c. Rinse d. Air dry Review of the facility Policy and Procedure for CPAP/BiPAP Support documented under the General Guidelines for Cleaning that specific instructions were obtained from the manufacturer of the device. The machine cleaning stated to wipe the machine with warm, soapy water and rinse a least once a a week and as needed. The humidifier (if used) stated to use clean distilled water only in the humidification chamber, clean humidifier weekly and air dry, and to disinfect to place in a vinegar-water (1:3) and soak for 30 minutes followed by a thorough rinse. The washable filters were to be cleaned by running under water once a week to remove dust and debris, and replaced at least once a year. Disposable filters needed to be replaced monthly. The policy stated to clean the masks, nasal pillows, and tubing daily by placing in warm, soapy water and soaking/agitating for 5 minutes. Mild dish detergent was recommended. Rinse with warm water and allow to air dry between uses. The headgear strap stated to wash with warm water and mild detergent as needed and allow to air dry. The policy was revised in March 2015. On 8/4/21 at 7:36 AM, an observation was made of CNA 4 inside resident 14's room obtaining vital signs. CNA 4 was observed wearing a surgical mask and face shield. CNA 4 stated she did not ask resident 14 about the CPAP machine, nor the time it was turned off. CNA 4 stated she was not present when the resident removed his CPAP machine, and did not know who did it. CNA 4 stated that she donned gloves in addition to her face shield and surgical mask when she obtained the vital signs. On 8/5/21 at 9:04 AM, a follow-up interview was conducted with the CRN. The CRN stated staff should be adhering to the TBP that were posted on the sign outside the door. The CRN stated that the day shift should be determining when the device was removed before entering the room. The CRN stated that for those residents that were independent with the CPAP it would be appropriate for staff to ask the resident when they removed the device. The CRN stated that the location of the PPE did not make sense. It needed to be located on the outside of the room. That was why the door was closed, the droplets were in the air. The CRN stated that the staff should be donning the PPE outside of the room. Review of the Centers for Disease Control and Prevention (CDC) on Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic documented under Implement Universal Use of Personal Protective Equipment stated that healthcare personnel (HCP) working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with SARS-CoV-2 infection. The guidance further recommended that HCP should follow Standard Precautions and TBP if required, a N95 respirator or equivalent should be used for all aerosol-generating procedures, and eye protection should be worn during patient care encounters to protect from exposure to respiratory secretions. The guidance was last updated on February 23, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html 2. Resident 22 was admitted to the facility on [DATE] with diagnoses which included congestive heart failure (CHF), morbid obesity, major depressive disorder, history of transient ischemic attack, sciatica, restless leg syndrome, and hypothyroidism. On 8/2/21 at 1:39 PM, an interview was conducted with resident 22. Resident 22 stated that she had been using a CPAP machine for many years and could operate it independently. Resident 22 was observed seated at the bedside with 1.5 liters of supplemental oxygen being administered via a nasal cannula. The CPAP machine was observed on the bedside table with a gallon bottle of distilled water next to it. The water was labeled with an open date of 7/1/21, and was initialed by a staff member. An observation was made of signs posted on resident 22's door that stated on droplet precautions during aerosolized procedure. Upon initiation of CPAP/BIPAP, during all duties and cares with CPAP, and for 30 minutes after removal of CPAP wear gloves, gown, N95, and face shield, and discard upon exiting room. The Personal Protective Equipment (PPE) was observed to be located inside the resident's room by the door hanging in a bag on the glove dispenser. The PPE bag contained disposable gowns, face shields, and N95 masks. On 8/3/21 resident 22's medical records were reviewed. Review of resident 22's July 2021 MAR and TAR revealed no documentation for cleaning and care of the CPAP equipment. On 8/4/21 at approximately 4:15 AM, a continuous observation was started outside of resident 22's room. The door to resident 22's room was observed open and the privacy curtain was observed closed. Resident 22's roommate's privacy curtain was also observed to be closed. On 8/4/21 at 5:46 AM, an interview was conducted with CNA 1. CNA 1 stated that resident 22 had refused the use of the CPAP machine and had not used it since she had been at the facility. CNA 1 stated that she had never assisted resident 22 with the device. CNA 1 stated that resident 22 had told her that it did not work correctly and because of this she did not want to use it. CNA 1 stated that she reported it to the nurse, but could not recall who as it was a long time ago. CNA 1 stated that she assisted the residents with applying the CPAP device at nighttime. On 8/4/21 at 8:03 AM, an interview was conducted with CNA 3. CNA 3 stated that she was just inside resident 22's room assisting the roommate with transferring to a wheelchair with CNA 2. CNA 3 stated that she only wore a surgical mask and face shield while inside the resident room. On 8/4/21 at approximately 8:05 AM, an observation was made of the facility Administrator stopping CNA 3 from entering resident 22's room. The Administrator was heard to ask CNA 3 if resident 22's CPAP was running. CNA 3 responded that she did not know. The Administrator stated that CNA 3 had to follow the droplet precaution sign that was posted on the door and donn all the required PPE. The Administrator was observed placing a bedside table outside resident 22's door in the hallway. The table contained alcohol based hand rub, biohazard bags, gloves, disposable gowns, face shields, and N95 masks. On 8/04/21 at 8:21 AM, an interview was conducted with CNA 2 and CNA 4. CNA 2 stated that the resident was not using the CPAP machine. CNA 2 stated that she had never seen resident 22 with the CPAP device on. CNA 2 stated that the night shift staff had reported that resident 22 did not like to wear it. CNA 2 stated that she provided care to the resident and did not donn any additional PPE prior to entering the residents room for the first time. CNA 4 stated that when she obtained vital signs the resident was not wearing a CPAP machine. On 8/05/21 at 9:12 AM, a follow-up interview was conducted with the CRN. The CRN stated that the Medical Director reported that resident 22 wanted to keep the CPAP machine to utilize on an as needed (PRN) basis. The CRN stated that the resident reported that she did not like it but wanted to have it available should she choose to use it. The CRN stated that resident 22 having a roommate with an aerosol generating procedure was not a concern for them because neither residents were symptomatic, both were vaccinated, and the equipment was not currently being utilized. 3. Resident 11 was admitted to the facility on [DATE] with diagnoses which included congestive heart failure, cirrhosis of liver, dysphagia, pnuemonitis, coronary artery bypass graft(s), atrial-fibrillation, hypertension, hyperlipidemia, nonrheaumatic tricuspid valve insufficiency, shortness of breath, edema, polyneuropathy, dysuria, osteoarthritis, cervicalgia, and cardiomegaly. On 8/03/21 at 9:48 AM, an interview was conducted with resident 11. Resident 11 was observed to be seated in a wheelchair at the bedside, a roho cushion was not observed present in the wheelchair. An air mattress was observed on the bed. Resident 11 stated she had a bandage on her hiney, and sometimes it hurts with sitting. Resident 11 stated that the nurses changed the bandage, and she was not aware if the wound was open. Resident 11 stated that the wound developed at the facility. Resident 11 was observed with a brace on the right lower extremity, and the device was secured around the foot, ankle, and calf. Resident 11 was not able to tell me what the device was for. The resident stated that she was not able to ambulate and that upset her. On 8/3/21 resident 11's medical records were reviewed. Review of resident 11's physician orders revealed the following: a. Coccyx Treatment Friction Wounds: Cleanse wounds with normal saline, pat dry. Apply Skin prep to peri wound, place calcium alginate to open wound bed and cover with island dressing. Change 3 times per week on Monday, Wednesday, and Fridays after showers and as needed to aid in wound healing until resolved. Monitor placement daily. The order was initiated on 7/30/21. b. Treatment to the Right Heel SDTPI (suspected deep tissue pressure injury): Apply skin prep to heel and bony prominence of foot and leave open to air. Place Podus Boot on right foot at all times to aide in wound healing until resolved. The order was initiated on 7/29/21. c. Place wheelchair air cushion in recliner chair for comfort and to aide in wound healing. Monitor for proper placement. The order was initiated on 7/26/21. d. Treatment to the Left Heel: Apply skin prep to heel and bony prominence of foot for protection of skin integrity every shift. The order was initiated on 7/20/2021. e. Alternating pressure mattress to bed for comfort/protection of skin integrity. The order was revised on 7/20/21. f. Float Heels for protection of skin integrity. The order was revised on 6/21/21. Review of resident 11's Weekly Skin Assessments revealed the following: a. On 7/25/21 Pitting edema noted +3 in bilateral lower extremities. Open friction wound on coccyx. Blister on right heel. b. On 8/2/21 Pitting edema noted +3 in bilateral lower extremities. Open friction wound on coccyx. Blister on right heel. Review of resident 11's progress notes revealed: a. On 7/26/2021 at 2:24 PM, the Skin/Wound Note documented, Pt (patient) continues to have two friction wounds to her coccyx region. One on the right and one on the left of the bony prominence on each buttock near gluteal cleft. Right buttock wound: Total compromised area measures 3.0 x (by) 1.8 cm (centimeters). Outer layer of dark purple skin has come off leaving two open sites visible with blanching pink epithelial tissue between the two. Proximal wound measures 0.5 x 0.5 cm. Wound bed is red, moist intact dermal tissue. Peri wound is blanching red, moist, intact tissue. Surrounding skin is pink, dry, and intact. Distal wound measures 1.3x1.8cm. Wound bed is red, moist, intact dermal tissue. Minimal light yellow mucousy drainage was cleansed from site, without odor. Peri wound is blanching red, moist, sloughing flaky tissue. Surrounding skin is pink, warm, and dry. Left buttock: Wound measures 1.5x1.5cm. Wound bed is red, moist, dermal tissue with minimal light yellow mucousy drainage without odor cleansed from site. Peri wound is blanching red, moist, flaky sloughing tissue. Surrounding skin is pink, warm, and dry. Pt continues to have a SDTPI to her right heel. Wound now measures 2.1x2.4cm. Wound continues to appear as a serous fluid filled raised blister with dark purple discoloration at the medial edge. Outer layer of skin is intact. Peri wound is blanching red, dry, intact tissue. Surrounding skin is pink, warm, and dry. Pt was more alert and oriented today than at last assessment. I reported my findings as well as discussed tx (treatment) options with pt. Following our discussion, and per pt permission, an order was obtained to place w/c (wheelchair) air cushion to recliner chair for comfort and to aide in wound healing. All tx completed as ordered. It was reported that pt coccyx wound is a PU (pressure ulcer). Upon assessment, it is determined that wound continues to be friction wound, there is no new PU to coccyx, and wounds to buttock near coccyx are not pressure related. There is increased moisture exposure to site as it is near gluteal cleft, and that site on pt is very tight, so there is increased moisture at site, and therefore may also be Moisture associated skin damage, but wounds started as friction, therefore will continue to be classified as friction wounds. Pt denied any other skin concerns; no others reported by nursing. No other skin was assessed. b. On 7/18/2021 at 5:05 AM, the progress note documented that the resident developed a blister on right heel and large reddened area with apparent blister on coccyx. Areas cleaned and padded dressings applied. On 8/4/21 at 5:39 PM the Wound Nurse (WN) provided the following documentation of the wound care that was provided on 8/2/21. Pt continues to have a SDTPI to her right heel. Wound now measures 2.1x2.1cm. Wound continues to appear as a serous fluid filled raised blister with dark purple discoloration at the medial edge. The perimeter is a light-yellow color. Outer layer of skin remains intact. Peri wound is blanching pink, dry, intact tissue. Surrounding skin is pink, warm, and dry. Pt now has only one friction wound to her coccyx region. The one on the right side has resurfaced. The one on the left of the bony prominence remains in place on the buttock near gluteal cleft. Right buttock site now has blanching pink epithelial tissue noted. Surrounding skin is pink, warm, and dry. Left buttock: Wound now measures 1.2x1.3cm. Wound bed is red, moist, dermal tissue with trace serous drainage without odor noted to dressing when removed. Peri wound is blanching red, moist, intact tissue. Surrounding skin is pink, warm, and dry. On 8/04/21 at 11:27 AM, an interview was conducted with RN 1. RN 1 stated that she completed the dressing change on resident 11 coccyx as the dressing had come off during the shower. RN 1 stated that she did not see me in the hallway so she went ahead and conducted the dressing change without me. On 8/04/21 at 11:52 AM, RN 1 stated that resident 11 had a suspected deep tissue pressure injury (SDTPI) on the back of the heel. The brace was placed to keep pressure off of the heel. The RN stated that she had a treatment order for that wound that was skin prep right now, and that she still needed to provide that treatment. On 8/04/21 at 1:56 PM, an observation was made of resident 11's wound care that was provided by the WN. The resident was seated in the wheelchair with a pillow positioned behind her back. The WN donned new gloves and assisted RN 1 with transferring resident 11 to the bed for the dressing change. RN 1 assisted the WN with position changes during the dressing change. Resident 11 was positioned on their back. The WN pulled resident 11's pants down, and proceeded to remove the tab brief. Resident 11's brief was changed. The WN removed the old composite dressing with a calcium alginate 2 by 2 square. The surrounding wound bed was cleaned with an adult wash cloth. The WN radioed for wound care supplies from another nurse. The wound care nurse stated that the wound had improved since Monday. The wound bed was observed pink, no exudate or eschar was noted. The WN doffed her gloves and new gloves were applied, no hand hygiene was performed. The WN removed the boot from resident 11's right foot. The WN cleansed the heel with skin prep, no dressing was applied. The right heel was observed with a large purple blister, and the skin was intact. The WN doffed her gloves and new gloves were donned, no hand hygiene was performed. The WN applied skin prep to the surrounding skin of the coccyx wound. A calcium alginate 2 by 2 dressing was applied to the wound bed and then a composite island dressing was applied over the top. The WN stated that wound measurements were obtained on Monday. The WN was observed to wash her hands upon completion of dressing change. 4. Resident 24 was admitted to the facility on [DATE] with diagnoses which consisted of Alzheimer's disease, benign prostatic hyperplasia, chronic kidney disease, osteoporosis, PU right heel stage 4, left artificial hip joint, protein-calorie malnutrition, and bilateral hearing loss. On 8/02/21 at 1:53 PM, an observation was made of resident 24. The resident was seated in a wheelchair at the bedside. Signs were observed posted on the wall next to the head of the bed that stated to put heel protectors on while in bed and to turn every 2 hours. The bed did not have an air mattress on it. Resident 24 was observed with heel protectors on bilateral feet and elbow cushions were noted under both elbows on the wheelchair armrests. Resident 24 stated that he previously had Methicillin-resistant Staphylococcus aureus (MRSA) infection in the heel wounds prior to being admitted to the facility. Resident 24 stated that he had dressing changes every 2 days to the wounds on his feet. Resident 24 reported a history of wounds on the bilateral feet that he received poor care for at a hospital in another state. Resident 24 spoke with great regard towards the WN and the care he had received in healing his wounds on his feet while at the facility. On 8/3/21 resident 24's medical records were reviewed. Review of resident 24's physician orders revealed the following: a. Treatment to Right Heel Split: Cleanse with normal saline and pat dry. Apply Skin prep to peri wound. Apply Calcium Alginate over wound. Cover with Silicone Bordered Foam Dressing 3 times a week on Tuesday, Thursday, and Saturday and as needed to aide in wound healing until resolved. The order was initiated on 8/4/2021. b. Treatment to L heel Stage III PU: 1. Remove old dressing. 2. Soak 4 x 4 gauze with Puracyn. Apply to wound for 10 minutes. Then remove, and pat dry. 3. Apply Collagen sheet to wound bed. 4. Apply Silver Hydrogel over Collagen. 5. Cover with a Gentle Bordered Foam 3 times a week on Tuesday, Thursday, and Saturday and as needed to aide in wound healing until resolved. Monitor daily for placement. *Set a timer if you need to ensure you leave the Puracyn on long enough* I peel back the current dressing, put the gauze on, and then reapply the current dressing so it stays in place. The order was initiated on 4/20/2021. c. Pressure relieving boots to left foot at all times and right foot at all times when in bed for protection of skin integrity and to aide in wound healing. *Ensure aides are placing boots on*. The order was initiated on 3/29/2021. d. Foam pad over mattress to bed for comfort/protection of skin integrity. No directions specified for order. The order was revised on 3/15/21. e. ROHO cushion-pressure relieving on wheelchair to coccyx. The order was revised on 12/4/19. On 8/4/21 at 5:39 PM the WN provided the following documentation of the wound care that was provided on 8/2/21. The left heel documented Pt continues to have a healing Stage III PU to his left heel that has slight decline since last assessment. Total compromised area now measures 1.1x1.5cm with 2 open areas remaining. Proximal and medial open site now measures 0.4x0.6cm. Proximal and lateral open site now measures 0.1x0.2cm. Red moist dermal tissue is exposed to wound beds. No drainage or odor was noted to dressing when removed. Blanching pink epithelial tissue is present in between each open site and to peri wound. Surrounding skin is pink, warm, dry intact epithelial tissue. The right heel documented Pt continues to have the split open wound to his right heel. Wound now measures 0.3x1.0cm. Wound bed is red moist dermal tissue. Peri wound white macerated tissue. Surrounding skin is light brown, hard, dry, calloused tissue. On 8/04/21 at 2:29 PM, an observation was made of the WN performing wound care on resident 24's bilateral heel wounds. The WN stated that resident 24 was able to ambulate independently and could transfer independently. The resident was observed to stand and transfer himself from the wheelchair to the bed with stand by assist. The WN stated that the resident's wounds had healed and resurfaced on the left heel. The wound nurse stated that the resident at one point stopped wearing his Podus boots because he thought he was finished with them. His healed wounds subsequently resurfaced. The WN stated that the resident had peripheral neuropathy and could not feel anything in his lower extremities so she educated him on the need to continue to wear the boots to protect his feet. The resident was compliant afterwards. The WN stated that the resident developed the PU while at the facility, but has had a long history of wounds in his bilateral lower extremities prior to being admitted . The WN stated that they suspected that the resident had some venous insufficiency, but the resident refused to have the testing done to confirm this diagnosis. The WN was observed to remove the bilateral Podus boots. The WN assisted resident 24 with foot placement in bed. The WN doffed gloves and new gloves were donned. The WN was observed to [NAME] back the sock and old dressing from the left heel, and apply a 2x 2 gauze soaked in Puracyn to the wound bed under the existing bandage. The sock and bandage was placed back over the wound. The WN then mixed collagen powder and silver hydrogel with a cotton tipped applicator. The WN doffed the gloves and new gloves were applied. The WN stated that the dressing for the left heel was to let the Puracyn sit for 10 minutes and then apply the collagen and silver hydrogel mixture to the wound bed and cover with a bordered foam dressing. The WN then removed the old dressing from the right heel. The WN stated that the heel was now macerated, and she would need to change the orders to apply calcium alginate now. The WN was observed to cleanse the wound with a 4 x 4 gauze soaked with normal saline. The WN doffed her gloves and hand hygiene was performed. New gloves were applied. The WN applied skin prep to the surrounding skin of the right heel wound, calcium alginate 2x2 was applied to the wound bed, and the wound was covered with a bordered gauze dressing. The WN doffed her gloves, and new gloves were donned. The WN removed the left sock and wound dressing. The WN was observed to apply a collagen sheet with silver hydrogel applied on top to the wound bed. The wound was covered with a bordered gauze dressing. Both dressings were dated and initialed by the WN. An immediate interview was conducted with the WN upon completion of the dressing change. The WN stated that she usually performed hand hygiene between wounds and every time she doffed and donned new gloves. I didn't this time. The WN stated that she typically doffed and donned new gloves between dressings and not between the old dressings removal and the new dressings application. On 8/05/21 at 9:19 AM, an interview was conducted with the CRN. The CRN stated that hand hygiene and doffing and donning of gloves should be performed when going from dirty to clean. 5. On 8/02/21 at 12:02 PM, the following observation was made of the lunch meal service in the main dining room: a. At 12:07 PM CNA 5 delivered the meal tray to resident 28. CNA 5 was

Based on interview and record review, it was determined that the facility did not employ a clinically qualified full-time dietitian or other clinically qualified nutrition professional to serve as the director of food and nutrition services. Specifically, the facility did not employ a full time Registered Dietitian (RD) and the Dietary Manager (DM) did not meet the requirements to serve as the director of food and nutrition services. Findings included: On 8/2/21 at approximately 11:28 AM, an interview was conducted with the facility's DM. The DM stated he was enrolled in classes to complete the certification for Dietary Manager. He stated he was enrolled in a fast track program that would take about 5 months to be completed. The DM stated he had been at the facility for 2 ½ years. The DM stated the facility had a Registered Dietitian (RD) consultant that came to the facility at least once per week, sometimes more frequently. The DM stated the RD participated in weekly skin and weight meetings at the facility. On 8/3/21 at approximately 4:00 PM, the date of hire and certifications for the DM were requested from Human Resources (HR). The correspondence from HR included the DM's hire date of 8/3/19 and current Serve Safe certificate. On 8/5/21 at approximately 11:30 AM, an interview was conducted with the facility RD. The RD stated she came to the facility every Wednesday for meetings, but mostly worked remotely from home. The RD stated the facility had a Dietary Technician (DT) that worked part time at the facility. She stated that the DT was in touch with her on a daily basis regarding resident needs. The RD stated the DT did resident assessments, including risk assessments and preferences. The RD stated the DM was also in touch with her regularly regarding residents and dietary needs. The RD stated assessments were completed within 10 days of a resident's admission to the facility, unless the resident was on a tube feed, had a pressure ulcer, low intake, or was on dialysis. The RD stated those assessments were completed within 72 hours with the goal being 48 hours. The RD stated the DM and the DT did not make recommendations on their own, but consulted with her about needs for the resident. The RD stated recommendations for supplements were approved by the Medical Doctor (MD). The RD stated the DM did not have any current credentials and had been falling behind in his schooling. The RD stated the facility was considering giving the DM some time off to finish the certification program.