**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of facility policies titled, Behavioral Assessment, Intervention, and Monitoring, Mood and Behavior, and Antipsychotic Medication Use, the facility failed to ensure Resident Identifier (RI) #75 received adequate monitoring related to the use of antipsychotic and antidepressant medications. Specifically, the facility failed: 1. to ensure RI #75 was monitored for behaviors for which an antipsychotic medication (Zyprexa) was administered. This deficient practice affected RI #75, one of three sampled residents reviewed for unnecessary medications who received an antipsychotic medication; and 2. to ensure RI #75 was monitored for side effects of an antipsychotic (Zyprexa) and an antidepressant (Zoloft) medication. This deficient practice affected RI #75, one of four sampled residents reviewed for unnecessary medications who received an antipsychotic medication and antidepressant medication. Findings included: A review of the facility's BEHAVIORAL ASSESSMENT, INTERVENTION, AND MONITORING, policy, dated 11/28/2017, indicated, . The facility will comply with regulatory requirements related to the use of medications to manage behavioral changes . The Monitoring 1. If the resident is being treated for altered behavior or mood, the IDT [Interdisciplinary Team] will seek and document any improvements or worsening in the individual's behavior, mood, and function.The nursing staff and the physician will monitor for side effects and complications related to psychoactive medications; for example, lethargy, abnormal involuntary movements, anorexia, or recurrent falling. A review of the facility's MOOD AND BEHAVIOR POLICY, last reviewed on 11/20/2020, indicated, Mood and Behavior tracking documentation will be completed by front line staff, . A review of the facility's ANTIPSYCHOTIC MEDICATION USE POLICY, last reviewed in December of 2020, indicated, The staff will observe, document, and report to the Attending Physician information regarding the effectiveness of any interventions, including antipsychotic medications .Nursing staff shall monitor for and report .side effects and adverse consequences of antipsychotic medications to the Attending Physician. A review of RI #75's admission RECORD indicated the facility originally admitted the resident to the facility on [DATE] and re-admitted the resident on 12/20/2021. The admission record indicated the resident had diagnoses to include Adjustment Disorder with Depressed Mood, Unspecified Psychosis Not Due To A Substance Or Known Physiological Condition, and Unspecified Dementia With Behavioral Disturbance. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/12/2022, revealed RI #75 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. Per the MDS, RI #75 had no potential indicators of psychosis and had exhibited no behaviors during the seven-day look back period. The MDS indicated the resident received antipsychotic and antidepressant medications seven of seven days during the look back period and had received antipsychotic medication only on a routine basis. A review of RI #75's Care Plan, last reviewed on 11/18/21, indicated the resident demonstrated verbally abusive and combative behaviors related to dementia. Interventions to address the focus area included evaluating the resident for side effects of medications and documenting observed behaviors and attempting interventions in the behavior log. The care plan also indicated the resident used psychotropic medications related to dementia and behaviors. Interventions included to monitor and document side effects and effectiveness of the medications and monitor/record/report to the physician side effects and adverse reactions of RI #75's psychoactive medications. A review of RI #75's Order Summary Report, with active orders as of 02/18/2022, indicated the resident was to receive Zoloft 50 milligrams (mg) one tablet by mouth in the morning related to other symptoms and signs involving cognitive functions following unspecified cerebrovascular disease and Zyprexa 10 mg one tablet by mouth at bedtime related to unspecified psychosis not due to a substance or known physiological condition. A review of the electronic health record (EHR), including the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for January 2022 and February 2022 (from 02/01/2022 - 02/17/2022) revealed there was no documentation to indicate the resident was monitored for target behaviors for which Zyprexa was administered and/or side effects potentially resulting from the Zoloft or Zyprexa. On 02/17/2022 at 10:51 AM, Employee Identifier (EI) #6, Licensed Practical Nurse, was interviewed. After reviewing the physician's orders for RI #75, she stated she saw neither an order to monitor behaviors for which the Zyprexa was administered, nor an order to monitor for side effects of the Zoloft or Zyprexa. EI #6 stated a resident who received antipsychotic medication(s) should be monitored for behaviors and side effects. On 02/17/2022 at 2:05 PM, EI #2, Director of Nursing, was interviewed. She stated she expected nursing staff to monitor residents who received an antipsychotic medication for target behaviors every shift. She stated she expected staff to monitor residents who received antipsychotic and/or antidepressant medications for side effects of the medication every shift. EI #2 stated the facility's policy and procedure for the administration of antipsychotic medications required monitoring of the target behaviors for which a resident was administered the antipsychotic medication and required monitoring for side effects of antipsychotic and antidepressant medication. After reviewing the resident's EHR, EI #2 stated there was no documentation which indicated the target behaviors for which RI #75 received Zyprexa were monitored. She stated there was no documentation of side effect monitoring for Zoloft or Zyprexa. She stated behavior and side effect monitoring should be documented in a resident's MAR. On 12/17/2022 at 4:00 PM, EI #1, Administrator, was interviewed. She stated, per regulations, she expected nursing staff to monitor for target behaviors for which a resident received an antipsychotic medication and to monitor for side effects of antidepressant and antipsychotic medications. On 02/18/2022 at 2:35 PM, EI #16, Psychiatric Nurse Practitioner, was interviewed. She stated she expected facility staff to monitor residents who received an antipsychotic medication for target behaviors and to monitor residents who received antidepressant and/or antipsychotic medications for side effects of the medications.

Based on record review, observations, interviews, and review of a facility policy titled, Administration of Medications, the facility failed to ensure a medication error rate less than 5%. There were 3 errors in 33 opportunities, which resulted in a 9.09% medication error rate involving Resident Identifier (RI) #62 and RI #20 during medication pass. Specifically, the facility failed to ensure: 1. RI #62 received a Senna tablet and a multivitamin with mineral tablet as ordered by the physician; and 2. RI #20 received 30 milliliters (mL) of lactulose solution as ordered by the physician. This deficient practice affected RI #62 and RI #20; two of six residents observed during medication pass. Findings included: The facility's ADMINISTRATION OF MEDICATIONS policy and procedure, last reviewed 11/2020, revealed, . Standards: Medications shall be administered in a safe and timely manner, and as prescribed .Practice Guidelines: To ensure that all medication(s) are administered accurately and safely .F759 - Facility must ensure that is free of medication error rates of five percent or greater .Medications must be administered in accordance with the orders, .Licensed Nurse/CMT [Certified Medication Technician] giving medication must follow the six rights to ensure safe medication administration. Each time you administer a medication, you need to be sure to have the .right medication .right dose. 1. A review of the admission Record for RI #62 revealed the facility admitted the resident on 12/31/2021 with diagnoses to include Drug-Induced Constipation, Vitamin D Deficiency, Iron-Deficiency Anemia, and Diabetes Mellitus Type 2 With Diabetic Neuropathy. A review of RI #62's Order Summary Report, with active orders as of 02/16/2022, indicated the resident was to be administered an oral Senna (laxative) 8.6 milligram (mg) tablet daily for constipation and an oral Thera-M (Multiple Vitamins - Minerals) tablet daily for supplementation. On 02/16/2022 at 8:08 AM, Employee Identifier (EI) #4, Licensed Practical Nurse, was observed during medication pass. EI #4 administered one oral Senna Plus [docusate (stool softener) and senna (laxative)] tablet and one multivitamin (without minerals) to RI #62. On 02/16/2022 at 10:35 AM, EI #4 stated she administered a Senna Plus tablet to RI #62 instead of a Senna tablet as ordered by the physician. On 02/16/2022 at 11:37 AM, EI #4 stated she administered a multivitamin tablet to RI #62 instead of a multivitamin with minerals tablet as ordered by the physician. 2. A review of the admission Record for RI #20 revealed the facility admitted the resident on 11/19/2020 with diagnoses to include Constipation. A review of RI #20's Order Summary Report, with active orders as of 02/16/20222, indicated the resident was to be administered 30 ml of an oral lactulose 10 grams/15 mL solution (laxative) daily for constipation. On 02/16/2022 at 8:20 AM, Employee Identifier (EI) #5, Licensed Practical Nurse, was observed during medication pass. EI #5 administered 15 mL of lactulose 10 grams/15 mL solution to RI #20. On 02/16/2022 at 10:41 AM, EI #5 stated she administered 15 mL of lactulose solution to RI #20 instead of 30 mL as ordered by the physician. On 02/16/2022 at 3:45 PM, during an interview with EI #1, Administrator, she was informed of the three medication errors observed during morning medication pass. She was informed the medication error rate would be greater than 5%. EI #1 had no questions regarding the medication errors. On 02/17/2022 at 2:28 PM, EI #2, Director of Nursing, was interviewed. She stated the facility attempted to ensure a medication error rate of less than 5% by in-servicing staff on the seven rights of medication pass, by providing continuing education to staff, and by the pharmacist consultant's medication pass audits. EI #2 stated the facility initiated Quality Assessment and Assurance activity regarding medication administration based on a medication error report. She stated the facility reviewed medication error reports to determine the root cause of medication errors. The surveyor informed EI #2 of the medication error rate of 9.09% resulting from three errors in 33 opportunities. The errors were explained in detail and she stated she had no questions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, review of a facility form titled, Smoking Guidelines and review of a facility policy titled, NOTIFICATION OF RESIDENT'S CHANGE IN CONDITION, the facility failed to ensure: 1. Resident Identifier (RI) #74's guardian was notified of a hospital visit on 5/26/19, and 2. RI #105's sponsor was notified of the resident's behavior during smoking, which resulted in him/her being placed on restriction. This affected RI #74 and RI #105, two of four sampled residents who were reviewed for notification. Findings Include: 1. A review of a policy titled, NOTIFICATION OF RESIDENT'S CHANGE IN CONDITION, with a revised date of 9/2016, revealed .POLICY STATEMENT Standards: This facility will promptly notify the resident, .Responsible Party of changes in the patients medical/mental condition PROCEDURE .Notification of Changes--Required notification to .legal rep .of .transfer or discharge . RI #74 was readmitted to the facility on [DATE], with diagnoses to include Unspecified Dementia without Behavioral Disturbance, Type 2 Diabetes Mellitus with Hypoglycemia without Coma and Rhabdomyolysis. A review of a court order with a date of June 6, 2017, revealed RI #74 had a court appointed guardian. On 7/09/2019 at 11:03 a.m., an interview was conducted with RI #74's guardian. RI #74's guardian was asked when did she become RI #74's guardian. RI #74 guardian replied, in 2017. RI #74's guardian was asked when did RI #74 get sent to the hospital. RI #74's guardian replied, she did not know. RI #74's guardian stated that she heard about the hospital visit from hospice staff. RI #74's guardian stated that she had a problem with the facility not calling her regarding RI #74's hospital visit. RI #74's guardian stated the facility did not call her when they sent RI #74 to the hospital. On 7/10/2019 at 4:39 p.m., an interview was conducted with Employee Identifier (EI) #7, Social Service. EI #7 was asked who was RI #74's sponsor. EI #7 replied, RI #74's guardian. EI #7 was asked what was the facility policy on contacting resident's sponsors or guardians when there was a change in the resident's condition. EI #7 replied to notify the family when there was a change. EI #7 was asked when a resident was had a court ordered guardian, should other family members be contacted. EI #7 replied, no. EI #7 was asked should a name be listed in the progress note that was contacted. EI #7 replied, yes. they should have documented who they talked to. EI #7 was asked who was listed as RI #74 guardian on the face sheet. EI #7 replied, the niece. On 7/10/2019 at 5:15 p.m., a telephone interview was conducted with EI #15, RN (Registered Nurse). EI #15 was asked who was responsible for notifying the resident's family when there was a change in condition. EI # 15 replied, the primary nurse or the supervisor. EI #15 was asked what nurse would have notified RI #74's family. EI #14 replied, the primary nurse that was on the unit. EI #15 was asked who was responsible for notifying RI #74's family on 5/26/19 hospital visit. EI #15 replied, the primary nurse, whoever was assigned to the resident. EI #15 was asked when should family members be notified. EI #15 immediately. EI #15 was asked why was it important that family members be notified when there was a change in condition. EI #15 replied, because they have decision making power involving care when there was a significant change. EI #15 was asked what family member was notified on 5/26/19. EI #15 replied, the primary nurse would have notified the family and told me the family was notified. EI #15 was asked who should be notified regarding a change with RI #74. EI #15 replied, the guardian. On 7/11/2019 at 8:33 a.m., a telephone interview was conducted with EI #16, LPN, (Licensed Practical Nurse). EI #16 was asked what was the facility policy on contacting family members regarding a change in a resident condition. EI #16 replied, to call the family member, the doctor and document. EI #16 was asked should she have documented the family member name that she talked to. EI #16 replied, yes. EI #16 was asked why was it important to contact family members regarding a change of status with the resident. EI #16 replied to let family members know what was going on with the resident. EI #16 was asked would she have been the nurse to contact the family on that day (5/26/2019). EI #16 replied, yes, ma'am. EI #16 was asked who did she tell that she called the family member. EI #16 replied, it should have been the supervisor. On 7/11/2019 at 9:17 a.m., an interview was conducted with EI #2, RN, DON (Director of Nursing). EI #2 was asked who was RI #74 sponsor on the face sheet. EI #2 replied, the niece. EI #2 was asked who was RI #74's legal guardian. EI #2 replied, the name listed in the computer today was RI #74's legal guardian. EI #2 was asked who should be notified regarding changes to RI #74's change of condition. EI #2 replied, the legal guardian. EI #2 was asked what was the name of the family member notified on 5/26/2019 in the progress note. EI #2 replied, she did not see a family member name. EI #2 was asked what was the facility policy on contacting a family member when there was a change in condition with the resident. EI #2 replied, call the family and notify them of a change of condition. EI #2 was asked should staff document the person's name they talk to. EI #2 replied, yes they should document the name. EI #2 was asked where should staff document who they contacted regarding a change in a resident's condition. EI #2 replied, they should document in the computer charting system. 2. A review of a facility form titled, Smoking Guidelines revealed: It is the protocol of this Facility to allow residents to smoke in accordance with the accepted smoking program designed to assure safety of residents, staff and visitors. The procedures involved in providing for smoking, include but are not limited to the following: .5. Any violation .is addressed immediately and intervention provided. The issue of any violation of the smoking Guideline is then reviewed by the Interdisciplinary Team in conference within 24 hours and the family notified. RI #105 was admitted to the facility on [DATE] and readmitted [DATE], with a diagnosis of Alzheimer's Disease. On 7/08/2019 at 4:22 p.m., RI #105 was out in the smoking area, but not smoking. Staff was asked why RI #105 was not smoking. The staff replied RI #105 was on restriction for behavior of throwing a cigarette on another resident and had been on restriction since July 1, 2019. On 7/9/2019 at 2:56 p.m., during a telephone interview with RI #105's daughter/sponsor, she revealed she was not aware RI #105 was on smoking restriction. The surveyor asked RI #105's sponsor if RI #105 was currently smoking she said yes as far as she knew. On 7/09/2019 at 5:27 p.m., a brief interview was conducted with EI #7, Social Service. EI #7 revealed making an entry in RI #105's record about the behavior but did not notify the resident sponsor. On 7/09/2019 at 5:54 p.m., a second interview was conducted with EI #7. EI #7 was asked when was RI #105's sponsor/ family notified of the restriction for smoking that started on 6/28/2019. EI #7 replied, today, 7/9/2019. EI #7 was asked who was responsible for notifying a sponsor/family. EI #7 replied, she was, she guessed. EI #7 was asked when did the incident happen. EI #7 replied, at the 4:00 p.m. smoke break on 6/28/2019. EI #7 was asked when was RI #105 placed on the smoking restriction. EI #7 replied, on 6/28/2019, starting after the 4:00 p.m. smoke break. EI #7 was asked if RI #105's sponsor was notified on 6/28/2019 when the incident occurred. EI #7 replied, no. EI #7 was asked why was the sponsor not notified. EI #7 replied, she failed to notify her. On 7/11/2019 at 8:16 a.m., an interview was conducted with EI #2, Director of Nursing. EI #2 was asked where was documentation of the smoking incident for RI #105 that occurred on 6/28/19. EI #2 replied, there was no documentation. EI #2 was asked when should the sponsor have been notified of the incident on 6/28/19. EI #2 replied, immediately upon the event happening. EI #2 was asked why should the sponsor have been notified. EI #2 replied, to inform of a change. EI #2 was asked what was the change. EI #2 replied, the resident was placed on smoking restriction. EI #2 was asked what was the harm in not notifying the sponsor of the resident being restricted from smoking. EI #2 replied, it was not a continuity of care. This deficiency was written as a result of the investigation of complaint/report #AL00036326.

Based on observations, interviews and review of the facility admission Agreement, the facility failed to ensure resident rooms were not observed with peeling paint, splintered doors, torn ceiling tiles, chest of drawers with a missing drawer, broken window blinds and missing or scuffed base boards. This was observed in Room Locators (RLs) 1-19, 19 of 66 RLs in the facility. Findings Include: A review of an undated facility documented titled, Resident Rights revealed: All Residents of the Healthcare Facility are granted a Federal Statutory [NAME] of Rights. The following outlines these Federal Resident's Rights .57. The resident has a right to a safe, clean comfortable and homelike environment . A review of a facility form titled, Environmental Rounds Check-List dated 6/24/19, revealed no identified issues with the following: Ceiling Tiles, Wall Paint in good repair (not scuffed or peeling), Electrical outlets covered (covers not broken), and no further documentation under resident rooms identified the broken blinds or missing drawer from the chest of drawers. A review of a facility form titled, Environmental Rounds Check-List dated 7/1/19, revealed in the resident rooms list no identified issues with the following: Ceiling Tiles, Wall Paint in good repair (not scuffed or peeling), Electrical outlets covered (covers not broken), and no further documentation under resident rooms identified the broken blinds or missing drawer from the chest of drawers. A review of a facility form titled, Environmental Rounds Check-List dated 7/8/19, revealed in the resident rooms list no identified issues with the following: Ceiling Tiles, Wall Paint in good repair (not scuffed or peeling), Electrical outlets covered (covers not broken), and no further documentation under resident rooms identified the broken blinds or missing drawer from the chest of drawers. An observation was made on 7/8/19 at 3:41 PM of Room Locator (RL) #17s scuffed baseboard around the room and the door frame with a large amount of missing paint. The wall around the air conditioning unit had 5 peeling paint spots. The room door was scraped with splintered edges from bottom to approximately 30-36 inches up. In-room side of bathroom door splintered at door knob to center of door. 1/2-3/4 inch wide. An observation was made on 7/8/19 at 4:11 PM of RL #18's door frame with a large amount of peeling paint. An observation was made on 7/8/19, beginning at 4:15 PM, of environmental issues as follows: RL #12-mini blinds were torn up; the room door scrubbed the floor. RL #13-the top drawer from the chest of drawer was missing. RL #14-scuffed base boards at the bathroom and sink area; wall scuffed barong the sink with peeling caulk. RL #15-scuffed walls behind beds; a hole in ceiling tile in corner of the room. RL #16-ceiling tiles causing opening in ceiling; paint peeling over room door. An observation was made on 7/9/19 at 8:20 AM of Room Locators 12-16. No changes were noted. An observation/interview was made on 7/10/19 at 8:00 AM, with Employee Identifier (EI) #12, the Maintenance Director. EI #12 and the surveyor began on the second floor making rounds to observe the environmental concerns. EI #12 was asked to describe what he observed in each room. His findings were as follows: RL #1 had paint flaking near the floor; the emergency outlet loose at the bottom-approximately 3/8 inch away from the wall at the bottom of the outlet cover; the corner wall from about hand rail height to the floor with paint missing with rough edges and room door edges-wood had been chipped away. EI #12 said, Let me make a note of that. That is a piece of flaked paint. RL #2 -The wood edges of the door werewood chipped away; Missing paint every one of them (resident room) is going to have that. EI #12 was asked if it looked like that was recently done/scraped off paint. EI #12 answered no, it had probably been like that a couple of months. RL #3 -(He touched the hinged side of the door edges before entering the room.) EI #12 was asked what happened. EI #12 answered a piece of wood fell off. EI #12 was asked how big the piece of wood was. EI #12 answered, 1/2 X 1 inch. Edges are rough on both sides of the door. While looking at the air conditioner unit, Paint is flaky, needs touch-up RL #4 -Door edges, Rough, both sides of the door; deeper spot about a foot below door handle missing wood; needs corner guard near sink for missing sheet rock with rough edges. RL #5 -Rough edges on both sides of room door. Paint flaking/splitting by air conditioner (AC). RL #6- Peeling paint by AC, room door edges rough on both sides. RL #7 -Door wood chipped and splintered away. It is the laminate surface. RL #8 -Door splintered across bottom and both edges. RL #9 -Door splintered across bottom and both edges, floor base molding missing, paint is wrinkled/bubbled over the AC unit approximately 6 inches. RL #10- Door splintered across the width of the door approximately 6 inches down and another row splintered approximately 2 feet from the floor. RL #11-Eight inches and below, splintered across the entire door and larger chunks missing on hinge side of the door. Needed caulking by AC, 6 inches on both sides. RL #12-The room door Approximately 6 inches down on door splintered/scraped all the way across. Worse chips of wood missing on the edges. The door frame had paint flaking. AC on top with peeling paint. EI #12 was asked about the mini blinds. Blind has small bent spot, straightened it. EI #12 reported there were three screw bases for hanging pictures up that had been painted over rather that removed. EI #12 was asked if that was how it should be and he answered, No. EI #12 was asked what should have been done. EI #12 answered, They should have been removed. RL #13- The door frame had missing paint in four spots. The emergency outlet cover was loose and approximately 3/8 inch away from wall. EI #12 was asked when the chest of drawers was replaced by bed A. EI #12 answered Yesterday when I got work order from (names EI #7, the Social Services Director). EI #12 was asked you said you make rounds daily, how long was that chest missing a drawer. EI #12 answered he could not say. RL #14- EI #12 was asked he noticed about the base boards. EI #12 answered, They have missing paint (around) entire room. Caulking (is) needed around the sink. Bent mini blinds. Hardware left from window covers. RL #15 -Tear in a ceiling tile in right corner by A bed side corner; scuffed/torn sheet rock; Door scratched from height of hinge, 6-8 inches across entire room door; Hinged side edges gouged both sides 7 chunks on that hinge side. RL #16 -The room door had scratched edges with missing wood 6-8 inches from floor all the way across. Door knob side was worse with deeper scratches. EI #12 was asked to please describe the paint on the door frame. EI #12 answered the hinged side has chunk of paint missing. The other side has some missing. EI #12 had not looked across the top of the door frame and was asked what about the top of the door frame. EI #12 answered 3 pieces of hanging peeling paint. (He removed the hanging pieces of paint.) RL #17 -Door frame has peeling paint. EI #12 was asked how many spots of peeling paint and he answered, Nine. EI #12 added the door edges were rough approximately 6-8 inches from floor, scratched from there down all the way across. Eight areas of wood that had been splintered off were missing. RL #18 (Pointing at door frame) large pieces of peeling paint. Room door scratched with some areas deep and wood missing. RL #19 the kick plate is peeling/rolling up on edge; door frame has missing paint. An interview was conducted on 7/10/19 at 11:48 AM with EI #12. EI #12 reported weekly rounds were made of the facility with a housekeeping staff member and a nurse staff member. EI #12 was asked when he last made rounds on the second and third floor prior to the start of the survey. EI #12 answered Monday. EI #12 was asked where those rounds were documented. He provided a copy of Environmental Rounds Check-List dated 7/8/19. EI #12 was asked on 6/24/19, what were his identified concerns on the check list. EI #1 answered paint, they need painting. EI #12 was asked on the check list, under resident rooms, what was indicated by Wall paint in good repair (not scuffed or peeling) . EI #12 answered it should have and X beside it, not a line, to indicate that it needs to be addressed. EI #12 said that would be the same thing with the ceiling tiles. EI #12 was asked when a horizontal line was drawn next to something he was assessing, what did that mean. EI #12 answered that meant it was okay. EI #12 was asked on 7/1/19, what concerns were identified. EI #1 answered the same as the previous week, he did not mark with an X as he should have. EI #12 was asked what the concerns on 7/8/19 were. EI #12 answered it was the same, no changes. EI #12 was asked what he discussed with housekeeping staff. EI #12 answered there were issues with paint and ceiling tiles and the residents having toilet paper available. EI #12 was asked where that was documented. EI #12 answered there was no documentation of that. EI #12 was asked when the blinds were changed in RL #12. EI #12 answered 7/9/19. EI #12 was asked describe the condition of the blinds he removed and replaced with new blinds. EI #12 answered damaged, bent and some slats were missing. EI #12 was asked if he made daily rounds, why the blinds were not replaced prior to 7/9/19. EI #12 answered he did not have them in stock. He had to go and buy them. EI #12 was asked why that was not done before 7/9/19. EI #12 answered he had other items to go there to pick up. EI #12 was asked how long those blinds in RL #12 had been in that condition. EI #12 answered maybe four or five days. EI #12 was asked what was the concern of blinds in that condition being in resident rooms. EI #12 answered it might make them feel bad. EI #12 was asked to please describe the chest of drawers he removed from RL #13. EI #12 answered it was a chest of drawers with a drawer missing. EI #12 was asked how long had it been missing. EI #12 answered at least a couple of days. EI #12 was asked what was the concern of a drawer missing from a chest of drawers. EI #12 answered the residents deserve better. EI #12 was asked when he identified concerns for needed repairs such as peeling paint, scuffed and splintered doors, what was done. EI #12 answered he had brought it to the Administrator's attention. Nothing else, he did not have the finances for it. EI #12 was asked when the scuffed and splintered doors were identified. EI #12 answered about a year or so. EI #12 said it was pre-existing. EI #12 was asked what the concern of scuffed and splintered doors was. EI #12 answered it could get a splinter in a resident. EI #12 was asked what the concern of peeling areas of paint was. EI #12 answered the residents could eat it. EI #12 was asked on his check-list, what the third bullet point indicated for him to do during rounds. EI #12 answered to document in detail any findings during rounds. EI #12 said he never documented it. If it was a major issue, he would take care of it immediately. EI #12 was asked if the peeling paint and splintered doors were a major issue. EI #12 answered yes. EI #12 was asked why they were not taken care of immediately. EI #12 answered he could not say. EI #12 was asked why that was not documented. EI #12 answered he did not have the time. EI #12 was asked why was the Administrator not maintaining the original forms in her office, as indicated on the check-list. EI #12 answered he did not know. EI #12 was asked how he could provide follow-up documentation, if no documentation of the concerns existed. EI #12 answered he could not do so. An interview was conducted on 7/10/19 at 12:40 PM, with EI #1, the Administrator. EI #1 was asked what completed environmental forms were maintained in her office. EI #1 answered none. EI #1 added there was an electronic record of what activities maintenance did. EI #1 was asked if she could provide documentation that indicated the wall paint was in good repair (not scuffed or peeling). EI #1 answered the Maintenance Director was telling her what he was working on. EI #1 was asked what documentation she could provide that indicated she was aware of what needed to be done. EI #1 answered the QAPI (Quality Assurance Performance Improvement) rounds that she had made with the Maintenance Director. EI #1 was asked what she had on a weekly basis of the maintenance directors observations of what needed to be done. EI #1 answered she only had what has been done or accomplished. EI #1 was asked how often were QAPI rounds made by her. EI #1 answered at least monthly. EI #1 was asked what was the concern of large pieces of peeling paint. EI #1 answered it was a safety concern. EI #1 was asked what the concern of doors with large splintered areas was. EI #1 answered safety. EI #1 was asked what the concern of broken mini blinds was. EI #1 answered safety and esthetics.

Based on observation, interview, record review and review of the facility policy titled, RESIDENT ASSESSMENT INSTRUMENT (RAI) POLICY, the facility failed to ensure Resident Identifier (RI) #111's admission Minimum Data Set (MDS) assessment, dated 6/27/19, was coded correctly. This affected RI #111, one of 23 sampled residents whose MDS assessments were reviewed. Findings Include: A review of a facility policy titled, RESIDENT ASSESSMENT INSTRUMENT (RAI) POLICY with an issue date of November 28, 2017, revealed: .STANDARD OF PRACTICE .3 .Each individual who completes a portion of the Minimum Data Set (MDS) must certify the accuracy of that portion of the assessment .7 . This information helps the interdisciplinary team to plan care that allows the resident to reach his/her highest level of practicable level of functioning . On 7/09/2019, RI #111 was observed by the surveyor sitting up the wheelchair with no lower extremities noted. A review of RI #111's admission MDS with an Assessment Reference Date (ARD) of 6/27/2019, revealed RI #111 had impairment on one side of the lower extremity. On 07/10/2019 at 5:42 PM, an interview was conducted with Employee Identifier (EI) #9, MDS Coordinator. EI#9 was asked, was the range of motion section coded correctly. EI#9 replied no. EI #9 was asked why was the range of motion (ROM) section not coded correctly on the MDS. EI #9 replied, it was an error. EI# 9 was asked, who was responsible for coding the MDS. EI #9 replied, she was. EI #9 was asked, what was the potential harm to the resident if the ROM was not coded correctly on the MDS. EI #9 replied the CNA and staff may not know how to transfer the resident and could cause more harm to him/her. EI #9 was asked, why should the ROM be coded correctly on the MDS. EI#9 replied, because they were the eyes and ears of the building.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of the medical record, review of a facility policy titled, SMOKING POLICY FOR RESIDENTS, and review of a facility document titled, Behavior Management Team Meeting Guidelines, the facility failed to ensure the plan of care was updated with a smoking restriction for Resident Identifier (RI) #93. This affected RI #93, one of five sampled residents identified as smokers whose care plans were reviewed. Findings Include: A review of the SMOKING POLICY FOR RESIDENTS with an issue date of 8/22/17, revealed: . POLICY STATEMENT It is the policy of this facility to establish and maintain safe resident smoking policies . SAFETY RESTRICTIONS: 1. The Attending Physician, Director of Nurses, and the Care Plan Team shall have the authority to make determinations as to which residents are responsible . and to what restrictions , if any, will need to be placed on the resident's smoking privileges. 2. Any restrictions placed on smoking privileges shall be noted on the care plan so that all personnel may be alert to smoking restrictions. A review of a facility document titled, Behavior Management Team Meeting Guidelines with a revision date of 10/26/17, revealed: Purpose: Assure appropriate team interaction to provide timely, resident-specific interventions .Initiate behavior analysis * Review findings and compare information .3. Outcomes of meeting: Update care plan . A review of the medical record revealed RI #93 was admitted to the facility on [DATE], with diagnoses to include Fusion of Spine Lumbar Region, Chronic Pain Syndrome and Chronic Obstructive Pulmonary Disease. A review of the admission Minimum Data Set assessment, dated 6/21/19, revealed the resident had a Brief Interview for Mental Status Score of 15 out of a possible 15. This score indicated the resident was cognitively intact for daily decision making skills. A review of the nurses' note dated 7/3/19, timed 16:23 revealed: . Note Text: Resident (RI #93) has been put on 30 days smoking restriction (he/she) has been noncompliant with the smoking rules and procedures at smoking breaks. A review of the nurses' noted dated 6/25/19, timed 12:56 revealed: . (RI #93) exhibited behavior of being non-compliant with smoke break and policy of smoke break. (RI #93) has been counseled about this behavior. It is on-going and (he/she) continues to have behavior. (He/She) cursed staff when (he/she) was redirected about (his/her) behavior. (He/She) is trying to persuade other residents and is threatening them if they don't give her their cigarettes. A review of the plan of care for RI #93 revealed there was no documentation or update indicating when the smoking restriction began or any other specifics of the restriction. An interview was conducted on 7/09/19 at 8:40 AM with RI #93. RI #93 reports his/her smoking privileges had been revoked for 30 days. An interview was conducted on 7/11/19 at 10:01 AM with Employee Identifier (EI) #1, the Administrator. EI #1 reviewed the smoking policy regarding restrictions and RI #93's plan of care. When asked about the event that caused RI #93 to lose smoking privileges not being included in the care plan, EI #1 responded, EI #7, the Social Services Director, should have added it to the care plan. An interview was conducted on 7/11/19 at 10:12 AM, with EI #7, the Social Services Director. EI #7 was shown a copy of the smoking policy and directed to the section regarding restrictions. EI #7 was asked, what the policy indicated regarding restrictions being added to the plan of care. EI #7 answered it should have been noted on the care plan so that all personnel would be alerted to the smoking restrictions. EI #7 was asked what should that update to the care plan have included. EI #7 answered that RI #93 was on restriction, as of what date it began, and how long the restriction would last. EI #7 was asked if that was done and she answered no. EI #7 was asked what was the concern of the update not being added to the plan of care. EI #7 answered staff would not be aware from the care plan about the specifics of the restriction. EI #7 was asked when should that update have been done. EI #7 answered the day RI #93 was placed on restriction or on the next business day, if the Social Services Director was off.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. RI #97 was admitted to the facility on [DATE], with diagnoses to include Encounter for Attention to Tracheostomy, Unspecified Cord Compression and Chronic Respiratory Failure. On 7/09/19 at 2:00 PM, the surveyor entered RI #97's room to interview the resident. The surveyor observed the oxygen tubing and the trach mask on the floor. EI #3, Registered Nurse, entered RI #97's room. The surveyor asked EI #3 what was the blue tubing. EI #3 replied oxygen. The surveyor asked if RI #97 was on continuous O2. EI #3 replied, yes. The surveyor asked where was the mask and tubing. EI #3 replied, on the floor. EI #3 picked up the mask and tubing and was attempting to place the oxygen mask back on RI #97 when RI #97 spoke up and said she could not put that back on until it was cleaned. EI #3 asked the medication nurse, EI #4, to get a new trach mask. EI #4 entered the room with a clean mask. The surveyor asked EI #4 if the blue tubing and the mask was on the floor what should be changed. EI #4 replied, all of it, the tubing and mask. EI #4 left the room to get clean tubing and returned. On 7/10/19 at 9:19 AM, an interview was conducted with EI #3. EI #3 was asked when should the oxygen tubing be on the floor. EI #3 replied, never. EI #3 was asked what should be done if the oxygen tubing and mask was found on the floor. EI #3 replied, it should all be replaced. EI #3 was asked when should staff use the same oxygen tubing and mask that was on the floor. EI #3 replied, they should not. EI #3 was asked what was the harm in using tubing that was on the floor. EI #3 replied, infection. Based on observations, interview and review of a facility policy titled, OXYGEN THERAPY POLICY the facility failed to ensure O2 (Oxygen) tubing and the humidifier water bottle were dated while in use for Resident Identifier (RI) #102. The facility also failed to ensure RI #97's O2 tubing was not found on the floor and the nurse did not attempt to place the trach mask back on RI #97 without it being cleaned or changed. This affected RI #102, and RI #97, two of four sampled residents receiving oxygen therapy. Findings Include: 1. A review of a facility policy titled, OXYGEN THERAPY POLICY with an issue date of 11/28//17 revealed, . POLICY STATEMENT Oxygen (O2) is administered to promote adequate oxygenation and provide relief of symptoms of respiratory distress. Action . 8. Change tubing weekly. 9. Date tube when changed (weekly). A review of the medical record revealed RI #102 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses to include Hemiplegia Left Dominant side Following Cerebral Infarction and Vascular Dementia. A review of RI #102's physician's order dated 7/8/19, revealed: . Oxygen via (by way of) nasal cannula PRN (as needed) @ (at) 2 L (Liters) R/T (related to) O 2 SATS (Oxygen saturation level) of < (less than) 94% . An observation was made on 7/08/19 at 4:17 PM of RI #102 receiving Oxygen therapy via nasal cannula at 2 liters per minute (LPM), with no date on the humidifier water bottle or the tubing. An observation was made on 7/09/19 at 2:34 PM of RI #102 receiving Oxygen therapy via nasal cannula at 2 LPM, with no date on the humidifier water bottle or the tubing. An interview was conducted on 7/11/19 10:28 AM with Employee Identifier (EI) #17, the Respiratory Therapist. EI #17 was asked who initiated the Oxygen therapy for RI #102. EI #17 said he put him/her on 2 LPM of oxygen via nasal cannula. EI #17 was asked what day he initiated the oxygen for RI #102. EI #17 answered, on 7/8/19. EI #17 was asked why the tubing and the humidifier bottle were not dated. EI #17 answered he guessed he forgot. EI #17 was asked why it was important to date the tubing and humidifier bottle. EI #17 answered so staff will know when it needed to be change.

Based on observation, interview and review of a facility policy titled, ADMINISTRATION OF MEDICATIONS, the facility failed to ensure the medication nurse locked the cart when unattended. This was observed on 7/10/19, and affected one of five nurses observed during medication administration and had the potential to affect the resident observed in the hallway at that time. Findings Include: A review of a facility policy titled, ADMINISTRATION OF MEDICATIONS with a revised date of January 2019 revealed: .Action . 8. During administration of medications; the medication cart is kept closed and locked when out of sight of the medication nurse On 7/10/19 at 8:13 AM the surveyor observed Employee Identifier (EI) #6, Licensed Practical Nurse (LPN) push the medication cart up the hall. EI #6 stopped it at the nurses station. EI #6 left the cart in the hall and went into the restroom to wash her hands. EI #6 left the cart unattended and unlocked while she was in the restroom washing her hands. While the cart was left in the hall unattended and unlocked, two surveyors were in the hall and two staff passed by the cart. One resident was sitting in the wheelchair in the hall. EI #6 returned to the cart after washing her hands, realized the cart was unlocked and locked the cart. EI #6 proceeded down the hall to continue medication administration. On 7/10/19 at 8:24 AM an interview was conducted with EI #6. EI #6 was asked when should the medication cart be left unlocked. EI #6 replied, never. EI #6 was asked when the medication cart was unattended, was she at the cart. EI #6 replied, no. EI #6 was asked how long was the cart unattended and unlocked. EI #6 replied, maybe a minute, but it should be locked if unattended. EI #6 was asked who was around the medication cart. EI #6 replied, the surveyors and she was not sure of others. EI #6 was asked what was the harm of leaving a medication cart unlocked and unattended. EI #6 replied, anyone could get in it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility policies LAUNDRY AND BEDDING, SOILED, BED BATH, and PERINEAL (SKIN) CARE FOR INCONTINENT RESIDENT, the facility failed ensure: 1. soiled linen was not placed in Resident Identifier (RI) #97's closet, 2. Certified Nursing Assistants (CNA)s did not use wash cloths that had been used to clean bowel movement from RI #97 to give him/her a bed bath, including the groin area, and 3. a CNA did not touch a clean pad, Oxygen tubing, clean pillows and linens with the same soiled gloves which were used to clean bowel movement from RI #97. Findings Include: 1. A review of a facility policy LAUNDRY AND BEDDING, SOILED with a revised date of April 1, 2018, revealed: POLICY INTERPRETATION AND IMPLEMENTATION .2. Place contaminated laundry in a bag or container at the location where is is used . RI #97 was admitted to the facility on [DATE], with diagnoses to include Encounter for Attention to Tracheostomy, Unspecified Cord Compression and Chronic Respiratory Failure with Hypoxia or Hypercapnia. On 7/10/19 at 9:59 AM, family visiting RI #97 called the surveyor to the room. The family member said they were placing clean clothing in RI #97's closet and found a bundle of bed linens in the closet. The surveyor observed a ball of linens; noted were two sheets, two blankets and a green pad. These linens were not in a trash bag. An interview with RI #97 at this time revealed the resident did not know exactly when the linens were placed in the closet. RI #97 said he/she thought the staff changed the linens in the night, but not sure of the time. On 7/10/19 at 10:09 AM, an interview was conducted with Employee Identifier (EI) #5, CNA, as she entered the resident's room to check on the resident and noticed the ball of linen. EI #5 was asked where was linen to be placed when removed from a resident's bed. EI #5 replied, in a bag then in a soiled barrel. EI #5 was asked when should soiled linen be placed in a resident's closet. EI #5 replied, it should not be in there; that was nasty. EI #5 was asked who put the linens in the closet. EI #5 replied, she did not know but it had to have been the evening or night shift as RI #97 received a bath on the 3 PM-11 PM shift ;or night shift if the bed required to be changed. EI #5 was asked what was harm of soiled linen being placed in the closet. EI #5 replied, it could pass germs to resident, family or other staff. On 7/11/19 at 8:16 AM, during an interview with EI #2, DON (Director of Nursing)she was asked where should staff place linens when removed from a resident's bed. EI #2 replied, if dirty place them in a soiled bag and take them to the soiled utility room. EI #2 was asked when should soiled linens be placed in a resident's closet in the room. EI #2 replied, never. EI #2 was asked what was the harm in soiled linens being placed in a resident's closet. EI #2 replied, contaminating everything in the closet. 2. A review of an undated facility policy titled BED BATH revealed: . Action .12. wash, rinse, and dry the chest and abdomen .Wash, rinse, and pat dry the leg and foot. 13. Repeat with other leg and foot. 14. Change the bath water. Apply gloves . 15. Turn the resident to the side. 16. Wash, rinse and dry from the neck to the buttocks, including anal area. 17. Change the water. Remove and discard gloves, if worn. Wash hands and obtain a new pair of gloves. Obtain a fresh wash cloth and towel. 18. Provide perineal care. On 7/10/19 at 5:00 PM, the surveyor observed CNAs give RI #97 a bed bath. The CNAs gathered supplies including three wash cloths, a green pad, a hospital gown and soap and two bath basins. EI #10, CNA filled both basins with warm water and she and EI #11, CNA, gave the bed bath. EI #10 took a wash cloth from the wash basin, placed soap on the cloth and washed RI #97's lower abdomen and groin area. Bowel movement was observed on the wash cloth. EI #10 put the cloth in the rinse basin and rinsed the soap. Using the same cloth, EI #10 rinsed the soap from RI #97's lower abdomen and groin area. Both CNAs turned RI #97 to the left side and EI #10 washed the lower back and buttock area with the same cloths use to clean bowel movement from the front side. On 7/10/19 at 5:25 PM, an interview was conducted with EI #10, CNA. EI #10 was asked how should she give a bed bath. EI #10 replied, get supplies of five wash cloths, pads, linens, gown, soap and basins. EI #10 said one was for wash and one was for rinse, but she got mixed up and put the soiled cloth in both basins. EI #10 was asked if there was bowel movement on the cloths in both basins. EI #10 replied, yes. EI #10 was asked when should the same wash cloth used to clean bowel movement from a resident be used to continue with the bath. EI #10 replied, we were not supposed to we, were supposed to have a clean cloth. 3. A review of a facility policy titled PERINEAL (SKIN) CARE FOR INCONTINENT RESIDENT with a review date of October 2018, revealed: . PRACTICE GUIDELINES .Action .4. Wash the resident's entire perineal area .6. Rinse the perineal area .7. Discard soiled linen. 8. Dry the perineal area .10. Remove gloves and discard. Wash Hands. 11. Place a dry brief (Pad) on the resident. 12. Replace any other articles .that may have been removed . On 7/10/19 at 5:00 PM, the surveyor observed EI #10,CNA place a clean brief under RI #97 with the same soiled gloves she had on to clean bowel movement from the resident. EI #10 repositioned RI #97's oxygen tubing and put clean pillows for positioning for the resident and touched the top clean linen with the same soiled gloves she had on to clean the bowel movement from RI #97. On 7/10/19 at 5:25 PM an interview was conducted with EI #10, CNA. EI #10 was asked when should gloves be changed during incontinent care. EI #10 replied, any time the gloves get soiled. EI #10 was asked if her gloves were soiled. EI #10 replied, yes with bowel movement. EI #10 was asked if she changed her gloves. EI #10 replied, no. EI #10 was asked when should she touch a clean pad, resident's oxygen tubing, clean linen and pillows with soiled gloves. EI #10 replied, they were not supposed to do it that way. EI #10 was asked what would the harm be in using a wash cloth soiled with bowel movement to continue with a bath. EI #10 replied, pass germs. EI #10 was asked what would the harm be in touching a clean pad, oxygen tubing, clean linen and resident pillows with soiled gloves. EI #10 replied, passing germs. On 7/11/19 at 8:16 AM, an interview was conducted with EI #2, Director of Nursing (DON). EI #2 was asked what was the policy for giving a bed bath. EI #2 replied, get a basin of clean water and rinse water, then change wash cloths and water if soiled with bowel movement. EI #2 was asked if staff cleaned bowel movement from a resident during the bed bath what should be done with the wash cloths and water. EI #2 replied, discard the water and get new cloths and water. EI #2 was asked when should staff clean bowel movement from a resident then place the soiled wash cloth in the water basin, rinse it and use it again to continue with the bath. EI #2 replied, never. EI #2 was asked what was harm in staff using a wash cloth soiled with bowel movement to give a bed bath. EI #2 replied, infection issue. EI #2 was asked what was the policy for incontinent care. EI #2 replied, wash with clean cloths change sides of the cloth, get clean water if resident had a bowel movement. EI #2 was asked when should the CNA change their gloves during incontinent care. EI #2 replied, when soiled, and when changing the water, they should change gloves. EI #2 was asked when should the CNA clean bowel movement from the resident then with the same soiled gloves touch a clean pad, linens and oxygen tubing. EI #2 replied, never. EI #2 was asked what was the harm in a CNA touching oxygen tubing, a clean pad and linens with soiled gloves. EI #2 replied, infection control issues.