**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of resident #59's medical record revealed he was initially admitted to the facility on [DATE] and re-admitted back to the facility on 1/09/2021 with diagnosis of Alzheimer's disease, dysphagia, and newly diagnosed congestive heart failure. Review of the Minimum Data Set (MDS) dated [DATE] documented resident #59 had a Brief Interview for Mental Status (BIMS) score of 03 out of 15, which indicated severe cognitive impairment. He required one person extensive assist for eating and had 5% weight loss in the last month and a loss of 10% of weight in the last six months and was not on a prescribed weight loss regimen. Review of resident #59's care plans with a completion date of 12/16/2020 documented he had a care plan for being at risk for weight fluctuations related to polypharmacy with goals to maintain adequate nutritional status as evidenced by no sign of weight change in 1, 3 and 6 months. Review of resident #59's medical record revealed he had a nutrition assessment completed upon his initial admission, dated and signed by the Registered Dietitian on 11/23/2021. There was no evidence of a nutritional assessment completed after his re-admission on [DATE]. Review of physician's orders revealed an active order dated 1/09/2021 for regular diet, with regular texture and thin consistency with fortified foods. A review of the resident's weights showed he weighed 209.6 pounds at admission and one month later on 12/28/2020, he weighed 187.6 lbs., a 10.5 % weight loss. Three months post admission, on 2/20/2021, the resident weighed 164.4 lbs. which was a 21.56% loss. On 02/23/21 at 12:23 PM, resident #59 was resting in bed with his lunch tray at his bedside. Certified Nursing Assistant (CNA) I came in to assist the resident to with his lunch. He ate 25% of his lunch. On 02/24/21 at 12:28 PM, resident #59 consumed 50% of his meal. On 02/23/21 at 5:19 PM, resident #59 stated he was not hungry and did not have an appetite. He said the loss of appetite had been going on for one week or so. He said he was not thirsty either. Review of resident #59's medical record revealed on 02/14/2021, he had a recently identified, facility acquired, unstageable pressure ulcer to his sacrum and heels. On 2/24/21 at 5:42 PM, the Registered Dietitian (RD) stated on 1/18/2021 resident #59 triggered for weight loss and she recommended fortified foods for weight stabilization. She stated at that time, the resident's sister was bringing in snacks. She noted she did not recommend any supplements. The RD acknowledged that there is a system in place to identify residents with weight loss but due to staff shortages I am not getting consistent weights. In the beginning, we did that, I had to learn to back off because of the lack of communication with staff. There is not enough staff to feed or get weights. Review of the Supplemental Nutrition policy, last revised on 01/01/2007, documented, supplemental nutrition is provided to the residents per physician's order. Supplemental nutrition may be provided for weight maintenance, weight loss, poor intake, low albumin level and/or pressure ulcers .Guidelines: residents with weight/intake concerns are evaluated weekly . Review of Residents with weight/intake concerns policy, last revised on 01/02/2007 documents, residents who have a significant weight variance are evaluated, and approaches are implemented per resident as needed . Review of the Residents with Pressure Ulcers policy, last revised on 11/11/2016, documents, the food and nutrition services department provides proper nutritional support when a resident is identified to be at risk for pressure ulcer/skin breakdown or has an identified pressure ulcer(s) . Review of the Nutrition/History Assessment and the Resident Assessment Instrument (RAI), last revised on 1/1/2007, documents, each resident receives a comprehensive nutrition assessment to determine nutritional needs .The nutrition data collection/assessment is completed on admission, annually and whenever the comprehensive minimum data set (MDS) is completed . Based on observation, interview and record review, the facility failed to ensure that recommendations from the Dietitian were implemented for nutritional status related to dialysis (#65) and failed to re-evaluate a resident readmitted from the hospital with significant weight loss, (#59) for 2 of 10 residents reviewed for nutritional status out of 42 total sampled residents, (#65 & 59). Findings: 1. Resident #65 was admitted to the facility on [DATE] and then re-admitted from an acute care hospital on 2/10/21 with diagnoses of end stage renal disease, dependent on dialysis, infected left below the knee amputation (BKA) stump, wound dehiscence with infection, protein, calorie malnutrition and diabetes. Review of the medical record revealed the Registered Dietitian's (RD) progress note dated 1/25/21 that read, his albumin level per dialysis was low at 2.9 (normal 3.2 to 5.5). Review of the 5 Day Minimum Date Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact with Brief Interview for Mental Status of 15. The assessment noted the resident received a therapeutic diet, was on dialysis and received intravenous (IV) antibiotics. An RD note dated 2/11/21 read, Recommend: double protein portions and sugar free Prosource (protein supplement) 30 milliliters (ml.) BID (twice per day) for dialysis support and support surgical wound healing . Resident #65's care plan revised on 2/11/21 noted the Resident at Risk for Weight Fluctuations and goal was to maintain adequate nutritional status. The interventions included, RD to evaluate and make diet change recommendations as needed. Review of the physician orders dated 2/10/21 included, Prosource sugar free 30 ml. 3 times per day for weight support and Liberal Renal Diet, Regular Texture. On 2/25/21 at 10 AM, the RD said she communicated monthly with the dialysis Dietitian regarding resident # 65's diet, labs, supplements and meal intake. She said the last labs she reviewed were from January 2021 and his albumin (protein) was low at 2.9. She then evaluated him again on 2/11/21 after he returned from the hospital and recommended double protein portions and sugar free ProSource twice per day. She said the process for making new recommendations included documenting in the progress notes, completing form titled Nutrition Assessment Recommendations which are placed in the mailboxes of the Unit manager (UM), Assistant Director of Nurses (ADON), and Director of Nursing (DON). She said the facility nurse then obtains physician orders for the new recommendations which can usually be implemented with the next meal. The RD was not able to find a copy of the Nutrition Assessment Recommendations form for 2/11/21 for resident #65. The RD was not aware until it was pointed out to her by the surveyor that the double protein portions for resident #65 had not been initiated now for 14 days. On 2/25/21 at 10:30 AM, the Certified Dietary Manager (CDM) joined the interview with the RD. The CDM validated the RD recommendations for double protein portions had not been initiated for resident #65. He said he did not have the Nutrition Assessment Recommendations form for 2/11/21 with the RD recommendations for resident #65. His process involved making a list of the orders not yet entered in the electronic system and then providing the list to the UM who follows up with the physician to obtain the needed orders. The RD said I want resident #65 to have double protein portions because he is a dialysis resident, he eats well and giving him double protein makes sense for him because he likes food. The added protein could benefit him because he loses protein in his dialysis treatments and needs it to help with healing the amputation wound. On 2/25/21 at 11 AM, the ADON said that she was covering for the UM on the 200/300/400 halls. She said that she did not remember getting any recommendations on 2/11/21 from the RD regarding increasing resident #65's protein portions. She stated that if she had received the recommendations, she would have obtained physician orders immediately, entered the order into the electronic medical record and the resident could have started the new orders with his next meal. The ADON noted she checked her mailbox daily and did not receive any recommendations from the RD for resident #65 dated 2/11/21. On 2/25/21 at 12:20 PM, resident #65's lunch tray was checked with assigned Registered Nurse (RN) A. The meal ticket read, Regular texture, liberal renal, CCH. The meal tray did not contain double protein portions and the ticket did not indicate double protein portions. On 2/25/21 at 12:40 PM, resident #65 was observed sitting up in bed eating his lunch. He was alert and oriented. He said he liked his lunch and was noted to have already consumed approximately 75% of his food and was still eating. The resident said he thought the facility staff had said something to him in the past regarding getting double protein portions. He said he would like double protein portions as he frequently refused the protein supplement as he did not like the taste. Review of the medication administration record (MAR) revealed that resident #65 was ordered Sugar free Prosource 30 milliliters 3 times per day. He refused it 7 times from 2/11 to 2/24/21 and did not receive it 9 times due to being absent from the facility. The facility Nutrition/History Assessment and the Resident Assessment effective 10/4/19 policy read, Each resident receives a comprehensive nutritional assessment to determine nutritional needs on admission, annually and when resident becomes at risk for compromised nutritional status .RD or designed completes the Nutrition Data Collection section .RD assesses the resident to determine nutritional needs by reviewing information and completing RD portion of nutrition assessment .A systematic approach will be used to optimize a resident's nutritional status. The process includes identifying and assessing each resident's nutritional status and risk factor, evaluating/analyzing the assessment information, developing and consistently implementing pertinent approaches and monitoring the effectiveness of interventions and revising them as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide dressing changes for a midline intravenous (IV) catheter according to current professional standards of practice for 1 of 2 residents reviewed for IV care out of 42 sampled residents, (#209). Findings: Resident #209 was admitted to the facility on [DATE] with diagnoses of cellulitis to lower limbs. He had a Midline IV line insertion order dated 2/15/21 for administration of IV antibiotics (Zosyn) for wound infection through 2/22/21. He had additional nursing orders in effect dated 2/17/21 for IV Midline Catheter-Measure upper arm circumference 10 centimeters above antecubital every 2 days with gauze dressing present, and flushing IV with normal saline every shift (3 times per day). On 2/22/21 at 12:50 PM, resident #209 was observed in his room sitting up in chair eating lunch. He had a gauze dressing covering his right upper arm midline IV site dated 2/21/21. Due to the presence of gauze over IV site, visualization for any signs of symptoms of infection was not possible. There was an IV pole next to resident #209's bed with empty bag of IV antibiotics hanging from the pole. On 2/22/21 at 12:55 PM, the Assistant Director of Nursing (ADON) acknowledged resident #209 had IV right upper arm with gauze under transparent dressing and over IV site dated 2/21/21. The ADON said the nurses should not have placed gauze over IV site as the insertion site could not be visualized with gauze present. On 2/24/21 at 9:32 AM, resident #209 was observed sitting up in chair. He still had the same gauze dressing with date of 2/21/21 covering the IV site right upper arm. The dressing was now over 48 hours or greater than 2 days duration and per standard of nursing practice should have been changed yesterday 2/23/21. The Infusion Nurses Society specifies that the site care frequency is based on type of dressing: Transparent semipermeable dressings should be changed every 5-7 days and gauze dressings should be changed every 2 days (www.sciencedirect.com). On 2/24/21 at 9:45 AM, Registered Nurse (RN) B verified she was assigned to resident #209 yesterday on the day shift 7 AM to 3 PM. She said that she flushed the IV but did not look at the site as it did not prompt on electronic medical record (EMR) for a dressing change on her shift. RN B observed the resident's dressing on his right upper arm IV site and acknowledged the gauze in place dated 2/21/21 was changed by RN A this past Sunday. RN B said the IV dressing should have been changed yesterday. She added that as per standards of practice it should be changed every 48 hours for gauze dressing and every 7 days for clear transparent dressing. On 2/24/21 at 9:53 AM, RN A said she changed resident #209's IV dressing on his right upper arm IV on Sunday 2/21/21. She said she used gauze as the facility did not have antibiotic disks to put over the site. On 2/24/21 at 11:30 AM, the Director of Nursing (DON) said, she did not know why the orders in the computer were put in for gauze dressing every 2 days and the nurses should have used transparent dressing. Gauze can harbor bacteria if not changed every 2 days. The DON reviewed the Medication Administration Record (MAR) which showed the nurses had documented gauze dressing change every 2 days which was not accurate since the nurse did change dressing with gauze on 2/21/21 and it was not on MAR. The nurse also documented on 2/22/21 that the dressing was changed, and we know that it was not. According to the facility Midline Catheter Dressing Change policy and procedure revised 7/1/12, The catheter insertion site is a potential entry site for bacteria that may cause a catheter related infection. A transparent dressing is the preferred dressing .When a transparent dressing is applied over a sterile gauze dressing it is considered and gauze dressing and is changed .Every two days .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow physician's orders for oxygen therapy for 1 of 5 residents reviewed for respiratory care, out of 42 total sampled residents (#100). Findings: Resident #100 was re-admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease, pneumonia, obstructive sleep apnea, dependence on supplemental oxygen (O2) and cognitive deficit disorder. Review of the Minimum Data Set (MDS) dated [DATE] revealed resident #100 received oxygen (O2) therapy. Resident #100 had a physician's orders dated 1/15/2021 for O2 at 2.5 liters/minute (LPM) continuously per nasal cannula (NC) every shift and keep the pulse oxygen levels >89%. Review of the care plan for resident #100, documented she had diagnosis of pneumonia with a goal to be free of symptoms of respiratory distress. There was no care plan for oxygen therapy nor any interventions to administer oxygen per physician's orders. On 02/25/2021 at 12:05 PM, the MDS Coordinator stated the process for care planning included reviewing new orders, faxing them to the to pharmacy, then transcribing them onto the Medication Administration Record (MAR) or the Treatment Administrator Record (TAR) and then initiating a care plan. It is ultimately MDS's job to develop care plans. If it does not get done, then it is definitely MDS's responsibility. Review of resident #100's MAR and TAR revealed no evidence of monitoring to ensure oxygen was being administered at 2.5 LPM via NC. Review of the medical record of resident #100, revealed on 2/10/2021 at 12:49 AM, her O2 saturation rate dropped to 88%. Observations conducted on 02/22/2021 at 11:59 AM, 02/22/21 2:05 PM, 02/22/21 4:30 PM, 02/23/21 5:08 PM, 02/24/21 12:45 PM revealed resident #100's oxygen concentrator was set at 2 LPM via NC. On 02/24/2021 at 2:33 PM, Registered Nurse (RN) A stated resident #100 received O2 at 2 LPM via NC. RN A stated her process was to check resident #100's oxygen every time she went in the room and she checked it approximately three or four times today. She could not remember what the oxygen was set at. On 2/24/2021 at 2:37 PM, RN A checked the resident's oxygen. RN A stood looking down at the oxygen concentrator flow meter and said, it's on 2.5 L. When RN A observed the oxygen flow rate at eye level, she said, oh, it's at 2 LPM, not 2.5. She acknowledged the oxygen flow rate should have been set at 2.5 LPM. Review of the Procedure checklist for oxygen administration, dated 2/25/2021 documented, .Oxygen administrator objective: to administer oxygen according to the standard of care . verify the practitioner's order. Review of the Oxygen Administration policy, reviewed November 20, 2020 documented, .all respiratory devices should be checked every shift by the licensed nurse .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure medications were administered as prescribed for 2 of 42 sampled residents, (#85, #87). Findings: Resident #85 was admitted to the facility on [DATE]. Her diagnoses included Gastro-Esophageal Reflux Disease, and compression fracture of vertebrae. On 02/22/21 at 2:56 PM, resident #85's roommate, resident #87 had medications in two stacked cups on his bedside table. The top cup contained a cream and the bottom cup had 2 pills. One pill was oval and the other round. Registered Nurse (RN) B came into the room and said she did not see the medications on resident #87's bedside table this morning. She took the medications, reviewed the Medication Administration Record for both residents. She determined the medications were for resident #85. She said the two medications were Synthroid, for hypothyroidism and Protonix for esophageal reflux. She added that resident #85 should have received these medications at 6 AM. A telephone interview was conducted on 02/24/21 at 9:49 AM with RN H, who was the residents' assigned nurse at 6 AM. She said she was giving medications to resident #85 at the end of her shift when she was called to another room for water leak. I set the medications for #85 on the roommate's bedside table. I totally forgot that I misplaced the medication for resident #85 on resident #87's bedside. RN H was not aware she did not give resident #85 her medications. A review of the Medication Administration Record showed RN H had signed the medication as given. On 02/25/21 at 2:10 PM, the Assistant Director of Nursing acknowledged that resident #85 had not received her 6 AM medications. Review of the Clinical Services Manual for Administration of Medication (Revised 5/06/20) Standard: All medications are administered safely and appropriately per physican order to address residents' diagnoses and signs and symptoms. The Policy noted :Medication administration is the responsibility of the nursing professional. Only licensed personnel administer medications. Review of the Pharmacy Med Pass Checklist under medication administration noted Nurse is with resident until meds are swallowed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide Beneficiary Protection Notification to 3 of 3 residents reviewed for skilled nursing facility advanced beneficiary notice (SNF ABN) out of a total of 42 sampled residents, (#22, #52 & #88). Findings: 1. Resident #22 was admitted to the facility on [DATE] with diagnoses of acute kidney disease, diabetes, hypertension, osteoarthritis and heart disease. The resident was currently in the facility. 2. Resident #52 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, cellulitis of abdominal wall, diabetes, and kidney disease. The resident was currently in the facility. 3. Resident #88 was admitted to the facility on [DATE] with diagnoses of displaced fracture of right femur, heart failure, Alzheimer's disease, and hyperlipidemia. The Discharge summary dated [DATE] at 10:42 AM, showed he was discharged to an Assisted Living Facility. On 2/25/21 at 2:00 PM, review of Skilled Nursing Facility Advance Beneficiary Notices of Non-Coverage (SNFABN- CMS10055 forms) for Resident #22, #52 and #88 showed incomplete documentation for the following fields in the body of the SNF ABN forms. The Beginning on date resident or responsible party will have to pay out of pocket for care, the Care: which was the care that will not be covered, the Reason Medicare May Not Pay: and the Estimated Cost:. Further review of the forms for Resident #22 and #52 revealed no documentation for Options: section located in the middle of the SNF ABN forms, which was where one option must be chosen by the beneficiary if there was a drop in the level of care. During an interview with Business Office Manager (BOM) on 2/25/21 at 2:21 PM, she stated the forms were given to the resident or family member, signed and dated on admission. That is when they are notified of what services are covered under the medicare guidelines. She confirmed the incomplete areas on the forms for Residents #22, #52 and #88 under the body section of the form for a beginning on date, care, reason medicare may not pay and the estimated cost as well as there was no selection chosen under the option section of the forms for Resident #22 and #52. She stated the options are not checked or filled in at the time the resident or responsible party signed the forms. She stated the forms were to be filled in and the responsibility, was pretty much mine. She stated, she received education on the SNF ABN forms annually and the last time was 5/16/19. Reviewed Facility SNF/ABN 2018 guideline for practice page 1-29. Showed page 2 The purpose is to inform the resident when their services will no longer be covered/Paid by Part A.page 5 To be considered timely, the SNF ABN form should be issued: ON or BEFORE the date Medicare coverage is ending .page 8 SNF ABN Body Complete the following fields: Beginning on blank .Page 9 Care .page 10 Reason Medicare May Not Pay .page 16 Estimated Cost .and page 17 SNF ABN Option Boxes he beneficiary must choose one of the options if there is a drop in level of care

Based on observation, interview and record review, the facility failed to ensure the appropriate rinse water temperature was maintained and rinse water pressure was monitored for the high temperature dish machine to ensure proper sanitation of dishes, silverware and glassware used by the residents. Findings: On 2/22/21 at 2:24 PM, the kitchen staff were in the dish room washing lunch dishware in the mechanical dishwashing machine. The wash temperature was 165-170° Fahrenheit (F). The rinse temperature was 195-200° F. Observation of the pressure gauge used to monitor the water pressure during the rinse cycle revealed the pressure was greater than 40 pound per square inch (PSI). Interview with the dietary aide who monitored the machine for temperature and functioning was not aware he had to monitor the PSI. During the observation, the Food Service Director also said he was not aware to monitor PSI. When questioned what the dial should register during the rinse cycle, he was not able to explain what the pressure should read during the rinse cycle. He confirmed they were not monitoring the rinse cycle PSI. Review of the Dishwashing temperature logs from 12/01/20 to 2/22/21 did not include monitoring of the PSI. Review of the operating manual for the high temperature dishwashing machine noted the incoming water temperature should be 180°F and the rinse cycle flow pressure required was 15-25 PSI. Review of Centers for disease Control (CDC) environmental health operations manual chapter 13.7, Warewashing evaluation pressure gauge for the in line hot water injection point pressure should be 15-25 PSI. (HTTPS://www.cdc.gov/nceh/vsp/operationsmanual/opsmanual2000.pdf)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to keep the call light in residents' reach for those able to use it for 3 of 41 residents, (#104, 36 & 67). Findings 1. Resident #104's medical record reflected that the resident was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, muscle weakness, difficulty walking, dependence on supplemental oxygen and anemia. On 7/29/19 at 11:07 AM, resident #104 sat in a wheelchair with the overbed table in front of him. The table had magazines and a styrofoam cup with a straw. The wheelchair was between the resident's bed and the bathroom. The resident picked up his cup to drink water, he shook the bottle and said, It's empty, I need some water. The resident looked around to use his call light and said, It's way over there, I can't reach that. The call light was attached to opposite side on the side rail. On 7/30/31/19 at 9:40 AM, Certified Nursing Assistant (CNA) B stated residents should always be able to reach call lights in their rooms. On 7/31/19 at 10:08 AM, License Practical Nurse LPN (C) stated that CNAs are expected to ensure that the call light is always within resident's reach. A review of resident #104's 14-day Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15/15 indicating the resident was cognitively intact. The functional status section G listed resident needed physical assistant for walking, eating, and toilet use. Resident #104's care plan dated 7/11/19 read, resident is at risk for falls related to decreased strength and endurance. Interventions included call light within reach. The care plan also reflected that the resident was continent of stool and required use of an indwelling catheter related to obstructive uropathy. The resident was at risk for incontinence related to weakness, impaired mobility, and disease process. Interventions included encourage resident to request assistance with toileting task. The resident would not be able to request assistance without the use of the call light within reach. 2. Resident #36 was admitted to the facility on [DATE] with diagnoses including muscle spasm of back, polyosteoarthritis, and rheumatoid arthritis. On 7/30/19 at 10:04 AM, the resident was in bed with the head of the bed elevated. She spoke in Spanish with facial grimace and pointed to her back. Bilingual housekeeper E interpreted that resident complained of back pain. The resident tried to use the call light to call the nurse but could not reach it. The call light was on the floor between both beds. On 7/31/19 at 11:11 AM, CNA F stated, I know the resident gets pain medicine because she has arthritis. She sometimes says her back hurts but helping her to change position helps her. The resident's call light should always be within her reach. At 11:40 AM, licensed practical nurse (LPN) G stated the resident gets routine pain medication, Tramadol. She is followed by the rheumatologist who gives her injections every 6 months. The resident can use her call light. The expectation is that she should always have access to the call light. Resident #36's quarterly MDS assessment dated [DATE], reflected a BIMS score of 9/15 indicating moderate cognitive impairment. The section for health condition reflected that the resident had been on scheduled pain medication. Resident #36's care plan, dated 5/23/19 read, Incontinent episodes of bowel and or bladder relating to impaired cognition, communication and mobility related to dementia. Interventions included encourage resident to request assistance with toileting task. The care plan for at risk for falls related to a syncope/collapse episode in the shower without injury reflected interventions to remind resident to call for assistance with transfer/mobility and reinforce safety awareness. This could not be done by the resident if her call light was not in her reach. 3. Resident #67 was admitted to the facility on [DATE] with diagnoses including difficulty walking, muscle weakness, urinary tract infection, osteoarthritis, and chronic congestive heart failure. On 7/31/19 at 9:38 AM, resident #67 sat in a wheelchair on the opposite side of the call light. The call light was attached to the left side of the bed. The resident sat on the right side of her bed. The resident stated she was waiting for the CNA to make her bed because she wanted to get back in the bed. At 9:40 AM, CNA B stated that whenever the resident would like to call me for help, she used the call light. Right now, the call light is on the opposite side wrapped around the side rail of the bed, closer to her roommate. The resident was in her wheelchair between her bed and the bathroom and she cannot get to the call light. She said, I should always make sure the call light is within the resident's reach. At 10:08 AM, LPN C stated that CNAs are expected to ensure that the call light is always within resident's reach. Resident's #67's 30-day MDS assessment dated [DATE] documented a BIMS score of 13/15 indicating she was cognitively intact. The functional status listed the resident as needed physical assist for bed mobility, and transfer. Resident #67's care plan, dated 6/05/19, reflected that the resident experienced incontinent episodes of bowel and or bladder related to impaired mobility and weakness. Intervention included to encourage resident to request assistance with toileting needs. Resident #67's care plan, dated 6/04/19 reflected that the resident was at risk for falls related to deconditioning, gait/balance problems, incontinence, psychoactive drug use and unaware of safety needs. Interventions included that the call light be within reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to honor resident's food preference for 1 of 3 resident reviewed for choices, (#106). Finding: Resident #106 was admitted to the facility on [DATE], with her most recent readmission on [DATE]. Her diagnoses included pleural effusion, end stage renal disease, diabetes type II, atherosclerotic heart disease and chronic obstructive pulmonary disease. The Medicare 5-day minimum data set (MDS), with assessment reference date 7/21/19, showed resident #106's cognition was intact, with a brief interview of mental status of 12/15. The resident required extensive assistance of one person for bed mobility, transfers, dressing, toilet use, and personal hygiene, and supervision for eating. The food and beverage preference list for resident #106 was obtained on 3/27/18, and showed that her dislikes included pork chops, pork roast, ham, sausages, and bacon. On 7/30/19 at 10:09 AM, resident #106 said she did not eat pork, and was served pork for supper on 7/29/19, on her return from dialysis. Resident #106 said she told staff she did not eat pork, and asked for something else, but was told the kitchen was closed. The resident said she had to eat walnuts and bread she had in her room. Resident #106's daughter visited the resident at this time, and confirmed the resident's report. On 7/31/19 at 2:30 PM, assistant certified dietary manager (ACDM) I said food preferences were obtained from residents on the day of admission or the following day. Review of the resident's food and beverage preference list provided by the ACDM showed the resident's dislikes included pork. On 7/31/19 at 2:46 PM, the resident's food and beverage preference list was also reviewed with registered dietician (RD) J. She verified that dislikes checked included pork chops, and pork roast. The RD said she was not sure why resident #106 was served pork on Monday 7/29/19. On 7/31/19 at 4:19 PM, certified nursing assistant (CNA) K said on Monday 7/29/19, when he served resident # 106 her meal tray, she told him to open the lid. The resident then asked what kind of meat was on her tray. CNA K said he told her he would verify by reviewing the menu. When he checked, it was pork. CNA K said that he commented to resident # 106, I know you are not going to eat it. She said that's right, I am Muslim. CNA K said the resident asked him to get some food from the refrigerator that her daughter had brought in for her, but the food had been thrown out. The CNA K said resident #106 asked him to go to the kitchen, and ask for chicken tenders. He stated that chicken tenders were not available. He got a fruit plate, crackers, and hot tea for the resident. A second interview was conducted with the RD and ACDM on 8/01/19 at 10:06 AM. They said the worker on the tray line might not have placed the correct item on the resident's tray. The staff checking the trays also did not catch the error. Both the RD and ACDM said the food preferences for resident #106 should have been honored, and the resident should not have been given pork. The ACDM said it was a mistake. A care plan for at risk for nutritional compromise related to endocrine/cardiac/renal dysfunction and fluid shifts as evidenced by diagnoses of diabetes, congestive heart failure, end stage renal disease requiring hemo dialysis was initiated on 5/31/19. An intervention was to honor food preferences as available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide a bed-hold notice upon transfer for 2 of 4 residents reviewed for hospitalization, (#216 & 106). Findings: 1. Resident #216 was admitted to the facility on [DATE] and transferred to the hospital on 7/07/19 for shortness of breath. Resident #216's medical record did not contain any documentation to indicate that the resident or the responsible party were provided with the bed-hold notice within 24 hours of transfer. On 8/01/19 at 3:48 PM, the Director of Nursing (DON) stated that it was the responsibility of the floor nurse to provide the bed hold notification to the resident or responsible party upon transfer to hospital. The DON confirmed that the facility did not have any evidence to indicate the resident or resident representative had been provided the bed hold information at the time of the transfer or within 24 hours of the transfer. 2. Resident #106's medical record reflected an admission to the facility on 3/23/18, with her most recent readmission on [DATE]. Her diagnoses included pleural effusion, end stage renal disease, dependence on renal dialysis, diabetes type II, atherosclerotic heart disease and chronic obstructive pulmonary disease. The discharge minimum data set assessments dated 5/22/19, 6/17/19 and 7/10/19 showed the resident was discharged to an acute care hospital, and return was anticipated. Nursing progress notes dated 5/22/19, 6/17/19 and 7/15/19 showed the resident was transferred to an acute care hospital due to changes in her medical condition. The resident's electronic and physical chart did not contain the notice of bed-hold policy issued to resident #106/or resident representative. On 8/01/19 at 3:45 PM, the DON said that with any change in condition of a resident, the physician and family should be notified, and the bed hold acknowledgement/reservation policy, was required. On 8/01/19 at 4:45 PM, the DON and assistant DON (ADON) said after review, documentation could not be identified regarding the bed hold acknowledgement/reservation policy for hospitalization of 5/22/19 and 6/17/19. This was verified by the DON. The facility's policy and procedure Bed Hold Acknowledgement/Reservation Policy, read, At the time the resident is to leave the Facility for a temporary stay in a hospital .The resident/legal representative will be given a written copy of the Bed Hold Policy.

Based on interview and record review, the facility failed to follow physician's order for weekly weights for 1 of 1 resident reviewed for edema out of 41 total sampled residents, (#21). Findings: Resident #21's medical record reflected an admission date of 10/26/18. Her diagnosis included atherosclerotic heart disease, atrial fibrillation, diabetes type II, hypertension, and cardiac pacemaker. The quarterly minimum data set (MDS) assessment with assessment reference date (ARD) 1/31/19 showed the resident required extensive assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The Significant Change MDS with ARD 5/02/19 showed improvement in the resident's functional ability. She now required limited assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The Physician's order, dated 6/27/19, was for weekly weight every night shift every Tuesday for edema, start date 7/02/19. Resident #21's medications included Bumex 0.5 milligrams (mg.) twice daily. Bumex is a diuretic that helps to rid the body of salt and water (Mayo Clinic). Record review showed the following entries for the resident's weight: 6/09/19: 155.6 pounds (lb.) and 7/02/19: 148.5 lb, for a total weight loss of 7.1 lb. Three weeks of weights were not documented in the resident's chart after 7/02/19. On 7/31/19 at 9:34 AM, licensed practical nurse (LPN) G said if a resident was on weekly weights, the weight would be obtained on the night shift. Weights should then be entered in the computer. Weights were reviewed with LPN G, who verified that the last documented weight for resident #21 was on 7/02/19. No other weight could be identified by LPN G for resident #21. On 7/31/19 at 11:32 AM, the unit manager (UM) said weekly weights were usually done by the 11 PM-7 AM staff. If staff were busy, the restorative certified nursing assistant would obtain the weights. The UM verified that resident #21 had a physician's order for weekly weights, and the last documented weight was on 7/02/19. The UM said she could not say why the resident's weight was not done. She said in reviewing the treatment administration record (TAR) for July 2019, it showed that resident #21 refused the weekly weights on 7/09/19, and 7/23/19. The UM said the facility's protocol, if a resident refused treatment, was for staff to notify the physician. Documentation could not be identified to indicate the physician was notified of the resident's refusal of her weekly weights. This was verified by the UM. On 8/01/19 at 1:10 PM, the director of nursing (DON) said if treatment was refused by the resident, the expectation is that the physician would be notified. The resident's TAR for July 2019 was reviewed with the DON, and assistant DON. The TAR indicated that the resident's weight was obtained on 7/02/19; she refused on 7/09/19 and on 7/23/19. The TAR also indicated the resident's weight was obtained on 7/16/19, but review of the Weights and Vitals Summary showed no weight documented corresponding with this date. Documented weights were 7/02/19 148.5 lb., and the next entry was on 7/29/19 146.3 lb. This was verified by the DON. A care plan for at risk for weight fluctuation related to use of diuretic as evidenced by edema to lower extremities was initiated on 6/27/19. The goal read, will not have greater than 3 lb. weigh gain in a week.

Based on observation, interview and record review, the facility failed to ensure a nourishment room was kept in a clean/sanitary manner and failed to ensure food items in the nourishment room refrigerator were labeled and dated in 1 of 2 nourishment rooms. Findings On 8/01/19 at 8:31 AM, the 300 and 400 unit nourishment room had dirty dessert cups, spoons and small plate. At this time, license practical nurse (LPN) A stated that the soiled dishes should not be in the nourishment room. LPN A then opened the refrigerator door and a white styrofoam box was observed on the second shelf. The box contained left over food brought into the facility from an outside source. On another shelf inside the refrigerator was a resealable zipper storage bag with sandwiches. The bag was not labeled or dated. LPN A stated, I must throw this out as it is not labeled and has no date. Review of the facility policy and procedure for Nourishment Storage Areas read, The areas where nourishments and snacks are stored for the residents outside of the food and nutrition services department are maintained according to the local/state and federal regulations and facility guidelines. The facility designates which department is responsible for the cleanliness and sanitation of the areas where resident snacks and supplements are stored. Food is covered, labeled and dated appropriately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to obtain the physician's signature on the State of Florida Do Not Resuscitate Order (DNRO) form in a timely manner for 1 of 1 resident reviewed for Advance directives, (#45). Resident #45 was admitted to the facility on [DATE] with diagnoses which included, encephalopathy, cardiac pacemaker, and hyperkalemia. Clinical record review showed the resident had a designated health care surrogate, and living will in the physical chart. A State of Florida DNRO form was located in the resident's chart, dated 4/12/18 which was not signed by the physician. On 4/24/18 at 12:09 PM the hospice nurse said, a verbal consent was obtained from the resident's son for DNR via telephone with two nurses as witnesses, and the form was now awaiting the physician's signature. On 4/25/18 the State of Florida DNRO form was still in the resident's physical chart, still flagged for the physician's signature. A care plan dated 5/05/17 for Resident has following Advance Directives on record documented full Code. Update on 2/14/18 read, Spoke with son does not wish a DNR at this time - full code, and on 4/25/18 (day 3 of the recertification re-licensure survey) DNR. On 04/25/18 at 02:16 PM registered nurse (RN) Y said that in order to find a resident's code status, she would look in the chart. Residents who have a DNR code status will have a red dot on the spine of the physical chart, and the canary colored Florida State DNRO form would be in the chart under the advance directives tab. Resident #45's DNRO form was reviewed with RN Y and she verified that the DNRO form was not signed by the physician. On 04/25/18 at 05:10 PM the Director of Social Services (DSS) said the DNRO form has to be signed by the resident/representative, and signed by the physician as soon as possible. If the physician was not in the facility, the DNRO form would be faxed to the physician for signature. The DSS said the State of Florida DNRO form for resident #45 was faxed to the physician today (4/25/18) at approximate 5:00 PM. She said it was the responsibility of the entire team, nursing, and social services to ensure that the DNRO form was signed by the physician. The DSS said the DNRO form for resident #45 should have been faxed to the physician for his signature and she had no answer as to why this was not done. On 04/25/18 at 6:44 PM the director of nursing (DON) said she could not say why the DNRO form for resident #45 was not signed by the physician. She said the physician had been in the facility since the telephone order for DNR on 4/12/18 was written, and usually the DNRO form would be faxed to the physician for signature. The DON could not explain why this was not done for resident #45's DNRO form. In a second interview with the DON on 04/26/18 at 3:17 PM, she said there was no collaboration between the unit nurse, Hospice, and DSS regarding obtaining the physician's signature for the DNRO form for resident #45. She said the process was not followed. The facility's policies and procedures for Advance Directives last revised 2/2018 read, A physician's order and written consent from the resident or resident's representative must be obtained .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident received the necessary treatment and services related to pressure ulcers for 1 of 3 residents sampled for pressure ulcers, (#27). Findings: Review of the medical record indicated resident #27 was admitted to the facility on [DATE] with most recent re-admission on [DATE] from acute care hospital with diagnoses including stage 4 pressure ulcers sacral region (triangular-shaped bone at the bottom of the spine) and ischium (the seat bone), pneumonia, gastrostomy, non-pressure chronic ulcers bilateral feet, neurogenic bladder and Alzheimer's disease. According to the International National Pressure Ulcer Advisory Panel (NPUAP), There are Stage 1 to 4 pressure ulcers, unstageable and suspected deep tissue injury . Stage 2 has partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough .Stage 4 has full thickness tissue loss with exposed bone, tendon or muscle The resident's most recent minimum data set (MDS) assessment dated [DATE] indicated the resident had severe cognitive impairment, indwelling urinary catheter, and was always incontinent of bowel. The resident was at risk for developing pressure ulcers and had 2 stage 4 pressure ulcers that were present since 10/18/17. The assessment indicated the skin and ulcer treatments that applied were pressure-reducing device for bed/chair, nutrition or hydration intervention to manage skin problems, pressure ulcer care and application of nonsurgical dressings/ointments/medications other than to feet. The care areas assessment (CAA) summary indicated he triggered for pressure ulcer to be addressed in care planning. Review of the nursing notes and activities of daily living (ADL) documentation from 4/1/18 to 4/26/18 revealed that he was bedbound, unable to turn self in bed and was totally dependent on 1-2 staff for all his care. An observation and interview was conducted with resident #27's wife on 4/23/18 from 9:46 AM to 10:25 AM in the resident's room while she was sitting at the bedside. The resident was observed on a specialty mattress positioned on his back with head of the bed elevated approximately 60 degrees. His eyes were closed and chest was moving up/down. He appeared to be asleep. Resident #27's wife stated that her husband had been at the facility for 15 months. She visited every day between 8-9 AM until 3 PM. Yesterday when she came in at approximately 9:00 AM he was soiled. She reported this to the nurse and had to wait until 1:00 PM for the staff to provide incontinence care. She said her main concern was that her husband was not getting the care he needed. It required 2 staff to care for her husband and the facility staff did not re-position him frequently enough unless she asked them to. Her husband had pressure ulcers on his back and was unable to move or talk. When she was present at the facility the staff only turned him when she requested. They did not come in routinely to turn and reposition him. On the 11:00 PM-7:00 AM shift he was not repositioned frequently enough. She brought her concerns to the attention of the Director of Nursing (DON) approximately one month ago. The DON had indicated to her that she met with the night staff about this but there was no monitoring and they still did not re-position him frequently enough. Resident #27 was observed on 4/23/18 at 3:25 PM laying on his back with head of bed up approximately 75 degrees with pillows under his bilateral shoulders resulting in resident resting directly on his sacral wounds. The facility's Care Directive had instructions to turn and position resident #27 every 2 hours and as needed. The care plan implemented on 2/12/18 for pressure ulcer had approaches listed to assist resident to reposition/shift weight to relieve pressure. Resident #27's wife requested on 3/15/18 to make sure he was turned and provided incontinence care timely due to wounds. The guidelines per NPUAC (National Pressure Ulcer Advisory Panel Pressure) Quick Guide dated 2014 read, General Reposition for All Individuals-1. Reposition all individuals at risk of, or with existing pressure ulcers, unless contra-indicated. Additional Recommendations for Individuals with Existing Pressure Ulcers. 1. Do not position an individual directly on pressure ulcer, 2. Continue to turn and reposition individual regardless of the support surface in use. Establish turning frequency based on the characteristics of support surface and the individual's response. On 4/25/18 at 9:35 AM observed resident #27 lying on specialty mattress positioned on his right side with head of bed up 60 degrees. The wife was sitting at bedside and said that she had been here since 8 AM and the staff had not yet come to turn or reposition him. On 4/25/18 at 12:00 PM the wife stated that no one came to reposition her husband so she went to find a CNA and they turned him a little while ago. On 4/25/18 at 12:41 PM CNA K verified that she was assigned to resident #27 today. She was told in report that he needed repositioning every 2 hours. The first time she repositioned him was sometime before breakfast, at approximately 8:00 AM and the 2nd time was before noon meaning the resident had not been turned for 4 hours. CNA K said she was with another resident when the resident's wife requested that he be turned. CNA K confirmed that she should be checking him and turning him at least every 2 hours and should not wait for the wife to come and ask for assistance. A wound care observation was conducted on 4/25/18 from 1:40 PM to 2:20 PM with Unit Manger (UM) C, CNA K and LPN J. The resident was totally dependent on 2 staff for positioning, made poor eye contact, and was nonverbal. UM C first washed her hands and then set up her supplies on the plastic lined bedside table. CNA K and LPN J assisted with positioning the resident onto his left side. UM C removed the soiled dressing from sacral region and exposed open wound which was approximately 5-6 centimeters (cm) and 1-2 cm deep, wound appearance was pink with approximately 20% slough (dead tissue) and was draining moderate amount of yellow blood tinged fluid. UM C then performed wound care procedures. She then removed the soiled dressing from the left ischium exposing a 2 cm X 2 cm wound that was approximately 1 to 2 cm deep. The wound appearance was dark pink in color with small amount of yellow blood tinged drainage. When she finished with the procedure the surveyor observed that the resident had 2 other areas of skin breakdown, one on the left buttock and one on his left calf. UM C said that she had rounded with the wound care physician yesterday and had not seen the 2 new areas of skin breakdown. She then measured the new areas; left buttock was dark brown discoloration measuring 1.7 cm X 2 cm X 0, and left posterior calf presented as a blood blister 2 cm X 2 cm x no depth. On 4/25/18 at 8:51 PM a telephone interview was conducted with CNA W who worked the 11:00 PM-7:00 AM shift and was assigned to resident #27's care. When asked specifically about resident #27 and how often she re-positioned or turned the resident. She said that it required 2 staff to turn him and she turned and repositioned the resident twice her shift meaning every 4 hours. A telephone interview on 4/25/18 at 9:41 PM was conducted with Registered Nurse (RN) I. She said that she worked the 11:00 PM-7:00 AM shift. When asked how often the CNAs checked and changed residents she said every 4 hours. We do not have enough staff to check them every 2 hours. On 4/26/18 at 9:41 AM an interview was conducted with Physician M. He said, he had been caring for resident #27's lower extremity wounds. He came to see him every week at the facility and was not aware of the wife's concerns regarding staff not re- positioning the resident frequently enough. He said the standard of care would be to reposition him at least every 2 hours. On 4/26/18 at 10:51 AM an interview was conducted with resident #27's Wound Care Physician L. She saw the resident every Tuesday morning and as of yesterday she was only treating 2 wounds (sacrum and ischium). She came in to see him this morning to assess the new area of breakdown that was reported to her on his left buttock. Physician L indicated she not aware of the resident's wife's concern about staff not re-positioning him frequently enough and night staff only positioning him twice in an 8 hour shift. Physician L said, re-positioning him only twice in an 8 hour shift was not adequate and she wanted him repositioned at least every 2 hours. On 4/26/18 at 5:23 PM the DON said that she was not able to print resident #27's Care Directive sheet showing the dates when new interventions were added or when it was initiated. The Care Directive sheet provided to survey team only had the actual date form was printed on 4/25/18. The DON confirmed the instructions for resident #27 read, Turn and position frequently, every 2 hours or as needed . On 4/26/18 at 5:53 PM a review of resident #27's Skin Integrity care plan initiated on 2/12/18 for pressure ulcer sacral area and left ischium was done with MDS Nurse X. She verified that the plan of care had approaches to assist resident to reposition/shift weight to relieve pressure. MDS Nurse X was asked how often should the resident be re-positioned and said the standard for bedbound total care residents would be at least every 2 hours. The facility policy and procedure for Pressure Ulcer/Injury Prevention dated 11/2017 read, 4. Measures to maintain and improve the patient's tissue tolerance to pressure and implemented in the plan of care: c) minimize injury due to shear and friction through proper positioning, transfers, and turning schedules .5. Measures to protect the patient against the adverse effects of external mechanical forces, such as pressure, friction, and shear are implemented in the plan of care: a) reposition at least every 2-4 hours as consistent with overall patient goal and medical condition; b) utilize positioning devices to keep bony prominences from direct contact; c) ensure proper body alignment when side-lying .e) maintain head of bed at the lowest degree of elevation consistent with medical conditions .

Based on observation, interview and record review the facility failed to ensure that a resident's left elbow splints were applied as per physician's orders for 1 of 2 resident reviewed for mobility/Range Of Motion (ROM) out of a sample of 43 residents, (#5). Findings: Resident # 5 was admitted to the facility in April 2017 with diagnoses including cardiovascular accident with left sided weakness, hemiplegia affecting left non dominant side, and cerebral infarction. The physician orders showed the following: 12/10/17, D/C (discontinue) RNP(restorative nursing program) LUE(left upper extremity) PROM (passive range of motion), left elbow splint-nursing maintenance. 12/13/17 left elbow splint as tolerated, 1/05/18 Left elbow splint as tolerated. The care directive read, Restorative: monitor wheel chair position and placement of equipment. Resident # 5's treatment administration record showed the following: 1/05/18 Left elbow splint as tolerated. The Occupational Therapy (OT) plan of treatment for resident #5 showed start of care was 6/27/17, and skilled services completed documentation read, Analysis of LUE (left upper extremity) muscle tone resulted in an adjustment to treatment plan of providing an elbow splint to prevent further development of contracture . Caregiver training in donning/doffing elbow splint with 100% returned knowledge and will continue with RNP (Restorative Nurse Program) Patient DC (discharged ) in this facility for LTC (long term care) with RNP for elbow splint management On 04/26/18 at 09:58 AM the Director of Rehab said resident # 5 was on therapy caseload on 4/03/17, and from 8/24-9/06/17. She said resident #5 required maximum assistance of two persons for bed mobility and transfers. ROM showed limitation in her left knee, right hand was within functional limit, and the left hand/arm had moderate hypertonicity (a state of abnormally high tension. www.dictionary .com) The director of Rehab said a left elbow splint was issued to resident #5 in June 2017, and the resident had a left hand and elbow splint while on therapy caseload from August-September 2017. On 04/26/18 at 10:35 AM restorative certified nursing assistant (CNA) H said, resident #5 had a splint for her left elbow about 5-6 months ago. When placing the elbow splint resident said it bothered her, and she could not tolerate the elbow splint. The restorative CNA said this was reported to the restorative nurse, Unit Manager/Licence practical nurse (UM/LPN) C. The director of rehab said if this was happening about 5-6 months ago, therapy should have been informed, so they could have reassessed the resident. Observations on 4/23/18 at 12:49 PM, and on 04/25/18 at 10:17 AM showed resident # 5 in bed without a left hand or elbow splint. On 04/25/18 at 11:26 AM resident #5 said she had left hand splint on during the nights, and it was taken off during the days. No elbow splints were observed. On 04/25/18 at 02:04 PM resident #5 was sitting in her high back wheelchair, socializing with her husband and sister. A splint was observed to the resident's left hand, but she did not have an elbow splint on. The resident, and her husband said she did not have a splint for her left elbow, she only had one for her hand/wrist. Resident # 5 said therapy would be getting her a splint for her left elbow. Interviews conducted with the resident's primary nurse RN Y on 04/25/18 at 02:10 PM, and with CNA Z on 4/25/18 at 3:04 PM respectively, revealed they were not aware of a left elbow splint for the resident. Both RN Y and CNA Z said the resident only had a left hand splint. On 04/26/18 12:36 PM the RNP nurse UM/LPN C said when the restorative CNA reports an issue with RNP, a referral is written immediately for therapy intervention. She said in reviewing resident #5's records she did not see a referral to therapy for the missing elbow splint until 4/20/18. She added that she was not aware that there was an issue with the elbow splints until 4/20/18. UM/LPN C said the splints were applied by the restorative CNA, and as the person responsible for the RNP, she reviews documentation for completion of task. The RNP nurse said resident #5 completed the RNP on 12/10/17, and care was transferred to nursing for maintenance and to apply the splints. The RNP/UM/LPN C could not say when it was identified that resident #5 was not wearing/tolerating her left elbow splint. OT screen conducted on 4/23/18 read, Nursing referral for OT screen for proper positioning devices for L(left) UE/hand due to limited ROM. Level of function The patient exhibits L UE hypertonicity elbow flexion contracture without application of elbow extension orthotic device and hand splint. The short term goal was, The patient will decrease L UE hypertonicity (and decrease elbow flexion contracture) with application of elbow extension orthotic device and hand splint in order to reduce further progressing/development of contracture. An intervention for care plan Impaired functional range of motion related to use of left elbow splint dated 4/11/18 was, apply and remove splint as per protocol/physician's orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident # 16 was admitted to the facility on [DATE], and readmitted on [DATE]. Her diagnoses included heart failure, diabetes type II, peripheral vascular disease, and left above knee amputation. Physician orders effective March 2018 showed the following: accuchecks before meals and at night without sliding scale coverage: <(less than)70 call doctor (MD), >(more than) 300 call MD. Resident # 16's Diabetic Administration Record for April 2018 showed the resident's blood glucose (BG) was above 300 on the following dates: 4/2/18: 318, 4/05/18: 499, 469, 380, 4/6/18: 342,4/08/18: 304, 4/9/18: 411, 4/11/18: 311, 301, 4/12/18: 332, 4/13/18: 313, 4/15/18: 315, 4/16/17; 324, 4/17/18: 305, 4/18/18: 310, 4/19/18: 314, 4/20/18: 318, 4/22/18: 344, 4/24/18: 318. Documentation notifying the physician regarding the elevated blood glucose was noted on two occasions, on 4/05/18, and on 4/06/18. No other documentation was identified for the dates listed, when the resident's BG was above 300. On 04/26/18 at 01:10 PM the resident's Diabetic Administration Record was reviewed with the unit manager/ Licensed practical nurse C (UM/LPN). She verified documentation informing the MD of the resident's elevated BG dated 4/05/18, and 4/06/18, but could not identify any other documentation in the progress notes, or on the back of the Diabetic Administration Record to indicate the MD had been notified regarding the resident's elevated BG as per order. The UM/LPN C said the physician should have been notified as per orders. On 04/26/18 at 03:33 PM LPN AA said resident #16's BG had been over 300 on a number of occasions. She verbalized that she called the MD on 4/05/18, and on one occasion the nurse practitioner came in and spoke with the resident. LPN AA said she did not call the MD every time the resident's BG was above 300 because the resident frequently refused insulin. She said the MD's orders should have been followed regardless of the resident's refusal of insulin. Care plan initiated on 1/24/18 for At risk for complications associated with hyper or hypoglycemia related to diagnosis of diabetes read, Resident will not have any symptomatic episodes of acute hypo/hyperglycemia reaction through next review. Approaches included, administer insulin as ordered, accucheck as ordered . Based on observation, interview, and record review, the facility failed to provide appropriate indication for use of a psychotropic medication for 1 resident, (#67) and did not provide blood glucose monitoring as per physician orders for 1 resident, (#16) of a sample of 43 sampled residents. Findings: 1. Resident #67 was admitted on [DATE] with diagnoses that included Alzheimer's dementia and a left femur fracture. She had an admitting order to receive an antipsychotic medication, Seroquel 25 milligrams (mg) by mouth daily in the evening for diagnosis of behavioral & psychological symptoms of dementia (BPSD). Her hospital discharge medication list revealed the hospital started the Seroquel 25 milligrams (mg) on 3/8/18, one day prior to her admission to the nursing home. Her home medications list did not include Seroquel. Resident #67's admission minimum data set (MDS) comprehensive assessment dated [DATE] revealed that she had long and short term memory problems, had a brief interview for mental status (BIMS) score of 5. It indicated that she had trouble sleeping, had little appetite, and was fatigued. Under the behavior section of the MDS, she had exhibited no behavior symptoms. A consultant pharmacy report dated 3/13/18 for resident #67 revealed a recommendation from the consultant pharmacist as follows: Please re-evaluate the need for the continued use of Seroquel, perhaps considering a gradual dose reduction to 12.5 mg in the evening with the end goal of discontinuation of therapy if possible .If therapy is to continue, please provide documentation of the specific diagnosis/indication requiring treatment .ensure ongoing monitoring of specific target behaviors; documentation of a DANGER to self or others The primary physician documented on 3/16/18 that he accepted the above pharmacy consultant recommendations with the following modifications: Psych to Eval & Treat. On 3/11/18 and on 3/20/18, telephone orders had been written and included the diagnoses of BPSD for Seroquel with an order for psychological evaluation and treatment for unorganized thinking and medication management On 4/25/18 at 10:45 AM, resident #67 was observed while sitting in her wheelchair in the 100 unit day room. She was with 20 other residents who were all part of a facility day program for residents at high risk for falls. The resident looked drowsy, eyes half opened, during the singing activity. Review of resident #67's medication administration record (MAR) behavior monitoring sheet for the month of April 2018 revealed she was being monitored for the behaviors of screaming and increased sadness. The medications listed on the monitoring sheet were Seroquel 25 mg and Paxil 10 mg ( for depression). There were no behaviors documented on the form for April 1- April 25, 2018. On 4/25/18 at 11:50 AM, interview with LPN BB validated that resident #67 received Seroquel 25 mg daily and did not have any type of combative behaviors. She said the resident could be delusional at times talking to her mom, and sometimes would get fidgety indicating she had to go to the bathroom. On 4/25/18 at 12:30 PM, interview with resident #67's primary physician validated that he had accepted the pharmacy consultant's recommendations and wanted psychiatry to evaluate and treat her. He stated that he wanted the psychiatrist to make the determination if the reduction of the Seroquel should occur. Review of the initial psychiatric evaluation for resident #67 dated 4/11/18 revealed the chief complaint and reason for the consultation was for reduction of disorganized thinking. The only diagnoses listed on the evaluation were major depressive disorder and severe intellectual disabilities. It was documented that the resident received Seroquel one time daily by mouth, but did not document what amount of Seroquel she received daily. There was no documented rationale for either a trial dose reduction or for a continuance of the Seroquel 25 mg. She documented, continue Seroquel . There was no dosage amount recommended. A telephone interview was attempted with the psychiatry ARNP (advanced registered nurse practitioner) on 4/25/18 at 12:46 PM but without success. On 4/25/18 at 12:40 PM, the unit manager validated that the psych consult had not adequately addressed the trial dosage reduction and diagnosis for resident #67's Seroquel medication as requested by the primary physician. She also validated that the April MAR monitoring sheets revealed that the resident had no behaviors from 4/1/18-4/25/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that meals were appetizing and served at an acceptable temperature for 4 of 43 sampled residents (#3, #51, #54, #366). Findings: 1. On 04/24/18 at 09:57 AM, resident #3 stated that every morning her scrambled eggs were cold and she could not eat them. Resident #3 stated that she ate in her room. She stated that none of her food was hot and on one occasion she asked the Certified Nursing Assistant (CNA) to reheat her meal. The resident stated that her meal tasted much better after it was warmed up. The resident added that she did not like to ask the staff to warm her food every time because the staff were too busy and did not have time to reheat every meal for her. On 4/25/18 at 11:54 AM the resident stated that earlier in the day she had spoken to the dietician about her food always being cold. Resident #3 stated the dietician suggested that she could eat her meals in the Main Dining Room. The Dietician explained to her that if she was in the Main Dining room her food would be served as soon as she ordered it and it would be hot as the dining room was served first. She stated that she did not wish to eat in the main dining room as she was a messy eater and would be embarrassed to have others watch her eating. On 4/26/18 at 1:30 PM, resident #3 stated that her dinner last night was cold and her breakfast this morning was cold again. She said her lunch was also cold but she asked the therapist to warm it. She did not like to ask staff to constantly heat her food but she had no choice. 2. On 4/23/18 at 8:20 AM resident #366 stated that her breakfast was cold. She had a plate of food on the over bed table that was covered. The resident gave permission to remove the cover and she was served 2 eggs over easy and 1 pancake. The resident gave her permission to touch the side of the plate and it was cool to the touch. Review of the Meal Schedule revealed that breakfast service began at 7:00 AM. 3. On 4/23/18 at 1:05 PM resident #54 stated that some meals were okay but most were not. He said the pork chops, roast beef and chicken were tough to chew. He stated, I don't think they know what they are doing. 4. Review of the facilities menus revealed that the main lunch meal would consist of fried chicken, gravy, mashed potatoes, green beans, biscuits, frosted cake and condiments. On 4/26/18 at 11 AM the lunch tray line was observed. Staff checked the holding temperatures and all hot food items were at 140 degrees Fahrenheit or above. The Registered Dietician and Certified Dietary Manager stated that the Main Dining room was served first followed by the room trays on each of the nursing wings/hallways. When discussing residents that ate in their rooms, the staff stated that the expectation was the meal trays to be delivered within 15 minutes after the meal/tray cart arrives on the unit/hallway. Shortly after 11:50 AM a test tray was requested and it was placed on the [NAME] Court meal cart. The meal cart arrived on the unit at 12:08 PM and the staff began passing out the meal trays. Approximately 20 minutes later the last resident was served her lunch meal and the test tray was sampled. The fried chicken was luke warm and a tough to chew. The mashed potatoes were luke warm. The green beans were cool/cold and mushy. The side of the biscuit was touching the green beans, which made it wet/soggy. 5. On 4/23/18 at 4:11 PM resident #51 stated that he did not like his baked potato to be microwaved. He stated that he had issues with cold food and that some of the meals were not good. During a follow up interview on 4/26/18 at 5:00 PM the resident was in bed playing solitaire on his computer. The resident recalled that for lunch he had chicken, mashed potatoes without gravy and green beans. He said his meal was on the cool side because his unit was served last.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #55 was admitted to the facility on [DATE] with diagnoses that included endstage renal failure. She required hemodialysis treatments three times a week on Mondays, Wednesdays, and Fridays (MWF) at a local dialysis center. Her transportation pick-up time to dialysis was at 10:00 AM on MWFs. . On 4/25/18 at 4:15 PM, resident #55 had returned from a dialysis treatment and stated that she always asked for an egg salad sandwich to take with her to dialysis for lunch. Her lunch bag was hanging on the bag of her wheelchair. Remains of her egg salad sandwich were observed inside the lunch bag. The lunch bag was made of an insulated material but there was not a cold pack or ice pack inside the lunch bag to keep the egg salad sandwich cold. She stated that the facility had never put cold packs in her lunch bag. On 4/25/18 at 4:20 PM, interview with the resident's nurse, LPN BB, said that she had never seen cold packs placed in the resident's lunch bag because she had been told that the dialysis center places the resident's lunch bag in their refrigerator. On 4/25/18 at 5:00 PM, the dietary manager validated that they did not put cold packs inside the resident's lunch bag because it was insulated and they assumed that the dialysis center refrigerated the lunch bag upon arrival. She verified that resident #55 requested egg salad sandwiches containing mayonnaise for lunch three times per week on her dialysis days. On 4/25/18 at 5:15 PM, a phone interview with the assistant facility administrator (AFA) of resident #55's dialysis center validated that the resident was their patient. She stated that the dialysis center did not put the resident's lunch bag in their refrigerator because of infection prevention purposes. The AFA stated that the resident had a 4 hour hemodialysis treatment that lasted from about 10:30 AM until about 2:30 PM. She verified that the resident did not eat her egg salad sandwiches for approximately 2 hours after getting to the facility. This meant that the egg salad sandwich remained in the lunch bag without a cold pack for approximately 3 hours. Review of the facility's food and nutrition services policy/protocol regarding sanitation/safety/disaster revealed the following: Safe food temperatures will be maintained for food transported from the facility with the resident such as a lunch or snack for a resident going to dialysis, sport center or day treatment programs. Appropriate food transport equipment will be used per facility guidelines to maintain safe temperatures. Based on observation and interview the facility failed to ensure food was served under sanitary conditions for a dialysis resident, (#55) and employees washed their hands between dietary tasks. Findings: On 4/26/18 at 11:00 AM the lunch tray line was observed. The food holding temperatures were taken and the tray line commenced shortly after. The cook was standing behind the steam table, plating meals while 2 dietary aides (Aides A &B) were on the other side of the steam table assisting with the process. Dietary aide B was at the end of the tray line and he placed the meal trays into the delivery carts. Once the delivery cart was full, aide B delivered the meal cart to the respective hallway. Aide B delivered the 400 Hall meal cart and returned to the kitchen. Aide B re-joined the tray line but did not wash his hands. Aide B placed a milk carton on a resident's tray before staff told him that he needed to wash his hands. Aide B washed his hands and returned to his spot at the end of the tray line. Another meal cart was filled and Aide B delivered the meal cart to the Private Hall. Aide B returned to the kitchen and assumed his position at the end of the tray line but did not wash his hands. Aide B grabbed a pellet lid, touching both the outside and the inside of the pellet lid and attempted to cover a plate of food. At that moment it was pointed out to the the managing staff that Aide B had not washed his hands for the second time before re-joining the tray line. The Certified Dietary Manger stated that the kitchen staff had been educated about hand washing but could not provide an answer as to why dietary aide B did not wash his hands.

Based on interview and record review, the facility failed to maintain medical records that accurately reflected the advance directive order to Do Not Resuscitate (DNR) for the 1 of 43 sampled residents (#366). Findings: Review of resident #366's April 2018 medication administration record (MAR) had a check mark on the resident's code status box to indicate that she was a full code. Review of resident #366's hard copy medical record revealed that it contained a yellow DNR order signed by the patient on 4/17/18 and signed by the physician on 4/18/18. Review of a social services assistant note dated 4/17/17 revealed the following: Spoke to pt.[patient]. Pt signed a DNR form. Pt is aware she remains a full code until the DNR form is signed by a doctor. The signed DNR form has been flagged in pts chart for the doctor to sign. Social worker with fu [follow-up] in a weeks time. On 4/25/18 at 2:00 PM, resident #366's licensed practical nurse, (LPN) BB, and the unit desk nurse, LPN DD, validated that the April MAR did not accurately reflect the signed DNR order. They also validated that there was not any evidence that the social services director had followed up with the DNR directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to have sufficient staffing to provide necessary treatment and services to promote healing of pressure ulcers for 1 of 3 residents (#27), to respond to call lights in a timely manner and to provide activities of daily living (ADL) care for 11 of 43 sampled residents, (#27,#60, #462, #54, #105, #16, #32, #74, #92, #51, #3) Findings: 1. An observation and interview was conducted with resident #27's wife on 4/23/18 from 9:46 AM to 10:25 AM in the resident's room while she was sitting at the bedside. She said her husband had been at the facility for 15 months. She visited every day between 8:00 AM until 3:00 PM. Yesterday when she came in around 9:00 AM he was soiled which she reported to the nurse and had to wait until 1:00 PM for the staff to change him. She said her main concern was the lack of Certified Nursing Assistants (CNAs). She could hear the CNAs talking and saying they were overwhelmed with the workload. It required 2 staff to care for her husband and the facility staff did not re-position him frequently enough when she was here unless she asked them to. Her husband had pressure ulcers on his back and was unable to move or talk. When she was present at the facility the staff only turned him when she requested. On the 11:00 PM-7:00 AM shift he was not repositioned frequently enough. She brought her concerns to the attention of the Director of Nursing (DON) approximately one month ago but she has not see any changes. Review of the medical record indicated resident #27 was admitted to the facility on [DATE] with most recent re-admission on [DATE] from acute care hospital with diagnoses including stage 4 pressure ulcers sacral region (triangular-shaped bone at the bottom of the spine) and ischium (the seat bone), pneumonia, gastrostomy, non-pressure chronic ulcers bilateral feet, neurogenic bladder and Alzheimer's disease. His most recent minimum data set (MDS) assessment dated [DATE] indicated the resident had severe cognitive impairment, had indwelling urinary catheter, and was always incontinent of bowel. The resident was at risk for developing pressure ulcers and had 2 stage 4 pressure ulcers that were present since 10/18/17. Review of the nursing notes and activities of daily living (ADL) documentation for 4/1/18 to 4/26/18 revealed that he was currently bedbound, unable to turn self in bed and was totally dependent on 1-2 staff for all his care. The facility's Care Directive had instructions to turn and position resident #27 every 2 hours and as needed. Resident #27 was observed on 4/24/18 at 10:32 AM positioned on his left side. The spouse was at the bedside and said she was upset because he did not get a bath all day yesterday and he needed one daily because he sweat a lot. She said the CNA was overwhelmed yesterday and had told her they were pulling her to work on the other side of the facility. On 4/25/18 at 12:00 PM observed resident #27 on his left side. The wife was sitting at beside and said that the staff came in and turned him a few minutes ago after she had asked the CNA. On 4/25/18 at 12:41 PM CNA K verified that she was assigned to resident #27 today. She was told in report that he needed repositioning every 2 hours. The first time she repositioned him was sometime before breakfast and the 2nd time was 30-40 minutes ago meaning the resident had not been turned for 4 hours. CNA K said she was with another resident when the wife asked to reposition her husband. CNA K confirmed that she should be checking him and turning him at least every 2 hours and should not wait for the wife to come and ask for assistance. CNA K was asked if she was going to give the resident a bath today and said she had not checked the Care Directive for this resident. On 4/25/18 at 8:51 PM a telephone interview was conducted with CNA W who worked the 11:00 PM-7:00 AM shift and was assigned to resident #27's care. She said, she had 12-20 residents to care for on her shift. When asked how often she checked and changed incontinent residents she said usually every 4 hours. When asked specifically about resident #27 and how often she re-positioned or turned the resident, she said that it took 2 staff to turn him. She stated that she turned him every 4 hours. A telephone interview on 4/25/18 at 9:41 PM was conducted with Registered Nurse (RN) I. She said that she worked the 11:00 PM-7:00 AM shift and usually had 26-36 residents on her assignment. When asked how often the CNAs check and change residents, she said every 4 hours. We do not have enough staff to check them every 2 hours and they do not give us anymore staff when residents were higher acuity. 2. Resident #60 was admitted to the facility on [DATE] and then readmitted on [DATE] from acute care setting with diagnoses of recurrent Enterocolitis due to Clostridium Difficile Toxin (CDT), muscle weakness, dementia, and abdominal pain. Clostridium difficile (also called C. difficile) are bacteria that can cause swelling and irritation of the large intestine, or colon. This inflammation, known as colitis, can cause diarrhea, fever, and abdominal cramps. Colitis caused by C. difficile can be mild or serious. (www.webmd.com). Resident #60's most recent MDS assessment, dated 3/10/18, indicated that she had moderate cognitive impairment, frequently incontinent of bladder and bowels, required 2 person extensive assist with bed mobility and 1 person extensive assistance with transfers, toilet use and personal hygiene. On 4/23/18 at 12:14 PM, observed resident #60 in bed with brief only secured on the right hip. The sheet was pulled up to her abdomen exposing her legs and her hair was greasy and uncombed. She made poor eye contact and was non-verbal. On 4/23/18 at 1:05 PM, observed resident #60 in her room lying in bed. She was incontinent of watery brown foul smelling stool that was coming out the edges of her brief and onto the sheets. The odor was strong and filled the room. she was confused and not able to use her call bell. Surveyor had to notify the staff, LPN A and request that care be provided to the resident. LPN A confirmed the resident was disheveled and had soiled her incontinence brief. On 4/24/18 at 10:15 AM resident #60 was observed in her room sitting up in chair she was more alert and said that she was not feeling well now for some time. The resident indicated to surveyor that she needed help to the toilet. Surveyor immediately notified RN S who said that the CNA was busy helping another resident and that resident #60 had a brief on indicating the resident could go in her brief. The resident was heard just outside of the room saying oh god, help me, help me, hurry, hurry. 3. Resident #462 was admitted to the facility on [DATE] from acute care hospital with diagnoses of difficulty walking, repeated falls, fractured femur, hip pain and muscle weakness. The activities of daily living documentation since her admission revealed she was occasionally incontinent of bowel and frequently incontinent of bladder. She was not able to walk and needed extensive assist to total dependence of staff with toileting, personal hygiene, and bathing. On 4/23/18 at 11:09 AM resident #462's spouse stated, The night shift take longer to answer call lights and the residents feel like they are bothering the staff when they press the call light. 4. Resident #54 was admitted to the facility on [DATE] from acute care hospital with diagnoses of urinary tract infection, benign prostatic hyperplasia (enlarged prostate), diabetes, muscle weakness, fractured vertebra, and difficulty walking. A review of the most recent MDS assessment, dated 3/1/18 revealed, he was cognitively intact, needed extensive 1-2 person assistance with transfers, toilet use, personal hygiene and bathing. On 4/23/18 at 12:59 PM, resident #54 said, the facility did not have enough staff especially during meals. He had no sensation when he had to move his bowels and had to wait up to 1 ½ hours for the staff to answer call light to assist with changing him. On 4/26/18 at 2:30 PM a follow up interview was conducted with resident #54 regarding staffing. He said he ate in the dining room and if he returned to his room prior to the staff passing out the trays he could usually get someone to assist him to the bathroom. If he did not return to his room quickly from meals, he had to wait 1 1/2 hours for staff to assist him with incontinence care. 5. Resident #105 was admitted to the facility on [DATE] from acute care hospital with diagnoses including pain to left knee, congestive heart failure, chronic obstructive pulmonary disease, muscle weakness and intestinal obstruction. A review of the MDS assessment, dated 4/8/18 revealed that she had moderate cognitive impairment, needed extensive 1-2 person assistance with transfers, dressing, toilet use, personal hygiene and bathing and was occasionally incontinent of bowel and bladder. On 4/23/18 at 11:02 AM resident #105 was observed sitting up in wheelchair in her room. She was talkative and pleasant. She was able to recall where she once lived, the work that she did and why she was here at the facility. She was asked if she had any concerns regarding the care and services at the facility. She said, I have to wait a long time for help to go to bed, sometimes when I press the call bell it does not call anybody. Resident #105 indicated she had to wait 15 minutes to an hour to get cleaned up after having a bowel movement in her brief and this usually occured on the night shift. She said I could press the button 10 times and nobody hears it. When asked how frequently this happened, she said about half the time. I need help with everything. I cannot get out of my wheelchair by myself and when they don't come in time I wet myself. 6. Resident #16 was admitted to the facility on [DATE] and re-admitted from acute care hospital on 8/27/16 with diagnoses including heart failure, muscle weakness, diabetes, amputated left leg, unsteadiness on feet, and absence of right toes, peripheral vascular disease and anxiety. A review of the MDS assessment, dated 4/12/18 revealed that she was cognitively intact and needed extensive 1-2 person assist with bed mobility, dressing, eating, toilet use and personal hygiene. She was always incontinent of bowel and frequently incontinent of bladder. On 4/23/18 at 9:59 AM resident #16 said it took more than ½ hour to get assistance with getting off the bedpan. 7. Resident #32 was admitted to the facility on [DATE] and readmitted from acute care hospital on 4/18/18 with diagnoses including muscle weakness, urinary tract infection, epilepsy, sepsis, dysphagia (difficulty swallowing), and congestive heart failure. Review of the MDS assessment, dated 2/18/18 revealed she was cognitively intact, needed 1-2 person extensive assistance to total dependence with transfers, eating, toilet use, personal hygiene and bathing. She was occasionally incontinent of bowel and had an indwelling urinary catheter. On 4/24/18 at 12:36 PM resident #32's granddaughter said she visited every week. She stated the facility needed more staff as her grandmother had to wait for long periods when she needed care. On 4/25/18 at 1:47 PM resident #32 was in her room and a family member was visiting. The family member stated that the facility was under staffed and the resident had to wait a long time for a bed pan or to be transferred. The family member stated that the resident required a mechanical lift for transfers. If the staff took too long, she had retrieved the mechanical lift herself then staff intervened. She stated the nurses at this facility only passed medications and did not answer the call lights. She stated that today was a surprise as a lot of staff were helping in the dining rooms. This was not usual and she attributed the increase of management staff on the units to the survey being conducted. She also stated that there was a group of resident in the courtyard this afternoon which was very unsual. 8. Resident #74 was admitted to the facility on [DATE] and readmitted from acute care hospital on [DATE] with diagnoses including gastroenteritis and colitis, abdominal/shoulder/leg pain, coronary artery disease and anxiety. Her MDS assessment dated [DATE] indicated she had moderate cognitive impairment, needed extensive 2 person assistance with bed mobility, transfers, toilet use and personal hygiene. She needed limited 1 person assistance with eating and was totally dependent on 2 persons for bathing needs. She was always incontinent of bladder and occasionaly incontinent of bowel. On 4/23/18 at 2:24 PM resident #74 stated it took a long time to get help when she pressed the call light. It sometimes took more than 30-45 minutes especially from Friday night to Monday morning. She had spoken with the nurses regarding her concerns but no one had followed up with her. When the CNA finally answered the call light she arrived with an attitude. The staff told me they were short-staffed. 9. Resident #92 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, hemodialysis, and benign prostatic hyperplasia (BPH) with urinary symptoms. Review of resident #92's most recent MDS assessment dated [DATE] indicated that he had severe cognitive impairment, needed extensive 1-2 person assist with bed mobility, transfers, dressing, eating, toile use, personal hygiene and bathing. He was occasionally incontinent of bladder and bowel. On 4/23/18 at 10:08 AM an interview was conducted with resident #92's daughter who said that it took 30 minutes or longer for staff to respond to call lights. The facility needed more staff. The other week the CNA claimed that she gave my Dad a shower but she didn't as he was wearing the same clothes as the day before. The daughter said she spoke to the DON this past Sunday regarding her concerns and the need for more staff. 10. Resident #51 was admitted to the facility on [DATE] with diagnoses including urinary tract infection, atrial fibrillation (irregular heartbeat), diabetes, neuromuscular dysfunction of the bladder and diabetic neuropathy. Resident #51 had his most recent MDS assessment completed on 3/3/18 which indicated that he was cognitively intact, needed extensive 1-2 person assistance with his activities of daily living, supervision with eating and totally dependent for bathing. He was always incontinent of bowel and had ostomy or indwelling catheter for urinary. On 4/23/18 at 4:10 PM resident #51 said, staff did not answer call lights timely especially during meals. He had to wait over an hour to get help with incontinence care. 11. Resident #3 was admitted to the facility on [DATE] from an acute care hospital with diagnoses including weakness, repeated falls, cerebrovascular disease, chest pain, difficulty walking, and fibromyalgia. Review of resident #3's MDS assessment dated [DATE] revealed that she was cognitively intact, needed limited to extensive assistance of 1-2 persons with all her ADLs and bathing. She used a wheelchair for locomotion and was occasionally incontinent of bladder and bowel. On 4/24/18 at 3:25 PM resident #3 said that there was not enough staff especially on the weekend. I try not to bother them. The resident indicated that she needed help to go to the bathroom but sometimes the staff were too busy so she had to go by herself. She was aware that she should call for assistance but stated she had no choice. 12. On 4/25/18 at 12:10 PM registered nurse (RN) O said that her assignment consisted of 18-21 residents and that the staffing was dependent on the census. When asked if the assignment was ever reduced due to high resident care needs and higher acuity, she stated no. She said that 2-3 of her residents today were higher acuity, needed frequent monitoring related to high fall risk. RN O indicated that when she had residents with increased care needs such as extensive wound care, she was not able to get her work done on time. She stated, there was high expectation of nurses to do wound care, round with physicians, pass medications, do treatments, and answer the phones. They did not have a desk nurse on the unit. She was sometimes not able to get her work done and left work for the next shift, such as wound care or unfinished admission paperwork. When asked how often bed bound residents or residents with pressure wounds should be checked, turned and repositioned, she said that they should be turned at least every 2 hours. Although she was aware that this was not being done due to workload. She said staff do call out a lot and occasionally they were able to find replacement. This is why staff had to float and therapists were doing CNA work last week. Every day I could stay past my shift up to 2 ½ hours however I was told by the staffing coordinator to get out or I will get written up. On 4/25/18 at 1:06 PM LPN J said that she worked on the 7 AM-3 PM shift. Her usual assignment was 18-24 residents. The only time her assignment had less residents was when the census was low. She stated that staffing was based on census. On 4/25/18 at 11:58 AM LPN A verified that she worked the 7 AM-3 PM shift and sometimes the 3 PM-11 PM shift. She said that her typical assignment was 18 residents. Approximately 1/3 of her residents required extensive to total assistance from staff with their ADLs. She had 2 residents who had frequent falls and required more supervision. LPN A said that 18 residents was the normal no matter their acuity. She said that they moved the CNAs around a lot and she always worked with different CNAs. She stated, consistent staff would be better for residents to have more continuity of care. On 4/25/18 at 8:35 PM LPN U from the 11 PM-7 AM shift was interviewed by phone. She stated the number of assigned residents did not change no matter the acuity. They had call outs at least once per week on the night shift and most staff worked extra shifts. On 9/25/18 at 8:51 PM a telephone interview was conducted with CNA W. She verified that she worked the night shift from 11 PM to 7 AM. Her usual assignment consisted of 12 to 20 residents. She said that they had been getting increased call outs, several every week. When asked about how often she checked, repositioned and turned her residents, she stated every 4 hours. On 4/26/18 at 3:16 PM the staffing coordinator said that she was a CNA and had been doing this positon for a month. She was asked what the facility process was for maintaining sufficient staffing to meet the needs of the residents. She said that on the 7-3 shift the had 9-10 nurses and 14-15 CNAs depending on the census. She stated that staffing was based solely on census. She said, if the census goes up I try to add staff. She verified that staffing was based on census and regulation of 2.5 hours per resident per day for a CNA. The staffing coordinator said that the CNAs should have 8-10 residents on the day and evening shifts and 13 residents on the night shift. She was asked what algorithm was used to determine staffing and she said staffing by labor hours and the census. When asked if there were any other factors used to determine how the facility was staffed and she said no. She said the bottom line was 10 residents per CNA on the day and evening shift with up to 13 on the night shift. She stated that she gets the schedule approved by the DON. The DON directs her to reduce or add more staff based on the census. The staffing coordinator said that the schedule is prepared in advance for 6 weeks. They need a total of 6 nurses on the medication carts, 2 unit managers and a discharge nurse. The discharge nurse's hours are calculated into the patient per day (PPD) although she does not work on the cart or had a resident assignment.

Based on observation, interview and record review the facility failed to follow the menu for residents on puree diets. Findings: Review of the facility's menu revealed that on 4/26/18 the lunch meal consisted of fried chicken, mashed potatoes, gravy, green beans, biscuit and frosted cake. On 4/26/18 at 11:00 AM the cook was putting pans of food on the steam table. This facility had residents that required their food to be pureed. Observations of the steam table revealed that all pureed foods were on the steam table except for the pureed bread/biscuit. After the food holding temperatures were taken, the tray line started. Staff were observed sending out pureed meals without the pureed bread. At 11:50 AM the cook stated she did not make the pureed bread because she did not have time. At this time, the Certified Dietary Manager could not explain why the cook did not have enough time to make the pureed bread.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow proper infection control practices to prevent the development, transmission and potential spread of infections for 2 of 4 residents reviewed for isolation precautions, (#60 & #1). Findings: 1. Resident #60 was admitted to the facility on [DATE] then readmitted on [DATE] with diagnoses of recurrent Enterocolitis due to Clostridium Difficile Toxin (CDT), muscle weakness, dementia, and abdominal pain. Clostridium difficile (also called C. difficile) are bacteria that can cause swelling and irritation of the large intestine, or colon. This inflammation, known as colitis, can cause diarrhea, fever, and abdominal cramps. Colitis caused by C. difficile can be mild or serious. (www.webmd.com). Review of the hospital history and physical dated 3/26/18 revealed resident #60 was brought to the emergency room from the facility due to abdominal pain and had a positive stool culture for CDT. She was admitted for further evaluation and treatment. On 4/23/18 at 12:14 PM, observed resident #60 in her room. There were no indications on the resident's room door of any isolation precautions. There was not any notice posted outside of the resident's room for visitor/staff to check with the nurse before entering the room and there was no Personal Protective Equipment (PPE) cart outside/or inside her room. Personal protective equipment (PPE) refers to protective clothing, helmets, gloves, face shields, goggles, facemasks and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness. (https://www.fda.gov/medical). On 4/23/18 at 1:05 PM, observed resident #60 in her room, in bed, incontinent of watery brown foul smelling stool that was coming out the edges of her brief and onto the sheets. Surveyor notified Licensed Practical Nurse (LPN) A that the resident needed assistance. Resident #60 was confused and not able to call for assistance or use her call light. LPN A said she would get the Certified Nursing Assistant (CNA) to come and clean up the resident. LPN A and CNA Q were observed going into the resident's room to give care and they were not wearing gowns and there was not any PPE outside the resident's room at this time. On 4/23/18 at 1:47 PM, CNA Q who was assigned to resident #60's care said the resident had 3 loose stools on the prior shift and 2 on her shift today. On 4/23/18 at 1:50 PM, LPN A who was assigned to the resident's care today verified that the resident was not on isolation precautions as evidenced by no sign on the interior/exterior door or PPE cart outside of her room. The nurse said she was going to call the physician to report that resident #60's stool result was positive for CDT. On 4/23/18 at 1:55 PM, Unit Manager (UM) B verified that the resident was not currently on contact isolation precautions. She had labs ordered on 4/20/18 for stool for CDT and should have been placed on isolation at that time because she was having diarrhea. Review of resident #60's medical record revealed that from 4/18/18 to 4/23/18 she was incontinent of multiple (3-5) episodes of loose stools daily. A physician order dated 4/20/18 for stool specimen for C difficile was noted in the medical record. The facility did not place implement transmission based precautions until the afternoon of 4/23/18. A stool culture that was obtained on 3/22/18 did reveal positive result for CDT. On 4/23/18 at 4:15 PM, observed that resident #60 did have sign posted on the interior door for Contact Precautions. There was not any notice posted on the outside of the resident's room for visitor/staff to check with the nurse before entering the room. Review of the facility policy for Transmission based Precautions and Isolation Procedures last revised 11/28/16 revealed, Purpose is to minimize risk of spread of infections between facility patient and or/associated .If an order has not been written, patients suspected of an isolatable condition are isolated on advice of the infection control nurse until an appropriate order by the physician is obtained .Contact precautions are used for diseases transmitted by contact with the patient or the patient's environment by direct or indirect contact .Contact Isolation Procedure: Stop sign on door .PPE: wear gown and gloves on room entry .Gowns/protective apparel-if contact with infectious material is anticipated. Review of the facility policy for Clostridium Difficile revised 4/2017 revealed, It can be spread from person to person .Contact Precautions: Residents with diarrhea caused by C. difficile should be assigned to a private room .A gown is needed to enter the room of a resident who has diarrhea caused by C difficile . On 4/24/18 at 1:07 PM the Assistant Director of Nursing (ADON) said, resident #60 was having 3-6 loose incontinent stools per day since return from the hospital on 4/5/18 and we had not place her on isolation precautions when she returned. The ADON was asked what the Center for Disease Control (CDC) guidelines were regarding CDT. She stated that best practice would have been to place her on contact precautions on 4/20/18 when she was symptomatic (having loose stools) and the physician had ordered a stool culture. The CDC CDT precautions revealed, Use Contact Precautions: for patients with known or suspected Clostridium Difficile infection: Place these patients in private rooms. Use gloves when entering patients' rooms and during patient care. Perform Hand Hygiene after removing gloves. Use gowns when entering patients' rooms and during patient care. (https://www.cdc.gov/hai/organisms/cdiff). 2. On 4/26/18 at 10:00 AM, during a medication administration observation of resident #1 with LPN F, the resident was noted to be on contact isolation in a private room. LPN F stated at this time that the resident was on contact isolation for Clostridium Difficile infection. LPN F stated that she needed to take the resident's blood pressure prior to giving the blood pressure medication. She put on gloves and gown, and rolled a multi-resident vital sign machine into the resident's room. She placed a disposable blood pressure cuff onto the non-disposable multi resident use vital sign machine and proceeded to take the resident's blood pressure who was resting in bed. The cords to the vital sign machine and blood pressure cuff hung down and made contact with the resident's bed linens as she did so. At 10:20 AM, after completing the medication pass, RN O came into the room and wiped the machine down with germicidal disposable wipes. The large 5 black wheels located at the bottom of the electronic vital sign machine were not cleaned. Review of the germicidal wipes disinfection instructions revealed that it did not kill C-Diff. RN O validated these findings. She requested housekeeping come and clean the machine. At 10:30 AM, housekeeper CC came and wiped down the machine with bleach germicidal disposable cloth wipes. The canister disinfection instructions revealed that it killed the C-Diff organism, but the surface to be sanitized had to be visibly wet for four minutes. The housekeeper did not keep the whole machine with all its moving parts visibly wet for four minutes. She wiped the wheels but they were not kept continuously wet for four minutes. Review of resident #1's orders validated that she had been placed on contact isolation by the physician for C. Diff on 4/20/18. On 4/26/18 at 4:15 PM, the director of nursing stated that taking the multi-patient rolling electronic vital sign machine into a contact isolation room with C-Diff was not normal practice. She stated that the central supply person had ordered the wrong disposable blood pressure cuffs and the nurse had brought the electronic vital sign machine into resident #1's room in error. Review of the facility's policy and procedure for Clostridium Difficile revealed the following: Items such as stethoscope, sphygmomanometer (blood pressure equipment), and rectal thermometer are dedicated to use on that resident only.