**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, resident record review, and the facility's Proper Use of Side Rails policy, the facility failed to perform ongoing assessments for the use of side rails for Resident Identifier (RI) #7 to ensure the side rails used met RI #7's needs. This deficient practice affected RI #7, one of one resident reviewed for side rail use. Findings included: The facility admitted Resident Identifier (RI) #7 on 03/17/2014. A review of RI #7's annual Minimum Data Set (MDS), dated [DATE], revealed severe cognitive impairment. Per the MDS, RI #7 required one-person extensive physical assistance with bed mobility and full staff performance of transfers. The MDS indicated the resident did not walk during the assessment period and did not use a bed rail. A review of RI #7's care plan revealed a problem of self-care deficit related to a history of Cerebrovascular Accident (CVA) with residual effects, with a problem onset date of 03/17/2014. Approaches included a bed with two 3/4 side rails with pads. A review of RI #7's physician's orders revealed an order for a bed with two 3/4 side rails with pads started on 04/10/2015. On 02/02/2022 at 9:30 AM RI #7 was observed in bed with full padded side rails in place on both sides of RI #7's bed. A review of RI #7's medical record revealed there was no consent or ongoing assessments completed for the continued use of side rails. During an interview on 02/03/2022 at 12:04 PM, Employee Identifier (EI) #1, a Certified Nurse Aide (CNA), stated RI #7 had side rails up when in bed because the resident moved around a lot. Per EI #1, the side rails were padded for protection and to prevent the resident from putting their legs through the side rails. During an interview on 02/03/2022 at 12:09 PM, EI #2, a Licensed Practical Nurse (LPN), stated RI #7 had padded side rails when in bed to prevent falls, and the pads were to protect RI #7's legs. Per EI #2, the side rails were put in place in 2014 and RI #7 did not have a history of falls. EI #2 did not know why the side rails were in place since RI #7 had no history of falls. EI #2 could not find documentation in RI #7's medical record as to why the side rails were started and stated EI #5, the LPN Restorative Supervisor, conducted side rail assessments. During an interview on 02/03/2022 at 12:36 PM., EI #3, a CNA, stated RI #7 had padded side rails in the up position when in bed. EI #3 thought RI #7 used to get out of bed, so the side rails were added. Per EI #3, it had been years since RI #7 tried to get out of bed; however, staff still put the padded side rails up when RI #7 was in bed because there was a physician's order. During an interview on 02/03/2022 at 1:27 PM, EI #4, a Restorative CNA, stated RI #7 did not try to get out of bed. EI #4 thought the family requested the padded side rails be in the up position when RI #7 was in bed. Per EI #4, the side rails were padded to keep RI #7 from bumping the rails. During an interview on 02/03/2022 at 1:31 PM, EI #5, the LPN Restorative Supervisor, stated RI #7 did not try to get out of bed, and it had been many years since RI #7 had a fall. EI #5 then stated EI #6, the LPN Restorative Nurse, did RI #7's side rail assessment. During an interview on 02/03/2022 at 1:41 PM, EI #6, the LPN Restorative Nurse, stated RI #7 did not try to get out of bed anymore, and the padded side rails were in place for safety due to family request. EI #6 did not do RI #7's side rail assessment and stated, if there was one, it would have been part of the initial resident paperwork, noting they did not conduct quarterly or annual assessments or obtain consents for side rails. EI #6 then stated side rails were not considered a restraint because they were in place for safety. Per EI #6, RI #7 did not try to get out of bed. On 02/03/2022 at 2:50 PM RI #7 was observed in bed with full padded side rails in place on both sides of RI #7's bed. During an interview on 02/03/2022 at 2:55 PM, EI #12, the Director of Nursing (DON)/Registered Nurse (RN), stated there were no restraints in the facility and side rails were not a restraint. EI #12 then stated a restraint was anything that stopped a resident from moving or touching their body, and EI #12 did not consider side rails a restraint. EI #12 stated RI #7 had not fallen in two or three years, and if the side rails were not there, RI #7 could roll out of bed. Per EI #12, the pads were in place to keep RI #7's legs or arms from going through the rails. EI #12 identified that assessments were done for side rails before initial use, an order was written, and the care plan was updated. EI #12 then stated EI #7, Maintenance Supervisor, was responsible for doing side rail assessments and that consents for side rail use were not obtained. During an interview on 02/03/2022 at 3:02 PM, EI #7, Maintenance Supervisor, stated EI #5 did side rail assessments and determined if a resident was at risk to fall out of bed. If an order was written, EI #7 stated he put the side rails on the bed. During an interview on 02/04/2022 at 8:55 AM, EI #11, the Administrator, stated a restraint was something that kept a resident from moving, and the facility had no restraints. EI #11 expected the proper staff to conduct assessments and what they provided to residents to be appropriate. Per EI #11, it was important to conduct ongoing evaluations of side rails because resident conditions were constantly changing, and they expected the proper paperwork to be completed as to why side rails were in place. A review of the facility's Proper Use of Side Rails policy, dated 09/09, revealed, The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. 2. Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. 3. An assessment will be made to determine the resident's symptoms or reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; and b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet. 4. The use of side rails as an assistive device will be addressed in the resident care plan. 9. Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks. 10. The resident will be checked periodically for safety relative to side rail use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review, interviews, and review of the facility's Antipsychotic Medication Use policy, the facility's Behavior Assessment and Monitoring policy, and the facility's Depression - Clinical Protocol policy, the facility failed to ensure Resident Identifier (RI) #31, was monitored for behaviors for which antipsychotic medication was administered and the facility further failed to ensure RI #31 and RI #47 were monitored for side effects of psychotropic medications to include: antipsychotic and antidepressant medications. This affected two of 4 sampled residents reviewed for unnecessary medications who received antipsychotic and antidepressant medication. Findings included: A review of the facility's Antipsychotic Medication Use policy and procedure, dated 09/2009, revealed, . 4. Nursing staff will document in detail an individual's target symptom(s). 14. Nursing Staff will monitor and report any of the following side effects to the Attending Physician: a. Sedation; b. Orthostatic hypotension; c. Lightheadedness; d. Dry mouth; e. Blurred vision; f. Constipation; g. Urinary retention, h. Increased psychotic symptoms . i. Extrapyramidal effects; j. Akathisia; k. Dystonia; l. Tremor; m. Rigidity; n. Akinesia; or tardive dyskinesia. A review of the facility's Behavior Assessment and Monitoring policy and procedure, dated 09/2009 revealed, Policy Statement 1. Problematic behavior will be identified and managed appropriately.3. The facility will comply with regulatory requirements related to the use of medications to manage problematic behavior. Monitoring 1. If the resident is being treated for problematic behavior or mood, the staff and physician will obtain and document ongoing assessments of changes (positive or negative) in the individual's behavior, mood, and function. A review of the facility's Depression - Clinical Protocol policy and procedure, dated 09/09, revealed, . The staff and physician will monitor the resident carefully for side effects specific to each class of medication as well as interactions between antidepressants and other classes of medications. RI #31 was readmitted to the facility on [DATE] and had diagnoses which included Vascular Dementia without Behavioral Disturbance, Adjustment Disorder with Depressed Mood, Major Depressive Disorder, Mood Disorder, Anxiety Disorder, Psychotic Disorder with Hallucinations, Delusional Disorders, and Schizophrenia. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/26/2021, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment and had exhibited no behaviors during the seven days prior to the ARD. The MDS indicated RI #31 had received antipsychotic and antidepressant medication on seven of seven days prior to the ARD and received antipsychotic medication on a routine basis only. RI #31's care plan with problems that included Dementia, Depression, Adjustment Disorder, Episodic Mood Disorder, Psychosis Disorder and Anxiety Disorder, history of making suicidal statements, hallucinations and episodes of paranoia, with a problem onset date of 01/15/2015, included other behaviors listed under approaches that included: yelling out, yelling at others, making accusations against staff and others. The care plan indicated the resident received antidepressant and antipsychotic medication which were ordered upon admission. Approaches to the problem included to report extrapyramidal related symptoms/adverse reaction and to document behaviors, interventions, and outcomes. The care plan also indicated the resident had a problem related to receiving multiple medications that was last reviewed 11/30/2021. An approach to the problem included to report possible unwanted drug-related side effects or interactions. A review of RI #31's February 2022 physician's orders revealed the resident was to receive Seroquel 200 milligrams (mg) by mouth every night for Schizophrenia and Celexa 20 mg by mouth daily for Major Depressive Disorder. The original date of the Seroquel order was 08/31/2018. The original date of the Celexa order was 01/12/2015. A review of RI #31's electronic health record (EHR) and hard chart revealed no behavior monitoring and/or side effect monitoring for the medications. On 02/04/2022 at 11:16 AM, Employee Identifier (EI) #9, a Licensed Practical Nurse, was interviewed. She stated the behavior for which the resident was administered Seroquel was hitting at staff during care. She reviewed the resident's EHR and hard chart and was unable to find documentation of monitoring for target behaviors and/or side effects of the Seroquel and Celexa. RI #47 was readmitted to the facility on [DATE] and had diagnoses to include: Psychotic Disorder with Delusions, Alzheimer's Disease, Depressive Episodes, Dementia with Behavior, Anxiety and Insomnia. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 12/24/2021, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5 which indicated severe cognitive impairment. The MDS indicated the resident had hallucinations and delusions as potential indicators of psychosis and had exhibited no behaviors during the seven days prior to the ARD. The MDS indicated the resident had received antipsychotic, antianxiety, and antidepressant medication on seven of seven days prior to the ARD. It indicated the resident was administered antipsychotic medication on a routine basis only. Review of RI #47's care plan with a problem onset date of 01/25/2019, most recently reviewed/revised 12/28/2021, indicated the resident's problems included the use of psychotropic meds for diagnoses of Dementia with Delusions, Depression, and Anxiety. An approach for the problem was to observe for any side effects of the medication. RI #47's care plan with a revised date of 12/28/2021 had a problem related to receiving medications with potential risk for adverse drug reactions/unwanted effects/interactions. An approach was to document unwanted side effects or interactions to medications. A review of the physician's orders, dated 02/2022, indicated the resident was to receive the following medications: Zoloft 50 milligrams (mg) for Depressive Episodes (original order was 10/12/2020); Trazodone 50 mg at bedtime for Insomnia (original order date was 07/19/2021); Buspar 10 mg twice daily for Anxiety (original order date was 10/12/2020); and Seroquel 50 mg at bedtime for Delusions (original order date was 08/10/2021). A review of the resident's electronic health record (EHR) and hard chart revealed no documentation of side effects monitoring for the use of Zoloft, Trazodone, Buspar, and Seroquel. On 02/04/2022 at 11:33 AM, Employee Identifier (EI) #9, a Licensed Practical Nurse (LPN), was interviewed. After reviewing the resident's EHR and hard chart, she stated side effects for the use of the medications had not been monitored. She stated the nurse who wrote the physician's order for the medications was responsible to ensure side effect monitoring was done. On 02/04/2022 at 12:19 PM, EI #12, the Director of Nursing (DON), was interviewed. She stated a resident who received an antipsychotic medication was supposed to be monitored for the target behaviors for which the medication was being administered. She stated the registered nurse who worked on the hall where the resident resided was responsible to ensure behavior monitoring was done for residents who received antipsychotic medication. The DON stated a resident who received an antipsychotic and/or an antidepressant medication was supposed to be monitored for side effects of the medication. She stated the nurse who administered the medication was responsible to ensure the resident was monitored for side effects of the medication. On 02/04/2022 at 1:08 PM, EI #12, in a follow up interview, stated she could not find documentation of behavior monitoring for the use of Seroquel and/or side effect monitoring for the use of Seroquel and Celexa for RI #31. She stated she could not find documentation of side effect monitoring for the use of Zoloft, Trazadone, Buspar, and Seroquel for RI #47. On 02/04/2022 at 1:14 PM, EI #11, the Administrator, was interviewed. He stated residents who received antipsychotic medications should be monitored for the behaviors for which they were administered the medication. The administrator stated residents who received antipsychotic and/or antidepressant medication should be monitored for side effects of the medication. On 02/04/2022 at 2:02 PM, RI #31's and RI #47's psychiatrist, EI #10, was interviewed by phone. He stated he expected the facility to monitor residents who received antipsychotic medication for behaviors for which the medication was administered. He stated he expected the facility to monitor for side effects of antipsychotic and antidepressant medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident record review, interviews, and review of the facility's Administering Medication policy, the facility's Administration of Metered-Dose Inhaler policy, and manufacturer's instructions for use, the facility failed to ensure a medication error rate of less than 5%. The facility had a medication error rate of 9.38%, which resulted from three errors in 32 opportunities and affected Resident Identifier (RI) #52 one of five residents observed receiving medications during the medication administration observation on 02/03/2022. Sixty-nine residents resided in the facility. Findings included: The facility's Administering Medications policy and procedure, dated 02/2014, indicated, . Medications will be administered by a licensed nurse in a safe and timely manner, and as prescribed. The facility's Administration of Metered-Dose Inhaler policy and procedure, not dated, indicated, . It is the policy of this facility to ensure medications are administered as prescribed, . 11. Instruct resident to exhale fully. 12. Press down on inhaler to release medication as the resident starts to breathe in slowly. 13. Instruct resident to hold breath and slowly count to ten, if possible, to allow medication time to deposit in airways. 14. Instruct resident to exhale slowly through pursed lips. 15. Repeat puffs as directed, waiting at least 1 (one) minute between puffs, or per the manufacturer's specifications. 16. If using a corticosteroid, allow resident to gargle with water if desired, to remove medication from mouth and back of throat. 17. If resident is using a corticosteroid and a bronchodilator, administer the bronchodilator first then wait 5 minutes before administering the corticosteroid. The Spiriva Respimat Instructions for Use information leaflet documented . Breathe out slowly and fully. While taking a slow, deep breath through your mouth, Press the dose-release button and continue to breathe in. Hold your breath for 10 seconds or for as long as comfortable. The Symbicort Inhaler Instructions for Use, safety information sheet documented: . After using your SYMBICORT inhaler: .Rinse your mouth with water and spit it out . Don't swallow the water . RI #52 was admitted to the facility on [DATE] and had diagnoses which included Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease (COPD), Asthma, Dependence on Supplemental Oxygen, Emphysema, Personal History of Recurrent Pneumonia, Personal History of other Diseases of the Respiratory System, Shortness of Breath, and Seasonal Allergy Rhinitis. A physician's order dated 03/27/2020, indicated the resident was to be administered Symbicort 160-4.5 micrograms (mcg) inhaler (a corticosteroid) - give one inhalation twice daily, for COPD. A physician's order, dated 03/27/2020, indicated the resident was to be administered Afrin 0.05% Nasal Spray, 2 sprays intranasally daily as needed for seasonal allergy Rhinitis. A physician's order dated 10/24/2021, indicated the resident was to be administered Spiriva Respimat 2.5 mcg inhalant (a bronchodilator) daily. The number of inhalations the resident was to be administered was not included in the physician's order. On 02/03/2022 at 8:28 AM, Employee Identifier (EI) #8, a Licensed Practical Nurse (LPN), was observed as she administered medications to RI #52 under the training supervision of EI #9, an LPN. Upon entry into the resident's room, EI #8 set the tray of medications on the overbed table in front of the resident. The resident immediately proceeded to self-administer two puffs of the Symbicort inhaler within 2-3 seconds, set it back on the medication tray, and self-administer one puff of the Spiriva inhaler. EI #8 did not instruct the resident to use the Spiriva inhaler first. For either inhaler, EI #8 did not instruct the resident to exhale fully, breathe in the medication slowly, hold their breath and slowly count to 10, and exhale slowly. EI #8 did not instruct the resident to inhale one puff of the Symbicort per the physician's order and did not instruct the resident to wait five minutes prior to using the second inhaler. After self-administering the Spiriva inhaler, the resident rinsed their mouth with water and swallowed the water. EI #8 did not instruct the resident to spit the water back into the cup after rinsing their mouth. EI #8 had set a bottle of Saline Nasal Spray on the tray instead of Afrin Nasal Spray. The resident picked up the bottle of Saline Nasal Spray and self-administered one spray into each nostril, although the physician's order was for two sprays of Afrin in each nostril. On 02/04/2022 at 8:18 AM., EI #8 and EI #9 were interviewed regarding the observation of the administration of the inhalers and nasal spray on 02/03/2022. Both LPNs stated they had not read the patient use instructions and/or the package insert for Spiriva or Symbicort inhalers. EI #8 stated she had not instructed the resident to inhale the inhalers slowing and hold for 10 seconds if possible. EI #8 acknowledged the resident had self-administered two inhalations of Symbicort and the physician's order was for one inhalation. She stated the physician's order for the Symbicort had not been followed. EI #8 stated she had not instructed the resident to use the Spiriva inhaler first, nor to wait five minutes to administer the Symbicort, per the facility's policy. EI #8 reviewed the physician's order for the Spiriva inhaler and acknowledged the order did not specify the number of inhalations the resident was to receive. She stated she had not instructed the resident to rinse their mouth with water and to spit back into a cup. EI #8 and EI #9 both stated they had not been in-serviced on the proper administration of respiratory inhalers and/or on the facility's Administration of Metered-Dose Inhaler policy and procedure. EI #8 stated she had provided Saline Nasal Spray for self-administration by the resident. She reviewed the physician's order and acknowledged Afrin Nasal Spray had been ordered. She stated the resident had self-administered one spray of Saline Nasal Spray in each nostril. EI #8 acknowledged the physician's order for Afrin Nasal Spray had not been followed. On 02/04/2022 at 8:28 AM, Employee Identifier (EI) #12, the Director of Nursing (DON), was interviewed. She stated licensed staff received training on the administration of inhalers and on the facility's policy and procedure for administration of inhalers during their orientation. She stated that no QA (Quality Assurance) had been initiated to ensure inhalers were being administered correctly. The DON reviewed the physician's order for the Spiriva inhaler and acknowledged the order, dated 10/24/2021, did not designate how many inhalations the resident was to be administered. She stated a licensed nurse, or the consultant pharmacist should have identified the problem and corrected it before then. The DON reviewed the order for Afrin Nasal Spray, dated 03/27/2020, and when informed Saline Nasal Spray was used instead of Afrin, stated nurses should have read the physician's order and obtained Afrin for the resident before then. The DON was informed of the medication error rate of 9.38% resulting from the administration of the wrong doses, administration errors, and/or administration of the wrong medications involving the Spiriva inhaler, Symbicort inhaler, and Afrin Nasal Spray. She stated she understood the errors and had no questions. On 02/04/2022 at 9:22 AM, EI #11, the Administrator, was interviewed. The above observations of the medication pass for RI #52 were reviewed with the Administrator. He stated his expectation was for licensed nurses to be trained to properly administer respiratory inhalers and to be in-serviced regarding the facility's respiratory inhaler policy and procedure. When informed of the medication error rate of 9.38%, he stated he had no further questions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of a facility policy titled, Acute Condition Changes- Clinical Protocol 3.12 the facility failed to ensure licensed staff notified the physician of blood glucose greater than 450. This affected Resident Identifier (RI) #88, one of one residence whose blood glucose levels were reviewed. Findings include: A review of the facility policy titled, Acute Condition Changes - Clinical Protocol 3.12, with a reviewed date of 01/18 revealed Assessment and Recognition . 1. As part of the initial assessment, the Physician will help identify individuals with a significant risk for having acute changes of condition during their stay . In addition, the Nurse shall assess and document/report the following . b. Neurological assessment . g. Recent labs . 5. The nursing staff will contact the Physician based on the urgency of of the situation. For emergencies, they will call or page the Physician and request a prompt response (within approximately one-half hour or less . Monitoring and Follow-up 1. The staff will monitor and document the resident's progress and responses to treatment, and the Physician will adjust treatment accordingly. RI#88 was readmitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes with diabetic peripheral angiopathy with gangrene. On May 13, 2019 at 05:15 PM, during an initial tour of the facility, the surveyor knocked on Resident Identifier (RI) #88 's room door and received permission to enter the room. Employee Identifier (EI) #9 was present in the room and reported to the surveyor that she just finished obtaining a blood sugar. EI #9 revealed the reading was 400. A review of RI #88's May 2019 electronic Medication Administration Record (eMAR) revealed the following: . 5/11/19 0700 = 206 / 4 units administered ; 1100 =356 / 10 units ; 1700 = 459 / 12 units administered, by Employee Identifier (EI) #8, 5/12/19 0700= 324 /8 units administered ; 1100 487 / 12 units administered by EI#8; 1700 = 374 /10 units . A review of Resident Identifier (RI) #88's May 2019 Physician Orders revealed 8/20/18 . Check blood sugar three times daily before meals cover SS (sliding scale) with Novolog 0-199 = 0 units , 200-250 = 4 units , 251-300 = 6 units , 301-350 = 8 units , 351-400=10 units, 401-450 = 12 units , >(greater than) 450 = notify Physician . A review of RI #88 Departmental Notes revealed no nursing note entry for May 11, 2019 and no nursing note entry for May 12, 2019. On 5/14/19 at 5:40 PM, an interview was conducted with EI #7, Registered Nurse (RN) Supervisor. EI#7 was asked, should the Physician be notified per the sliding scale order for a capillary blood glucose (CBG) or blood glucose reading over 450. EI #7 replied, yes. EI #7 was asked, was the Physician notified after the results on 5-11-19 at 1600 results or after the 5-12-19 1100 results. EI #7 replied, not that she was aware of. EI#7 was asked, what would the potential harm be of not notifying the physician of CBG over 450. EI #7 replied, the resident could go into a diabetic coma or have other issues from sugar. EI#7 was asked, where should the Physician notification be documented. EI #7 replied, under the notes tab on Echart. EI#7 was asked, when should the nurse document notification of Physican. EI #7 replied, immediately after notification. On 5/15/19 at 11:13 AM, an interview was conducted with EI #8, Licensed Practical Nurse (LPN). EI#8 was asked, did RI#88 have a sliding scale ordered. EI#8 replied, she/he did. EI#8 was asked, what was the results for RI#88 capillary blood glucose (CBG) check on Saturday, May 11, 2019 at 1700. EI#8 replied, 459. EI#8 was asked, what treatment did the resident receive. EI#8 replied, 12 units, and EI #6, the Physician was there and he ordered the 12 units and to be rechecked in a few hours, it was down to 200 something then. EI#8 was asked, should she document when the Physician was notified. EI#8 replied, yes . EI#8 was asked, did she document that she notified the Physician. EI#8 replied, no. EI#8 was asked, what was the results for RI #88 blood glucose check on May 12, 2019 at 1100. EI#8 replied, 487. EI#8 was asked, what treatment did the resident receive. EI#8 replied, 12 units of insulin because it was greater than 450 and she did not notify the Physician but did recheck it a few hours later and it was below 199. EI#8 was asked, what treatment did the ordered sliding scale prescribe for blood glucose greater than 450. EI#8 replied, notify Physician. EI#8 was asked, should she have notified the Physician. EI#8 replied, yes. EI#8 was asked, did she notify the Physician. EI#8 replied, no. EI#8 was asked, what was the policy or procedure for notifying Physicians. EI#8 replied, notify RN and she will notify the Physician. On 5/15/19 at 11:53 AM, a phone interview was conducted with EI #6 , Physician. EI#6 was asked, was he familiar with RI#88. EI #6 replied, yes. EI #6 was asked, did he have a standard sliding scale for insulin. EI #6 replied, yes. EI #6 was asked, if the order was written for staff to notify Physician for blood glucose greater than 450, when should staff notify the Physician. EI #6 replied, when they check it. EI#6 was asked, should staff notify him each time blood glucose is greater than 450. EI # 6 replied, yes, they should. EI#6 was asked, what should a nurse do for blood glucose reading of 459 or 487. EI # 6 replied, text me or call me. EI#6 was asked, did he recall if he was present at the facility on 5-11-19, Saturday. EI # 6 replied, he was there on Sunday, not Saturday. On 5/15/19 at 12:28 PM a second interview was conducted with EI#8, LPN. EI#8 was asked, what was the harm in not notifying the Physician for a resident with Stage 3 Chronic Kidney Disease (CKD) with blood glucose greater than 450. EI #8 replied,they could go into kidney failure, blood sugar could send her/him into a diabetic coma, several things. EI#8 was asked, was she sure she talked with EI#6, Physician on Saturday 5-11-19. EI #8 replied, it was Sunday, she did not notify the Physician on Saturday, 5-11-19. EI#8 was asked, should she have notified th Physician on Saturday. EI #8 replied, yes. EI#8 was asked, why did she not notify the Physician on Saturday. EI #8 replied, sometimes it took the Physician awhile to respond , so she used her judgement and gave the max ordered dose of 12 units and re-assessed. EI#8 was asked, should she notify the Physician every time it is greater than 450. EI #8 replied, yes. EI#8 was reminder that earlier they spoke and she said RI#6, Physician, was there on Saturday and gave her orders, now she was saying it was Sunday. EI #8 was asked did she notify the Physician on Saturday or Sunday. EI #8 replied, Sunday. On 5/15/19 at 03:29 PM an interview was conducted with EI#8, LPN. EI #8 was asked, when should you notify family of significant change. EI #8 replied, as soon as possible. EI #8 was asked, did you notify family. EI #8 replied, no. On 5/15/19 at 04:29 PM, an interview was conducted with EI #1, RN, Director Of Nursing. EI #1 was asked, regarding EI#6, Physician's sliding scale order, what required Physician notification. EI #1 replied, anything greater than 450. EI #1 was asked, who was responsible for notification of Physician. EI #1 replied, LPN charge nurse or Registered Nurse (RN). EI #1 was asked, why should staff notify the Physician when readings were outside ordered ranges. EI #1 replied, it was dangerous not to keep control of diabetes, (residents could experience complications) like hyperglycemia and Ketoacidosis. EI #1 was asked, when should staff not notify a Physician of blood glucose greater than 450, with an order to notify Physician greater than 450. EI #1 replied, should always, unless there was an order not to. EI #1 was asked, who was responsible for documenting notification of a Physician. EI #1 replied, the nurse that notified the Physician. EI #1 was asked, where should notification of Physician be documented. EI #1 replied, in the medical record in nurses notes. EI #1 was asked, why should notification of the Physician be documented. EI #1 replied, if it was not documented they did not do it, and it kept record of blood glucose and number of notifications. EI #1 was asked, when should staff not document notification of Physician. EI #1 replied, never. EI #1 was asked, who was responsible for documenting blood glucose values. EI #1 replied, the nurse that checked the blood glucose. EI #1 was asked, where were blood glucose values documented. EI #1 replied, eMAR. EI #1 was asked, when should staff not document blood glucose values. EI #1 replied, never. EI #1 was asked, when should staff not follow Physician Orders. EI #1 replied, they should until otherwise directed by the Physician or if it would put a resident at risk or danger. EI #1 was asked, when blood glucose was greater than 450 should staff always notify the Physician, when ordered. EI #1 replied, yes. EI #1 was asked, what was the potential harm for not notifying the Physician. EI #1 replied, he could not give orders to help residents blood glucose come down. EI #1 was asked, what was the potential for harm for not documenting notification of Physician. EI #1 replied, if it was not documented then they did not do it. The can say they checked it, but if it was not documented, it was not there.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure the treatment nurse removed her gloves and sanitized her hands after cleaning the wounds for Resident Identifier (RI) #77 and RI #4, and before placing the clean treatment and outer coverings. This affected two of two residents observed for wound care. Findings Include: RI #77 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease. A review of RI #77's May 2019 Physician Orders revealed .5/13/19 .Clean Stage II to coccyx with Vashe cleanser, apply Multidex powder and cover with border dressing QD (everyday) . On 5/14/19 at 10:18 AM, the surveyor observed wound care for RI #77 performed by Employee Identifier (EI) #2 , Licensed Practical Nurse, Treatment nurse. EI #2 prepared the needed supplies and entered the resident's room. EI #2, washed her hands and put on gloves. The nurse assisting removed the soiled dressing. EI #2 cleaned the wound, then measured the wound. EI #2 used another 4x4 and cleaned the wound again. EI #2, with a clean 4 x 4 patted the wound dry. EI #2 applied the Multidex powder and outer covering with same soiled gloves she had on to clean the wound with. RI #4 was admitted to the facility 11/29/16 with a diagnosis of Alzheimer's Disease. A review of RI #4's May 2019 Physician Orders revealed . 5/8/19 . Clean Stage II wound to coccyx with Vashe cleanser, apply Multidex powder and cover with Tegaderm Q 3 days (every 3 days) . On 5/14/19 at 10:43 AM, EI #2 was observed performing wound care for RI #4. EI #2 prepared the needed supplies: 4 x 4's wet with Vashe cleanser, dry 4 x 4 for drying, Multidex powder, and a tegaderm dressing dated prior to entering the resident room. The assisting nurse removed the resident's pants and loosened the brief and held the resident over for EI #2. EI #2 rolled the brief down and away from the wound with her gloved hand. EI #2 said the brief was wet. EI #2 used her left hand and held the brief down then cleaned the wound using her right hand. EI #2 measured the wound. EI #2 used the pre wet 4x4s and cleansed the wound again, then with the dry 4 x 4 patted the area dry. EI #2 placed the skin prep, the Multidex powder and the Tegaderm with the same soiled gloves she cleansed the wound with and touched the wet brief. On 5/14/19 at 11:00 AM, an interview was conducted with EI #2 regarding the wound care for both RI #77 and RI #4. The surveyor recapped the wound care for RI #77 and RI #4 with EI #2. EI #2 recalled she did not remove her gloves after cleaning the wound for each resident. EI #2 was asked when should she wash her hands and change gloves during wound care. EI #2 replied, before starting, if gloves get soiled or dirty to change, after cleaning a wound before placing the clean treatment and when finished. EI #2 was asked if her gloves were considered clean or dirty after cleaning a wound. EI #2 replied, dirty. EI #2 was asked when should a nurse clean a wound then with the same gloves apply the clean treatment and outer covering. EI #2 replied, they should not do that. EI #2 was asked if she changed her gloves and washed her hands after cleaning the wounds on both residents before placing the clean treatment and outer coverings. EI #2 replied, no, their policy did not specify to do that way. EI #2 was asked what was the risk for harm in using the same gloves to clean a wound then place the clean treatment and outer coverings. EI #2 replied,spread infection. On 5/15/19 at 3:00 PM, an interview was conducted with EI #5, RN, Infection Control Nurse. EI #5 was asked what was the recommended procedure for glove changes and washing hands during the performance of wound care. EI #5 replied, wash hands, put on gloves, remove the old dressing, remove gloves wash hands, put on new gloves, clean the wound remove gloves wash hands new gloves and place treatment and outer covering. EI #5 was asked when should a treatment nurse clean a resident's wound then with the same gloves place the clean treatment and outer covering. EI #5 replied, they should not. EI #5 was asked what would the risks be in a nurse cleaning a wound then with the same gloves place the clean treatment. EI #5 replied, it could spread infection. EI #5 was asked when should a nurse remove IV equipment from a resident's room. EI #5 replied, after the last dose was given. EI #5 was asked when should IV pump, pole and equipment remain in a resident room [ROOM NUMBER] days after the medication was discontinued. EI #5 replied, it should not, the nurse discontinuing the medication should have removed the pump, pole and equipment. EI #5 was asked what would the risks be in an IV pump, pole and equipment not being removed from a resident room for 23 days after the medication was discontinued. EI #5 replied, it could be a safety issue and infection control issue; it should have been removed the day the medication was discontinued and cleaned.

Based observation, interview and review of a facility policy titled, Food Storage in Freezer, the facility failed to ensure that tater tots, okra and sweet potato patties where sealed properly while in the freezer. This was observed on 5/13/2019 and had the potential to effect 101 residents receiving meals from the kitchen. Finding include: A review of a facility policy titled, Food Storage in Freezer with a review date of 5/15/19 revealed: . Procedure Frozen Foods: . 3. All foods should be covered , labeled , and dated with delivery date. On 5/13/2019 at 03:19 PM, the surveyor observed a half bag of tarter tots, a half bag of okra in a box and a half bag of sweet potatoes patties inside of a box. The bags were not completely sealed. On 05/15/19 at 10:39 AM, an interview was conducted with Employee Identifier (EI) #4, Dietary Director. EI#4 was asked how should food be sealed while in the original container. EI#4 replied, the bag needs to be closed as good as it can. EI #4 was asked, how were the tarter tots, sweet potatoes patties and okra sealed. EI#4 replied, the bags were not fully closed on the tarter tots, on the sweet potatoes patties and okra the box was pushed down, but the bag was not closed. EI#4 was asked, why was it important that food be sealed. EI#4 replied, when foods are in the freezer, to keep from getting freezer burn and to ensure quality. EI#4 was asked, what was the facility policy on sealing food. EI#4 replied, if it is taken out of the original container it should be put in zip lock storage bag with a use by date, and if left in the the original container, needed to tie the bag closed in the box. EI#4 was asked, who was responsible for the food to be sealed. EI#4 replied, the cook or staff member that used it

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of a facility policy Resident Assessment Instrument , the facility failed to ensure the Minimum Data Set (MDS) dated [DATE] and 12/9/17 was coded for hospice care. This affected Resident Identifier (RI) #9, one of three residents sampled for hospice care. Findings Include: A review of a facility policy Resident Assessment Instrument (MDS) with a revised date of 1/18 revealed: .Policy Interpretation and Implementation . 4. The purpose of the assessment is to describe the resident's capability to perform .5. Information derived from the comprehensive assessment enables the staff to plan care . RI #9 was admitted to the facility 9/0/17 with a diagnosis to include Alzheimer's Disease. A review of RI #9's Physician Order dated 9/18/17 revealed .Admit patient to .Hospice with terminal diagnosis of Alzheimers . On 6/13/18 at 9:49 AM a review of RI #9's Significant Change (SC) MDS dated [DATE] and an SC MDS dated [DATE] revealed hospice was not coded under section O - Special Treatments, Procedures and Programs. On 6/13/18 at 12:27 PM an interview was conducted with Employee Identifier (EI) #2, Licensed Practical Nurse. EI #2 was asked if RI #9 was receiving hospice services. EI #2 replied, yes. EI #2 was asked when was hospice ordered. EI #2 replied 9/18/17. EI #2 was asked if a SC MDS was completed. EI #2 replied, yes. EI #2 was asked if hospice was coded. EI #2 replied, it was not coded in section O. EI #2 was asked if hospice should have been coded. EI #2 replied, yes. EI #2 was asked what were the risks of hospice not being coded on the MDS. EI #2 replied, the assessment would not be accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and a review of a facility policy titled, Posting Direct Care Daily Staffing Numbers, the facility failed to ensure staffing report was posted for 6/12/18 and the evening shift was posted on 6/13/18. This had the potential to affect all residents and their family members. Findings Include: A review of a facility policy titled, Posting Direct Care Daily Staffing Numbers (undated) revealed: .Policy: It is the policy of this facility to make staffing information readily available in a readable format to residents and visitors at any given time. Policy Explanation and Compliance Guidelines: .2. The facility will post the nurse staffing at the beginning of each shift On 6/12/18 at 5:50 PM, an observation of the posted [NAME] County Health and Rehabilitation Facility Direct Care Staff Daily Report revealed the report posted was dated 6/11/18. On 6/13/18 at 4:13 PM, the surveyor observed staffing posted for the morning shift, however the evening shift was not posted. Again at 5:25 PM, the surveyor observed that staffing for the second shift was not posted. On 6/14/18 at 2:07 p.m., an interview was conducted with with EI (Employee Identifier) #7, RN (Registered Nurse). EI #7 was asked who was responsible for posting the staffing report daily. EI #7 replied, in the morning the RN that gets the shift started. EI #7 stated she (EI #7)tally's up the actual hours from the previous shift. EI #7 was asked why was there no staffing report completed for 6/12/18. EI #7 replied, she was on the cart and she did not think she completed a sheet for the morning. EI #7 was asked when was a staffing form completed for 6/12/18. EI #7 replied she could not remember, it may have been done on the 13th. EI #7 was asked why was it important that staffing was posted and accurate. EI #7 replied, for visitors and others to know how many staff they have on hand. EI #7 was asked why was the second shift daily report not posted on 6/13/18 by 5:25 PM. EI #7 replied, she could not answer that, she did not complete the second shift posting. EI #7 was asked was the staffing on 6/13/18 accurate and current. EI #7 replied, no ma'am. On 6/14/18 at 2:42 p.m., an interview was conducted with EI #8, RN. EI #8 was asked who was responsible for posting staffing each day. EI #8 replied, the RN supervisor will do it when she gets here but if she was working on the cart, she (EI #8) normally did it. EI #8 was asked why was it important that staffing was posted correctly. EI #8 replied it shows how many staff are working in the building and how many hours they work. EI #8 was asked why was the second shift daily report not posted on 6/13/18 by 5:25 PM. EI #8 replied, yesterday was a busy day and she forgot to complete it. EI #8 was asked was the staffing form on 6/13/18 at 5:25 PM accurate and current. EI #8 replied, no ma'am.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, this facility failed to ensure that infection control practices were utilized in the preparation of medications for medication delivery for one of 9 residents (Resident Identifier [RI]) #30 observed during medication pass. This deficient practice involved one of five nurses during the medication pass observed to stir crushed medication with her index finger. Findings Include: RI #30 was readmitted to the facility on [DATE] with a diagnosis of Gastrostomy status. A review of RI #30's June 2018 Physician Orders revealed : .Two Tums tablets crushed and give .Feosol liquid .CALTRATE D 600 Milligram TABLET . On 6/12/18 at 11:02 AM Employee Identifier (EI) #3, Licensed Practical Nurse, was observed giving RI #30's medication by way of gastrostomy tube. EI #3 prepared each of the medications in separate medication cups. EI #3 crushed medication separately then melted each with water. EI #3 used a plastic spoon to stir the medication and water. EI #3 gathered her supplies and the medication and went into RI #30's room. EI #3 washed her hands and put on gloves. EI #3 checked the placement of the tube then proceded administering the medication. EI #3 poured the melted caltrate in the barrel of the syringe. EI #3 poured additional water in the medication cup and stirred the contents with her left first finger and poured it in the barrel of the syringe. EI #3 poured the melted tums in the barrel of the syringe. EI #3 added additional water to the medication cup and stirred the contents with her first left finger then poured the contents in the barrel of the syringe. EI #3 followed the medication with water completing the task. On 6/12/18 at 11:30 AM an interview was conducted with EI #3. EI #3 was asked what was the policy on stirring crushed medications. EI #3 replied, stir with a spoon. EI #3 was asked if she stirred the medications with a spoon after she took the medications in RI#30's room. EI #replied, no she used her gloved finger. EI #3 was asked if she should use her finger to stir medications. EI #3 said no. EI#3 was asked what was the risks in using her finger to stir medication. EI #3 replied, spread germs. On 6/13/18 at 2:44 PM an interview was conducted with EI #1, Director of Nursing, Infection Control Nurse. EI #1 was asked what was the policy on stirring crushed medications. EI #1 replied, use a spoon or a stir stick. EI #1 was asked when would a nurse use her finger to stir medications. EI #1 replied, never. EI #1 was asked why would nurse not use her finger to stir medications. EI #1 replied, infection control issue and she could contaminate the medications.

Based on observations, interviews and a review of facility policies Dry Storage Areas, Record of Food Temperatures, and Temperature Sheet, the facility failed to ensure: 1) peanut butter was not on the lid of the peanut butter container; 2) an opened and used by date was on a container of gravy mix and; 3) the temperature of the pork chops was taken on the tray line before serving to the residents. This had the potential to affect 100 of 107 residents receiving meals from the kitchen. Findings Include: 1) A review of a facility policy titled, Dry Storage Areas (undated) revealed: Policy: Dry storage areas will be kept in a condition which protects stored food from infestation. .Care of Storeroom .Food storage containers are cleaned after each use. On 06/12/18 at 9:16 a.m., the surveyor along with (Employee Identifier) EI #4 Dietary Director, toured dry storage. The surveyor observed a container of creamy peanut butter with peanut butter on top of the lid. On 6/14/18 at 9:24, an interview was conducted with EI #4, Dietary Director. EI #4 was asked what was on top of a lid of a peanut butter jar. EI #4 replied, peanut butter. EI #4 was asked who was responsible for making sure food containers were cleaned when putting them back into dry storage. EI #4 replied, whoever was using it is supposed to wipe it down if anything was on the jar. EI #4 was asked what did the facility policy say regarding dirty lids on food containers in dry storage. EI #4 replied, food containers should be cleaned before placing back into dry storage. EI #4 was asked what was wrong with food on top of a closed food container in dry storage. EI #4 replied, it could attract pests. 2) On 06/12/18 at 9:16 a.m., the surveyor along with (Employee Identifier) EI #4 the Dietary Director observed a 24 ounce bag of old fashion gravy mix in a medium zip lock bag with no open or used by date. 06/14/18 at 9:39 a.m., an interview was conductd with EI #4. EI #4 was asked what was the use by date on the gravy. EI #4, replied, it was not wrtitten on it. EI #4 was asked what did the facility policy say regarding using an open and use by date on food products. EI #4 replied, dry food storage must have an open date on it and use by date. EI #4 was asked who was responsible for putting use by dates on food items once opened. EI #4 replied, once opened, use the use by date that is printed. EI #4 was asked why was it important to put use by dates on food products. EI #4 replied to esure the quality of the food. 3) A review of a policy titled, Record of Food Temperatures (undated) revealed: Policy: It is the policy of this facility to record food temperatures daily to ensure food is at the proper serving temperature(s) before trays are assembled. .Procedure: . 1. Food temperature will be checked on all items prepared in the dietary department. 6. Measure and record the temperatures for each food product. Record temperature on temperature log. A review of the facility's Temperature Sheet dated 6/12/18 did not show the recording for the second batch of pork chops. 6/12/18 at 12:00 p.m., the surveyor observed a second batch of pork chops in a fryer basket. EI #5, dietary aide, took the basket of pork chop and put them in a pan that was on the trayline. EI #5 did not take the temperature of the pork chosp before placing them in the pan with other pork chops. The serveyor observed mashed potoatoes on the stove. Prior to serving the mashed potatoes to the residents, the temperature was not checked. On 6/14/18 at 9:32 a.m., an interview was conducted with EI #4. EI #4 was asked who took the temperatue of the second batch of pork chops. EI #4 replied, she did not see anyone take it. EI #4 was asked where was the second batch of pork chops temperature recorded on the menu log. EI #4 replied, it was not . EI #4 was asked who was responsible for taking food temperatures. EI #4 replied, the cook. EI #4 was asked why was it important to take food temperatures on the tray line. EI #4 replied it was the only way to ensure the food was cooked properly. On 6/14/18 at 10:53 a.m., an interview was conducted with EI #6, the head cook, supervisor. EI #6 was asked what was the temperature of the second batch of pork chops. EI #6 replied, she was not 100 percent sure. EI #6 was asked who was responsible for food temperatures. EI #6 replied, the cooks. EI #6 was asked why it is important to take food temperatures. EI #6 replied, to make sure it was at the temperature before it goes out on the hall. EI #6 was asked if she served pork chops and no temperature was taken. EI#6 replied, the first batch EI #5 pulled off was not taken. EI #6 was asked if she took the temperature of the second batch of pork chops. EI #6 replied, she did not.