**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide adequate supervision and assistance to prevent falls, and failed to assess, implement and monitor interventions consistent with resident needs for two (#3 and #9) of three residents reviewed for falls out of seven sample residents. Specifically, the facility failed to have a registered nurse (RN), nurse practitioner or physician assess the residents after unwitnessed falls, prior to the removal of the residents from off the floor. Findings include: I. Facility policy The Falls and Fall Risk Managing policy, revised January 2024, was provided by the nursing home administrator (NHA) on 8/20/24 at 8:31 a.m. The policy revealed on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks/causes to try to prevent the resident from falling and to try to minimize complications from falling. According to the minimum data set, (MDS) a fall was defined as an unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force; such as a resident pushed by another resident. An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, would be considered a fall. A fall without injury was still considered a fall. Unless there was evidence suggesting otherwise, when a resident was found on the floor, a fall was considered to have occurred. The staff, with the input of the attending physician, would implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. If a systematic evaluation of a resident's fall risk identified several possible interventions, the staff might choose to prioritize interventions, such as trying one or a few at a time, rather than many at once. Examples of initial approaches might include exercise and balance training, rearrangement of room furniture, improving footwear, and/or changing the lighting. If falling recurred despite initial interventions, staff would implement additional or different interventions, or indicate why the current approach remained relevant. If the underlying causes could not be readily identified or corrected, staff would try various interventions, based on an assessment of the nature or category of falling, until falling was reduced or stopped, or until the reason for the continuation of the falling was identified as unavoidable. The Fall policy, not dated, was provided by the NHA on 8/20/24 at 11:18 a.m. The policy revealed a post fall physical head to toe assessment should be conducted by a licensed nurse. If spinal cord injury was suspected, staff were to ensure the resident's neck/head were stabilized, the resident should remain as still as possible, and staff would call emergency services (911). A licensed nurse and the interdisciplinary team (IDT) would evaluate the chain of events or circumstances preceding the fall. This would include: the time of day of the fall; the time of the last meal; what the resident was doing; whether the resident was standing, walking, reaching, or transferring from one position to another; whether the resident was among other persons or alone; whether the resident was trying to get to the toilet; whether any environmental risk factors were involved (such as a slippery floor, poor lighting, furniture or objects in the way); whether there is a pattern of falls for this resident; recent changes to medication and last administration of medication (narcotic, cardiac, psychotropic); the resident's location; the type of footwear; and the location of any assistive devices and call lights. The nursing staff would initiate the neurological evaluation flowsheet if a fall was unwitnessed or if the resident hit their head, or had a change in their mental status. A licensed nurse must initiate the first set of neurological vital signs and evaluation. A licensed nurse must fill out the entire time span of monitoring on the neurological evaluation flowsheet. A licensed nurse must follow the frequency outlined at the top of the neurological evaluation flowsheet. All areas on the neurological evaluation flowsheet must be filled out and completed. Any abnormal vital signs or evaluation findings must be notified to the resident's physician. II. Resident #3 A. Resident status Resident #3, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the August 2024 computerized physicians orders (CPO), diagnoses included history of falling, abnormalities of gait/mobility, anxiety, heart failure, restless legs syndrome and wedge compression fracture of thoracic seven and eight vertebra. The 6/18/24 minimum data set (MDS) assessment identified the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out 15. The resident had no impairments in either the upper or lower extremities. The resident was independent in her ability to roll to her left and right side. The resident required supervision or touch assistance in her ability to walk at least 150 feet in a corridor or similar space, after she had stood upright. B. Resident interview Resident #3 was interviewed on 8/20/24 at 10:10 a.m. Resident #3 said for two of her falls, the mattress on her bed slid as she turned over in bed. She said she was asleep and then she woke up on the floor with the mattress on top of her. She said for both of the falls out of bed, she had to go to the hospital. She said she had a lot of all over body pain from each of the falls. She said she hit her head both times and had some bleeding but did not break anything. She said she still had some pain in her back. She said she did have sufficient pain medications. C. Record review The care plan for a history of falls, medication use, new environment and unsteady balance/gait was initiated on 2/26/24. The interventions included to provide the resident with a clutter free environment that was free from spills, provide the resident with adequate lighting and place personal items within reach. Staff were to ensure the call light was within reach and encourage the resident to use the call light. Nursing staff were to provide the resident with assistive devices as needed and refer the resident for therapy services as needed (initiated on 2/26/24). Nursing staff were to remind the resident to use the call light for safety which (initiated on 2/26/24). Nursing staff verbally educated the resident on the use of the call light, to ask for assistance as needed, and to use the proper footwear (initiated on 3/4/24). Nursing staff were verbally educated to anticipate the resident's needs and the visual cues for the use of the call light (initiated on 3/4/24). Staff were to provide the resident with non-slip socks and place the resident's walker within reach (initiated on 3/16/24). The resident was verbally educated to wait to undress at the toilet and not prior to going to the toilet (initiated on 3/16/24). Nursing staff were to provide visual cues for the resident to call for help as needed and staff were to anticipate the resident's needs (initiated on 3/18/24). Physical therapy and occupational therapy was approved and a cognitive evaluation to be performed by therapy (initiated on 3/18/24). The maintenance staff were to check the bed/mattress for proper fit (initiated on 3/23/24). The resident was currently working with physical therapy and occupational therapy (initiated on 3/23/24). Therapy services were to evaluate if a lipped mattress was appropriate for the resident (initiated on 3/29/24). The fall risk tool, dated 3/3/24 at 1:43 p.m., revealed the resident had a score of seven, or a moderate risk for falling. D. Fall 3/16/24 The incident report dated 3/16/24 at 8:45 p.m., revealed a certified nurse aide (CNA) reported to the nurse that during walking rounds the resident was found on the floor. Upon entering the room, the resident was found sitting upright and said she fell trying to get her shorts off to go to the bathroom. The resident was not wearing any footwear nor using her walker for assistance. The resident had been educated prior to the fall related to being a high fall risk and not wearing any kind of footwear. The resident said that she just forgot. A head to toe assessment was completed. The resident said she hit her head and there were no concerns observed during the assessment of her head. The resident's range of motion and vital signs were at her baseline (normal). There were no observed cognitive changes and the resident returned to bed with two staff members assistance. All appropriate parties were notified of the fall. The resident was provided with non-skid socks and her walker was placed within reach. Resident #3 was able to make all needs known and the call light was placed within reach. She reiterated she slipped trying to take her shorts off to go to the bathroom. The resident was oriented to person, place, time and situation. The interdisciplinary team (IDT) interventions were to provide the resident with non-slip socks and have her walker placed within reach. The resident was verbally instructed to wait to undress when at the toilet not prior to going to the toilet. -Resident #3's clinical record revealed the resident was not assessed by a registered nurse (RN), nurse practitioner (NP) or physician before the resident was assisted from off the floor, after the fall on 3/16/24. The pain assessment tool, dated 3/16/24 at 9:53 p.m., revealed the resident had a pain rating of 3 out of 10. The nurse note dated, 3/16/24 at 9:57 p.m. and written by a licensed practical nurse (LPN), revealed the resident was found sitting on the floor. Neurological assessments were initiated according to facility protocol. All appropriate parties were notified. E. Fall 3/18/24 The incident report, dated 3/18/24 at 6:30 a.m., revealed a CNA informed the nurse that the resident was lying on the floor outside of her room, near her door. The resident's feet were towards the door and her head was facing near the Sunlight hallway. The resident was lying on her back. The resident's mattress was off the frame of the bed. The resident sustained bruising to the left knee and bruising to the right shoulder/arm. The resident had a laceration to the right side of her head with obvious bleeding. The resident said she fell to the floor while getting out of bed to use the restroom. She said the mattress landed on top of her body and she crawled to the hallway to scream for help. A full set of vital signs were taken and the staff assisted the resident back to bed. The resident and staff were verbally educated on the importance of call light use. The staff were also verbally educated on the importance of assisting the resident to and from her bathroom. Nursing staff called emergency services and the resident was sent to the emergency department (ED) for an evaluation. All contacts were notified. The resident was oriented to person, place, time and situation. The IDT interventions were to provide visual cues for the resident to call for help when needed, staff to anticipate the resident's needs, physical/occupational therapies had been approved, and a cognitive evaluation would be completed by therapy. -Resident #3's clinical record revealed the resident was not assessed by a RN, NP or a physician before the resident was assisted from off the floor, after the fall on 3/18/24. The pain assessment tool dated 3/18/24 at 6:30 a.m., revealed the resident had a pain rating of 2 out of 10. The hospital documentation revealed the resident arrived at the emergency department (ED) on 3/18/24 at 7:01 a.m. The resident presented with a primary complaint of a fall. The resident was in her bed, fell off the side of the bed and the mattress fell on top of the resident. The resident said she felt the mattress was unstable and when she laid too far to the side, the mattress started to slide off the bed. The resident hit the back of her head either on furniture or on the floor. The resident denied any loss of consciousness and reported pain to the right posterior head and neck. The resident also had right shoulder pain. The computed tomography (CT) images of the head and cervical spine did not reveal any acute injuries. A right shoulder x-ray was obtained and no obvious fractures or any dislocation was observed. The nurse note, dated 3/18/24 at 10:03 a.m. and written by a LPN, revealed the resident was on follow-up for a fall with no injuries. The resident was observed on the floor in the morning and was sent to the ED for evaluation. The resident had a gash to the right side of her head with a bruise to her left knee. The nurse note, dated 3/18/24 at 11:00 a.m. and written by a LPN, revealed the resident had returned to the facility from the ED. All performed tests ruled out any abnormalities. The CT was negative. The resident received pain medication as requested for a headache with effectiveness. The resident was educated on the importance of using the call light and staff would continue to monitor. The fall risk tool, dated 3/18/24 at 11:04 a.m., revealed a score of 11, or a moderate risk for falling. F. Fall 3/23/24 The hospital ED progress note, dated 3/23/24 at 1:22 p.m., revealed the resident had fallen out of bed. The resident was reported to have been sitting on the edge of her bed while placing her socks on her feet. She slid off the bed onto her right buttock and she denied any head trauma. The resident said she was unable to stand unassisted and a large amount of bruising was observed to the right buttock. Pelvic and right hip x-rays did not reveal any acute bony abnormalities or other acute pathologies. The incident report, dated 3/23/24 at 2:29 p.m., revealed the nurse was called to the resident's room by a CNA, related to the resident lying on the floor. Upon entrance to the room, the resident was lying on her back by the side of the bed. The resident was assessed and it was determined the resident should be sent to the ED for evaluation. Management, the physician and the family were notified. The resident said she was trying to put her socks on and fell out of bed. The resident had an injury to her right buttock. The resident was helped by paramedics and staff to be placed on the stretcher and taken to the hospital ED. The IDT interventions were for maintenance to check the resident's bed/mattress for a proper fit. The resident was currently working with physical and occupational therapies. The pain assessment tool, dated 3/23/24 at 2:29 p.m., revealed a score of 3 out of 10. The nurse note, dated 3/23/24 at 2:43 p.m. and written by a LPN, revealed the resident was found on the floor by the side of the bed. The resident was lying flat on her back and her bottom, when the nurse arrived. The resident was assessed by two nurses, her hips looked dislocated and she was in pain. Emergency services were called. When the paramedics arrived, the resident received an injection of pain medication. The resident was taken to the hospital. Management, the physician and the family were notified. The ED was called and a report was provided. The fall risk tool dated, 3/23/24 at 2:49 p.m., revealed a score of nine, or a moderate risk for falling. -Resident #3's clinical record revealed the resident was not assessed by a RN, NP or physician before the resident was assisted from off the floor, for the fall on 3/23/24. III. Resident #9 A. Resident status Resident #9, age [AGE],was admitted on [DATE]. According to the August 2024 CPO, diagnoses included stage 3 chronic kidney disease, anxiety, asthma, chronic diastolic congestive heart failure and chronic obstructive pulmonary disease. The 6/8/24 MDS assessment identified the resident had moderate cognitive impairment with a BIMS score of 10 out 15. The resident had no impairments in her upper or lower extremities. B. Resident interview Resident #9 was interviewed on 8/20/24 at 12:11 p.m. She said the fall on 5/1/24 was her fault because the facility wanted her to stay in her bed and she did not. She said her right knee and foot were the cause of her fall. She said she did hit her head and her back still hurt at times. C. Record review The care plan for being at risk for falls related to medication use, a new environment, weakness, unsteady balance/gait and the use of a Hoyer lift was initiated on 12/15/23. The interventions included to keep her environment free from clutter, free from spills, provide adequate lighting and to ensure her personal items were within reach. Staff were to encourage the resident to keep her bed in the lowest position. The facility would request hospice to provide a bolster sheet to be applied to her air mattress. Staff were to ensure the call light was within reach and encourage the resident to use the call light. Staff were to ensure the resident used the appropriate footwear when ambulating. Staff were to review the documentation on past falls and attempt to determine the cause of the falls. Staff would apply the bolster sheet and ensure it fit the bed properly related to the resident leaning to the right (initiated on 5/1/24). Staff would modify the resident furniture placement to ensure snacks were within reach (initiated on 5/1/24). Staff were to offer the resident snacks when in the room (initiated on 5/1/24). The fall risk tool, dated 1/25/24 at 2:28 p.m., revealed a score of 11, or a moderate risk for falling. D. Fall 5/1/24 The incident report, dated 5/1/24 at 5:30 a.m., revealed the writer heard a shout for help. The resident had slid out of bed onto the floor. The resident was still upright when found. The resident received a scrape to the right side of her head that was approximately three inches in length. The resident was unaware of the injury and did not know how it had occurred. The resident said she was reaching for a snack that was out of reach. The resident was assessed head to toe and no other injuries were observed from the fall. The resident's range of motion was within normal limits. The resident was returned to bed with three staff assistance and the use of a gait belt. The resident denied any pain (0 out of 10) related to the fall. All parties were notified. The resident was resting quietly in her bed with her eyes closed and no physical indications of pain or acute distress were observed. The resident's bed was placed in the lowest position. The resident was oriented to person and place. The resident's room had been previously rearranged by her granddaughter's preference for more room between the dresser and the bed. The IDT interventions were to ensure a bolster sheet was properly fitted to the bed related to the resident had a tendency to lean to the right. The resident's furniture was modified to ensure snacks were within reach. Staff were to offer snacks when they were in the room. A nurse note, dated 5/1/24 at 5:30 a.m. and written by a LPN, revealed the resident had an unwitnessed fall from the bed that resulted in a small laceration to the right scalp area. All appropriate parties were notified. The fall risk tool, dated 5/1/24 at 11:15 a.m., revealed a score of 16, or a high risk for falling. IV. Staff interviews LPN #2 was interviewed on 8/20/24 at 1:06 p.m. LPN #2 said a RN, NP or a physician should complete an assessment of the resident, prior to moving the resident from off the floor. She said during this assessment, they would be looking for fractures, head injuries, bleeding, abnormalities in range of motion and the resident's consciousness. She said when a resident fell, during the next day's morning meeting, the fall would be discussed. She said Resident #3's mattress had slid off the frame and dycem ( a non-slip material used to help stabilize objects, hold objects firmly in place, or to provide a better grip) was placed on the bed. She said the resident removed the dycem and threw it in the trash can. She said clips were placed on the bed to keep it from moving. LPN #3 was interviewed on 8/20/24 at 1:30 p.m. LPN #3 said a resident should be assessed by a RN, NP or a physician before they were moved off the floor. She said an RN would do an assessment because the LPN could not do the assessment prior to moving the resident off the floor. She said staff would be assessing the resident for any head injuries, bleeding, fractures, skin tears, bruises, lacerations, cognitive deficit, range of motion concerns and pupil size. LPN #1 was interviewed on 8/20/24 at 1:50 p.m. LPN #1 said a RN, NP or a physician should assess a resident after an unwitnessed fall, prior to moving them from off the floor. She said during the assessment, they would be looking for any signs of a concussion, fractures, bleeding, range of motion problems, if the resident was alert/oriented and any possible head injuries. She said they were also looking for any changes in the resident's baseline (normality). The NHA and the director of nursing (DON) were interviewed on 8/20/24 at 3:20 p.m. The NHA said, for Resident #9, there were no RN, NP or physician assessments for the resident, prior to moving the resident from off the floor, for the unwitnessed fall in her room on 5/1/24. The DON said that a RN, NP or physician should perform an assessment for all unwitnessed falls, prior to moving the resident from off the floor. She said a fall was a resident unintentionally moving from one plane (position in space relative to the ground) to another plane. The DON said the assessment should include range of motion, skin assessment, vital signs and neurological assessments. She said the outcomes from a lack of an assessment could be any type of injury to the resident, fractures, orthostatic hypertension, low blood pressure, bleeding, skin tears, cognitive changes, altered mental status and aberrant range of motion. The NHA and the DON were interviewed together a second time on 8/20/24 at 4:20 p.m. The NHA said Resident #3 reported the two falls from the bed were due to the mattress issues. The resident's bed was locked and in the lowest position at the time of the two falls. The NHA said after the two falls from the bed, a new mattress was placed on her bed and anchor clips were placed on the bed to prevent it from sliding. The NHA said after the second fall from the bed, a dycem mat was placed under the mattress. He said the resident removed the dycem and placed it in the trash can. The NHA and the DON both said there were no RN, NP or physician assessments for Resident #3, prior to moving the resident from off the floor, for the unwitnessed falls on 3/16/24, 3/18/24 and 3/23/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure quality of care and address needed communication for one (#45) of six residents reviewed out of 26 sample residents. Specifically, the facility failed to: -Ensure Resident #45's cardiac specialist was notified when the facility chose not to implement the specialist's recommended physician's orders; and, -Inform Resident #45 about medications ordered by a specialist that were not implemented by the facility. Findings include: I. Resident #45 status Resident #45, age [AGE], was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included heart disease, cirrhosis of the liver, right leg amputation above the knee and peripheral vascular disease (reduced blood flow to limbs). The 12/23/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required substantial assistance with hygiene, mobility and transfer. II. Facility policies The Medication and Treatment Orders: Guiding Principles policy, undated, was provided by the nursing home administrator (NHA) on 2/26/24 at 10:20 a.m. It read in pertinent part, Physicians shall write medication orders that reflect known benefits and risks of medications in the facility's population. Medication orders will be accurate, timely, appropriate, and legible. The Physician Services Policy, revised February 2021, was provided by the director of nursing (DON) on 2/29/24 at 8:05 a.m. It read in pertinent part, The attending physician will determine the relevance of any recommended interventions from other disciplines. The physician is not obligated to accept these recommendations if he or she has clinically valid reasons for not doing so. -The policy did not address any required communication with residents, nursing staff, or specialists from another discipline if the recommended interventions were not accepted by the attending physician. II. Resident interview Resident #45 was interviewed on 2/26/24 at 3:47 p.m. He said he had a heart and vascular clinic appointment on 2/26/24 and learned he had not received medications ordered by the specialist two months ago. He said he had been to the emergency room on several occasions to drain excess fluid from his abdomen (paracentesis) and he was told by the heart and vascular specialist this might not have been necessary if he had taken the medication which was prescribed in December 2023. He said the head nurse told him there had been a communication problem and this was the reason he did not start the medications. III. Record review The MD Office Visit Communication form for the heart and vascular clinic visit, dated 12/27/23, was provided by the DON on 2/28/23 at 9:00 a.m. The new orders and signature section contained the following physician's orders from the heart and vascular physician assistant: -Begin 25 milligrams (mg) Toprol XL (medication which can be used to treat heart failure) daily; and, -Begin 12.5 mg Spironolactone (a diuretic medication used to treat heart failure) daily. Hold if systolic blood pressure is less than 90. -The orders were signed by registered nurse on (RN) #1 on with the word noted next to the signature and dated 12/27/23. -However, the orders were not entered into Resident #45's electronic medical record (EMR) A comprehensive review of Resident #45's physician orders revealed Spironolactone 12.5 mg one time a day was ordered on 1/4/24, however it was discontinued on 1/18/24. The MD Office Visit Communication form for the heart and vascular clinic visit on 2/26/24 was provided by the DON on 2/28/23 at 9:00 a.m. The notes from the physician section were signed by the heart and vascular physician (HVP) and contained the following documentation in pertinent part: Recent paracentesis for heart failure. Not sure why guideline directed medical therapy (GDMT) medications have been stopped. Need to escalate GDMT as tolerated. This will likely help with minimizing the need for paracentesis. The 2/26/24 visit new orders and signature section contained the following physician's orders from the HVP: Start Spironolactone 25 mg PO (by mouth) daily. Start Toprol XL 12.5 mg PO daily. After visit hospital summaries revealed Resident #45 had undergone paracentesis procedures on 12/29/23, 1/25/24 and 2/23/24 -Resident #45 began receiving Spironolactone and Toprol XL as ordered on 2/27/24 (during the survey), almost two months after the heart and vascular physician had originally ordered the medications. IV. Staff interviews The DON was interviewed on 2/27/24 at 3:11 p.m. The DON said Resident #45 told her there were medications he was not receiving as ordered. She said an MD Office Visit Communication form was returned with the resident to the facility on [DATE]. She said the nurse who received the heart and vascular specialist orders signed off both medications, however, she said the orders were not entered by the nurse in the resident's EMR. The DON said she considered the instructions from the specialist to be actual orders. She said the facility needed to work on its process for communication of new orders. The DON said she reviewed the orders with the nurse practitioner (NP) on 12/27/23 and the NP decided not to start the Spironolactone and Toprol XL medications until after the resident's paracentesis scheduled for 12/29/23. The DON said she did not communicate with the heart and vascular specialist regarding the NP's decision to wait to start the medications and she did not know if the NP consulted with him regarding non-implementation of the orders. The DON said she did not know why the Toprol XL was never started or why the Spironolactone medication was ordered from 1/4/24 to 1/18/24 and then discontinued. The DON said the NP preferred Lasix medication over Spironolactone. She said the provider group for the facility changed on 2/25/24. The DON was interviewed a second time on 2/27/23 at 3:52 p.m. The DON said RN #1 should not have noted the orders written by the heart and vascular specialist on 12/27/24 as they had not been entered in the EMR or initiated for administration. The facility's physician's assistant (PA) was interviewed on 2/27/24 at 4:00 p.m. The PA said the facility received a new form on 2/26/24 from the heart and vascular specialist with the same medications which were ordered on 12/27/23. The PA said she would document in her note if she did not agree with the specialist's treatment plan. She said she was happy the facility was starting Spironolactone as the new medication could decrease Resident #45's frequency of paracentesis. The NP was interviewed on 2/28/24 at 11:24 a.m. The NP said she did not start the Spironolactone and Toprol XL as ordered on 12/27/23 by the heart and vascular specialist because of the resident's trend of low blood pressures. She said she did not know if the heart and vascular specialist was aware the medication was not started. The pharmacist consultant (PC) was interviewed on 2/28/24 at 11:34 am. She said the resident did not have orders for Spironolactone prior to 1/4/24. She said the pharmacy did not have orders for both Spironolactone and Toprol XL until 2/26/24. She said Spironolactone could help with reduction of fluid in the abdomen. She said Toprol XL would not be as helpful for fluid reduction, but would be indicated for the resident's heart condition. The facility's physician (PH) was interviewed on 2/28/24 at 12:48 p.m. The PH said Resident #45 had advanced heart disease and cirrhosis of the liver. She said if she disagreed with the specialist, her process was to reach out to the specialist directly. (This physician began working at the facility on 2/25/24). She said Resident #45 was medically fragile with a lot of chronic disease. She said it was important to communicate why medication should not be started. She said any order in the facility had to be signed by a provider at the facility. The PH said the communication sheet from the specialist was a recommendation and when the facility provider cosigned, it became an order. RN #1 was interviewed on 2/28/24 at 3:53 p.m. RN #1 said she signed the order at the bottom of the MD Office Visit Communication form and she said it meant she had seen the orders. She said she did not enter the orders into the electronic record as the NP wanted to wait to start the medications. She said she did not document this in Resident #45's record. The heart and vascular physician (HVP) was interviewed on 2/28/24 at 4:41 p.m. The HVP said the facility did not communicate with him when Toprol XL was not started or about the delayed start and then discontinuation of Spironolactone. He said two months of treatment was lost. He said he would expect the facility to call if there was concern regarding Resident #45's blood pressure being too low with the addition of Spironolactone and Toprol XL, as the parameters for low blood pressure was different for a population who were not as sick as Resident #45. The HVP said he hoped the facility provider would have communicated immediately with him if they were not going to follow his recommendations. The DON was interviewed again on 2/29/24 at 10:11 a.m. The DON said she asked the NP if she wanted to talk with the heart and vascular specialist (ordering physician) and the NP declined. She said there was a lack of collaboration between the primary care provider and the heart and vascular specialist. She said she would expect the nurse to document in the record if orders were not implemented. She said the facility process needed to be improved to provide better communication. Licensed practical nurse (LPN) #5 was interviewed on 2/29/24 at 1:33 p.m. LPN #5 said she would discuss with the DON if orders were not implemented by the facility physician. She said she would document in the resident's chart if the physician did not implement a specialist's orders. LPN #2 was interviewed on 2/29/24 at 1:47 p.m. LPN #2 said she discussed with the unit manager if there were order changes. She said she signed noted at the bottom of the orders, which means the orders have been completed and entered into the record. She said she would not sign the form if the orders were not implemented. She said she would check with the unit coordinator to see if she needed to document in the record if orders were not implemented. The NHA was interviewed on 2/29/24 at 2:07 p.m. The NHA said he expected the resident to be notified by nursing staff if the ordered medications were not implemented by the facility provider. He said he would expect the facility provider to discuss this with the resident. LPN #1 and the DON were interviewed together on 2/29/24 at 3:00 p.m. Both LPN #1 and the DON said RN #1 should have notified the resident if he was not going to start taking medications prescribed by the specialist. V. Facility follow-up On 2/29/24 at 3:55 p.m., the DON provided the following documentation: Quality Assurance Orders Action Plan: Identified areas for improvement: -Physician Services Collaboration related to new orders. -When a new order is received from an alternate physician other than the attending physician collaboration is to occur between the two providers and nursing. -Communicate these changes with resident and/or family. Plan: -Education with new in-house providers related to collaboration with outside physicians. -Education with nurse's related to new orders received from outside providers. Nurses will also be educated on documenting follow up related to new order from outside providers. -MD communication forms will be reviewed and audited by DON and clinical coordinator. -The facility did not implement the action plan until the concern for orders not being implemented was brought to their attention during the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored and labeled in one of five medication carts and one of three medication storage rooms. Specifically, the facility failed to ensure: -Medications were labeled with the date opened; and, -Expired and discontinued medications were removed from the medication cart and storage room in a timely manner. Findings include: I. Facility policy and procedure The Storage of Drugs and Biologicals Policy, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 9:32 a.m. The policy read in pertinent part, The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. II. Professional references According to the manufacturer [NAME] Lilly and Company, Humalog U-100 Insulin (February 2024), retrieved on [DATE] from https://www.humalog.com/u100, Opened Humalog vials, prefilled pens, and cartridges must be thrown away 28 days after first use, even if they still contain insulin. III. Observations and interviews On [DATE] at 7:35 a.m., the Red Cloud unit medication cart was observed with licensed practical nurse (LPN) #3. The following items were found: -A used Albuterol HFA inhaler was not labeled with the date it was opened; -A used QVAR Redihaler inhaler was not labeled with the date it was opened; and, -A used Humalog U-100 insulin Kwik Pen with a date opened label of [DATE]. -The Humalog insulin pen should have been discarded on [DATE], 28 days after opening. LPN #3 said the inhalers should be discarded because they were not labeled with the date they were opened. She said the insulin should have been discarded, however, she was not certain of the date it should have been discarded. On [DATE] at 9:31 a.m., the Frontier unit medication storage room was observed with registered nurse (RN) #2. The following item was found: Five vials of Hepatitis B Vaccine Recombinant Engerix B with an expiration date of [DATE]. RN #2 said the vaccines were expired and should be discarded. IV. Director of nursing (DON) interview The DON was interviewed on [DATE] at 11:06 a.m. The DON said nursing staff should label inhalers when opened. She said the insulin expired by [DATE]. The DON said she thought the insulin had been discontinued and should have been removed from the cart on the same day it was discontinued. She said expired vaccines should be discarded immediately upon expiration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to provide bed hold policy information for one (#73) of one resident reviewed for hospitalization out of 33 sample residents. Specifically, the facility failed to ensure Resident #73 was informed, in writing, of the bed hold policy when the resident transferred to the hospital from the facility. Findings include: I. Facility policy and procedure The Bed Hold policy, undated, was provided by the nursing home administrator (NHA) on 12/10/19 at 8:43 a.m. The policy revealed before a resident was transferred to a hospital or the resident went on therapeutic leave, the facility would provide written information to the resident and/or resident's representative that specified: the duration of the state bed-hold policy during which the resident was permitted to return and resume residency in the facility; the reserve bed payment policy in the state plan; and the facility's policies regarding the bed-hold period, which were consistent with the law permitting the resident to return. II. Resident status Resident #73, age [AGE], was admitted on [DATE]. According to the December 2019 computerized physician orders (CPO), diagnoses included diabetes mellitus, diastolic heart failure, respiratory failure, paroxysmal atrial fibrillation, and chronic obstructive pulmonary disease. The 11/22/19 minimum data set (MDS) assessment indicated the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. The resident required limited staff assistance with bed mobility, transfers, dressing and toileting. The resident was administered insulin injections daily and the insulin orders were changed twice in the seven day review period. III. Record review The nurse note, dated 12/3/19 at 3:09 a.m. by a registered nurse, revealed the resident had a blood glucose level of 73. The resident's skin was very white without any blue discoloration from inadequate oxygenation. The resident utilized three liters of oxygen per minute with a nasal cannula. The resident's respirations were labored and the resident had a harsh non-productive cough. The resident responded briefly to increased stimulation and presented with slurred speech. Physician orders were obtained to transfer the resident to the hospital emergency room for evaluation and treatment. The physician's order, dated 12/3/19 at 3:25 p.m., revealed to send the resident to the hospital emergency room for evaluation and treatment for hypoglycemia with altered mental status. The ambulance arrived at the facility and the resident was transferred to the emergency room with all appropriate paperwork. There was no documentation which showed the resident was verbally informed or received a written copy of the bed hold policy. A review of the resident's computerized clinical record failed to reveal the resident was notified by the facility of its bed hold policy. VI. Staff interviews The business office manager (BOM) was interviewed on 12/9/19 at 12:15 p.m. She said the resident was not issued a bed hold policy when she went to the hospital on [DATE]. She said the facility admission packet contained a copy of the bed hold policy that residents sign as an acknowledgement of receiving the document. She said this resident did not sign the document. She said she was not aware a bed hold policy needed to be provided to a resident when the resident was transferred to the hospital. The NHA was interviewed on 12/10/19 at 8:00 a.m. He said this resident was not issued a bed hold policy when she went to the hospital on [DATE]. He said residents sign a bed hold policy form upon admission to the facility and this resident did not sign the document. He said when a resident was transferred to the hospital, the resident or the resident's representative, were not provided written information regarding the bed hold policy that detailed the duration of the bed-hold in which the resident was permitted to return and resume residency in the facility, nor the reserve bed payment policy in the state plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#36) of two residents reviewed out of 33 sample residents received care and treatment in accordance with professional standards of practice. Specifically, the facility failed to accurately and thoroughly complete skin assessments to monitor a bruise to the resident's left forearm. Findings include: I. Facility policies and procedures The Investigating Unexplained Injuries policy, revised January 2011, revealed an investigation of all unexplained injuries including bruises, abrasions and injuries of an unknown source would be conducted by the director of nursing (DON) and/or other individuals appointed by the nursing home administrator (NHA), to ensure the safety of the residents has not been jeopardized. Should a resident be observed with unexplained injuries including bruises, abrasions, and injuries of an unknown source, the nurse supervisor on duty must complete an accident/incident form and record such information into the resident's clinical record. An injury of an unknown source was defined as an injury that meet both of the following conditions: (1) the source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and (2) the extent of the injury or the location of the injury which was not in an area generally vulnerable to trauma. Documentation should include information of relevant risk factors and conditions that could cause or predispose someone to similar signs and symptoms such as receiving anticoagulants. Any description in the medical record should be objective and sufficiently detailed such as the size and location of a bruise. The nursing staff should discuss the situation with the resident's physician or the medical director to consider whether medical conditions or other risk factors would account for the findings. The resident's physician or the medical director should review and verify conclusions about the possibility of a medical or other similar cause of the findings. II. Resident status Resident #36, age [AGE], was admitted on [DATE]. According to the December 2019 computerized physician orders (CPO), diagnoses included presence of coronary angioplasty implant with graft and long term use of antithrombotics and antiplatelets. The 10/31/19 minimum data set (MDS) assessment revealed the resident was moderately impaired in cognitive skills for decision making with a brief interview for mental status (BIMS) score of 8 out of 15. The resident required extensive staff assistance for bed mobility, transfers, dressing, toileting and personal hygiene. The resident did not receive any anticoagulant medications during the assessment period. III. Resident interviews with observations The resident was interviewed on 12/4/19 at 11:34 a.m. The resident had a reddish purple bruise on her left forearm measuring approximately two inches in circumference. The resident said she did not know how this occurred. She said the bruise had been on her forearm for a few weeks. She said the staff had not measured the bruise and she did not think it occurred from receiving a routine blood draw. The resident was interviewed on 12/5/19 at 2:02 p.m. She again said she did not know how the reddish purple bruise on her left forearm occurred. She said it had been there for some time and it did not hurt. IV. Record review Physician orders, dated 9/24/19 at 9:54 p.m., revealed to perform weekly skin observations every Sunday and document findings on the skin observation tool form. Physician orders, dated 9/24/19 at 9:54 p.m., revealed to administer Plavix (anticoagulant) orally each morning for myocardial reinfarction prevention. The care plan for anticoagulant use, revised on 8/16/19, revealed the resident was at risk for bleeding and bruising easily due to the use of anticoagulant medication for the treatment of atrial fibrillation. Some of the interventions were to administer medications as ordered, and to observe/report signs or symptoms of excessive bleeding such as increased bruising, bleeding gums, nose bleeds, ect. The care plan did not reiterate the necessity of objectively documenting the description and location of a bruise in the resident's medical record. The skin observation tool, dated 11/10/19 at 9:26 a.m., revealed the resident had a bruise to the left forearm. There were no measurements for this bruise. There were no nurse progress notes to correspond with this skin observation. The skin observation tool, dated 11/17/19 at 6:21 a.m., revealed the resident did not have any skin integrity issues and the resident was at risk for the development of skin integrity issues. The skin observation tool, dated 11/24/19 at 6:21 a.m., revealed the resident did not have any skin integrity issues and the resident was at risk for the development of skin integrity issues. The skin observation tool, dated 12/1/19 at 1:47 p.m., revealed the resident did not have any skin integrity issues and the resident was at risk for the development of skin integrity issues. The skin observation tool, dated 12/8/19 at 8:23 p.m., revealed the resident did not have any skin integrity issues and the resident was at risk for the development of skin integrity issues. The form noted the resident had healing bruises to the back of her left hand. There were no nurse progress notes to correspond with this skin observation. V. Staff interviews The DON was interviewed on 12/10/19 at 9:27 a.m. She reviewed the skin assessment tool forms. She agreed the skin assessment tool dated 11/10/19 revealed a bruise to the resident's left forearm. She agreed the skin assessment did not contain any measurements or description of the bruise. She said there were no further assessments or investigations related to this bruise. The DON reviewed the weekly skin assessments dated 11/17, 11/24, 12/1 and 12/8/19. She said the bruise to the resident's left forearm was not mentioned on any of the assessments and it should have been documented on each assessment. The DON said a risk management assessment should have been completed in the facility's computerized documentation system, point click care (PCC), for this bruise. She said there was no assessment for this bruise in PCC. The DON said when a bruise was first observed, she or the unit manager should be notified immediately. She said staff would talk with the resident to see what might have caused the bruise. She said a progress note would be made of the conversation and any determination on how the bruise occurred. She said she was unable to find any progress notes regarding a conversation with the resident or a determination of the cause of this bruise. She said nursing staff should follow facility policies and procedures. Licensed practical nurse (LPN) #1 was interviewed on 12/10/19 at 10:26 a.m. He said if he observed a bruise on a resident, he would complete the risk management assessment in PCC. He said the completed assessment could then be reviewed by the nursing staff. He said the DON, unit manager, resident's physician and the resident's responsible party would be notified of the observation. Registered nurse (RN) #2 was interviewed on 12/10/19 at 10:55 a.m. He said when a bruise was first observed, a risk management assessment would be completed in PCC. He said a nurse progress note might also be incorporated in PCC regarding the observation. He said the resident's physician and their representative would be notified of the observation. He said the assessment would be discussed in the next morning meeting. He said all current risk management assessments were discussed in the Thursday morning meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews; the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range resulting in significant/severe weight loss and the facility failed to recognize, evaluate, and address the needs of every resident already experiencing impaired nutrition for one (#63) of two residents reviewed for nutritional status out of 33 sample residents. Specifically, the facility failed to ensure Resident #63 received adequate nutrition resulting in significant/severe weight loss of 9% in one month and 13% in six months. The facility failed to obtain weekly weights for two consecutive weeks as ordered by the physician. The facility failed to assess, evaluate, and document on the resident after Resident #63 experienced significant/severe weight loss. The facility failed to document the resident's physician was notified of the weight loss. The facility failed to assess the adequacy of nutritional interventions resulting in continued weight loss down to 115 pounds resulting in 9.8% weight loss in one month and 13% weight loss in six months. Findings include: I. Facility policy and procedure The Weight Assessment and Intervention policy revised September 2008, provided by the director of nurses (DON) on 12/9/19 at 2:15 p.m. revealed, in part, The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents . The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a) 1 month- 5% weight loss is significant; greater than 5% is severe; b) 3 months- 7.5% weight loss is significant; greater than 7.5% is severe; c) 6 months- 10% weight loss is significant; greater than 10% is severe. II. Resident #63 status Resident #63, age [AGE], was admitted on [DATE] with readmission on [DATE]. According to the December 2019 computerized physician orders (CPO), diagnoses included gastro-esophageal reflux disease (GERD), dementia, chronic obstructive pulmonary disease (COPD) and depression. The 10/28/19 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. The 11/18/19 MDS assessment revealed a BIMS score was not conducted. The resident was marked as supervised performance for eating with setup help only. III. Observations Resident #63 was feeding herself in the main dining room on 12/4/19 at 12:47 p.m. She was eating half of a peanut butter and jelly sandwich. She had a container of nutritional supplement, a glass of water and a cup of coffee with her meal. Resident #63 was observed on 12/5/19 at 8:30 a.m. in the main dining room. She was able to feed herself. She received toast with butter and poached eggs. She ate approximately 75% of one of the poached eggs and she was feeding herself half of the toast. She also received a cup of coffee, a glass of water, a glass of juice and some orange slices. Resident #63 was observed again on 12/9/19 at 12:52 p.m. in the main dining room. She received a large scoop of mashed potatoes with gravy, chocolate cake, a glass of water and a cup of coffee. She was feeding herself the mashed potatoes. The resident was observed again in the main dining room on 12/10/19 at 8:24 a.m. She received a cup of coffee, orange slices, toast with butter and poached eggs. She appeared weak and had difficulty getting the jelly package open. IV. Record review The care plan, revised 11/25/19, revealed, .is at nutritional risk related to significant weight loss, COPD, GERD, history of refusing meals . benefits from encouragement to come to breakfast, but staff does respect her right to refuse . providing active protein in the afternoon and Juven 2x (times) a day for skin integrity. Interventions included: Notify family and physician of any significant weight changes .snacks between meals as desired and weigh per facility protocol. Review of the most recent RD assessment, completed by the RD on 4/28/18, revealed Regular diet . house supplement once daily . weight: 134 pounds with a body mass index (BMI) of 21.7. Ideal body weight: 130 pounds . weights have fluctuated between 126 and 142 since admitting . estimated needs: 1525-1830 calories; 61 grams protein. There were no recent RD assessments in the resident's chart regarding the resident's readmission to the facility or the resident's significant weight loss. Review of the weights and vitals summary revealed the following: 6/3/19: weight of 132.8 pounds 3/4/19: weight of 122 pounds 11/7/19: weight of 129.8 pounds (after readmission [DATE]) 11/11/19: weight of 127.6 pounds 11/18/19: Missing weight 11/25/10: Missing weight 12/1/19: weight of 118 pounds (9% weight loss x 1 month and 11% weight loss x 6 months) 12/9/19: weight of 115 pounds (9.8% weight loss x 1 month and 13% weight loss x 6 months) Review of the most recent dietary profile assessment, completed by the certified dietary manager (CDM) on 11/7/19, revealed the resident was on a regular texture diet; power cookie and house supplement. -There were no orders for the power cookie and the house supplement was discontinued on 11/5/19. Review of the November 2019 treatment administration record (TAR) and the weights and vitals summary revealed missing weights for 11/18/19 and 11/25/19. Review of the November 2019 medication administration record (MAR) revealed the resident was receiving house supplement, every day and evening shift for nutritional support from 11/23/18 with a discontinued date of 11/5/19. Review of the progress notes revealed the following: -11/5/19: Resident readmitted to facility . with right lung pneumonia . no edema noted. -11/6/19 at 16:55: .contacted by (hospice) and they plan to meet with patient to initiate hospice care on 11/7 at 10am. -11/6/19 at 19:21: resident remained in bed for supper. Remains lethargic. -11/7/19 at 8:40: .hospice eval ordered from the hospital . hospice evaluation today. (Signed by the physician) -11/7/19 at 13:34: .up for meals eating more than 50%. -11/7/19 at 19:55: .drinking fluids well. Appetite poor for supper. -11/8/19 at 12:57: .good appetite and fluid intake. -11/14/19 at 11:50: Nutrition Note: Resident's weight is trending up since last month and previous weight loss . Will continue to encourage adequate oral (po) intake and monitor residents weight. There were no progress notes or assessments from the registered dietitian (RD), the interdisciplinary (IDT), or the physician throughout December 2019 related to the resident's weight loss. The progress notes did not have any documentation related to the physician notification of the resident's significant weight loss. Review of the December 2019 CPO revealed the following: -11/5/19 with a start date of 11/6/19: protein liquid in the afternoon; -11/5/19: Juven two times a day for skin integrity support; -11/5/19 with a start date of 11/11/19: weigh patient weekly on Monday; -11/25/19: hospice There were no physician orders for snacks or any additional supplementation until this week. House supplement was ordered three times a day on 12/9/19. Review of the nighttime (HS) snacks documentation revealed the resident consumed 25-75%. Meal oral intakes revealed variable intakes. V. Interviews Licensed practical nurse (LPN) #4 was interviewed on 12/5/19 at 10:14 a.m. She acknowledged the resident was receiving liquid protein supplement with 70 calories and 16 grams of protein per 30 milliliters (ml) and Juven (arginine and glutamine) twice a day (BID) with 95 calories per packet. The CDM was interviewed on 12/9/19 at 9:24 a.m. She said the RD was contracted and was only in the facility about 10-12 hours/week. LPN #2 was interviewed on 12/9/19 at 10:35 a.m. She said she would assign the weights first thing in the morning and gave the list to the certified nurse aides (CNAs). She said the CNAs should have obtained the weights by 2:00 p.m. or she would have weighed the residents herself. The CDM was interviewed on 12/9/19 at 12:17 p.m. She said she completed the dietary profile for the residents on admission. She said this form contained the resident's likes and dislikes. She said she would have seen the resident if the resident had a weight loss. She said she kept track of the weight losses. She said she would have looked into the electronic medical record for any weight triggers. She said the RD would have looked at some of the weight triggers. She said they had meetings every Thursday and would place interventions as needed. She said snacks could have been ordered or the snacks would have been available upon request. She said she was not sure if this resident had been discussed at the meeting held the past Thursday with IDT. LPN #3 was interviewed on 12/9/19 at 12:29 p.m. She said if the resident had a weight loss, they would notify the clinical manager. She said either the clinical manager or the RD would ask for a reweigh. She said some of the residents had an order for snacks and some received snacks between meals. She said this resident took her protein liquid and Juven supplements well. She said oh yeah this resident would have taken a high calorie supplement. She said it depended on if they offered the supplement to her. The resident's family was interviewed on 12/9/19 at 12:45 p.m. She said she was aware of the resident's weight loss. She said there was really no food item the resident disliked. She said it took awhile for the resident to finish breakfast and so she would not be very hungry for lunch. She said this resident would have drank a chocolate high calorie supplement all day long. She said the physician and hospice were aware of her weight loss. The RD was interviewed on 12/9/19 at 1:40 p.m. For residents with weight loss, she said she would have talked to the resident and the nurses to see how the resident was eating. She said she would have charted on the resident. She said she would have evaluated what supplements the resident would have accepted. She said they had IDT meetings weekly, on Thursdays. She said she would have to look up to see if Resident #63 had a weight loss. She said she thought this resident may have been on her previous list or the current list for this week. The unit manager (UM) was interviewed on12/9/19 at 1:44 p.m. She said they obtained weights either weekly or monthly. She said the RD would have assessed whether the resident needed weekly or monthly weights. She said the nurse would have documented any refusals in the progress note section. She said they would have notified the physician for any significant weight losses. She said they would have evaluated reasons for the weight loss and obtained any preferences. She said she would assess Resident #63 this day. She said she would talk to the daughter and the RD to see what changes they needed to make. The DON was interviewed on 12/9/19 at 2:15 p.m. She said they interviewed the daughter and the RD had been contacted. She said this resident was not reviewed this past week because they did not have the meeting. She said the RD was not in the building that Friday.

Based on observations, record review and interviews, the facility failed to provide food that was palatable, attractive, and appetizing for nine (#5, #6, #43, #52, #47, #56, #30, #8, and #29) out of 33 sample residents. Specifically, the facility failed to provide food that was not undercooked or overcooked, resulting in bland, runny, dry and/or tough foods for five residents representing resident council along with Resident #30, Resident #56, Resident #52, Resident #8 and Resident #29. Findings include: I. Facility policy and procedure The 2016 Dining Experience policy, undated, provided by the nursing home administrator (NHA) on 12/10/19 at 11:46 a.m., revealed Staff members will strive to enhance the resident's quality of life while serving meals that . are palatable to the resident. The 2019 Poached Egg recipe, undated, provided by the NHA on 12/9/19 at 3:14 p.m. revealed: .cook seven minutes to hard cook the eggs. Whites and yolks should be completely set. II. Observations The main dining room was observed on 12/9/19 at 9:02 a.m. Two residents were observed to have received undercooked poached eggs. The whites of the eggs were runny, not fully cooked. III. Test tray Review of the test tray on 12/9/19 at 11:55 a.m. revealed the pork was dry, bland and tough. The pork was difficult to cut or chew. IV. Resident council interview Five members of the resident council (Residents #5, #6, #43, #52 and #47) were interviewed on 12/5/19 at 11:00 a.m. All five residents said the food was going downhill fast. They felt the food was bland and overcooked, especially the vegetables. Three residents (#5, #43 and #52) said they did not order the vegetables any longer because they would taste awful. All five residents said the meat was overcooked, tough, and hard to chew so they would not eat it. V. Record review and resident interviews Resident #30 was interviewed on 12/4/19 at 9:43 a.m. The 10/29/19 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 15 out of 15. He said the eggs were undercooked. He said when he ordered the biscuits and gravy recently, the biscuits tasted frozen. Resident #30 was interviewed again on 12/9/19 at 9:01 a.m. He said he no longer ordered the eggs because they were always undercooked. Resident #56 was interviewed on 12/10/19 at 8:19 a.m. The 11/12/19 MDS assessment revealed the resident had intact cognition with a BIMS score of 15 out of 15. When asked about the food, she said I don't like it. She said the food was institutional and too salty. The meat was overcooked. She said she got the pork the day before and was unable to chew it. She said she received chicken (turkey) on a biscuit the night before without the biscuit because it was always raw. Resident #52 was interviewed on 12/10/19 at 10:11 a.m. The 11/7/19 MDS assessment revealed the resident had intact cognition with a BIMS score of 14 out of 15. She said she sometimes did not care for the food at all. She said the meat was sometimes tough. She said they had green beans a lot which she liked, but needed more flavor. She said they did not season the food at the facility. Resident #8 was interviewed on 12/10/19 at 10:22 a.m. The 12/4/19 MDS assessment revealed the resident had intact cognition with a BIMS score of 15 out of 15. She said the food was alright. She said the meat was a little tough to chew, and she did not have teeth. Resident #29 was interviewed on 12/10/19 at 10:26 a.m. The 10/28/19 MDS assessment revealed the resident had intact cognition with a BIMS score of 15 out of 15. She said she would eat the food sometimes. She said she did not always know what the food was. She said she lost 15 pounds and was not trying to lose weight. VI. Staff interviews The certified dietary manager (CDM) was interviewed on 12/10/19 at 12:14 p.m. She said they had a dining committee meeting after resident council, once a month. She said they previously had complaints about the eggs being overcooked which may have resulted in them undercooking the eggs. She said the biscuits arrived precooked and were placed into the walk-in. She said they would run the biscuits through the toaster or microwave. She said she had heard of the residents stating the meat was tough and overcooked. She said they were trying different products to see what worked best. -At 12:41 p.m., she confirmed the biscuits were put through the toaster belt during service. She said she would get some additional condiments for the residents to help enhance flavor.

Based on observations, record review, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to properly sanitize/disinfect scissors and other equipment (a flashlight and a permanent marker) used for multiple residents before and after providing wound care. Findings include: I. Facility policy and procedure The Infections-Clinical Protocol policy, revised March 2018, provided by the director of nursing (DON) on 12/9/19 at 1:50 p.m., read in pertinent part: The physician or provider and staff will identify infection transmission risks and (in conjunction with the infection preventionist) will implement relevant precautions. The manufacturer's guidelines for the Micro-Kill plus disinfecting wipe, provided by the DON on 12/9/19 at 1:50 p.m., read in pertinent part: This product is not to be used as a terminal sterilant/high level disinfectant on any surface or instrument that is introduced directly into the human body, either into or in contact with the bloodstream or normally sterile areas of the body. Thoroughly wet pre-cleaned, hard, non-porous surface with a wipe, keep wet for two minutes, and allow to air dry. Use as many wipes as needed for the treated surface to remain wet for the entire contact time. You may use a wipe to pre-clean the surface to be disinfected, but thorough re-wiping with a fresh wipe is required for disinfection. II. Observations An observation of a wound VAC (vacuum-assisted closure of a wound) change on 12/9/19 at 11:08 a.m. with registered nurse (RN) #1 revealed the following: He gathered supplies from the top drawer of the treatment cart, that included a flashlight, a black permanent marker, and two pairs of scissors, (a black handled pair of bandage scissors, that had the word autoclave imprinted on the handle, and a metal pair of pointed scissors) that were lying loose in the top drawer with several other pairs of bandage scissors. He did not clean these items and placed the supplies on a paper barrier, and entered the resident's room, placing it on the resident's bed. He used the black handled bandage scissors to cut the tubing of the wound vac close to the connection on the resident's hip. He did not clean the scissors and placed them back on the paper barrier. Wearing gloves, he removed the soiled dressing material and the wound vac sponge from the wound bed. He did not change gloves and picked up the flashlight to view the wound bed, then placed it back on the paper barrier. He used a cotton tipped applicator to measure the wound by placing it into the wound bed several times, then laying it on a paper measuring strip, touching the tip of the applicator that had been in the wound. The wound measured: length 4.0 centimeters (cm) x width 5.7 cm x depth 2.9 cm. He used the same cotton tipped applicator to measure undermining (when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound's edge) at the five to seven o'clock position of 2.2 cm. Wearing the same gloves, he used the black permanent marker to write the measurements on the paper strip. At this point he changed gloves and opened the sealed package of wound vac supplies. He cut a long piece of plastic film with the bandage scissors and covered the entire wound and the skin across the resident's hip. He used the pointed metal scissors to cut out an opening over the wound bed. He then used the bandage scissors to cut a piece of black foam to fit into the wound. He placed the piece of foam into the wound, removed it to trim more off of it several times with the bandage scissors and placing it back into the wound each time. Wearing the same gloves, he then used the bandage scissors to cut strips of foam and plastic film to create a bridge across the resident's hip where the vacuum would be attached. He used the pointed scissors to snip a small opening in the film at the end of the bridge, and attached the tubing connector to the bridge to allow suction once the vacuum was turned on. He removed his gloves and opened a new vacuum drainage canister. When he tried to place it into the suction machine he dropped it on the floor. It rolled under the resident's bed. He retrieved it and placed it into the machine and turned it on. He placed the paper barrier, with the soiled supplies, on the resident's over-bed table. He donned gloves and exited the room, touching the door handle, and reentered the room wearing the same gloves and carrying two sanitizing wipes. He then wiped both pairs of scissors, the flashlight, and the marker with the same wipe and placed them back onto the paper barrier he used throughout the wound treatment process. He did not keep the items wet for the required two minute dwell time. He exited the room again, wearing gloves, touching the door handle, and returned with another wipe and wiped the wound vac machine and its case, using the same wipe. He did not keep the items wet for the two minute dwell time required by the manufacturer's guidelines. He removed his gloves and picked up the scissors, flashlight, and the marker from the paper barrier and placed them on top of the treatment cart, then back into the top drawer of the cart with the other scissors and supplies. He did not clean the resident's over-bed table after removing the supplies and the paper barrier. III. Interviews RN #1 was interviewed on 12/9/19 at 11:55 a.m. He said he had 12 residents with wounds that he provided treatments for. He said he had different scissors he used for different things and they were all kept loose together in the top drawer of the treatment cart. He said he used these scissors on all the residents for their wound treatments. He was unaware the black handled bandage scissors had the word autoclave imprinted on the handle. He acknowledged the facility did not have an autoclave machine to sterilize the scissors. He said he used the Micro Kill plus wipe to clean the scissors after use, because it was his understanding it killed everything and he was not aware of the two minute dwell time of the wipe. The DON was interviewed on 12/9/19 at 12:05 p.m. She acknowledged the potential for cross contamination by using the same scissors for multiple residents when doing wound care, especially if the scissors were labeled to be autoclaved. She acknowledged the facility did not have an autoclave machine to sterilize scissors. She said the Micro Kill plus wipe had a dwell time of two minutes, and items that were being cleaned had to remain wet that length of time. She said the nurses should follow manufacturer's guidelines. She said the wipe was not a good choice to clean scissors because it could not get into all areas of the scissor. She said it would be ideal for each resident to have their own supplies, and she would ask the facility central supply clerk to order disposable scissors for each resident who was receiving wound treatment. IV. Facility follow-up On 12/10/19 at 2:30 p.m. the DON said she had ordered enough pairs of scissors for each resident that was receiving wound care to eliminate the possibility of cross contamination from using the same scissors for multiple residents.

Based on observations, record review and staff interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in two of two kitchens. Specifically, the facility failed to: -Dispose of expired foods; -Ensure foods were labeled, dated and covered during storage; -Ensure food was stored at the proper temperature; -Ensure the kitchen and food equipment was clean; -Prevent potential contamination; -Ensure proper thawing practice for frozen foods; and -Ensure proper food temperatures were taken for tray line service. Findings include: I. Facility policy and procedure The Food Preparation and Service policy, revised October 2017, provided by the nursing home administrator (NHA) on 12/9/19 at 3:14 p.m., revealed Refrigerated foods must be stored below 41 degrees Fahrenheit (F) unless otherwise specified by law . Food and nutrition services staff shall wear hair restraints . so that hair does not contact food . Food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of food-borne illness Gloves can become contaminated and/or soiled and must be changed between tasks . Thawing frozen food . submerging the item in cold running water . The danger zone for food temperatures is between 41 and 135 degrees F. The Sanitization policy, undated, provided by the NHA on 12/9/19 at 3:14 p.m. revealed All kitchens, kitchen areas and dining areas shall be kept clean .all utensils, counters, shelves and equipment shall be kept clean .All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils. II. Expired foods The main kitchen was observed on 12/4/19 at 8:00 a.m. The walk-in refrigerator contained a half-gallon container of lowfat buttermilk with a manufacturer's date of 10/8/19. The walk-in refrigerator was observed again on 12/9/19 at 9:35 a.m. with the following: -A half-gallon container of low fat buttermilk was dated with a manufacturer's date of 10/8/19. The container was marked as received on 9/26. (Two months past the manufacturer's date.) -Three five-pound containers of Ricotta cheese were dated with a manufacturer date of 8/26/19. The containers were marked as received on 7/26. (Over three months past the manufacturers date.) The certified dietary manager (CDM) was interviewed on 12/9/19 at 4:03 p.m. She said she looked through the food items for ordering purposes. She said she had not noticed the expired food items. She said she had not thought about it. She said the cooks should have been looking at the foods for expiration. She said she needed to make a better habit of looking at the food items for expiration. III. Labeling, dating and covering The main kitchen was observed on 12/4/19 at 8:00 a.m. The walk-in refrigerator had a small container of five large hot dogs. The container was not labeled or dated. The sandwich station refrigerator had the following: -A container of chicken fingers, undated and uncovered; -A container of beef stew, uncovered; -A container of cubed white meat, uncovered; and -Containers of rice, soup and shredded cheese, all uncovered. The sandwich station refrigerator was observed again on 12/9/19 at 9:27 a.m. with the following: -A large container of white shredded cheese, uncovered; -Containers of mushrooms and green peppers, uncovered; -A tall carton of liquid eggs, open and uncovered; -A container of breaded nuggets, unlabeled and uncovered; and -The top of the sandwich station contained shredded white cheese, sliced American cheese, ham slices, egg salad, potato salad and refried beans -- all uncovered. IV. Cold storage temperatures The main kitchen was observed on 12/4/19 at 8:10 a.m. The sandwich station refrigerator thermometer read 45 degrees F. The sandwich station refrigerator was observed again on 12/9/19 at 9:27 a.m. with a temperature of 45 degrees F. At 10:47 a.m., the temperature was approximately 44 degrees F. At 11:24 a.m., the temperature was 42-44 degrees F. The CDM was interviewed on 12/9/19 at 4:03 p.m. She said she had noticed the temperatures this morning. She said they had turned the temperature down and it had gotten to 42 degrees F. She said more adjustments were made. V. Cleanliness The main kitchen was observed on 12/9/19 at 9:25 a.m. The soap dispenser at the handwashing sink was dirty with spatter. The dish machine room had paint peeling from the walls and spatter all along the walls. The sandwich station refrigerator was observed on 12/9/19 at 9:27 a.m. It was dirty with food debris all along the bottom of the refrigerator and all along the internal shelving. The right side of the sandwich station refrigerator was dirty with spatter along the outside. -At 9:34 a.m., the wall behind the knife rack was observed as dirty along. One of the knives was dirty. The main kitchen was observed on 12/9/19 at 10:38 a.m. One of the red sanitizer buckets was stored on the floor with several dirty rags in the solution. The shelving to the right of the prep table was dirty along the shelves and the arms of the rack. A pie crust was stored on top of a container of donut glaze and had flour debris all over the crust. The large container of baking powder was dirty. -At 11:06 a.m., the rack of skillets were observed with visible debris along the outside of the skillets. Resident #30 was interviewed on 12/4/19 at 9:43 a.m. He said the silverware was not always clean. Resident #56 was interviewed on 12/10/19 at 8:19 a.m. She said the trays were filthy and her coffee mug stuck to the tray this morning. VI. Contamination The main kitchen was observed on 12/9/19 at 11:12 a.m. [NAME] #1 was observed wearing gloves. He touched the open trash can with his gloved hands. He then proceeded to pick up the cooked loaves of pork with the same gloves hands. He cut the pork using the same gloved hands on a yellow cutting board. At 11:15 a.m., the took the gloves off and washed his hands for a few seconds. He then put on a new pair of gloves. The CDM was interviewed on 12/9/19 at 4:03 p.m. She said she didn't think she had educated the staff on proper glove use. She said they had a list of the proper cutting board usage hanging on the wall. Review of the Prevent Cross Contamination guideline for cutting boards revealed the brown cutting board should have been used for cutting cooked meats. VII. Thawing practice The main kitchen was observed on 12/9/19 at 11:22 a.m. There was frozen chicken in one of the sinks of the three-pan sink. Water was running over a small portion of the chicken. The chicken was not fully submerged in the water. The CDM was interviewed on 12/9/19 at 4:03 p.m. She said she had not previously noticed any improper thawing practices. VIII. Tray line temperatures The main kitchen was observed on 12/9/19 at 11:30 a.m. [NAME] #1 was taking temperatures of the food items. He appeared to have difficulty reading the thermometer. For the brussels sprouts, the temperature was approximately 130 degrees F and the cook said it was 140 degrees F. For the mashed potatoes, the temperature was approximately 150 degrees F and the cook said it was 160 degrees F. The temperatures of the food on the sandwich station was as follows: -The potato salad was approximately 50 degrees F.; -The egg salad was approximately 42 degrees F.; -The tuna salad was approximately 42 degrees F; -Sliced ham was approximately 44 degrees F. Review of the Food Temperature Log for the main kitchen revealed the following: 12/9/19 at lunch: all the hot foods were documented as 160 degrees F except for the pureed vegetable which was documented as 120 degrees F. Review of the Food Temperature Log for Frontier kitchen revealed the following: 11/17/19 for dinner meal: all of the hot foods documented as 150 degrees F. and all cold foods documented as 40 degrees F. 11/18-11/19/19 for dinner meals: all hot foods documented as 150 degrees F. and all cold foods documented as 40 degrees F. 11/21-11/23/19 for dinner meals: all hot foods documented as 150 degrees F. and all cold foods documented as 40 degrees F. 12/8/19: missing documentation; 12/1/19- 12/7/19 for dinner meals: all hot foods, except the pureed meat, were documented as 150 degrees F. All of the cold foods documented as 40 degrees F. No variation in temperatures. The CDM was interviewed on 12/9/19 at 4:03 p.m. She said she had just ordered about 10 new thermometers. She said she had noticed some of the same temperatures documented for the food items. She said they did not have any logs when she first started. IX. Additional interviews The CDM was interviewed again on 12/9/19 at 4:03 p.m. She said the RD completed a monthly sanitation audit. She said that the infection control nurse also completed an audit related to infection control for the kitchen. She said he looked at the sinks, refrigerators and hair restraints. She said she tried to fix anything the RD identified during her inspections. She said she did not have her own audit tool.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to report alleged violations of potential abuse to the state survey and certification agency in accordance with state law for one (#9) of one resident reviewed for abuse of 39 sample residents. Findings include: I. Facility policy and procedure The Abuse, Neglect, and Exploitation Prevention policy and procedure, undated, was provided by the nursing home administrator (NHA) on 12/10/18 at 11:00 a.m. The policy read in pertinent part, Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. Administrator, or his/her designee, shall immediately (within 24 hours) notify the State Health Department, local law enforcement, and local ombudsman. II. Resident #9's status Resident #9, age [AGE], was admitted on [DATE]. According to the December 2018 computerized physician orders (CPO), diagnoses included Parkinson's disease and vascular dementia. The 9/19/18 minimum data set (MDS) assessment revealed she was severely impaired with a brief interview for mental status (BIMS) score of seven out of 15. She required extensive assistance with activities of daily living (ADLs). III. Facility failure A. Family interview On 12/11/18 at 9:18 a.m. Resident #9's family member was interviewed. She said Resident #9 was blocked in the hallway by two male residents and they would not let her pass. Afterwards she went crying to her sister who lived in an assisted living apartment in the building down the hall to tell her what happened. She said the incident occurred before Resident #9's care conference in September of 2018. She said she was never given a full explanation of the incident or the facility's investigation. B. Record review The resident's activities care plan, initiated on 9/22/17 and revised on 9/26/18, revealed the resident enjoyed visiting with staff and her peers, continued her therapy program and was self mobile using her wheelchair. The psychosocial care plan, initiated on 7/13/17 and revised on 6/17/18, revealed the resident had a diagnosis of depression, at times self isolated in her room, would make negative comments, and would experience moments of hallucinations, delusions and paranoia. Interventions included to offer psychosocial support as needed, redirect to activities, provide 1:1 support, and offer validating responses to the resident's current reality. There was no documentation in the resident's medical record of the September 2018 incident (see family interview above). C. Staff interviews The social services director (SSD) and licensed practical nurse (LPN) #2 were interviewed on 12/11/18 at 12:23 p.m. The SSD said on 9/8/18 Resident #9's sister, who resided in the assisted living section of the facility, came and reported something was wrong with Resident #9, and she was saying something about two men not letting her pass by. She said she was not sure what time of day it was, but she immediately went to interview Resident #9 and her story changed. She said Resident #9 said she went to visit her mother (who was not alive), and Resident #9 said staff came in and told her she could not be in there and a nurse grabbed her by her shirt and pulled her into the hallway. She said Resident #9 felt her mother was still alive and she had been in her room. The SSD said she called Resident #9's daughter and left her a message to call back. She contacted the nursing home administrator who told her to call the police, and then she immediately notified police. She said the police said they would not be opening a case or investigating because Resident #9 had a history of delusions. She said they did complete an investigation through interviews but did not report it to the state agency as an occurrence because they thought it did not meet criteria. LPN #2 said they felt the incident was a part of Resident #9's grief process because her daughter had just passed away on 8/29/18. She said the resident was very confused that day. She said staff completed a skin assessment and identified no issues. They said the floor nurse was interviewed and said there was nothing unusual with the resident other than having neck pain. They said they contacted hospice for grief support and senior counseling for support. They said after Resident #9's daughter returned their call, they agreed Resident #9 was grief stricken because of the recent loss of her mother and her daughter. The SSD said Resident #9's daughter said Resident #9 had called her multiple times that day and was not making any sense. They said Resident #9 was more confused and experiencing more delusions secondary to her Parkinson's dementia, and her story changed when she was interviewed by different individuals. They said Resident #9 was receiving medication to help with the delusions. They said they provided validation and offered Resident #9 emotional support and she returned back to baseline. The SSD said any abuse allegation should be reported; however, felt the above was not reportable because Resident #9 had been having hallucinations and her story was inconsistent. The SSD and nursing home administrator (NHA) were interviewed on 12/13/18 at 12:03 p.m. The NHA said when the incident was first reported by Resident #9 to her sister, her sister said she was acting funny and thought something was wrong with her. She said when the SSD interviewed Resident #9 her story changed from two people being involved in the conversation to one person being involved in the conversation. She said there was no concrete allegation of abuse because her story could not have happened because her mother was not alive. She said the family said she was having inaccurate memories. She said they notified the police in the event that there was abuse as they often took a while to respond, but the police said they did not need to investigate. She said Resident #9 was not fearful of anyone, she was not crying, guarded, she did not decline the skin assessment, there were no skin issues, and the nurse medicated her for neck pain. The SSD said they offered validation and support and she returned to her baseline. They felt the concern was not an allegation of abuse and felt they provided appropriate emotional care to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** II. Resident #37 A. Resident status Resident #37, age [AGE], was admitted on [DATE]. According to the December 2018 computerized physician orders, diagnoses included osteoporosis, depressive episodes, gastro-esophageal reflux disease (GERD), and history of falling. The 9/7/18 MDS assessment revealed the resident has moderate cognitive impairment with a BIMS score of 11 out of 15. The resident required extensive assistance from two people with bed mobility, transfers, and activities of daily living including eating and positioning. B. Observations On 12/12/18 at 12:37 p.m. resident #37 had lunch delivered by CNA #5. The resident was in bed at a 30 degree angle and leaning to the left. The resident was left with the tray. At 12:56 p.m. CNA #5 took the tray. The CNA did not offer repositioning assistance. On 12/12/18 at 5:56 p.m. it was observed that the resident was in bed leaning to the left and had dinner delivered.The resident was not offered repositioning during meal. In an observation on 12/13/18 at 8:33 a.m., the resident was sleeping and had breakfast delivered earlier in the morning. The resident woke at 8:54 a.m. when the transportation specialist asked about a shopping trip. Licensed practical nurse (LPN) #1 was alerted that the resident had not eaten or taken morning medications that had been left at the bedside. The resident was lying flat on her back and asked to eat breakfast and take pills. The resident then asked to be inclined to a 30 degree angle before taking medications. The resident was observed leaning towards the left and was left in this position. LPN #1 said the resident had been in this condition for a while and they were watching it. LPN #1 then left the room. The resident's breakfast tray was picked up at 9:20 a.m. Nursing staff were not observed to offer or provide repositioning assistance to the resident during her meal although the resident had requested bed repositioning. C. Interviews CNA #5 was interviewed on 12/13/18 at 8:33 a.m. CNA #5 said the resident was able to eat independently. CNA #5 said the resident required no assistance and at times did not eat, it depended upon the day. CNA #5 said the resident's leaning to the left side as a potential hazard was not in the care plan that he had seen. The director of nursing (DON) was interviewed on 12/13/18 at 9:23 a.m. The DON stated that the resident was to be monitored for meal intake, positioning, and mealtime hazards. The DON stated that in regards to the resident's leaning to the left side, a new safety assessment was being completed by the physical therapist. The DON indicated the leaning could be a concern. The registered dietitian (RD) was interviewed on 12/13/18 at 11:20 a.m. The RD said the CNAs were responsible for all positioning and assistance with meals, and physical therapy would do the positioning assessments. D. Record review The resident's care plan revised on 2/15/18 identified nutritional risk due to missing teeth, gastroesophageal reflux disorder (GERD), and the inability to position independently. The resident was at risk for spillage of hot beverages. The head of the resident's bed was to be at 30 degrees when eating and drinking. Interventions during eating included monitoring for difficulty with chewing/swallowing or aspiration.The interventions required the CNA to be cueing, encouraging eating, and provided assistance while eating. Review of physical therapy notes revealed on 12/11/18 that the resident received a rehabilitation screen that indicated there was a necessity for a change in positioning. Skilled physical therapy was indicated for proper bed positioning and comfort. This was not included on the care plan. Based on observations, record review and interviews, the facility failed to ensure two (#49 and #37) of four residents reviewed for activities of daily living of 39 sample residents were provided appropriate treatment and services to maintain or improve their abilities. Specifically, the facility failed to ensure: -Resident #49 received encouragement to eat; and -Resident #37 received assistance with eating and positioning. Findings include: I. Resident #49 A. Resident status Resident #49, age [AGE], was admitted on [DATE]. According to the December 2018 computerized physician orders, diagnoses included memory impairment and hypertension. The minimum data set (MDS) assessment dated [DATE] showed the resident had severe cognitive impairment with a score of four out of 15 on the brief interview for mental status (BIMS). The resident was coded as requiring extensive assistance with activities of daily living. The resident required set up with meals. The resident weighed 170 pounds. The MDS inaccurately coded the resident as six feet tall. B. Observations 12/10/18 --At approximately 12:15 p.m., the resident was observed to have her meal in front of her. --At 12:28 p.m., the resident did not receive any encouragement to eat. 12/12/18 --At 12:17 p.m., the resident received her lunch meal. --At 12:24 p.m., the resident was observed to not eat her meal. The resident was not receiving any cueing or encouragement to eat. --At 12:28 p.m., the resident was not eating and did not receive any cueing or encouragement to eat. --At 12:45 p.m., the resident was eating a few bites of food. She did not receive any cueing. --At 12:47 p.m., the resident was assisted away from the table. The certified nurse aide (CNA) did not provide encouragement. The resident ate approximately 25% of her meal. However, the resident's meal intake was inaccurately documented as 75%. --At 5:15 p.m., the resident received her dinner meal. --At 5:21 p.m., the resident was not eating her meal. The resident was not receiving any assistance with eating. --At 5:44 p.m., the resident continued to eat a few bites of her food, however, she did not receive any encouragement. --At 5:50 p.m., the resident was assisted from the table. The resident had eaten 25% of her meal when she left the table. C. Record review The care plan last updated on 11/16/18 identified the resident at nutritional risk related to poor intake and weight loss related to dementia. Pertinent approaches included encourage adequate oral intake and assist resident as needed. The registered dietitian note dated 12/13/18 documented, New weight 160#, down 6# from previous weight on 12-6-18, weights continue to trend down. This writer discussed eating in the therapeutic dining room with resident . D. Interviews Licensed practical nurse (LPN) #1 was interviewed on 12/13/18 at 9:15 a.m. The LPN said the resident was newly admitted to the facility. He said the resident was able to feed herself, but needed encouragement to eat. The registered dietitian (RD) was interviewed on 12/13/18 at approximately 9:45 a.m. The RD said she was aware the resident's intakes varied and that she was newly admitted . She said it took time for the resident to adjust to a new placement. She said the resident required encouragement to eat. The RD was interviewed a second time on 12/13/18 at approximately 1:30 p.m. The RD said the resident did experience a weight loss of an additional six pounds. The RD said that at the noon meal on 12/13/18, the resident ate in the therapeutic dining room, so she could receive cueing and encouragement to eat. The RD said she did well.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#34) of three residents reviewed of 39 sample residents was positioned properly and physician-ordered heel boots applied to relieve pressure. Specifically, the facility failed to position Resident #34 properly and provide physician-ordered pressure-relieving bilateral heel-lift boots when the resident was in bed. Findings include: I. Professional reference According to DM Systems, Inc., the manufacturer of Heelift® Suspension Boot (2016) retrieved from http://heelift.com/heelift-suspension-boot.html 12/24/18: Heelift Suspension Boot can play an integral role in heel pressure ulcer prevention regimens for susceptible, high-risk patients as well as for patients already suffering from heel pressure ulcers. Risk factors for the development of heel pressure ulcers include: age, decreased sensation in the lower extremities from spinal cord injuries or neurological diagnoses, Moisture from perspiration or incontinence, poor nutrition, circulatory complications, friction or shearing caused by dragging or sliding a patient across bed sheets, which can allow unprotected heels to rub on the bed surface. II. Resident #34 A. Resident status Resident #34, age [AGE], was admitted on [DATE]. According to the December 2018 computerized physician orders (CPO), diagnoses included spinal stenosis, osteoarthritis of the knee, unspecified dementia with behavioral disturbance, Parkinson's disease, other chronic pain, cervicalgia, and major depressive disorder. The 10/24/18 minimum data set (MDS) assessment documented the resident missed some part/intent of conversation and cognition was severely impaired. The resident scored three out of 15 on the brief interview for mental status (BIMS). The resident needed extensive assistance for bed mobility, transferring between bed and chair, and ambulating in a wheelchair. The resident had an intact stage one pressure sore and was at risk for developing additional pressure sores. B. Observations Resident #34 was observed continuously on 12/10/18 from 9:48 a.m. through 11:52 a.m. The resident was lying in bed, back flat facing forward and upper torso leaning slightly to the right with a neck pillow supporting the neck. The resident's feet were sticking out of the covers; the resident did not have heel-lift boots on either foot. The resident's legs were slightly bent with a pillow under them at the knee; heels were touching the mattress. Certified nurse aide (CNA) #7 collected the resident's food tray at 10:15 a.m. and offered to reposition the resident. The resident's response was inaudible, and the resident was not repositioned at that time. Resident #34 was observed continuously on 12/10/18 from 3:16 p.m. through 4:31 p.m. She was asleep lying flat in bed, the head of the bed elevated at 45 degrees. The resident was leaning slightly to the right with a neck pillow supporting the head. The resident was in the same position throughout the observation, and did not have heel-lift boots on either foot. Resident #34 was observed continuously on 12/11/18 from 8:08 a.m. through 9:55 a.m. The resident was lying in bed, back flat facing forward and upper torso leaning slightly to the right with a neck pillow supporting the neck. The resident was in the same position throughout observation. CNA #7 entered to deliver a morning snack. Although the resident did not have heel-lift boots on either foot, CNA #7 did not offer to apply them. Resident #34 was observed continuously on 12/11/18 from 3:28 p.m. through 4:11 p.m. The resident was lying in bed, back flat facing forward and upper torso leaning slightly to the right with a neck pillow supporting the neck. The resident was in the same position the entire time, but was able to demonstrate the ability to use bed controls to raise the head of the bed up and down. The resident attempted to raise her upper body and reposition but was unable to move the lower torso or buttocks in the bed. The resident did not have heel-lift boots on either foot. The resident had a pillow under the knees which left the resident's feet hovering on top of the mattress. Resident #34 was observed continuously on 12/12/18 from 8:50 a.m. through 11:09 a.m. The resident was lying in bed, back flat facing forward and upper torso leaning slightly to the right with a neck pillow supporting the neck, in the same position throughout the observation. CNA #7 entered to collect resident's tray and offer additional food. The resident did not have heel lift boots on either foot. The resident had a pillow under her knees which left her feet touching the top of the mattress. CNA #7 was not observed to offer repositioning or heel-lift boots to the resident. C. Interviews Resident # 34 was interviewed on 12/13/18 at 9:26 a.m. The resident said she was unable to sleep the night before, as she was very uncomfortable. CNA #7 was interviewed on 12/13/18 at 9:27 a.m. CNA #7 said Resident #34 was offered repositioning assistance between 6:00 a.m. and 7:00 a.m. when the day shift first began. Resident #34 usually refused to be put in any position other than flat in bed. When Resident #34 allowed repositioning, a pillow was placed under the resident's side, but the resident did not like it and would usually refuse or only permitted the CNA to place the pillow under her side for a short time. The CNA said Resident #34 always had a pillow under her legs; if not, the resident would ask for it. CNA #7 said the resident had never worn off-loading heel boots. Licensed practical nurse (LPN) #4 was interviewed on 12/13/18 at 11:15 a.m. LPN #1 was also present during the interview. LPN #4 reviewed the resident orders (see below) and remarked that there were two orders for bilateral boots. LPN #1 offered to check the resident's feet, and the resident was not wearing the heel-lift boots. LPN #1 found both heel-lift boots in the back of the resident's closet. The LPN said they would make sure the boots were applied as ordered, and would educate the CNAs. D. Record review The December 2018 CPOs, signed by the physician on 12/11/18, documented an order for bilateral (both) heel-lift boots when in bed, and Right elbow elevation with pillow when in bed every shift, effective date of 10/30/18. A second order on the same CPO documented please float heels when in bed use off-loading boots every shift, effective date 10/2/18. The December 2018 medication administration record (MAR) documented the resident had daily orders for bilateral (both) heel-lift boots when in bed, and right elbow elevation with pillow when in bed every shift, effective date of 10/30/18, with a second order on the same CPO which read, please float heels when in bed use off-loading boots every shift, effective date 10/2/18. The MAR showed nurses' initials and check marks for administration of the bilateral heel-lift boots when in bed. However, observations (above) failed to show that the resident was wearing the heel-lift boots when in bed as ordered. The comprehensive care plan dated 12/10/18 documented the resident had an alteration in skin integrity, with an intervention for positioning heels off the bed as ordered, date initiated 10/31/18. The resident's December 2018 visual bedside [NAME] documented under the heading resident care, position heels off the bed as ordered. Review of the electronic record failed to reveal documentation of assessment for alternative and tolerable positioning options for Resident #34.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#42) of one resident reviewed for dialysis care of 39 sample residents received services consistent with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to provide ongoing communication, coordination, and collaboration between the nursing home and the dialysis therapy center. Findings include: I. Facility policy and procedure According to the ESRD/Hemodialysis Residents policy, dated September 2010, provided by the director of nursing (DON) on 12/13/18 at 10:50 a.m., Staff caring for residents receiving dialysis care outside the facility shall be trained in the care and special needs of these residents. The facility will communicate with staff all aspects of how the resident's care will be managed and how information will be exchanged between the facilities. II. Resident status Resident #42, age [AGE], was admitted on [DATE]. According to the December 2018 computerized physician orders, diagnoses included coronary artery disease, hypertension, renal failure and dementia. The 12/1/18 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 15 out of 15. Dialysis was not found on the MDS. III. Record review According to the resident's care plan initiated on 9/10/18, interventions included: complete communication form for dialysis facility, dialysis M-W-F, monitor for dry skin and apply lotion as needed, monitor labs, monitor thrill and bruits as indicated, monitor vital signs as ordered, monitor and document any signs of infection to access site, report to MD, and no blood draws from access arms. Review on 12/13/18 of the facility's dialysis book revealed it contained two dialysis communication forms, dated 12/10/18 and 12/13/18. Neither of the forms were completed and were found to be missing information including: the nurse completing the form, medications given, meal provided, pre-dialysis information, and post dialysis information. Included in the dialysis book was a form dated 12/12/18 that did not contain the communication form from the dialysis center. This communication form did not have a signature/title or date signed. The dialysis book also contained information from dialysis services completed on 9/12/18 and 12/14/18. Neither date included a communication form. IV. Interviews Licensed practical nurse (LPN) #1 was interviewed on 12/12/18 at 3:15 p.m. LPN #1 said the dialysis log that held the communication between the facility and the dialysis therapy center was not up to date and they were working on improving communication. LPN #1 reported the resident received dialysis services on a regular basis. The director of nursing (DON) was interviewed on 12/13/18 at 5:31 p.m. The DON confirmed the communication sheets were not always up to date and they were struggling with getting the communication sheets back from the dialysis center. She stated it was an ongoing conversation and all documents for the resident's dialysis services were located in the folder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#60) of one resident reviewed for physician visits of 39 sample residents, was seen by a physician at least once every 30 days for the first 90 days after admission. Specifically, the facility failed to ensure Resident #60 was seen by the physician every 30 days for the first 90 days after admission. Findings include: I. Facility policy and procedure The Physician Visits policy, undated, was provided by the director of nursing (DON) on 12/13/18 at 5:00 p.m. The policy read in pertinent part, The Attending Physician must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter. II. Resident #60's status Resident #60, age [AGE], was admitted on [DATE]. According to the December 2018 computerized physician orders (CPO), diagnoses included dementia, chronic obstructive pulmonary disease, and major depressive disorder. The 11/8/18 minimum data set (MDS) revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. She required limited assistance with activities of daily living (ADLs). She was frequently incontinent of bowel and bladder. A. Record review Review of Resident #60's record revealed the resident had not been seen by the attending physician since her admission on [DATE] (41 days). B. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 12/13/18 at 3:30 p.m. She said Resident #60 had not been seen by the physician or a practitioner since admission. She said because of the resident's current insurance plan the resident was only able to be assessed by a practitioner at an outside clinic. She said Resident #60's insurance discontinued their contract with a current provider at the facility so the provider would not see Resident #60 at the facility. She acknowledged there was a delay in following up with her being seen under the regulatory guidelines. The director of nursing (DON) was interviewed on 12/13/18 at 6:21 p.m. She said Resident #60 was admitted at the time her insurance ceased providing care to residents under long term care at the facility. She said practitioners were available by phone for emergent concerns only. She said they contacted the clinic and she was scheduled to be seen outpatient and transportation was set up for the resident to be seen. She acknowledged there was a delay in following up with her being seen per regulatory guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to complete the necessary provider assessment every 14 days for the use of an as-needed psychotropic medication ordered for one (#60) of five out of 39 sample residents. Specifically, the facility failed to obtain an assessment from Resident #60's physician every 14 days to justify the continued use of an as-needed (PRN) psychotropic medication. Findings include: I. Resident #60's status Resident #60, age [AGE], was admitted on [DATE]. According to the December 2018 computerized physician orders (CPO), diagnoses included dementia, chronic obstructive pulmonary disease, and major depressive disorder. The 11/8/18 minimum data set (MDS) revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. She required limited assistance with activities of daily living (ADLs). She did not exhibit any behaviors. She received antidepressant and antipsychotic medication seven out of seven days. II. Record review The care plan, initiated 11/2/18, revealed the resident was at risk for adverse reactions related to the use of antipsychotic medication. Interventions included to conduct an AIMS (abnormal involuntary movement scale) routinely, obtain consent from the resident, review black box warning, and monitor routinely for possible dose reduction. The December 21018 CPO revealed an order dated 11/1/18 which read, Quetiapine Fumarate (an antipsychotic) tablet 25 mg (milligrams) Give 1 tablet by mouth every 6 hours as needed for dementia w (with) behavioral disturbances. This order did not have an end date. The November 2018 medication administration record (MAR) revealed the resident received the as needed (PRN) medication once. The December 2018 MAR revealed the resident did not use the PRN medication. The 11/2/18 care conference note revealed no mention of reviewing or discontinuing PRN Quetiapine. The 11/10/18 social services quarterly note revealed no mention of reviewing discontinuing PRN Quetiapine. III. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 12/13/18 at 3:30 p.m. She said Resident #60 had not been seen by the physician or a practitioner since admission. She said because of the resident's current insurance plan the resident was only able to be assessed by a practitioner at an outside clinic. She acknowledged there was a delay in the resident's psychotropic medication being reviewed under the regulatory guidelines. She said she notified the physician that day to discontinue the order. The director of nursing (DON) was interviewed on 12/13/18 at 6:21 p.m. She said Resident #60 was admitted at the time her insurance ceased providing care to residents under long term care at the facility. She said practitioners were available by phone for emergent concerns only. She acknowledged there was a delay in the resident's psychotropic medication being reviewed under the regulatory guidelines.

Based on record review and staff interview, the facility failed to ensure money from personal funds accounts was dispersed within 30 days after discharge for four of four discharged residents reviewed for personal funds accounts. Findings include: Facility policy and procedure The Resident Trust Fund policy read in pertinent part, Upon discharge or death of a resident the facility shall transfer the resident's personal needs funds and a final accounting of the funds to the person responsible for settling the resident's estate or, if there is none, to the resident's heirs within 30 days. If there is not an estate or heir, it should be sent to the state's recovery unit. Record review Review of the current trust account balance provided by the facility revealed four residents, who had discharged over 30 days before, had remaining balances in their personal funds accounts. Staff interview The business office manager was interviewed on 12/13/18 at 3:10 p.m. She said if the resident passed away the remainder of their funds would go to the family or towards burial costs. She said if the resident received Medicaid, their funds would be returned to the state. She said all funds should be dispersed within 30 days, and she did not know why funds for the four discharged residents had not been dispersed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** E. Resident #46 1. Resident status Resident #46, age [AGE], was admitted on [DATE]. According to the October 2018 computerized physician orders, diagnoses included atherosclerotic heart failure. The 12/1/18 MDS assessment revealed the resident has moderate cognitive impairment with a BIMS score of 11 out of 15. The resident required extensive assistance of two people with bed mobility and transfers.The MDS stated she was on oxygen therapy as a resident. 2. Observation and resident interview Resident #46 was observed wearing oxygen on 12/11/18 at 10:56 a.m. Upon interview, the resident said they always required oxygen. 3. Staff interview LPN #4 was interviewed on 12/13/18 at 10:35 a.m. LPN #4 said oxygen was not on the resident's care plan and there were no physician-ordered parameters for the oxygen in the [NAME]. However, the LPN stated that the resident's pulse ox should be above 90. She said the resident's vitals were checked every shift. 4. Record review The resident's care plan dated 12/11/18 failed to identify oxygen use and parameters. The [NAME] likewise failed to identify oxygen use. III. Medications left at bedside and not administered timely A. Professional standard According to the Institute for Healthcare Improvement, 1/25/17, www.ihi.org/resources/Pages/ImprovementStories/FiveRightsofMedicationAdministration.aspx [NAME], [NAME] (12/27/18), One of the recommendations to reduce medication errors and harm is to use the 'five rights': the right patient, the right drug, the right dose, the right route, and the right time. B. Resident #37's status Resident #37, age [AGE], was admitted on [DATE]. According to the December 2018 computerized physician orders, diagnoses included osteoporosis, depressive episodes, gastro-esophageal reflux disease (GERD), and history of falling. The 9/7/18 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 11 out of 15. The resident required extensive assistance from two people with bed mobility, transfers, and activities of daily living. C. Observation On 12/13/18 at 8:30 a.m.Resident #37 was observed sleeping, it was observed that on the bedside tray were the resident's medications in small cups. It was brought to the attention of certified nursing assistant (CNA) #5. The CNA #5 stated that medications left bedside were the choice of the nurse on duty. At that time the transportation specialist came in the room and combined the pills and said she would alert the nurse. LPN #1 came in and the resident was then handed the medication and took it. The LPN #1 said that there were times when the medication was left on the table beside the bed until the resident wakes up. D. Interviews When interviewed on 12/13/18 at 8:30 a.m., CNA #5 said that it was the nurse's choice as to where to leave the medication for the residents and it was not his responsibility to administer medication. The DON was interviewed at 9:23 a.m.on 12/13/18 and stated that medication should never be left beside the bed. The DON also stated Resident #37 was not on a self medication plan. The DON said this should have never happened. The DON said that follow up would include education and training would be put in place for the nursing staff and the staff would review the medication administration policy. E. Record Review Review of the resident's December 2018 medication administration record (MAR) revealed the resident's medication administration was inaccurately noted as given on 12/13/18 at 6:57a.m. However, it was observed (see above) that LPN #1 had administered the resident's medications at 9:15 a.m. on 12/13/18 after the medications had been left at the resident's bedside The resident did not have a care plan that included medication self-administration. II. Oxygen orders A. Professional reference According to [NAME]/[NAME], Fundamentals of Nursing, ninth edition, Elsevier, Canada, 2017, p 900, Oxygen is a therapeutic gas and must be prescribed and adjusted only with a health care provider's order. B. Facility policy The Oxygen Administration policy, revised October 2010, was provided by the facility on 12/13/18 at 10:50 a.m. The policy purpose was to provide guidelines for safe oxygen administration, and read in pertinent part: - Verify there was a physician's order for the procedure (of oxygen administration). - Review the resident's care plan to assess for any special needs of the resident. C. Resident #35 1. Resident status Resident #35, age [AGE], was admitted on [DATE]. According to the December 2018 computerized physician orders (CPOs), diagnoses included chronic respiratory failure with hypoxia, chronic combined systolic and diastolic heart failure, cerebral infarction, history of transient ischemic attack, hypertension and dementia. The 10/24/18 minimum data set (MDS) assessment documented Resident #35 had severe cognitive impairment as evidenced by a brief interview for mental status (BIMS) score of six out of 15. The resident had shortness of breathing (dyspnea) or trouble breathing, and received oxygen therapy. 2. Record review According to the December 2018 CPO, Resident #35 had a verbal physician order started on 10/16/18 for oxygen via nasal cannula PRN (as needed). The order did not include the reason for oxygen, indications for use as a PRN treatment, cannula flow rate, perimeters for oxygen saturation, or how often to check saturation levels. The care plan, initiated 2/23/18 and revised 10/1/18, read the resident May experience shortness of breath/difficulty breathing related to chronic heart failure (CHF), chronic respiratory failure and COPD. Interventions included to provide oxygen as ordered. The care plan did not indicate the liters per minute (LPM), the appropriate range for safe saturation levels, or clarification on how long to continue PRN use. The medication administration record (MAR) and the treatment administration record (TAR) did not include administration orders for oxygen use. The certified nurse aide (CNA) care guide read to provide oxygen as ordered. 3. Observations The resident was observed in his room visiting with his wife on 12/11/18 at 11:45 a.m. The resident wore oxygen via nasal cannula in form of a concentrator. The oxygen concentrator was set at 3 LPM. -At 4:24 p.m., the resident was in his room. He wore oxygen via nasal cannula at 3 LPM. The resident was observed in bed on 12/12/18 at 8:30 a.m. The oxygen concentrator was on and resident wore oxygen via nasal cannula. -At 3:05 p.m., Resident #11 was in his room. He wore oxygen via nasal cannula set at 3 LPM. -At 5:17 p.m., Resident #11 was in his room. He wore oxygen via nasal cannula set at 3 LPM. 4. Interviews The resident was interviewed with his wife on 12/11/18 at 11:30 a.m. According to the wife of Resident #35, she visited every day from morning till mid afternoon. She said Resident #35 used oxygen continuously since his last respiratory infection. She said that he was no longer ill but maintained the continuous oxygen use. The wife said he wore oxygen all the time. CNA #2 was interviewed on 12/13/18 at 7:21 a.m. The CNA said she received directions from the nurse regarding how often the resident would need oxygen and how many LPMs. The resident used oxygen every day. The CNA said she and the nurse would check his pulse oximetry for oxygen saturation levels. Licensed practical nurse (LPN) #3 was interviewed on 12/13/18 at 12:30 p.m. LPN #3 said the resident could have had a saturation level of 88% or above with oxygen use and his pulse oximetry was regularly tested. The LPN could not find directions for administration in the CPOs or in the MARs and TARs. The LPN said she would seek out clarification. The medical director (MD), was interviewed on 12/13/18 at 12:36 p.m. The MD said a resident with COPD is safe to have a pulse oximetry at or above 88%. The nurse should follow nursing protocols. LPN #3 was interviewed again on 12/13/18 at 1:51 p.m. LPN # 3 said she spoke with the MD and was not aware that Resident #35 did not have a specific order for oxygen use. LPN #3 said an order with directions for administration would be added to the CPO. The LPN said the order should include the resident's shortness of breath, parameters, and how often to monitor. Based on observations, record review and staff interviews, the facility failed to ensure the services provided or arranged met professional standards of quality for five (#56, #35, #39, #46 and #37) of seven residents reviewed of 39 sample residents. Specifically, the facility failed to: -Obtain catheter care orders timely to help prevent infection after a catheter was placed for Resident #56; -Ensure Residents #35, #39 and #46 had physician orders for the use of oxygen; -Timely administer and assess medication administration safety for Resident #37, whose medications were left at the bedside. Findings include: I. Catheter care orders A. Facility policy and procedure The Indwelling Catheter protocol, undated, was provided by the director of nursing (DON) on 12/13/18 at 5:00 p.m. The policy read in pertinent part, The physician is responsible for writing the order for placement of the Foley catheter. The registered nurse or licensed practical nurse is responsible for placing an indwelling urinary catheter (Foley catheter). Clean the perineal area and catheter tubing proximal to distal, daily and after every bowel movement. B. Resident #56's status Resident #56, age [AGE], was admitted on [DATE]. According to the December 2018 computerized physician orders (CPO), diagnoses included malignant neoplasm of prostate and palliative care. The 11/24/18 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required supervision with grooming and extensive assistance with all other activities of daily living (ADLs). He had an indwelling catheter and was occasionally incontinent of bowel. C. Observation and resident interview On 12/10/18 at 9:53 a.m. Resident #56 was observed in his room with a Foley catheter in place. Resident #56 said the catheter had been reinserted and had been in for one week. D. Record review The care plan, initiated 11/20/18, revealed Resident #56 had prostate cancer and catheter placement interventions included to monitor tubing for kinks and to monitor for signs and symptoms of infection. Review of physician orders revealed an order dated 11/20/18 to discontinue the Foley catheter. The physician order dated 11/21/18 read Post void residual bladder scan four times a day for catheter removal, notify physician if greater than 400 milliliters. The physician order dated 12/2/18 read, Place 18FR (French) Foley catheter related to inability to urinate. Review of the treatment administration record (TAR) revealed no orders for catheter care to help prevent catheter associated urinary tract infection. There was not an order to provide catheter care every shift until 12/11/18, during survey. E. Staff interview The director of nursing (DON) was interviewed on 12/13/18 at 6:26 p.m. She said the licensed nursing staff were responsible for obtaining orders timely for continuing maintenance for catheter care. She said they planned to educate licensed staff on a new order set in their electronic record for catheter orders and care. D. Resident #39 1. Resident status Resident #39, age [AGE], was admitted on [DATE]. According to the December 2018 computerized physician orders (CPO), diagnoses included hypertension, dementia and depression. The minimum data set (MDS) assessment dated [DATE] showed the resident had a score of 14 out of 15 for the brief interview for mental status (BIMS), which indicated the resident had minimal cognitive impairments. He required extensive assistance with personal hygiene and transfers. Was oxygen therapy listed? Pertinent whether it was nor not 2. Observations The resident was observed on 12/10/18 at 11:08 a.m. The resident was sitting in his wheelchair. He had his oxygen set at two liters per minute (LPM) via nasal cannula. On 12/12/18 at approximately 11:00 a.m., the resident was observed lying in bed. The oxygen concentrator was set at two LPM via the nasal cannula. On 12/13/18 at 9:15 a.m., the resident was observed lying in bed. The oxygen concentrator was set at two LPM via the nasal cannula. 3. Record review The December 2018 CPO failed to show the resident had an oxygen order. The care plan last updated 11/23/18 failed to identify oxygen use. The last time the resident's pulse oximeter was checked was 10/18/18 and was 99% on room air, per the treatment administration record?. 4. Interviews Licensed practical nurse (LPN) #4 was interviewed on 12/13/18 at 9:37 a.m. The LPN said the resident was on two liters of oxygen. She said she was not sure the reason for the oxygen. The LPN reviewed the medical record and confirmed the resident did not have a physician order for the use of the oxygen. The LPN said a physician order must be obtained for a resident to use oxygen. The MDS coordinator (MDSC) was interviewed on 12/13/18 at approximately 3:00 p.m. The MDSC said after reviewing the medical record, the resident was not prescribed oxygen as there was no reason or diagnosis for the oxygen. She said when he was first admitted he had oxygen from the hospital, however, he had not been on it for quite some time. She said the physician would evaluate him for the need for oxygen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide an environment free from accident hazards for two (#8 and #26) of two residents reviewed for wandering/elopement risk, and additional residents throughout the facility. Specifically, the facility failed to ensure: -A safe, secure environment regarding sliding glass doors that led to the outdoor courtyard area for Residents #8 and #26; and -An environment free of accident hazards in resident rooms on the 100 and 200 halls; and Red Cloud, Sunlight and Rehab shower rooms. Findings include: I. Unsecured doors in room where Residents #8 and #26 resided A. Resident #8 and #26 status 1. Resident #8, age [AGE], was admitted on [DATE]. According to the December 2018 computerized physician order diagnoses included Alzheimer's disease and dementia. The 5/2/18 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of two out of 15. According to an elopement assessment dated [DATE], the resident scored at a high risk for elopement. 2. Resident #26, age [AGE], was admitted on [DATE]. According to the December 2018 computerized physician orders, diagnoses included Alzheimer's disease, dementia, and anxiety disorder. The 12/1/18 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of two out of 15.The resident had dementia, osteoporosis, history of falling and a history of wandering due to confusion. According to the current care plan an assessment conducted on 6/16/16 identified the resident was at high risk for elopement. B. Observations On 12/10/18 at 10:08 a.m. it was noted that the glass door window treatments were moving in the room shared by Residents #8 and #26. Upon further investigation the sliding glass door was found to be unlocked and slightly open. The sliding glass doors led to a large courtyard with discarded medical equipment, old lawn furniture, and a garage with power tools and chemicals. On 12/10/18 at 4:30 p.m., the residents ' sliding glass door was checked and found to be unlocked and open. On 12/10/18 at 5:48 p.m., a certified nurse aide (CNA) was notified and the CNA ensured the doors were shut and locked. On 12/11/18 at 8:39 a.m. and 4:32 p.m., the sliding glass doors were observed unlocked and open. On 12/12/18 at 5:58 p.m., the sliding glass doors were unlocked and open. The CNA was notified and locked the sliding glass doors. On 12/13/18 at 7:55 a.m., the doors were unlocked and ajar. C. Staff interviews CNA #5 was interviewed on 12/13/18 at 8:33 a.m CNA #5 stated the doors were open for ventilation and the residents liked the fresh air while sleeping. The CNA said it was not uncommon for the doors to be left open during the night. The director of nursing (DON) was interviewed on 12/13/18 at 4:10 p.m. The DON said the doors should never be open and that this was a great concern. The DON stated they should always be locked. The DON also said the residents were not typically in this room, and they had been moved to this new location due to construction. The DON confirmed that both residents were at risk for elopement. The DON said they would follow up and the facility would audit the doors and educate the staff. II. Environmental accident hazards A. Material safety data sheets for Micro-Kill Q3 and Clorox bleach germicidal wipes The Medline safety data sheet (SDS) for Micro-Kill Q3 Concentrated Disinfectant, Cleaner and Deodorizer was provided on 12/13/18 at 4:50 p.m by the staff development coordinator (SDC), who also managed infection control. The SDS contained a hazard statement warning that read: - Causes serious eye damage. - Causes severe skin burns. - Flammable liquid and vapor. - Harmful if swallowed. The precautionary statement read, Store in a well-ventilated place. Keep cool. Store locked up. The Micro-Kill Q3 was the main product used to disinfect residents' shower rooms. According to the SDS, the primary active cleaning ingredients in Micro-Kill Q3 was quaternary ammonium compounds, benzyl-C12-16-alkyldimethyl, chlorides at 8.90%, and decanaminium n n-dimethyl-n-octyl- chloride at 6.67%. The Clorox Company safety data sheet (SDS) for Clorox Bleach Germicidal wipes, retrieved from the product's website, https://www.thecloroxcompany.com/wp-content/uploads/Clorox-Healthcare-Bleach-Germicidal-Wipes.pdf, under toxicological information, the bleach wipes may: - Cause irritation of the respiratory tract. - Cause slight irritation (with eye contact). - Substance may cause slight skin irritation. - Ingestion may cause irritation to mucous membranes. Ingestion gastrointestinal irritation, nausea, vomiting and diarrhea. B. Observations Resident room [ROOM NUMBER] was observed on 12/12/18 at 11:50 a.m. and again on 12/13/18 at 10:22 a.m. with the SDC. In the bathroom was a specimen collection container referred to as a toilet hat. The hat was on a shelf above the toilet. The shelf was above eye level. The Red Cloud shower room was observed on 12/13/18 at 10:30 a.m. Two used razors were observed on a shelf in the shower. The razors not did not have caps covering the blades, and the shelf was within reach of residents. Resident room [ROOM NUMBER] was observed on 12/12/18 at 12:16 p.m. Above the sink was a medicine cabinet with sliding mirrored doors. The left mirrored door was off its track, preventing the door to close. The open cabinet revealed a razor on the shelf. The Sunlight hall shower room was observed on 12/12/18 at approximately 12:20 p.m. In the shower room was a bottle of Micro-Kill Q3 disinfectant stored on a shelf, within reach of residents. The Rehab shower room was observed on 12/13/18 at 10:38 a.m. Above the toilet was a cabinet unit. On the shelf of the cabinet was a can of shaving cream. On top of the cabinet rested a sharps container which contained needles. The container was within reach of someone standing. The sharps container was not attached to a wall. A second observation for room [ROOM NUMBER] was conducted with the SDC on 12/13/18 at 11:20 a.m. A container of Clorox germicidal bleach wipes was on the resident's sink. The SDC removed the container from the room. A second observation for the Rehab shower room was conducted with the SDC on 12/13/18 at 11:26 a.m. The observation revealed a bottle of Micro-Kill Q3 on the shelf next to the can of shaving cream. C. Staff interviews The SDC was interviewed on 12/13/18 11:05 a.m. The SDC said a urine collection hat should not be stored above the waistline. Storing any items where bodily fluids or cleaning products could pool in the bottom of a container, could be harmful to a resident or staff member if it fell down.She said bleach wipes should not be stored on a shelf in the resident's room. The container could spill and splatter on the resident. The SDC said used razors could be a safety concern and should not be stored in the open, whether in the shower room or in a resident's room. The SDC was interviewed after the shower room observation on 12/13/18 at 11:30 a.m. The SDC said it was dangerous to store the sharps container on top of a cabinet in a shower room. The container could open and used needles could fall out, injuring a resident or staff. She said a resident could also remove the unattached sharps container, open the lid, and reuse a needle. The SDC said the sharps container needed to be removed from the shower room. She said a bottle of disinfectant and shaving cream should not be stored in the open. Exposed chemicals could put a resident at risk. She said safety in shower rooms should be a focus.

Based on record review, observations and interviews, the facility failed to ensure all medications and biologicals were stored and labeled properly in two of five medications carts. Specifically, the facility failed to: -Remove expired and undated medication from the Red Cloud cart; and -Remove undated insulin and an expired treatment from the Castle Unit cart. Findings include: I. Facility policy and procedure The Storage of Medications policy, revised April 2007, was provided by the director of nursing (DON) on 12/13/18 at 5:00 p.m. It read in pertinent part, The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. II. Observations and staff interviews The Red Cloud medication cart was observed with licensed practical nurse (LPN) #4 on 12/12/18 at 11:55 a.m. The following items were found: -An opened, undated vial of testosterone (replacement hormone) with a delivery date from the pharmacy of 5/8/18; and -A bottle of expired magnesium citrate dated 11/2018. LPN #4 said the expired magnesium citrate should have been removed from the medication cart. She said she did not know the testosterone vial needed to be dated when opened. The Castle medication cart was observed with LPN #1 on 12/12/18 at 2:40 p.m. The following items were found: -Two Lantus insulin vials were opened and undated; -Two Humalog insulin vials were opened and undated; and -One Desonide 0.05% cream (topical steroid cream) with the expiration date 2/18. LPN #1 said all insulin should be dated when opened, because they expired within 28 days. He said the Desonide Cream should have been removed from the medication cart because it was expired. III. Administrative interviews The director of nursing (DON) was interviewed on 12/13/18 at 9:53 a.m. She said the pharmacist completed routine cart checks and provided education as needed if they found expired or undated medication on the carts. She said all of the licensed nurses were responsible for dating appropriate medications and removing expired and discontinued medications from the medication carts. She said the nurses had all received education about dating eye drops, insulin, and multi-dose vials and removing expired medications, after the above observations were made. The pharmacist was interviewed on 12/13/18 at 3:12 p.m. She said all multi-dose vials such as testosterone and insulin should be dated when opened and discarded in 28 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and record review, the facility failed to ensure infection control practices were established and maintained to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to prevent a systemic failure to ensure a sanitary environment in resident rooms and showers, as evidenced by failure to: - Provide a clear labeling system of personal hygiene items and linens to prevent cross-contamination; - Follow dwell times per manufacturer recommendations for disinfection; and - Create a standard procedure and training for shower room sanitation. The findings included: I. Observations The bathroom in resident room [ROOM NUMBER] was observed on 12/12/18 at 11:40 a.m. and again on 12/13/18 at 11:06 a.m. with the staff development coordinator (SDC), who identified herself as the infection control nurse. The bathroom was shared by two residents. A tube of toothpaste was on top of the toilet tank. An electric toothbrush, a brush and a comb were on the sink. The toothbrush was touching a used hand towel. Next to the sink was a towel rack. On the rack, there were two sets of hand towels, and two sets of wash cloths.The personal hygiene items in the bathroom were not marked with a name to identify who the items belonged to. room [ROOM NUMBER] was observed on 12/12/18 at 11:50 a.m. and again on 12/13/18 at 11:18 a.m. with the SDC. The bathroom was shared by two residents. A brush and a comb were on the sink. The personal hygiene items were not marked with a name to identify who the items belonged to. By the sink were two towel racks. The racks were on the same wall. One rack was above the second rack. On each rack was a set of hand towels, and two sets of washcloths. Neither the towels, washcloth or towel racks identified which set of towels each resident should use. In the bathroom was a specimen collection container referred to as a toilet hat. The hat was on a shelf above the toilet. The shelf was above eye level. The hat was not marked with a resident name. room [ROOM NUMBER] was observed on 12/12/18 at 11:57 a.m. and again on 12/13/18 at 11:18 a.m. with the (SDC). The room was shared by two residents. Neither the towels nor racks were labeled. An unmarked toothbrush sat in a cup on the sink. Additional observations on 12/12/18: - At 12:00 p.m., room [ROOM NUMBER] had one towel rack. On the rack was one towel for two residents. - At 12:04 p.m., room [ROOM NUMBER], shared by two residents, had two racks. Neither the rack or set of towels were labeled. On the sink were a comb and two brushes. The personal hygiene items were not labeled or marked with the residents' names distinguishing who they belonged to. -At 12:10 p.m., room [ROOM NUMBER], shared by two residents, had a brush on the sink. The brush was not labeled. There was a towel rack on each side of the sink not labeled. On the sink was a brush not labeled or marked. -At 12:13 p.m., room [ROOM NUMBER] had one towel rack for two residents. Neither the rack nor the towels were marked. - At 12:16 p.m., room [ROOM NUMBER], shared by two residents, had an open medicine cabinet door above the sink. A razor was on the middle shelf of the cabinet. The razor and shelf were not labeled to identify the owner. On the sink was an unmarked brush. The Red Cloud shower room was observed on 12/13/18 at 10:30 a.m. Two used razors were observed on a shelf in the shower. The razors were not marked with resident names. A cleaning brush hung on the grab bar in the shower. A personal hygiene deodorant stick was on a shelf behind the toilet. The deodorant was not marked with a resident name. A hairbrush was in a basket behind the toilet in the shower room. The brush was not marked with a resident's name. On 12/13/18 at 11:26 a.m., the rehab shower room was observed with SDC. The second observation revealed a bottle of micro kill q3 on the shelf next to the shaving cream and 11 boxes of nutritional supplement that were stacked on the floor in cardboard boxes across from the bathtub. II. Staff interviews Certified nurse aide (CNA) #5 was interviewed on 12/13/18 at 10:32 a.m. He said, after a shower, he took the towels to housekeeping. He said he did not have access to the housekeeping supply storage, so he took the disinfectant bottle off the housekeeping cart. He said he cleaned the shower by spraying disinfectant on the surface and letting in sit for one to one and a half minutes. He said the housekeeper did a complete shower room clean twice a day. CNA #8 was interviewed on 12/13/18 at 10:44 a.m. She said the towel set closest to the wall was for the resident in A bed. She said some of towel racks were marked to identify, however most were not. CNA #8 said she often showered residents. She said she used the disinfectant from the housekeeping supplies. She said when she cleaned the shower, the shower chair and the toilet with the disinfectant, she made sure to apply a full coverage spray and then scrubbed the surface waiting for about two minutes before wiping off the disinfectant. CNA #3 was interviewed on 12/13/18 at10:39 a.m. She said she had not had to clean the shower and tub in a while. She said most of the residents on the rehab side used the showers in the rooms. She said a resident could use the rehab shower if they preferred it over theirs or needed the use of a hoyer lift to bathe. CNA #3 said after resident use, she wiped the hoyer lift down with towels and called housekeeping to sanitize. The housekeeper (HK) #1 was interviewed with her supervisor, the maintenance supervisor (MS) #1 on 12/13/18 at 10:51 a.m. HK #1 said she cleaned the shower rooms once a day. She said she did not clean the showers after every use and usually several residents would use the shower before she could clean it. HK #1 said she cleaned with micro kill q3, with a dwell time of eight to ten minutes. The SDC was interviewed on 12/13/18 11:05 a.m. during a tour of resident rooms. The SDC said cross contamination could occur when personal items were not marked with a resident's name. Residents and CNAs may not know who the items belonged to and the wrong resident could use the item. Towel racks in rooms that were shared should be clearly labeled to prevent cross contamination. She said a tube of toothpaste should never be placed on the back of a toilet where it could be exposed to bodily fluids. The SDC said a urine collection hat should not be stored above the waistline.She said staff received a verbal training on infection control practices in orientation, but more training was needed. The SDC was interviewed after her shower room observation on 12/13/18 at 11:30 a.m. The SDC said she witnessed multiple concerns. The SDC said showers were a high risk for cross contamination if not cleaned properly. She said a process to monitor shower cleanliness had not been established, but should be included under infection control. She said shower room cleaning products should contain bleach. (Refer to the material safety data sheet and instructions for disinfectant below.) The SDC said staff should clean top to bottom which included the shower chair, and the CNA should clean the shower room after each use. She said she was not sure what the dwell time was for the disinfectant but if left on the surface under two minutes, it would not be effective. She said that there had not been a recent staff training, and the cleaning procedure for shower rooms has not been clearly defined but should have been. Her goal was to have more involvement in the cleaning process and train staff accordingly. -At 4:56 p.m. the SDC said the facility was without an infection control nurse for awhile. III. Record review The material safety data sheet (SDS) and instructions for Micro-Kill Q3, the disinfectant used to clean resident rooms and showers, was provided by the SDC on 12/13/18 at approximately 4:50 p.m. Micro-Kill Q3 was the main product used to disinfect residents' shower rooms. According to the SDS, the primary active cleaning ingredients in Micro-Kill Q3 were quaternary ammonium compounds, benzyl-C12-16-alkyldimethyl, chlorides at 8.90%, and decanaminium n n-dimethyl-n-octyl- chloride at 6.67%. According to the product website, retrieved on 12/27/18, https://www.medline.com/media/catalog/Docs/MKT/LIT806_BRO_Cleaning%20Chemicals_178245.pdf, Micro-Kill Q3 required a three minute surface contact time.