**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews and a review of facility policies titled, Abuse, Neglect and Exploitation, Controlled Substances, Inventory Control of Controlled Substances and Online Incident Report, the facility failed to ensure licensed staff members were following the facility policy on conducting counts with the exchanging of the cart keys, which resulted in missing medications for Resident Identifier (RI) #4. This deficient practice affected RI #4, one of one resident's who were investigated for missing narcotic medication. Findings Include: A review of a facility policy titled, Abuse, Neglect and Exploitation, with a date of 12/19/2022, revealed: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions . Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. A review of a facility policy titled, Controlled Substances with a revised date of December 2012 revealed: Policy Statement The facility shall comply with all laws, regulations and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. Policy Interpretation and Implementation . 9. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. A review of a facility policy titled, Inventory Control of Controlled Substances with a revised date of 01/01/2013 revealed: . Procedure: . 1.2 Facility should ensure that the incoming and outgoing nurses count all Schedule II controlled substances and other medications with a risk of abuse or diversion at the change of each shift . A review of a pharmacy delivery sheet revealed, (RI #4's name) . 5/17/22 . Quantity Description . 90 EA (each) Lorazepam 1 MG (Milligram) tablet . received by Employee Identifier (EI) #7 dated 5/17/22 at 10:50 PM. A review of RI #4's Physician Orders revealed, . 5/17/22 Lorazepam 1 MG. One tablet TID (three times a day) . for nerves . A review of a copy of a medication card for RI #4 revealed, Lorazepam 1 mg tablet . 5/17/22 .1 of 3 . RI #4 was admitted to the facility on [DATE] with a diagnosis of Unspecified Dementia with behavioral disturbance. A review of an online Incident Report revealed: . On June 6, 2022, at 3:30 p.m., EI #6, (Registered Nurse) RN and EI #5, (Licensed Practical Nurse), LPN were counting the 100 hall medication cart. While counting the cart EI #6 realized there were two cards of Lorazepam 1 mg that belonged to RI #4 that did not have a sheet. Furthermore, the two cards were labeled 2 and 3 but there was not another one which should have been labeled 1. This meant that there was a card containing 30 pills of Lorazepam that was missing. On June 7, 2022, EI #3, RN was interviewed. On June 6, 2022, EI #3 said that she did not count her cart that morning. On June 9, 2022, EI #4, LPN was interviewed. She said she came in at 6:45 a.m. (June 6th). She said she counted the 100 hall cart with EI #8, LPN. She said the count was correct. EI #4 said she locked the cart and put the keys in her left pocket. She said she went straight to the 400 hall to help start feeding. EI #4 said she never opened the 100 hall cart back up. She went on to say . EI #3 came to the room. EI #4 said at that time, she handed EI #3 her cart keys. She said she did not count the cart with EI #3. On July 14, 2022 EI #7 was interviewed. She said that she received the 90 pills of Lorazepam 1mg pills for RI #4 on May 17, 2022 at 10:50 pm from Omnicare Pharmacy. She said that she counted all three blister packs and noted that 90 pills were there. EI #7 said that she recorded in the narcotic book and that she added all three cards and record of controlled substance paper to 100 hall narcotic box and placed the sign off sheet in the narcotic book. On 01/04/2023 at 11:25 AM, an interview was conducted with EI #3. EI #3 was asked what was the practice at shift change. She said count the cards and each medication verifying the number on the control sheet. It was to be done at the beginning of the shift, at the end and if they hand off the keys to someone. EI #3 was asked who counted the narcotics with shift change. She said the oncoming nurse and the off going nurse. When asked what could she tell about RI #4's Lorazepam; she said she came in late, she had asked another nurse to hold the keys until she got there. When asked who was holding the keys she said EI #4, and she did not count the cart when she got there and she should have. EI #3 was asked why did she not count when she took the keys. She said she was not sure why, she was late and it was unfortunate on her part. EI #3 was asked when was the narcotic count done. She said it was not done by her and EI #4. EI #3 was asked what form of abuse would missing Lorazepam be. She said misappropriation. On 01/04/2023 at 2:30 PM, an interview was conducted with EI #4, LPN. She was asked who she counted with on 06/06/2022; she said EI #8. EI #4 was asked who was supposed to get the keys. She said EI #3, she was late. EI #4 was asked what should have been done when she gave the keys to EI #3. She said they should have counted the cart, but they did not. EI #4 was asked why the count was not verified when she gave the keys to EI #3. She said EI #3 came to the resident's room she was in and got the keys. EI #4 was asked how the empty Lorazepam card was found. She said it was in the shred box with no pills in it and she was not sure when it was found. EI #4 was asked what it was when resident medication was missing. She said misappropriation of property, EI #4 was asked when should nurses count controlled medications. She said the beginning and end of shift and anytime they switch keys. EI #4 was asked what was done before a nurse accepted cart keys. She said the oncoming and off going nurses count together. EI #4 was asked what the procedure facility nurses use to ensure narcotic medications were accounted for. She said oncoming and off going nurses count together and then sign the shift change sheet. EI #4 was asked what should have been done when EI #3 came in. She said they should have counted the narcotic box together then she should have given the keys to EI #3, but that was not done. EI #4 was asked what was the harm of the nurses not counting. She said diversion or misappropriation of resident's medication. On 01/05/2023 at 9:15 AM, an interview was conducted with EI #2, the Director of Nursing. EI #2 was asked how often RI #4 was out of the Lorazepam an. She said it was three times a day and RI #4 was never out of the medication as there were three cards and card one was missing. EI #2 was asked how many Lorazepam were delivered to the facility and when. She said they were delivered on 05/17/2022 according to the delivery sheet 90 pills also 3 cards and EI #7 signed for them. EI #2 was asked how did she determine how many Lorazepam were missing. She said she did not, other than the card said 30, therefore, the facility replaced that many. EI #2 was asked what was the policy for nurses at shift change regarding the narcotic keys. She said both nurses, oncoming and off going, count and sign the log before exchanging keys. She was asked if EI #3 and EI #4 did that; she said no. EI #2 was asked how the policy was followed if EI #3 did not count when she got the keys from EI #4. She said it was not. EI #2 was asked what it was when a resident's medication was diverted. She said misappropriation of property. EI #2 was asked what should have been done to prevent the misappropriation of RI #4's Lorazepam. She said both EI #3 and EI #4 should have counted. EI #2 was asked what would the harm be in nurses not counting the controlled medication when handing off the keys. She said a risk for misappropriation. EI #2 was asked to review the pharmacy delivery sheet then asked how many Lorazepam were delivered. She said 90 pills, three cards and two cards were in the cart. EI #2 was asked where was card one of the Lorazepam found. She said in the shred box no pills in it had 30 on the card. On 01/05/2023 at 9:50 AM an interview was conducted with EI #1, the Administrator. He was asked what should occur at shift change related to controlled medications. He said oncoming and off going nurses should count controlled medications after the count, the oncoming nurse accepts the keys if the count was correct. EI #1 was asked according to the investigation, did the nurses count before exchanging the keys. He said no, EI #4 was providing care when EI #3 went to that room and got the keys. EI #1 was asked what was it when a resident's medication was diverted. He said misappropriation of property. EI #1 was asked what led staff to look in the shred box during the investigation. He said they looked everywhere, that box was emptied at 9:45 AM so it had to have been placed in it after then.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and review of a facility policy titled Perineal Care, the facility failed to provide incontinence care to RI (Resident Identifier) #43 in a timely manner. This deficient practice had the potential to affect RI #43, one of one resident sampled for incontinence care. Findings included: A review of the facility's policy titled Perineal Care, last revised in February of 2018, indicated Purpose The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. RI #43 was admitted to the facility on [DATE] and had diagnoses which included Autistic Disorder and need for assistance with personal care. A review of a quarterly Minimum Data Set (MDS), dated [DATE], indicated RI #43 had severely impaired cognitive function. Per the MDS, the resident required extensive assistance of one person for dressing and toileting, Further review of the MDS indicated RI #43 was always incontinent of bowel and bladder. A review of RI #43's Care Plan, reviewed 03/30/2022, revealed the facility developed a care plan related to RI #43's bowel and bladder incontinence. Care plan interventions included providing incontinence care as needed and providing incontinence briefs as appropriate. Continuous observations of RI #43 on 04/27/2022 from 9:16 AM until 2:03 PM revealed staff did not provide incontinence care for approximately five hours, from 9:16 AM until 2:03 PM. The observations were as follows: Observation at 9:16 AM revealed RI #43 was sitting cross-legged in bed with his/her back against the bed rail. RI #43 was wearing only an adult incontinence brief. At 9:48 AM, Employee Identifier (EI) #5, Certified Nurse Aide (CNA), walked by the resident's room and called out the resident's name, but continued walking down the hallway. Continued observation at 10:05 AM revealed EI #13, Licensed Practical Nurse (LPN) walked into RI #43's room, asked the resident if he/she wanted the radio on, turned on the radio, then walked out of the room. At 11:25 AM, observation revealed EI #5 entered RI #43's room with a lunch tray, turned the radio down, set down the tray, assisted the resident into a chair, and walked out of the room. The resident then started eating. At 11:33 AM, RI #43 got out of the chair and returned to the bed. Observation at 12:02 PM, revealed EI #5 entered the room, picked up the lunch tray, and walked out after documenting the percentage of the meal eaten on a clipboard. Observation at 2:03 PM revealed EI #14, CNA, entered RI #43's room to provide incontinence care for the resident. RI #43 would not allow incontinence care to be provided with the surveyor in the room. At 2:05 PM, EI #14 came out of RI #43's room carrying a bag of trash. RI #43 was sitting cross-legged in the middle of the bed and leaning over, with his/her head on the bed and covered with a sheet. During an interview on 04/27/2022 at 2:05 PM, EI #14 stated RI #43 was totally dependent on staff for personal hygiene. An interview on 04/28/2022 at 2:39 PM with EI #9, Restorative Aide (RA), indicated that, except for transfers, RI #43 required total care with ADLs. EI #9 stated RI #43 should be checked for incontinence every two hours. During an interview on 04/29/2022 at 10:35 AM, EI #13, Licensed Practical Nurse (LPN), indicated RI #43 was not able to use the bathroom and should be checked every two hours for incontinence and changed if needed.

Based on observations, record review, and interviews, the facility failed to ensure Resident Identifier (RI) #31, had documented medical justification for the use of an indwelling urinary catheter. This deficient practice affected RI #31; one of seven residents reviewed for catheter use. Findings included: A review of RI #31's Face Sheet revealed no diagnoses related to the use of an indwelling urinary catheter. A review of a Physician's Orders Form revealed a read-back verbal order was received on 04/06/2022 to place an indwelling urinary catheter. The order lacked information regarding the catheter size to be used or any diagnoses related to the use of the catheter. Review of RI #31's record revealed no documented valid medical justification for the indwelling urinary catheter placement and no indications for its continued use. On 04/26/2022 at 12:44 PM, a urinary drainage collection bag containing urine that was orange in color was observed to be hanging on the side of RI #31's bed. The tubing contained a great deal of sediment. On 04/27/2022 at 12:19 PM, the urinary drainage collection bag containing dark orange-yellow urine was observed hanging on the side of RI #31's bed. The associated tubing contained sediment. The size of the urinary catheter was illegible. During an interview on 04/29/2022 at 9:30 AM, Employee Identifier (EI) #2, Director of Nursing, stated orders for an indwelling urinary catheter should include the size of the catheter and the reason for the catheter. EI #2 stated the physician should provide a diagnosis for the use of the catheter. During an interview on 04/29/2022 at 10:35 AM, EI #13, Licensed Practical Nurse, stated a resident with a catheter should have orders that included a related diagnosis, the size of the catheter/bulb to be used, and how often to change the catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review and review of Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, the facility failed to ensure Resident Identifier (RI) #65's Minimum Data Set (MDS) assessments did not have Gabapentin, an anticonvulsant medication, coded as an antipsychotic, which resulted in the assessments being inaccurate for use of antipsychotic medication. This deficient practice affected RI #65, one of 24 sampled residents whose MDS assessments were reviewed. Findings Include: A review of CMS's RAI Version 3.0 Manual, Chapter 3: MDS Items (N), Page N-6, documented: . Coding Tips and Special Populations * Code medications in Item N0410 according to the medication's therapeutic category and/or pharmacological classification, not how it is used. Resident #65 was admitted to the facility on [DATE]. RI #65 diagnoses included, Unspecified Dementia with Behavioral Disturbance. A review of RI #65's medical record revealed no Physician Orders for antipsychotic medications for August 2018, November 2018, February 2019 or May 2019. Further review of RI #65's medical record revealed: 1. a Quarterly MDS assessment dated [DATE], was coded for 7 days of antipsychotic use under Section N, 2. a Quarterly MDS assessment dated [DATE], was coded for 7 days of antipsychotic use under Section N, 3. a Quarterly MDS assessment dated [DATE], was coded for 7 days of antipsychotic use under Section N, and 4. a Significant Change in Status MDS assessment dated [DATE], was coded for 7 days of antipsychotic use under Section N. On 06/13/19 at 3:01 p.m., an interview was conducted with Employee Identifier (EI) #3, Licensed Practical Nurse (LPN)/MDS Coordinator. EI #3 was asked was RI #65 coded for antipsychotic use EI #3 said yes, for seven days. EI #3 was asked what medication was coded as an antipsychotic. EI #3 replied Gabapentin. EI #3 was asked what classification was Gabapentin. EI #3 stated anticonvulsant. EI #3 was asked according to the RAI Manual should Gabapentin have been coded as an antipsychotic on the MDS. EI #3 explained that she had been taught to list the medication for the reason it was given and RI #65's Gabapentin was given for Dementia with Behaviors. EI #3 was asked to review the RAI Manual. EI #3 then stated, code the classification of the drug. EI #3 was then asked was RI #65's MDS coded accurately for antipsychotics. EI #3 answered no.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure Resident Identifier (RI) #87's care plan regarding code status was revised to reflect RI# 87's DNR (Do Not Resuscitate) decision. This affected RI # 87, one of twenty-four residents whose care plans were reviewed for code status. Findings Include: RI# 87 was admitted to the facility on [DATE] with diagnoses including, Cirrhosis of Liver, Ascites and Vascular Dementia. On 06/13/19 at 01:30 PM, a review of RI #87's medical record revealed a DNR order was written on 05/28/2019, along with an Advance Directive depicting the family's wishes of DNR. Further review revealed a Full Code Care Plan initiated on 04/22/2019 and reviewed by the facility on 05/27/2019, RI #87's Facesheet also depicted Full Code and did not reflect RI #87's decision for DNR. On 06/13/19 at 03:28 PM, an Interview was conducted with Employee Identifier (EI) #3, Licensed Practical Nurse (LPN) / Minimum Data Set (MDS) Coordinator. EI #3 was asked what did the Care Plan for RI #87 depict as Code Status. EI #3 stated the Care Plan depicted Full Code. EI #3 was asked what the physicians orders state for the code status of RI #87. EI #3 replied DNR as of 5/28/19. EI #3 was further asked what did RI #87's Face sheet depict as code status. EI #3 stated that the Face Sheet depicted Full Code. EI #3 was asked, when a code status was documented in multiple places in the medical record, what should she ensure. EI #3 responded that all areas have the same Code status according to the most recent Physician orders. EI #3 was asked what would be the concern with all areas of the medical record not matching and EI #3 replied, the proper code status may not be performed. EI #3 was asked, did RI #87's code status on the face sheet, Physician orders and care plan match. EI #3 answered, no, none of it matched.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, interviews, and review of a facility polity titled Enteral Nutrition, the facility failed to ensure Resident Identifier (RI) #9's tube feeding was infusing at 60 ml (milliters) /(an) hr (hour) and tube feeding water flush was infusing at 25 ml (milliliters) /(an) hr( hour) as ordered by the physician. This was observed on 6/12/2019 and affected one of six resident sampled to receive tube feeding and feeding tube water flush. Findings Include: A review of a facility policy titled, Enteral Nutrition, with a revised date of 11/2018, revealed, .Policy Interpretation and Implementation . 11. The nurse confirms .orders for . e. Volume and rate of administration; . RI # 9 was readmitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's disease, Unspecified, Encounter for Attention to Gastrostomy, and Mild Protein-Calorie Malnutrition. A review of RI #9's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/20/2019 revealed RI #9 had severe cognitive impairment for daily decision. The MDS also reflected RI #9 received tube feeding. A review of RI #9's June 5, 2019 Physician Order's revealed .Glucerna 1.2 at 60 ml/hr . free water flush at 25 ml/hr . On 6/12/19 at 9:26 a.m. and 4:36 p.m., the surveyor observed Glucerna 1.2 tube feeding at a rate of 50 ml/hr and tube feeding water flush was at a rate of 35 ml/hr. On 6/12/19 at 4:43 p.m, the surveyor observed with Employee Identifier (EI) #6, a LPN (Licensed Practical Nurse), RI # 9's Tube Feeding Pole. The following was observed Glucerna 1.2 tube feeding infusing at a rate of 50 ml/hr and water flush infusing at 35 ml/hr. Surveyor asked EI #6 asked what was the current rate observed for the tube feeding and water flushes for RI #9. EI #6 replied the Glucerna 1.2 50 ml/hr and 35 ml/hr for water flush. Surveyor then asked EI #6 to review the physician orders and was asked what did the order state regarding the tube feeding. EI #6 said RI #9's order stated the Glucerna 1.2 should be at 60 ml/hr with a water flush at 35 ml/hr. EI #6 was then asked what was the harm with the tube feeding not running at the correct rate. EI #6 stated the resident was not getting enough nutrition, mainly calories. On 6/12/19 at 10:25 a.m. the surveyor asked EI #4, the DON (Director of Nursing) what was the rate of the tube feeding and water flush that was hanging for RI #9 on 6/12/19 at 4:36 p.m. EI #4 stated Glucerna 50 ml/hr and the water flush was 35 ml/hr. EI #4 went on to say the tube feeding Glucerna 1.2 should have been at 60 ml/hr and the water flush should have been at 25 ml/hr. Surveyor asked EI #4 what was the potential harm in the rate not running at the correct rate. EI #4 stated the resident not receiving the amount of calories and the amount of fluids the resident needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, medical record review and review of [NAME] and [NAME] Fundamentals of Nursing Ninth Edition, Chapter 23 Legal Implications in Nursing Practice, the facility failed to ensure a physician's order was accurately transcribed for Resident Identifier (RI) #87's code status. This affected RI #87, one of 24 sampled residents for whom medical records were reviewed. Findings Include: Review of [NAME] and [NAME] Fundamentals of Nursing Ninth Edition, Chapter 23 Legal Implications in Nursing Practice, copyright 2017, page 311, revealed the following: . Health Care Providers' Orders . Make sure that all health care provider orders are in writing . and transcribed correctly . RI #87 was admitted to the facility on [DATE]. The resident's diagnoses included Cirrhosis of Liver, Ascites and Vascular Dementia. A review of RI #87's medical record revealed a Do Not Resuscitate (DNR) order on 05/28/19. Further review of the medical record revealed RI #87's face sheet and care plan documented full code, making the medical record inaccurate. On 06/13/19 at 3:28 p.m., an interview was conducted with EI #3, Licensed Practical Nurse (LPN)/Minimum Data Set (MDS) Coordinator. EI #3 was asked what did RI #87's physician's order indicate for code status. EI #3 said, DNR as of 05/28/19. EI #3 was asked what did RI #87's face sheet and care plan document for code status. EI #3 replied full code. EI #3 was asked what was the concern with the physician's order not matching in all areas of the medical record. EI #3 stated the proper code status may not be performed. EI #3 was asked was RI #87's physician's order, face sheet and care plan accurate in the medical record. EI #3 answered no, none of it matched.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of facility policies titled, Standard Precautions and Instillation of Eye Drops, the facility failed to ensure: 1. a Licensed Practical Nurse (LPN) did not place inhaler mouthpieces on an unclean surface prior to putting them on RI #28's inhalers before storing them in the medication cart, and 2. an LPN did not wear the same gloves she wore while administering RI #1's crushed medication with an ice cream spoon and then administer RI #1's eye drops. These deficient practices affected RI #1 and RI #28, two of four residents and two of four nurses observed during medication pass observations. Findings Include: A review of a facility policy titled, Standard Precautions, Revised October 2018, documented: Standard precautions include the following practices: . 5. Resident-Care Equipment soiled . are handled in a manner that prevents . transfer of microorganisms to other residents and environments. 1.) RI #28 was readmitted to the facility on [DATE]. A review of RI #28's June 2019 Physician's Orders included the order for Atrovent and Proventil inhalers, dated 4/20/19, for shortness of breath. On 06/05/19 at 5:47 p.m., the surveyor observed EI #7, LPN, place caps for RI #28's Proventil Inhaler and Atrovent Inhaler on the ledge of the bathroom mirror without a barrier and then place them back on the inhalers after she had rinsed them. On 06/05/19 at 5:59 p.m., an interview was conducted with EI #7, LPN. EI #7 was asked what should she do before placing items on an unclean surface. EI #7 said she should put down a barrier. EI #7 was asked where did she put the caps for RI #28's inhaler mouthpieces. EI #7 replied she did not have them on the barrier but beside it. EI #7 was asked what was the concern with placing them on an unclean surface. EI #7 answered, they could get bacteria on them and have germs and cause an infection. 2.) A review of a facility policy titled, Instillation of Eye Drops, Revised January 2014, revealed: .Steps in the Procedure 1. Place the equipment on the bedside stand or overbed table.2. Wash and dry your hands thoroughly. 3. Put on gloves. RI #1 was readmitted to the facility on [DATE]. The resident's diagnoses included unspecified glaucoma. A review of RI #1's June 2019 Physician Orders included the order for Combigan for unspecified glaucoma. On 06/13/19 at 8:28 a.m., the surveyor observed EI #6, LPN, administer RI #1's crushed medications with an ice cream spoon while wearing gloves. EI #6 was then observed administering RI #1's eye drops wearing those same gloves. On 06/13/19 at 9:10 a.m., an interview was conducted with EI #6, LPN. EI #6 was asked what was the concern with not changing gloves when needed. EI #6 said cross-contamination. EI #6 was asked did she change gloves after she administered RI #1's medications by mouth before administering RI #1's eye drops. EI #6 replied no and she should have changed them. EI #6 was asked what was the concern with not changing her gloves before administering RI #1's eye drops. EI #6 answered when giving RI #1's medications with the spoon and helping her drink she touched those items and could have touched RI #1's mouth so she could have cross- contaminated which was an infection control issue. On 06/13/19 at 4:04 p.m., an interview was conducted with EI #4, Registered Nurse/Director of Nursing. EI #4 was asked when should nurses change gloves and wash their hands. EI #4 said every time they do a treatment or if they are doing eye drops, touching skin or any time their hands are potentially contaminated. EI #4 was asked should a nurse change gloves and wash her hands after giving crushed medications with an ice cream spoon while wearing gloves before administering eye drops to a resident. EI #4 replied yes. EI #4 was asked should caps for mouthpieces be placed on a ledge without a barrier and then be placed on inhalers that have been rinsed before storing them in the medication cart. EI #4 responded no. EI #4 was asked what was the concern with not changing gloves and washing hands when potentially contaminated. EI #4 answered possibly causing and infection and infection control.

Based on observation, interview and review of the Food Code United States Public Health Service facility failed to ensure: 1) ice cream cups in the walk-in freezer were frozen solid, 2) opened items in the walk-in freezer were properly resealed, 3) walk-in freezer was maintained at a temperature to ensure food items were frozen solid, and 4) a dietary aide did not continue to serve trays after dropping the handle of the thermometer into the gravy. This deficient practice had the potential to affect 86 residents receiving meals from the kitchen. Findings Include: The Food Code U.S. Public Health Service 2017 indicates the following: . Temperature and Time Control 3-501.11 Frozen Food. Stored froze Foods shall be maintained frozen. . 3-202.15 Package Integrity. Food packages shall . protect the integrity of the contents so that the food is not exposed to ADULTERATION or potential contaminates. . Temperature and Time Control 3-501.11 Frozen Food. Stored froze Foods shall be maintained frozen. . 3-302.11 . (A) Food shall be protected from cross contamination . On 06/11/2019 at 11:08 AM, an observation of the walk-in freezer revealed the temperature at 11 degrees Fahrenheit. Seventeen strawberry ice cream cups were noted to not be frozen solid. A box with cinnamon rolls and a box with biscuits were opened and not resealed, with no open or use by dates noted. Employee Identifier (EI) #2, Dietary Manager, was asked if the ice cream cups were frozen solid. EI #2 replied, no they were not solid. On 06/12/19 at 11:28 AM, during lunch tray line observation, Employee Identifier (EI #1), dietary aide, dropped a thermometer into the brown gravy, then continued to plate a regular tray, adding the brown gravy to the beef patty. The plate was placed on the tray covered with a dome lid and placed into the cart for delivery. EI #1 then proceeded to plate another meal. On 06/13/19 at 9:38 AM, an interview was conducted with EI #1, dietary aide. EI #1 was asked what occurred during the lunch tray line service on 06/12/19. EI #1 said she dropped the thermometer in the brown gravy and the handle fell into the gravy. EI #1 was asked what was the concern with the handle of the thermometer not being clean and falling completely in the pan of food. EI #1 replied the handle was not clean by then causing cross contamination. EI #1 was asked what did she do after the thermometer fell in the gravy. EI #1 stated she kept serving. EI #1 was asked what should she have done. EI #1 said she should have pulled the gravy immediately. EI #1 was asked what was the concern with serving a resident food that was potentially contaminated. EI #1 answered it could make them sick. On 06/13/19 at 9:43 AM, an interview was conducted with EI #2, Dietary Manager. EI #2 was asked what happened during the lunch tray line on 06/12/19. EI #2 stated EI #1 dropped the thermometer in the gravy. EI #2 was asked what was the concern with the handle of the thermometer falling completely into a food item. EI #2 replied the germs that would be on the handle would cause cross contamination. EI #2 was asked did EI #1 continue to plate the contaminated gravy. EI #1 replied yes. EI #2 was asked what should EI #1 have done. EI #2 answered as soon as the thermometer fell she should have stopped and removed the gravy and made more gravy. EI #2 was asked what was the concern with serving a resident a food item that was potentially contaminated. EI #2 said could cause illness. EI #2 was asked what was the concern with the two boxes being opened in the walk-in freezer. EI #2 replied freezer burn that would diminish the product affecting the quality of the food. EI #2 was asked what should have been done. EI #2 stated they should have been tied properly, sealed and the tops closed. EI #2 was asked what was the concern with the 17 cups of strawberry ice cream. EI #2 said they were soft. EI #2 was asked should they have been. EI #2 replied per policy they should have been frozen solid.

Based on observations, interviews and review of a facility policy titled, Resident Rights and a facility document titled, Maintenance Supervisor Job Description, the facility failed to ensure Room Locators (RL)'s #1-63 were free of chipped paint on walls and doors, missing tiles on floors, missing curtains on closets, equipment in disrepair and worn furniture. This was observed three of three days of the survey and affected 63 of 66 rooms on four of four halls of the facility. Findings Include: A review of a facility policy titled, Resident Rights, no date, page 5, revealed: . 9. Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, . A review of a facility document titled, Maintenance Supervisor Job Description, no date, revealed: . Ensure the building(s), equipment and utilities are maintained in good working order . are properly maintained in accordance with Company and facility policies and State and Federal Regulations . Essential Job Functions * Perform minor repairs and supervise the day-to-day repair, improvement and preventive maintenance of the building, equipment . and supervise floor care. During the initial tour of the facility on 06/11/2018 the following observations were made: RL #1 - bedside table chipped, A bed head board loose RI #2 - torn armrest on wheelchair, chipped paint closet RL #3 - crack between air conditioner and wall RL #4 - chipped paint bathroom door, geri chair needs torn RL #5 - A bed head and foot board loose and torn, torn blinds, arms worn on green chair, left closet chipped paint RL #6 - chipped paint bathroom door, chipped paint closet on right side RL #7 - A bed head and foot board loose and chipped, B bed bedside table and overbed table chipped, chipped paint bathroom door RL #8 - chipped paint left closet RL #9 - chipped paint closet on left, chipped paint wall behind recliner RL #10 - A bed head board chipped, foot board chipped RL #11 - back of geri chair torn, B bed overbed table torn, chipped paint closet on right RL #12 - chipped paint left closet RL #13 - A bed foot board loose and chipped, chipped paint on wall RL #14 - missing curtain on right closet, chipped paint bathroom door RL #15 - chipped paint bathroom door RL #16 - foot board loose and chipped RL #17 - chipped paint closet and wall behind A bed RL #18 - bedside table chipped, bathroom door sticking, bed on blocks RL #19 - chipped paint wall behind A bed RL #20 - head and foot board loose and chipped, bedside table chipped RL #21 - chipped paint closet on left, floors dirty under bed and TV RL #22 - bedside table chipped, wheelchair armrests worn and torn, arms are worn on chair in room RL #23 - A bed overbed and bedside table chipped, missing curtain on left closet RL #24- closets chipped paint, bed wheels on blocks RL #25 - A bed overbed table chipped, chipped paint closet, cracked air conditioner cover RL #26 - both beds bedside tables chipped, chipped paint on closet RL #27 - B bed overbed table chipped, chipped paint both closets RL #28 - A bed wheelchair in disrepair, chipped paint wall beside bed, chipped paint closet, bed on blocks RL #29 - A bed bedside table chipped, B bed bedside table chipped, chipped paint on closet RL #30 - A bed bedside table chipped RL #31 - chipped paint closet on right side RL #32 - A bed wheelchair armrests worn and torn, B bed overbed table chipped RL #33 - A bed bedside table chipped, B bed overbed table chipped, closet loose board RL #34 - A bed overbed table chipped, armrests on green chair are worn, bathroom door chipped paint RL #35 - bedside table chipped, gap between air conditioner and wall, cracked plastic cover behind bed RL #36 - cracked air conditioner cover, loose cable cover, overbed table with worn edges RL #37 - floor tiles cracked and discolored RL #38 - cracked air conditioner cover RL #39 - chipped paint closets, B bed wheelchair armrests worn and torn RL #40 - cracked air conditioner cover RL #41 - A bed chipped and loose foot board RL #42 - A bed chipped overbed and bedside table, chipped paint wall by B bed RL #43 - missing tile going into bathroom, chipped paint edge of B bed closet, chipped paint door going into room RL #44 - chipped paint door going into room, discolored tile by B bed, chipped paint on wall RL #45 - arms worn on chair in room, closet missing curtain RL #46 - room door chipped, top of closet on left side loose board RL #47 - B bed closet chipped paint, bedside table chipped RL #48 - tan chair has worn arms, overbed table is chipped RL #49 - A bed head board loose and chipped, B bed's overbed table chipped RL #50 - overbed table chipped, closet chipped paint, closet needs curtain RL #51 - bedside table chipped RL #52 - bed needs cleaning, bed wheels in wooden blocks, closet curtain missing RL #53 - A bed bedside table chipped, both closets with chipped paint RL #54 - bed needs foot board loose, closet paint chipped and loose board RL #55 - A bed overbed table and nightstand chipped RL #56 - closets chipped paint, B bed wheelchair armrests worn and torn, armrests on green chair in room are worn RL #57 - both beds overbed tables chipped RL #58 - bathroom trim chipped paint RL #59 - door paint chipped, end of closet chipped paint, A bed overbed table chipped RL #60 - A bed bedside table chipped, air conditioner cover needs replaced RL #61 - closets chipped paint, A bed head and foot board loose and chipped and overbed table chipped RL #62 - closets have chipped paint, A bed needs new head and foot board, B overbed table chipped RL #63 - cable cover is broken, chipped paint on closet, sink in bathroom is leaking, overbed tables chipped. On 06/12/19 02:13 p.m. a facility environment tour with Employee Identifier (EI) #5, Administrator, was made regarding concerns identified by surveyors regarding homelike environment with above concerns acknowledged and agreed upon by EI #5 during the tour. On 06/13/19 at 4:15 p.m., an interview was conducted with EI #5, Administrator. EI #5 was asked what was important in regard to the residents' environment. EI #5 said that it should be homelike, kept clean and in good repair. EI #5 was asked what concerns were identified during the tour of the facility. EI #5 replied, some of the furnishings were in disrepair, closets and walls that needed painting and equipment that was not working or in disrepair, such as overbed tables. EI #5 was asked what was the concern with residents not having equipment in good repair and the environment not being homelike. EI #5 answered, they will not be happy and feel like they are at home.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and a review of the facility's policy titled, Administering Medications, the facility failed to ensure Resident Identifier (RI) #44 did not self administer a nebulizer treatment after being assessed as not having the ability to self administer medication. The affected one of one resident observed administering a nebulizer treatment. Findings Include: A review of the facility's policy titled, Administering Medications dated December 2012, revealed the following: Medications shall be administered in a safe . manner, and as prescribed. Policy Interpretation and Implementation 24. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision - making capacity to do so safely. Resident Identifier (RI) #44 was admitted to the facility on [DATE] with the diagnosis of Chronic Obstructive Pulmonary Disease. On 7/25/18 at 5:57 p.m., the surveyor observed RI #44 self administering his/her nebulizer inhalant medication treatment. A review of RI #44's Assessment for Self-Administration of Medications form dated 05/30/18, revealed RI #44 was unable to administer inhalant medications. On 7/26/18 at 3:58 p.m., an interview was conducted with EI (Employee Identifier) #2, RN (Registered Nurse), MDS (Minimum Data Set) Coordinator. EI #2 was asked if RI #44 was assessed for self-administration of medications. EI #2 said RI #44 was assessed for self-administration of medication and he/she was unable to administer medications. EI #2 was asked if RI #44 was unable to self administer his/her medications, should RI #44 have been doing that (self-administering medications). EI #2 said No. EI #2 was asked what was the potential harm if RI #44 was assessed as not being able to self-administer medications, but was observed self-administering medications. EI #2 said he/she could administer medications inappropriately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and a facility policy titled, .Quality of Life-Accommodation of Needs, the facility failed to ensure Resident Identifier (RI) # 22 was given a choice for method of bathing. This affected one of one sampled resident who expressed a concern regarding baths. Findings include: A review of the facility policy titled, .Quality of Life-Accommodation of Needs with a revised date of 8/09, revealed: .The resident's individual needs and preferences shall be accommodated to the extent possible . RI #22 was admitted to the facility on [DATE] with diagnoses including Chronic Ischemic Heart Disease, Chronic Obstructive Pulmonary Disease and Muscle Weakness. RI #22's care plans included the plan for requiring extensive assistance with all ADL (activity of daily living) skills due to a right below knee amputation, muscle weakness, and abnormal gait/mobility. Approaches included: . Ask resident is he/she ready to take a bath, shower, etc. On 07/24/18 at 3:39 PM during an interview, RI #22 asked the surveyor why he/she could not have a tub bath. RI #22 commented he/she had only one shower since he/she was admitted to the facility on [DATE]. RI #22 reported he/she had not had a tub bath. RI #22 reported the staff had to bring him/her a pan of water to bathe off while in the bed. RI #22 reported he/she would love to have a tub bath. RI #22 reported he/she did not like the way the staff gave the shower he/she had. When asked why, RI #22 said they laid him/her on a shower table and the water was cold. When asked if he/she would use a shower chair, RI #22 said yes, he/she took showers at home because it was easier. RI #22 reported the staff would ask him/her if he/she wanted to shower, but he/she would refuse. RI #22 reported he/she was told they (the facility) did not have a bath tub. On 07/25/18 at 5:52 PM, Employee Identifier (EI) #11, Maintenance Director, was interviewed. EI #11 reported the facility had four showers but no tubs. EI #11 also reported they had a whirlpool tub, but it had not worked in a longtime. EI #11 said she had been there for two years and the tub was not working when she started, as far as she knew. On 07/26/18 at 7:40 AM, EI #12, the Administrator was interviewed. EI #12 reported he had been the Administrator since June 2011. When asked why the facility did not have a tub and why the whirlpool tub had not worked in years, EI #12 replied he had not had any request from anyone for a tub. EI #12 agreed residents should have a choice in a bathing method. On 07/26/18 at 1:48 PM, EI #13, Licensed Practical Nurse/Unit Manager, was interviewed. EI #13 was informed of RI #22 expressing his/her desire for a tub bath. When asked why the resident did not like showers, EI #13 replied she did not know why the resident would not take showers. EI #13 stated the Certified Nursing Assistants just told her RI #22 did not want to take showers. EI #13 confirmed, when asked, that she did not go and speak to RI #22 about the showers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, and a facility's policy titled, . - Confidentiality of Information and Personal Privacy, the facility failed to ensure Resident Identifier (RI) #88's MAR (Medication Administration Record) was not left open to public view. This affected (RI) #88, one of three residents observed during medication administration. Findings Include: The facility's policy titled, . - Confidentiality of Information and Personal Privacy with a revised date of October 2017, revealed the following information: Policy Statement Our facility will protect and safeguard resident confidentiality and personal privacy. The Policy Interpretation and Implementation revealed, 2. The facility will strive to protect the resident's privacy regarding his or her: .b. medical treatment . 4. Access to resident personal and medical records will be limited to authorized staff . RI #88 was readmitted to the facility on [DATE], with a diagnosis of Type 2 Diabetes Mellitus. On 07/25/18 at 11:05 AM, Employee Identifier (EI) #6, Licensed Practical Nurse (LPN) was observed during medication administration. EI #6 entered RI #88's room with medication and the MAR was left opened to public view. Other staff and residents were observed on the hallway. RI #88's MAR documented the resident's name, room numbers, allergies, medications, diet and physician's name. EI #6 exited the room and opened the medication cart to obtain a gauze. The MAR was still observed up and opened to the public view. On 07/25/18 at 11:10 AM, during an interview with EI #6, the surveyor asked what was left up and opened for public view. EI #6 stated, The resident's MAR. The surveyor asked what was the policy for leaving MARs up and opened for public view. EI # stated, I should have closed it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and the facility policy titled, . Care Plan, Comprehensive Person - Centered, the facility failed to ensure staff consistently followed Resident Identifier (RI) #85's care plan for self care deficit with eating by not providing a weighted spoon during the breakfast and lunch meal on 07/24/18. This affected one of 23 sampled residents whose care plans were reviewed. Findings include: The facility's policy titled, . Care Plan, Comprehensive Person - Centered , with a revision date of December 2016, was reviewed. The Policy Statement indicated that, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The Policy Interpretation and Implementation included, . 4. g. Receive the services and/or items included in the plan of care: . RI #85 was readmitted to the facility on [DATE]. Diagnoses included Autistic Disorder and Other Intellectual Disabilities. RI #85's careplans with a review date of 06/27/18 revealed: . require special equipment during meals times . Approaches .Use appropriate devices, weighted spoon to assist resident to feed self. On 07/24/18 at 8:13 AM, RI #85 was observed sitting up in bed for breakfast. A view of the tray card revealed the following: . weighted spoon, . A weighted spoon was not provided to RI #85. On 07/24/18 at 12:25 PM, an observation was made of the lunch meal. No weighted utensils were provided to RI #85. On 07/26/18 at 11:35 AM, during an interview with EI (Employee Identifier) #2, (Minimum Data Set) MDS Coordinator, RI # 85's care plan was reviewed. EI #2 was asked what was the care plan for the resident's adaptive equipment/utensils. EI #2 stated, Self-care deficit for feeding. The surveyor asked what was the approach. EI #2 stated, Use appropriate device, weighted spoon to assist resident to feed (her/himself). The surveyor asked what was the date on the care plan and intervention. EI #2 stated, Problem onset date was 10/13/17. I reviewed it last 6/27/18, (that) was my last review date. The surveyor asked what was her review outcome related to the weighted spoon. EI #2 stated, The resident still needed the weighted spoon and there was an order and I observed (her/him) use the spoon. (She/he) could use it but with difficulty and required assistance with feeding. The surveyor informed EI #2 that RI #85 was observed on 7/24/18, for breakfast and lunch. For breakfast RI #85 received a weighted fork and for lunch the resident received no weighted utensils. The surveyor asked was the care plan for self care deficit followed. EI #2 stated, No, because (he/she) is care planned for a weighted spoon.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and a review [NAME] and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure staff followed Resident Identifier's (RI) #85's physician's order for a weighted spoon. This affected one of 23 sampled residents whose physician's orders were reviewed. Findings Include: A review of [NAME] and Perry's FUNDAMENTALS OF NURSING Ninth Edition, page 311 revealed the following: . Health Care Providers' Orders.follow health care providers' orders . Resident Identifier (RI) #85 was readmitted to the facility on [DATE]. Diagnoses included Autistic Disorder and Other Intellectual Disabilities. A review of RI #85's July 2018 Physician's Orders revealed an order for WEIGHTED SPOON WITH EACH MEAL. The order/start date was 01/12/18. On 07/24/18 at 8:13 AM, RI #85 was observed sitting up in bed for breakfast. A weighted spoon was not provided to RI #85. On 07/24/18 at 12:25 PM, an observation was made of the lunch meal. No weighted utensils were provided to RI #85. On 07/24/18 at 12:30 PM, during an interview with Employee Identifier (EI) #3, Certified Nursing Assistant (CNA), the surveyor asked where was RI #85's weighted spoon. EI #3 stated, Dietary did not send it. The surveyor asked if the resident received the weighted spoon for breakfast. EI #3 stated, No ma'am. The surveyor asked should the resident have gotten a weighted spoon with breakfast and his lunch. EI #3 stated, Yes ma'am. The surveyor asked could the resident use the weighted spoon. EI #3 stated, Yes. On 07/26/18 at 7:35 AM, an interview was conducted with EI #4, a Licensed Social Worker. EI #4 was asked when had she observed RI #85 to use a weighted spoon. EI #4 stated, I am actually the one that requested the weighted spoon. The surveyor asked why. EI #4 stated, The resident can actually feed himself/herself and when he/she used the regular spoon he/she would shake really bad, but he/she can use the weighted spoon.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, activity participation records, record review and the facility's policy titled, Activities Policies and Procedures Manual, the facility failed to provide Resident Identifier (RI) #55 with activities of choice from March 2018 to July 2018. The facility further failed to provide RI #73 with activities of choice on three of three days of the survey. This affected two of 23 sampled residents whose activity records were reviewed. Findings Include: The facility's policy titled, Activities Policies and Procedures Manual, with a revised date of October 29,2014 revealed: Procedure: . 2) The department will continuously offer residents a wide range of activities program opportunities so that they may explore any and all potential leisure interests. 5) The department will continue to invite residents to group programs, one-to-one activities contacts, . 1) RI #55 was readmitted to the facility on [DATE]. Diagnoses included Blindness of Both Eyes and Restlessness and Agitation. A review of RI #55's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had short and long term memory deficits. The MDS also revealed RI #55 required extensive assist of two person for bed mobility and transfers. A review of RI #55's care plans revealed the resident enjoyed being read to, music and visits with family. The care plan was initiated on 09/13/17. A review of RI #55's ACTIVITY INITIAL ASSESSEMENT (ASSESSMENT) SHEET dated 03/05/18, revealed the following resident interests: listening to TV, visits and being read to. A review of RI #55's IN ROOM ACTIVITY PARTICIPATION records from March 2018 to May 2018, revealed staff had visited and talked with the resident, however, there was no evidence staff had read to the resident. On 07/24/18 at 12:06 PM, RI #55 reported to the surveyor that she/he liked to listen to the radio and watch TV. On 07/25/18 at 7:58 AM, during an interview with Employee Identifier (EI) #7, Activities Director, the surveyor and EI #7 reviewed RI #55's Activity Initial Assessment Sheet, notes and In Room Activity Participation records. EI #7 was asked what did the resident like to do, as documented on the Activity Initial Assessment Sheet dated 3/5/18. EI #7 stated, Listen to radio, have TV, visit, enjoys being read to and visit with family and staff. The surveyor asked for the month of March how many times was RI #55 read to. EI #7 stated, It don't look like any. The surveyor asked for the month of April, how many times was RI #55 read to. EI #7 stated, None. The surveyor asked for the month of May, how many times was RI #55 read to. EI #7 stated, None. The surveyor asked for the month of June, how many times was she/he read to. EI #7 stated, None. The surveyor asked for the month of July, how many times was RI #55 read to. EI #7 stated, None yet. The surveyor asked from February to July 25, 2018, had the resident been provided with activities based on the resident's activity assessment dated [DATE]. EI #7 stated, No, not according to this. 2) RI #73 was admitted to the facility on [DATE]. Diagnoses included Severe Intellectual Disabilities and Spastic Quadriplegic Cerebral Palsy. A review of RI #73's Activity Initial Assessment Sheet, dated 01/04/18, revealed the resident's interest included group singing, listening to a band, listening to the radio, parties, visits, church service and that the resident did wish to participate in activities. A review of the July 2018 activity calendar was conducted. The activity department offered music, coffee club and church service on 07/24/18. On 07/25/18 the activity department offered bible study. On the 07/26/18 TV, bible group and coffee club were offered, among other group activities. A review of RI #73's July 2018 activity group roster for the days during the survey (07/24/18-07/26/18) were reviewed. The activity staff documented RI #73 participated in group activity by talking and conversing on 07/24/18 and 07/25/18. The activity department also documented on the resident's independent roster that RI #73's independent activities consisted of TV/Movies, conversations/phone and exercise on 07/24/18, 07/25/18 and 07/26/18. On 07/25/18 at 7:50 AM, RI #73 was observed in the hall in the gerichair. At that time, an interview was conducted with Employee Identifier (EI) #14, Certified Nursing Assistant (CNA). EI #14 reported that RI #73 ate meals in the dining room and sometimes was taken to an activity but she/he was mainly placed in the hall so staff could keep an eye on her/him. EI #14 also reported it did not bother RI #73 to be around other residents. On 07/25/18 at 10:30 AM, RI #73 was observed in the hallway next to her/his room. Snack time was the listed activity at that time. On 07/25/18 at 2:31 PM, RI #73 was observed in the hallway in the gerichair. Snack break was the listed activity at that time. On 07/26/18 at 3:23 PM, the Activity Director, EI #7, was interviewed regarding the activities the facility provided to RI #73. EI #7 reported RI #73 did not do well in large groups but could tolerate small group activities. When asked about RI #73's activities, EI #7 reported she considered RI #73 being in the hallway and eating in the dining room as an activity and interacting with others. When asked when was the last time RI #73 attended any activities that week, she reported, not since Monday (07/23/18).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and a review of the facility's policy titled, Administering Medications through an Enteral Tube, the facility failed to ensure a licensed staff member administered water flushes in a Gastrostomy Tube (GT) in between each medication administration. The facility further failed to ensure the licensed staff diluted each crushed medication with at least 15 cubic centimeters (cc) of water for administration to Resident Identifier (RI) #39. This affected one of one residents observed during medication administration via a GT. Findings Include: A review of the facility's policy titled, . Administering Medications through an Enteral Tube, revised April 2018, was conducted. The purpose of the policy was to provide guidelines for the safe administration of medications through an enteral tube. General Guidelines included the following, . 4. Administering each medication separately and flushing between medications in considered standard of practice .Steps in the Procedure .22. Dilute the crushed or split medication with 15-30 ml (milliliters) .water . RI #39 was readmitted to the facility on [DATE]. Diagnoses included Gastrostomy Status. A review of RI #39's Quarterly Minimum Data Set (MDS) dated [DATE] revealed RI #39's Brief Interview for Mental Status (BIMS) score of 11, indicating cognition was moderately impaired. The MDS also revealed RI #39 received nutrition per feeding tube. A review of RI #39's July 2018's Physician's Orders revealed an order for a gastrostomy tube for nutritional therapy. On 7/25/18 at 8:55 AM, the following observation was made during medication administration for RI #39. Employee Identifier (EI) #8, Licensed Practical Nurse(LPN) dispensed the following medications for administration via GT: 1. Valproic Acid 20 cc BID (Twice a day) PT (per tube), 2. Vitamin D3 1,000 Units one PT QD (Once a day) , 3. Zinc Sulfate 220 mg one tablet PT BID, 4. Vitamin B 12 1,000 mcg (microgram) one tablet PT QD, 5. Ascorbic Acid 500 mg one PT BID and 6. Primidone 50 mg one PT BID EI #8 administered 30 cc's of air into RI #39's GT. Medications were crushed and mixed with five cc's of water. Six medications were administered with no water flushes in between medication administration. A moderate amount of a whitish substance (medication) was left in the four medication cups that contained the crushed Primidone, Ascorbic Acid, Vitamin D3, and Zinc Sulfate. A moderate amount of the liquid Valproic Acid was also left in a medication cup. On 07/25/18 at 9:10 AM, during an interview with EI #8, the surveyor asked what was left in five of six of the medication cups. EI #8 stated, Medication was left in five cups. The surveyor asked why were medications left in the cups. EI #8 stated, I guess the medications did not get stirred around enough. The surveyor asked did the resident get the dose ordered for the medications that were left in the medication cups. EI #8 stated, No. The surveyor asked how much water flush did she administer between each medication. EI #8 stated, None. The surveyor asked what was the policy and procedure for how much water flush to use in between each medication that was administered. EI #8 stated, I would have to check.

Based on interview, review of Record of Destruction forms and a review of the facility's policy titled, Discarding and Destroying Medications, the facility failed to ensure drug destruction records contained the method of destruction from February 2018 to May 2018. This affected four months of Record of Medication Destruction forms reviewed. Findings Include: A review of the facility's policy titled, Discarding and Destroying Medications with a revised date of October 2014, revealed the following: . Policy Interpretation and Implementation . 10. The medication disposition record will contain the following: f. Method of disposition; . A review of the facility's Record of Medication Destruction forms from February 2018 to May 2018, revealed no method of destruction was listed on the forms provided to the surveyor. On 07/26/18 at 6:36 PM, during an interview with Employee Identifier (EI) # 1, Director of Nursing(DON), she was asked what method of destruction did the facility use for the non-controlled drugs from February 27, 2018 until May 22, 2018. EI #1 stated, Kitty Litter. The surveyor asked where was the evidence of the method of destruction for those months. EI #1 stated, The destruction forms are not marked for form of med destruction. The surveyor asked should that information be on the record of medication destruction. EI #1, stated, Yes ma'am. The surveyor asked what was the policy and procedure for information to be included on the record of medication destruction. EI #1, stated, Two nurse signatures, pharmacist signatures and the method of destruction. The surveyor asked was policy and procedure followed for including the method of medication destruction. EI #1 stated, No.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the medication error rate was less than 5%. There were a total of 26 opportunities observed during medication administration with five errors. The medication error rate was 19.23 %. This deficient practice affected RI (Resident Identifier) #39, one of four residents observed during medication administration. Findings include: RI #39 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Vascular Disorder of the Intestine and Moderate Protein-Calorie Malnutrition. A review of RI #39's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 4/09/18, revealed the resident had a BIMS (Brief Interview for Mental Status) of 11, which indicated moderate impairment in cognition. The MDS also revealed RI #39 had a feeding tube. A review of RI #39's July physician orders revealed: .VALPROIC ACID 250 MG/ML (MILLIGRAM/MILLILITER) .GIVE 20 ML .PER TUBE TWICE A DAY . VITAMIN D3 1,000 UNIT TABLET GIVE ONE TABLE PT (PER TUBE) EVERYDAY (CRUSHED) . VITAMIN B-12 1,000 MCG (MICROGRAM) TABLET GIVE ONE TABLET PT EVERYDAY . PRIMIDONE 50 MG TABLET ADMINISTER ONE TABLET PER GASTRONOMY (GASTROSTOMY) TUBE TWICE DAILY . ASCORBIC ACID 500 MG TABLET ADMINISTER ONE TABLET PER GASTRONOMY TUBE TWICE DAILY . ZINC SULFATE 220 MG TABLET GIVE ONE TABLET PT TWICE DAILTY (DAILY) . On 7/25/18 at 8:55 AM, the following observation was made during medication administration. Employee Identifier (EI) #8, Licensed Practical Nurse(LPN) dispensed the following medications for administration by gastrostomy tube: 1. Valproic Acid 20 cc (cubic centimeters) BID (Twice a day) PT 2. Vitamin D3 1,000 Units one PT QD (Every day) 3. Zinc Sulfate 220 mg one tablet PT BID 4. Vitamin B 12 1,000 mcg one tablet PT QD 5. Ascorbic Acid 500 mg one PT BID 6. Primidone 50 mg one PT BID EI #8 entered RI #39's room and administered 30 cc's (cubic centimeters) of air into the gastrostomy tube. The medications were crushed and mixed with five cc's of water. Six medications were administered to RI #39. A moderate amount of a whitish substance (medication) was left in the four medication cups that contained the crushed Primidone, Ascorbic Acid, Vitamin D3, and Zinc Sulfate. A moderate amount of the liquid Valproic Acid was also left in a medication cup. On 07/25/18 at 9:10 AM, during an interview with EI #8, the surveyor asked what was left in five of six of the medication cups. EI #8 stated, Medication was left in five cups. The surveyor asked why were medications left in the cups. EI #8 stated, I guess the medications did not get stirred around enough. The surveyor asked did the resident get the dose ordered for the medications that were left in the medication cups. EI #8 stated, No.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review and a review of the facility policy titled, Accuracy and Quality of Tray Line Service, the facility failed to ensure Resident Identifier (RI) #83 and RI #67 received fried eggs for breakfast on 07/24/18 and 07/25/18 as requested. This affected two of 23 residents observed during meals. Findings Include: A review of the facility policy titled,Accuracy and Quality of Tray Line Service with a 2010 date, revealed the following: . 7. Each tray will be checked for: . *Special requests (food preferences) . 1) RI #83 was readmitted to the facility on [DATE]. A review of RI #83's most recent Minimum Data Set (MDS), dated [DATE], revealed the resident was cognitively intact. A review of RI #83's care plan for at risk for alteration in nutritional status and weight fluctuation, with an onset date of 03/13/18 revealed: . Approaches .Maintain accurate and current listing of resident food likes and dislikes . A review of RI #83's tray cards for breakfast, lunch and supper revealed: Notes: . 2 FRIED EGGS . RI #83 was observed in her/his room on 07/24/18 at 9:49 AM. RI #83 said she/he ordered fried eggs and grits that day and got the grits after she/he notified the Certified Nursing Assistant (CNA), but did not get the fried eggs. RI #83 reported she/he got scrambled eggs and they were burned and cold. A review of the breakfast tray card revealed fried eggs were listed. On 07/25/18 at 07:40 AM, RI #83 was up to the bedside and eating breakfast. Observed on RI #83's tray were two pieces of toast, a big bowl of oatmeal, three slices of bacon and scrambled eggs. The tray card indicated two pieces of toast, big bowl of oatmeal, three slices of bacon, and two fried eggs. RI #83 said she/he still did not get the fried eggs or grits. RI #83 reported that she/he had told them (every staff that brought his/her tray) several times to bring her/him some grits. 07/25/18 at 2:34 PM, The Certified Dietary Manager (CDM), Employee Identifier (EI) #10 was interviewed. EI #10 was asked who was responsible for ensuring RI #83 received her/his fried eggs, as listed on the tray cards. EI #10 reported the [NAME] Supervisor was held accountable and it was double checked by the Dietary Aide prior to loading the carts, then triple checked by the CNAs who delivered the trays to the residents. 2) RI #67 was admitted to the facility on [DATE]. A review of RI #67's admission MDS, dated [DATE], revealed the resident's cognition was intact. A review of RI #67's care plan revealed a problem of risk for impaired nutrition with an onset date of 6/27/18. Approaches included: * Determine food preferences . A review of RI #67's tray cards for breakfast indicated, Notes: . 2 FRIED EGGS . On 07/24/18 at 09:49 AM, RI #67 was observed in his/her room eating breakfast. RI #67 said she/he got scrambled hard cold eggs and should have gotten fried eggs. RI #67 said the CNA was told and she went to the kitchen. RI #67 said the CNA came back and said there were no fried eggs, per the kitchen. On 07/25/18 at 07:40 AM, RI #67 was observed eating breakfast. The meal consisted of two pieces of toast, a big bowl of oatmeal, three slices of bacon and scrambled eggs. A review of the tray card revealed, 2 pieces of toast, big bowl of oatmeal, 3 slices of bacon, 2 fried eggs . On 07/25/18 at 2:34 PM, EI #10 was interviewed. EI #10 was asked who was responsible for ensuring RI #67 received her/his fried eggs, as listed on the tray cards. EI #10 reported the [NAME] Supervisor was held accountable and it was double checked by the Dietary Aide prior to loading the carts, then triple checked by the CNAs who delivered the trays to the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and the facility's policies titled, Assisting the Resident with In-Room Meals, and Adaptive Eating Devices, the facility failed to ensure RI #85's weighted spoon was provided during the breakfast and lunch meals on 07/24/18. This affected one of one resident observed for weighted utensil use during meals. Findings Include: A review of the facility's policy titled, Assisting the Resident with In-Room Meals with a revised date of December 2013 revealed: Purpose .The purpose of this procedure is to provide assistance for residents who choose to receive meals in their rooms . 4. Ensure that the necessary non-food items, ( . special devices, .) are on the tray. Equipments and Supplies The following equipment and supplies will be necessary when performing this procedure: . 3. Special feeding devices (as indicated) . A review of the facility policy titled, Adaptive Eating Devices with a date of 2008, revealed: Procedure: .5. The food service department is responsible for ensuring that each individual receives the appropriate feeding devices for each meal. Resident Identifier (RI) #85 was readmitted to the facility on [DATE]. Diagnoses included Autistic Disorder and Other Intellectual Disabilities. On 07/24/18 at 8:13 AM, RI #85 was observed sitting up in bed for breakfast. A view of the tray card revealed the following: . Weighted Spoon . RI #85 was observed eating the meal with regular utensils. A weighted spoon was not provided to the resident. On 07/24/18 at 12:25 PM, an observation was made of the lunch meal. No weighed utensils were provided to RI #85. On 07/24/18 at 12:30 PM, during an interview with Employee Identifier (EI) #3, Certified Nursing Assistant(CNA), the surveyor asked where was RI #85's weighted spoon. EI #3 stated, Dietary did not send it. The surveyor asked if the resident got the weighted spoon for breakfast. EI # stated, No ma'am. The surveyor asked should the resident have gotten a weighted spoon with breakfast and his lunch. EI #3 stated, Yes ma'am. The surveyor asked could the resident use the weight spoon. EI #3 stated, Yes. On 07/25/18 at 2:34 PM, the Certified Dietary Manager (CDM), EI #10 was interviewed. When asked who ensured the residents received weighted spoons/utensils, EI #10 replied, the one loading the meal carts and the CNAs double checked when the tray was taken to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and a facility policy titled, Standard Precautions Infection Control, the facility failed to ensure staff washed their hands before gloves were applied, after gloves were removed and before touching personal items of residents. This affected Resident Identifier (RI) # 88 and #39, two of four residents observed during medication administration. Findings include: A review of the facility's policy titled, Standard Precautions Infection Control with a copyright date 2016, revealed: Policy It is our policy to assume that all patients are potentially infected or colonized with an organism that could be transmitted during the course of providing patient care services and therefore our facility applies the Standard Precautions infection control practices outlined below: . 1. Hand Hygiene: . e. perform hand hygiene: . iv. If hands will be moving from a contaminated-body site to a clean-body site during patient care. v. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. vi. After removing gloves. 1) RI #88 was readmitted to the facility on [DATE], with a diagnosis of Type 2 Diabetes Mellitus. On 7/25/18 at 11:05 AM, an observation was made of Employee Identifier (EI) #6, Licensed Practical Nurse (LPN), entering RI #88's room to administer medication. EI #6 applied gloves, however, she did not wash or sanitize her hands before applying gloves. EI #6 exited the room with the gloves still on and opened the medication cart and obtained a gauze. After returning to the room, EI #6 did not wash or sanitize her hands. EI #6 obtained RI #88's FSBS (Finger Stick Blood Sugar). EI #6 then removed the gloves. EI #6 did not wash or sanitize her hands after removing the gloves. EI #6 touched the computer mouse that was on the medication cart, opened the medication cart, grabbed alcohol swabs, locked the medication cart and closed the tablet. EI #6 did not wash or sanitize her hands during her tasks. On 07/25/18 at 11:10 AM, during an interview with EI #6, the surveyor asked what should be done after gloves are removed and before applying clean gloves. EI # stated, I should have used hand sanitizer or washed my hands, but I did not do that. The surveyor asked after gloves were removed and before touching any personal items of the resident or computer, what should be done. EI #6 stated she should have used hand sanitizer. The surveyor asked what was the potential harm when gloves were removed and staff touched a resident's personal items, the medication cart and computer but hands were not washed. EI #6 replied, when gloves were removed and personal items were touched, that was cross-contamination and potential infection from one patient to another. The surveyor asked EI #6 did she follow policy and procedure for infection control. EI #6 stated, I did not. 2) RI #39 was readmitted to the facility on [DATE] with diagnoses including Gastrostomy Status. A review of RI #39's Quarterly Minimum Data Set (MDS) dated [DATE], revealed RI #39's Brief Interview for Mental Status score of 11, indicating cognition was moderately impaired. The MDS also revealed RI #39 received nutrition per feeding tube. On 7/25/18 at 8:55 AM, an observation was made of EI #8, LPN, administering medications to EI #39. During the observation, EI #8 applied gloves and touched the colostomy bag. A brownish colored substance was observed on EI #8's gloves. EI #8 did not change her gloves after they were soiled with the brownish colored substance from the colostomy bag and continued to administer medication to RI #39. On 07/25/18 at 9:10 AM, during an interview with EI #8, the surveyor asked what was the brownish substance she got on her gloves. EI #8 stated, Stool from the resident's colostomy. The surveyor asked after she got stool on the gloves, when did she change gloves. EI #8 stated, I did not change gloves. The surveyor asked what did she touch with her contaminated gloves with stool on them. EI #8 stated, The resident's tube, medication cups and the syringe. The surveyor asked what was the potential for harm after gloves become contaminated and not changed. EI #8 stated, Infection. On 07/26/18 at 3:48 PM, Infection Control Nurse, EI #15 was interviewed. EI #15 was asked what should nurses do when they remove gloves and before touching other items. EI #15 replied, go and wash their hands. EI #15 was asked when should hands be washed. EI #15 replied, before donning gloves, in between glove changes, basically any time going to do anything for the resident, and in between resident care,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents were provided with knowledge of what an Advance Directive was and provide proof of whether they wanted to formulate one or not. This deficient practice affected Resident Identifiers (RI) #'s 11, 22,33, 36, 41, 45, 46, 50, 55, 57, 60, 62, 67, 68, 73, 76, 77 and 83, 18 of 22 sampled residents reviewed for implementation of Advance Directives. Findings include: The facility's policy regarding, Advance Directives revised December 2016 was provided to the surveyors. The policy interpretation and implementation included, . 7. Information about whether or not the resident has executed an advance directive shall be displaced prominently in the medical record. 8. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. RI #22 was admitted to the facility on [DATE]. RI #33 was admitted to the facility on [DATE]. RI #36 was admitted to the facility on [DATE]. RI #41 was admitted to the facility on [DATE]. RI #46 was admitted to the facility on [DATE]. RI #50 was admitted to the facility on [DATE]. RI #57 was admitted to the facility on [DATE]. RI #60 was admitted to the facility on [DATE]. RI #62 was admitted to the facility on [DATE]. RI #68 was admitted to the facility on [DATE]. RI #73 was admitted to the facility on [DATE]. RI #76 was admitted to the facility on [DATE]. On 7/24/18 and 7/25/18, chart reviews were conducted regarding advance directives acknowledgement for RI #22, RI #33, RI 36, RI #41, RI #46, RI #50, RI #57, RI #60 RI #62, RI #68, RI #73 and RI #76. No proof of acknowledgement directives could be located on the charts. On 7/25/18 at 4:30 PM, Employee Identifier (EI) #16, (LSBW) Licensed Bachelor Social Worker, was interviewed regarding Advance Directives. When asked about the Advance Directive acknowledgement forms and where they were located on the chart, EI #16 replied the DNR's (Do Not Resuscitate) were on the charts. When asked what she did about finding out whether or not residents wanted to formulate an advance directive, EI #16 reported they put the forms in the admission packet and told the resident and family it was there in case they decided to formulate an advance directive. EI #16 was asked if she explained to the resident and family what an advance directive was and she replied no. There was no evidence in the charts that Advance Directives had been explained to the residents or that they were given an option to formulate one. RI #11 was admitted to the facility on [DATE]. RI #45 was admitted to the facility on [DATE]. RI #55 was admitted to the facility on [DATE]. RI #67 was admitted to the facility on [DATE]. RI #77 was admitted to the facility on [DATE]. RI #83 was admitted to the facility on [DATE]. On 07/26/18 at 5:15 PM, an interview was conducted with EI #16, regarding the lack of Advance Directive Acknowledgement forms on the resident's medical charts. The surveyor and EI #16 reviewed the charts of RI's #11, RI #45, RI #55, RI #67, RI #77, and RI 83. EI #16 said no resident record had an advanced directive, but the facility would be educating on completing the forms. On 07/26/18 at 5:19 PM, an interview was conducted with EI #17, LBSW. EI #17 was asked how were the residents informed of their right to execute an advance directive. EI #17 replied, usually on admission, they asked the resident or the resident's responsible party if they had an advance directive. EI#17 was asked what if the resident did not have an advance directive. EI#17 reported they (residents) were automatically a full code and sometimes they changed to DNR (Do Not Resuscitate) later. EI #17 was asked if she assisted residents in making an advance directive. EI #17 replied, yes, if they wanted to. EI #17 was asked did she have evidence that she discussed advance directives with the family. EI #17 replied, yes there was a form that was in the admission packet. EI #17 said there was an acknowledgement form when they discussed advance directives with families that was kept in the business office. EI #17 was asked if she had evidence that she discussed the resident's right to formulate an advance directive. EI #17 could not provide evidence of acknowledgement of advance directives for 18 sampled residents.