**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, record review, and review of the facility's policy titled, System Policy and Procedures Advance Directives, the facility failed to ensure they had a copy or had followed up to obtain the Advanced Directive for one out of 24 residents reviewed in the initial pool (Resident (R) R80). R80's Family Member (F)80 indicated, at the time of admission, that they had R80's advanced directive documentation; however, did not bring it into the facility at the time of admission. Findings include: Review of the facility policy titled, System Policy and Procedures Advance Directives dated August 2021 revealed, If a patient has an Advance Directive, but does not present the document upon admission, Facility personnel encourage the patient, or his or her representative, to provide a copy as soon as possible .In addition, the Facility personnel member includes a reminder in the patient's medical record which indicates that the patient should be further queried as to whether he/she wishes to provide a copy of the Advance Directive to the Facility .All copies of Advance Directives and any amendments thereto remain in the patient's medical record. Review of the undated Face Sheet provided by the facility revealed R80 admitted to the facility on [DATE]. F80 was designated as R80's emergency contact. Review of R80's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/14/2024 in the electronic medical record (EMR) under the MDS tab revealed R80 was intact in cognition with a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating cognitively intact. Review of the Advance Directive Questionnaire dated 8/12/2024 and signed by F80 provided by the facility revealed, I have executed an advance directive and will provide a copy to (Facility name) personnel as soon as possible. I understand that the staff and physicians of (Facility name) will not be able to follow the terms of my advance directive until I provide them a copy. Review of R80's EMR revealed no advanced directives document in the record. Review of the care plan dated 8/13/2024, and provided by the facility, identified the problem area of Advance Directives. The goal was, Full code will be honored, and intervention, No Advance Directive on file. Review of the Long Term Care Forms Social Service Assessment dated 8/16/2024 and provided by the facility revealed, Advance Directive: No, Family or Rep Notify . No. All social service documentation was requested following admission. There was no documentation provided showing the Social Service Coordinator (SSC) had followed up with the family to obtain R80's advance directive. Interview on 9/12/2024 at 3:59 pm, the SSC revealed the admission Director typically obtained residents' advanced directives documentation on admission, and the admission Director would give her a copy. The SCC revealed when she completed her admission assessment, she followed up if advanced directives had not been provided. The SCC revealed all residents were designated full code (resuscitate in the event their heart stopped beating/they stopped breathing) until advanced directives were provided or completed. The SCC verified there was no advanced directive provided or completed for R80 and stated she had not followed up with F80 to bring the advanced directive to the facility. Interview on 9/12/2024 at 4:27 pm, the admission Director revealed when residents were admitted to the facility, the Advance Directive Questionnaire was completed. The admission Director said she asked the resident or responsible party if there were any advanced directives and to provide them at that time. The admission Director stated if there was an advanced directive, but it was not provided at admission, she would ask them to bring it to the facility. The admission Director revealed she did not follow up after that and that the SSC was responsible for following up. Interview on 9/13/2024 at 3:07 pm, R80 revealed that F80 assisted with the completion of paperwork when she was admitted to the facility. R80 stated she was not sure about what advanced directive was in place and indicated she deferred the decision whether to be resuscitated to F80. Interview on 9/13/2024 at 5:40 pm, the Administrator verified the staff should follow up to obtain copies of the advanced directive if they were not provided at admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and review of the facility's policy titled, Compliance Investigations, the facility failed to protect the resident's right to be free from physical abuse by another resident for one of two residents (R) (R22) reviewed for abuse. Specifically, R22 alleged she was slapped hard on the hand by Certified Nurse Assistant (CNA) 1 and the allegation was substantiated by the facility, resulting in CNA 1's termination of employment. Findings include: The facility's Abuse Prevention Policies were requested on 9/13/2024. The facility provided a system wide policy titled Compliance Investigations dated 1/1/2020 addressed the provider system's investigations into potential compliance concerns. The policy did not address expectations related to prevention of abuse in neglect in the long-term care setting. Record review of R22's admission Record. dated 9/12/2024 provided by the facility indicated the resident was admitted to the facility on [DATE] with diagnoses including but not limited to history of stroke. Review of R22's admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 6/18/2024 indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. Review of R22's significant change in status MDS with an ARD of 8/6/2024 and found in the EMR under the MDS tab, indicated a BIMS score of one out of 15, which indicated the resident was severely cognitively impaired. Review of R22's care plan, updated 8/12/2024 indicated R22 had difficulty communicating due to her history of stroke. Interventions included speaking slowly, clearly, and concisely with the resident. The care plan indicated R22 had no behaviors exhibited. Review of the facility's Incident and Accident Log dated 3/1/2024 to 9/13/2024 revealed an incident of potential staff to resident abuse reported by R22 on 9/3/2024. The facility's Incident Report dated 9/3/2024 related to R22's report of potential physical abuse indicated, Resident reported staff was rough during care and would not stop when she was yelling help. She (R22) revealed CNA 1 was loud talking to her and that she slapped her on the hand. Resident stated she stayed awake because she did not know if the CNA would going to [sic] come back and smother me with a pillow. Review of the facility's document titled, Patient Relations dated 9/10/2024 provided by the facility indicated, Narrative description: On the afternoon of 9/3/2024, I visited with (R22) in her room. She told me she was feeling down because of an incident that occurred the night before. She told me that a CNA came into her room and slapped her on the hand when (R22) tried to tell her that she was hurting her. She stated to me She hit me! and She came in the room angry like she was trying to provoke me. R22 also told me that she was scared of this CNA and tried to stay awake all night because she was afraid the CNA will smother me. The document indicated CNA 1 had been suspended on 9/3/2024 pending results of an investigation into the incident and had been terminated related to the investigation on 9/9/2024. Review of the investigation summary related to R22's allegation of potential physical abuse indicated, Conclusion: As a result of the investigation on September 3, 2024, it was determined that the CNA's behavior and actions were not appropriate, and the CNA (CNA 1) was suspended until further notice. After review of the investigation and interview with the Resident and in coordination with Human Resources, CNA 1 will be terminated. Interview on 9/13/2024 at 11:30 am, R22 confirmed she reported the incident during which CNA 1 allegedly slapped her on the hand and stated, She was really rough with me. I was afraid of her. When she hit me, she didn't hit me easily. She hurt me. I was stunned. I was really afraid. Interview on 9/12/2024 at 3:28 pm the Director of Nursing (DON) confirmed R22's reported allegation of abuse and confirmed CNA 1 had been terminated related to the incident. Interview on 9/12/2024 at 3:34 pm with the health care system's Risk Manager, he confirmed he was responsible for investigating incidents system wide and confirmed CNA 1's employment had been terminated at the conclusion of his investigation into the event.

Based on review of facility policy and interviews, the facility failed to ensure policies were in place to comprehensively address abuse prevention and investigation in the healthcare system's long-term care facility. The healthcare system's policies and procedures utilized to direct the facility's prevention and investigation of abuse did not specifically incorporate elements of the long-term care regulation set related to abuse/neglect. Findings include: The facility's Abuse Prevention Policies were requested on 9/13/2024. The facility provided a system wide policy titled, Compliance Investigations dated 1/1/2020 and addressed the provider system's reporting of potential compliance concerns. The policy did not address expectations related to prevention of abuse and neglect in the long-term care setting, such as the mandatory vetting of staff members prior to hire or the recognition of abuse, nor did it address the specific long-term care requirements related to the investigation of allegations of potential abuse. Interview with the Heath System's Compliance and Accreditation Manager on 9/13/2024 at 10:50 am, she provided the health system's Compliance Investigations Policy and stated the policy was the only policy being utilized related to abuse in the facility. She confirmed the policy only addressed the reporting of potential abuse/timeframes based on the healthcare system's timeframes and did not address the facility's expectations or procedures related to the prevention of abuse, the vetting of staff, staff recognition of abuse, or the elements of an investigation of potential abuse in the long-term care setting. Interview with the Director of Nursing (DON) on 9/13/2024 at 3:29 pm, she stated she thought the facility had old policies and procedures related specifically to the prevention and investigation of abuse in long-term care somewhere, however there had been a push to try to merge the facility's long-term care policies together with the healthcare system's hospital policies related to risk management. The DON stated, We need our own policies and procedures (related to abuse). The DON confirmed the current policies and procedures being utilized by the facility were related to Risk Management rather than to elements required per the long-term care regulation set.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, review of the facility's abuse policies, and review of the facility's policy titled, Compliance Investigations, the facility failed to ensure an allegation of abuse by one resident (R) (R22) of two residents reviewed for abuse was thoroughly investigated. R22 alleged she was slapped hard on the hand by a Certified Nurse Aide (CNA) 1 and the investigation into the allegation did not include interviews with additional residents or staff members to ensure no other residents had been exposed to potential abuse by CNA 1. Findings include: The facility's Abuse Prevention Policies were requested on 9/13/2024. The facility provided a system wide policy titled, Compliance Investigations. The policy was dated 1/1/2020 and addressed the provider system's investigations into potential compliance concerns. The policy did not address expectations related to the investigation of allegation of potential abuse. Review of R22's admission Record. dated 9/12/2024 provided by the facility indicated the resident was admitted to the facility on [DATE] with diagnoses including history of stroke. R22's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/18/2024 and found in the EMR (electronic medical record) under the MDS tab, indicated a Brief Interview for Mental Status (BIMS)score of 14 out of 15, which indicated the resident was cognitively intact. R22's Significant Change in Status MDS with an ARD of 8/6/2024 and found in the EMR under the MDS tab, indicated a BIMS score of one out of 15, which indicated the resident was severely cognitively impaired. Review of the facility's Incident and Accident Log dated 3/1/2024 to 9/14/2024 revealed an incident of potential staff to resident abuse reported by R22 on 9/3/2024. Review of the facility's Incident Report, dated 9/3/2024 and related to R22's report of potential physical abuse indicated, Resident reported staff was rough during care and would not stop when she was yelling help. She (R22) states CNA was loud talking to her and that she slapped her on the hand. Resident stated she stayed awake because she did not know if the CNA would going [sic] to come back and smother me with a pillow. Review of the facility's investigation into R22's allegation of potential physical abuse revealed interviews had been conducted with R22 and CNA 1 related to the reported abuse, however the investigation file did not include any documentation to show interviews had been conducted with other residents in the facility to ensure no additional residents had been abused by CNA 1, nor did it include interviews with staff familiar with CNA 1 to ensure staff had not observed or received any reports of abusive behavior by CNA 1. Interview with the Director of Nursing (DON) on 9/12/2024 at 3:28 pm, revealed the facility did not have a designated abuse coordinator. She stated all potential abuse was reported to the health system's Risk Manager and the Risk Manager conducted all investigations. The DON stated the Risk Manager spoke with R22 as well as CNA 1 during the investigation, but she was not aware of whether he interviewed any additional staff or residents related to R22's allegation of abuse. Interview with the Risk Manager on 9/12/2024 at 3:34 pm, he confirmed he conducted the investigation into R22's allegation of potential abuse by CNA 1. He confirmed he interviewed R22 and CNA 1 during his investigation and stated he also obtained information about R22 from the resident's primary nurse, reviewed the facility's grievances, reviewed R22's medical record, completed a physical assessment of R22, and had R22 demonstrate to him how she had been slapped. The Risk Manager revealed he had not obtained statements from additional residents or staff members related to the allegation to ensure no further abuse had occurred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of the facility's policy titled, System Policy and Procedures Behavioral Health, the facility failed to ensure one of three residents (R) (R36) who was reviewed for Pre-admission Screening and Resident Review (PASARR) services was referred to the state-designated authority for Level II PASARR after a new mental illness diagnosis of schizoaffective disorder was added during her stay. Findings include: Review of the facility's policy titled, System Policy and Procedures Behavioral Health dated 1/30/2023 and provided by the facility revealed, [Facility name] staff reviews admission orders, history and physical, consultation report, as well as Pre-admission Screening and Resident Review (PASARR) recommendations for diagnosis of mental disorder or psychosocial adjustment difficulty. When diagnosis is indicated, appropriate services and treatment are provided. Review of the untitled, undated admission record provided by the facility revealed R36 was admitted to the facility on [DATE]. Review of the PASARR Level I Assessment dated 11/3/2022 and provided by the facility revealed R36 had no serious mental illness diagnosis at the time of admission. Review of the Annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/3/2023 in the electronic medical record (EMR) under the MDS tab revealed R36 had diagnoses including anxiety disorder, schizophrenia, and dementia. Section C reported a Brief Interview for Mental Status Score (BIMS) of two out of 15, which indicated the resident's cognition was severely impaired. Review of the Quarterly MDS with an ARD of 7/31/2024 in the EMR under the MDS tab revealed R36 had a BIMS score of six out of 15, which indicated severely impaired in cognition. Review of a psychiatry Office Clinic Note dated 1/11/2023 and provided by the facility revealed R36 saw a psychiatrist on this date and a diagnosis of schizoaffective disorder was initiated. The note read, She does report long history of mental health issue. Speaks of when she first began seeing psychiatrist in [location]. They told me then, sometimes my mind will be okay and sometimes it won't. Speaks of a time when she had to go get shots to calm me down. Unable to give any specific detail about this .Evidence of paranoia noted . Acting out with staff at times, refusing care, can be difficult to redirect . Interview on 9/12/2024 at 1:59 pm, Registered Nurse (RN) (RN 1) revealed a psychiatrist started seeing R36 on 1/11/2023 and a diagnosis of schizoaffective disorder was added at that time. Interview on 9/12/2024 at 3:51 pm, the Social Services Coordinator (SSC) revealed that when there was a mental illness diagnosis, the facility should request a PASARR Level II. The SCC stated she did not have access electronically to request PASARRs. The SSC stated she could not see the PASARRs; however, if she had been aware of R36's schizoaffective disorder diagnosis added after admission, that would have been a trigger to request a PASARR Level II. The SSC stated other staff such as the Admissions Director had access and could request PASARR Level II. Interview on 9/13/2024 at 10:13 am, the Compliance and Accreditation Manager revealed R36 had not been referred to the state-designated authority for Level II PASARR after the mental illness diagnosis of schizoaffective disorder was added. Interview on 9/13/2024 at 5:42 pm, the Administrator stated R36 should have been referred for a PASARR Level II once the schizoaffective disorder diagnosis was added.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to implement the comprehensive care plan for three residents (R) (R35, R71 and R25) of 21 sampled residents. Specifically, the failure created the potential for R25 to have inadequate care for an indwelling urinary catheter, and R35 and R71 to have inadequate care for edema in their lower extremities. Findings include: 1. Review of R35's undated Face Sheet provided by the Director of Nurses (DON) revealed R35 was admitted on [DATE] with diagnoses of combined systolic and diastolic heart failure and vascular dementia. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/12/2024 located under the Resident Assessment Instrument (RAI) tab revealed a Brief Interview for Mental Status (BIMS) score of seven out of 15 which indicated R35 was severely cognitively impaired. Review of R35's Physician Orders, provided by the DON, revealed an order dated 4/24/2024 for Above the knee Grad Compression Stocking. Review of R35's Care Plan, dated 8/22/2024 provided by the DON, revealed a problem of Fluid volume excess, with a goal to remain free of edema. The interventions included, .compression stockings as ordered; elevate extremities if edema present. Observations of R35 on 9/10/2024 at 11:24 am; 9/10/2024 at 3:46 pm; 9/11/2024 at 8:53 am; 9/11/2024 at 5:00 pm; and 9/13/2024 at 9:04 am revealed the compression stockings had not been put on the resident. Interview on 9/11/2024 at 5:00 pm, Licensed Practical Nurse (LPN2) confirmed R35 did not have TED (thrombo-embolic deterrent) hose (compression stockings that help prevent blood clots in the legs) on and stated, They may be in the laundry. I don't know if he has a second pair. Interview on 9/13/2024 at 9:12 am, LPN 1 confirmed R35 was not wearing TED hose and stated, They had to be put in the laundry, and we have only one pair. 2. Review of R71's undated Face Sheet, provided by the DON, revealed R71 was admitted on [DATE] with diagnosis chronic systolic congestive heart failure. Review of R71's annual MDS with an ARD of 7/23/2024 revealed a BIMS score of 10 out of 15 which indicated R71 had moderate cognitive impairment. Review of R71's Physician Orders, provided by the DON, revealed an order, dated 7/12/2024, for Above the knee grad (graduated) compression stockings, wear in the daytime, may remove at night. Review of R71's Care Plan, dated 6/20/2024, provided by the DON, revealed a problem of Fluid volume excess, with a goal to remain free of edema and have a decrease in fluid overload. The interventions indicated, .graduated compression stockings (TED hose) to be worn daily, may be removed at night. Observations of R71 on 9/10/2024 at 12:12 pm; 9/10/2024 at 2:17 pm; 9/11/2024 at 9:20 am; and 9/11/2024 at 4:45 pm revealed R71 was not wearing his compression (Ted hose) stockings. During an interview on 9/11/2024 at 5:04 pm, R35's physician stated, I do expect both residents to have them (TED hose) on when I order them. Interview on 9/13/2024 at 3:25 pm, the DON stated, We follow the physician's orders. We have extras [NAME] hose, so we don't need to order another pair of [NAME] hose for either resident. 3. Review of the undated Face Sheet provided by the facility revealed R25 was admitted to the facility on [DATE]. Review of R25's admission MDS with an ARD of 8/26/2024 and provided by the facility revealed R25 was moderately impaired in cognition with a BIMS score of 11 out of 15. The MDS assessment also documented R25 utilized an indwelling urinary catheter. Review of All Active Orders dated 8/23/2024 through 9/12/2024 and provided by the facility revealed, Urinary Catheter Care LTC (Long Term Care) (Foley Care LTC) every 12 hr. (hours). The frequency that nurses were to change the indwelling urinary catheter was not documented in the orders. Review of the Care Plan dated 8/28/2024 and provided by the facility revealed a problem of LTC Urinary Incont (incontinence) indwelling cath [catheter]. The goal was, Optimal level of bladder function without complications. Interventions were in pertinent part, .Check urinary bag for proper placement, Change catheter according to MD (Medical Doctor) orders. Observation and interview on 9/10/2024 2:41 pm and on 9/11/2024 at 4:58 pm, R25 was in bed and her catheter bag was wrapped in a sheet and lying directly on the floor near the bed. R25 revealed she did not know how long it had been on the floor. During an observation and interview on 9/11/2024 at 5:00 pm, Registered Nurse (RN) 2 entered R25's room and verified the catheter bag and tubing were lying directly on the floor. RN 2 stated the catheter bag should not be on the floor due to the possibility of infection, and it could be stepped on and pulled out. Interview on 9/13/2024 at 11:44 am, RN 2 verified there were no physician's orders specifying when the indwelling urinary catheter should be changed even though the care plan directed changing it in accordance with physician's orders. Interview on 9/13/2024 at 4:55 pm, the DON revealed staff knew the catheter bag and tubing should be below the bladder but not placed directly on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, and record review, the facility failed to ensure one of one resident (R) (R25) reviewed for indwelling urinary received appropriate care and services to prevent urinary tract infections (UTI). Specifically, there was no physician orders for the size of the indwelling urinary catheter and how often to change it and R25's catheter and/or tubing were observed resting on the floor for three out of four days of the survey. These failures created the potential for R25's catheter to become dislodged and for R25 to get a UTI. The sample size was 31 residents. Findings include: Review of the undated Face Sheet provided by the facility revealed R25 was admitted to the facility on [DATE]. Review of R25's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/26/2024 and provided by the facility revealed R25 was moderately impaired in cognition with a Brief Interview for Mental Status (BIMS) score of 11 out of 15. During an interview on 9/12/2024 at 12:38 pm, the Medical Director, who was also R25's attending physician, revealed he was not sure why R25 had a catheter. The Medical Director stated the rationale for the catheter was likely in the History and Physical (H & P) note. Review of the Physician's History and Physical Consultation Note dated 8/23/2024 and provided by the facility revealed, No dysuria [painful or uncomfortable urination] or frequency. Foley catheter in place for some reason. The rationale/diagnosis was not documented. Review of All Active Orders dated 8/23/2024 through 9/12/2024 and provided by the facility revealed, Urinary Catheter Care LTC [Long Term Care] (Foley Care LTC) every 12 hr. [hours]. Specific information such as the size of the catheter, frequency nurses were to change the catheter, or whether urinary output should be monitored was lacking. The reason for use of the catheter was not documented. Review of the Care Plan dated 8/28/2024, provided by the facility, revealed a problem of LTC Urinary Incont [incontinence] indwelling cath [catheter]. The goal was, Optimal level of bladder function without complications. Interventions indicated, Eval [Evaluate] for symptoms of UTI. Promote hydration, proper cleansing. Check for physician diagnosis of urinary retention or other medical justification for use of continuous foley. Anchor drainage tube of foley to prevent tension. Check urinary bag for proper placement. Change catheter according to MD [Medical Doctor] orders. During an interview on 9/10/2024 at 2:41 pm, R25 stated she did not know why she had the catheter, and she had not used one at home prior to admission. During an observation and interview on 9/10/2024 2:41 pm and on 9/11/2024 at 4:58 pm, R25 was lying in bed and her urinary catheter bag was wrapped in a sheet and the catheter bag and tubing were lying directly on the floor near the bed. R25 stated she did not know how long it had been on the floor. During an observation on 9/11/2024 at 5:00 pm, the Registered Nurse (RN)2 entered R25's room and verified the catheter bag and tubing were lying directly on the floor. RN2 stated there was usually a hook for the catheter bag so it could be hung on the bed frame; however, she stated she did not see a hook as she looked under the bed. RN2 stated R25 would not have been able to put the bag on the floor. RN2 stated that Certified Nursing Assistants (CNAs) were responsible for securing the bag. RN2 stated the catheter bag should not be on the floor due to the possibility of infection, and it could be stepped on and pulled out. During an interview on 9/11/2024 at 5:13 pm, CNA4 stated she was assigned to R25, and the catheter had been hooked on the side of R25's bed earlier. CNA4 stated, It must have fallen off. CNA4 stated the catheter bag, and tubing should not be on the floor. CNA4 verified R25 would not have been able to put the catheter bag on the floor herself. During an observation on 9/13/2024 at 10:05 am, R25 was seated in her wheelchair in her room. The catheter bag was in a privacy bag attached to the chair; however, the tubing was resting on the floor. During an observation and interview on 9/13/2024 at 10:28 am to 10:34 am, the Compliance and Accreditation Manager stated the facility did not have a policy and procedure for catheters. During the observation of R25's catheter tubing on the floor while R25 was in the wheelchair, the Compliance and Accreditation Manager verified the tubing was resting on the floor. During an interview on 9/13/2024 at 11:44 am, RN2 verified there were no physician's orders specifying when the catheter should be changed. RN2 stated the physician's order should document the size of the catheter and when it should be changed. RN2 stated R25 had an appointment on 9/18/2024 to see a urologist and that was why no attempt had been made in the facility to remove the catheter. RN2 stated the catheter had been inserted in the hospital prior to the resident's admission to the facility and an attempt had been made in the hospital to remove it. RN2 stated there was hospital documentation that indicated R25 had urinary retention and obstruction. Review of the hospital Insert Urinary Catheter (Order [number]) dated 8/19/2024 and provided by RN2 revealed, Indicate reason for foley. Urinary retention, obstruction or training. During an interview on 9/13/2024 at 4:55 pm, the Director of Nursing (DON) stated staff knew the catheter bag and tubing should be below the bladder but not directly on the floor. The DON stated the catheter bag should be hung, in a privacy bag, and the catheter bag should have a hook on it. The DON verified there should be an order for the size of the indwelling urinary catheter and how often to change the catheter as well as the reason for the catheter's use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, record review, and review of the facility's policy titled, Bed Rail Policy, the facility failed to ensure one of three Residents (R) (R27) reviewed for accidents had been assessed for the use of bed/side rails, had physicians orders for the bed/side rails, a care plan, and an informed consent from the resident for the use of the bed/side rails. Specifically, R27 had bilateral 1/3 bed/side rails applied to his bed and his bed/side rail assessment, physician orders, and care plan did not accurately reflect the resident's use of the bed/side rails. This failure created the potential for the resident to be injured related to the potentially unnecessary bed/side rails on his bed. The sample size was 31 residents. Findings include: Review of the facility's policy titled, Bed Rail Policy dated 7/31/2023 under the section titled, Policy revealed, An evaluation for bed rail use and an entrapment assessment is completed before bed rails are applied .The risks, alternatives and benefits of bed rails are reviewed with the resident and his/her representative prior to use .Once consent is signed, staff obtain an order from the resident's physician for bed rail use .The resident's care plan is then updated by staff to include the use of bed rails. Review of R27's admission Record dated 9/13/2024 and provided by the facility indicated the resident was admitted to the facility on [DATE] with diagnosis of quadriplegia. Review of R27's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 7/12/2024 and found in the EMR under the MDS tab indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. The MDS indicated the resident was dependent upon staff to move in his bed and was dependent upon staff for transfers in and out of his bed. The assessment indicated R27 was not using bed/side rails on his bed. Review of R27's Physicians Orders, dated 9/13/2024 and found in the EMR under the Orders tab, indicated no orders for the resident's use of bed/side rails on his bed. Review of R27's comprehensive care plan dated 5/30/2024 and found in the EMR under the Care Plan tab did not indicate the resident's use of bed/side rails. Review of R27's EMR under the Assessment tab revealed the most recent Bed Rail Evaluation, was dated 8/9/2020 and indicated bed/side rails were in use for the resident for a sense of security. Review of R27's EMR revealed no documentation that the resident had been provided with information related to the risk and benefits of using bed/side rails and that the resident had given informed consent for the use of bed/side rails on his bed. Observation on 9/11/2024 at 9:45 am, on 9/12/2024 at 9:56 am, 11:22 am, and 5:17 pm, and on 9/13/2024 at 8:51 am revealed R27 was lying in his bed with bilateral 1/3 bed/side rails in the raised position at the head of his bed. Interview on 9/11/2024 at 9:45 am, R27 revealed he was not able to use his bed/side rails at all due to his quadriplegia and contractures to both of his hands/arms. He confirmed he was not able to move at all on his own and was completely dependent upon staff for mobility. Interview with the Compliance and Accreditation Manager on 9/13/2024 at 10:17 am, she confirmed that R27 did not have physician orders for the bed/side rails, the care plan did not indicate the use of the bed/.side rails, a recent bed/side rail assessment, and documentation that the resident had consented for the use of bed/side rails. She stated R27 was not supposed to have bed/side rails on his bed because he was unable to use them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interviews, record review, and review of the facility's arbitration agreement, the facility failed to ensure three of three Residents (R) (R25, R80, R44) reviewed for arbitration agreements had agreements in place that provided the resident/responsible party a period of 30 days to rescind the agreement after it was signed. The facility's arbitration agreement provided a period of 10 days to rescind the agreement which had the potential to affect all residents of the facility. In addition, R80 and R44 had not been educated regarding the arbitration agreements and were not aware the arbitration agreements had been signed by their family members. Findings include: Review of the facility's Conditions of Service and Consent for Treatment located within the admission Agreement included a section titled Agreement to Alternative Dispute Resolution, which was the facility's arbitration agreement. The document read, Patient agrees that any claim or dispute arising out of or related to the provision of health care services to Patient by [name of medical provider] . or their employees or agents, except as otherwise provided by herein, shall be resolved by final and binding arbitration . Patient is waiving right to Patient's right to a jury trial . Patient understands that Patient has the right to revoke this agreement no later than ten (10) days following signature . 1.Review of the untitled, undated admission record provided by the facility revealed R25 was admitted to the facility on [DATE]. Review of R25's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/14/2024 in the electronic medical record (EMR) under the MDS tab revealed R25 was intact in cognition with a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Review of R25's Agreement to Alternative Dispute Resolution dated 8/23/2024 revealed it was signed on 8/23/2014 by R25's family member (F)25. The agreement documented a 10-day period after being signed in which the agreement could be revoked. 2. Review of the untitled, undated admission record provided by the facility revealed R80 was admitted to the facility on [DATE]. Review of R80's admission MDS with an ARD of 8/14/2024 in the EMR under the MDS tab revealed R80 was intact in cognition with a BIMS score of 13 out of 15. Review of R80's Agreement to Alternative Dispute Resolution dated 8/12/2024 revealed the document was signed on this date by R80's family member (F)80. The agreement documented a 10-day period after being signed in which the agreement could be revoked. During an interview on 9/13/2024 at 3:07 pm, R80 was interviewed and stated she did not know anything about an arbitration agreement; however, she trusted F80 to sign documents on her behalf. 3. Review of the untitled, undated admission record provided by the facility revealed R44 was admitted to the facility on [DATE]. Review of R44's admission MDS with an ARD date of 8/30/2024 in the EMR under the MDS tab revealed R80 was intact in cognition with a BIMS score of 15 out of 15. Review of R44's Agreement to Alternative Dispute Resolution dated 8/12/2024 revealed the R44's document was signed on this date by F44. The agreement documented a 10-day period after being signed in which the agreement could be revoked. Review of R44's Georgia Advance Directives for Health Care dated 8/28/2024 and provided by the facility revealed R44 designated his spouse as health care agent in the event he could not or did not want to make decisions. F44 was back up agent number two. Interview on 9/13/2024 at 3:18 pm, R44 stated his wife and then daughters assisted him with making medical/legal decisions. R44 stated he did not know anything about an arbitration agreement being signed or in place, but it was okay if his family had signed it for him. Interview on 9/13/2024 at 3:20 pm, the Admissions Director verified that F44 was listed as the third decision maker after R44's spouse and daughters. During the interview, the Admissions Director stated the Agreement to Alternative Dispute Resolution was located within the admission Agreement under the Conditions of Service and Consent for Treatment and she reviewed it with the resident or the family member either before or at the time of admission. The Admissions Director stated if the resident could participate the resident signed it; otherwise, the family did. The Admissions Director verified the facility's arbitration agreement provided a 10-day period for revocation after it had been signed. The Admissions Director stated she implemented the hospital's arbitration agreement (part of the same organization) about two years ago and did not know the requirement was for a 30-day period to rescind the agreement. Interview on 9/13/2024 at 5:29 pm, the Administrator stated the arbitration agreement was hospital based and that was why the period to rescind was 10 days and not 30 days. The Administration stated he had not been aware of the discrepancy between the requirement for 30 days and the facility's policy of 10 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and review of the facility's arbitration agreement, the facility failed to ensure three of three Residents (R25, R80, R44) reviewed for arbitration had arbitration agreements in place that allowed for a mutually agreed upon arbitrator and venue for arbitration. The facility's arbitration agreement delineated the specific arbitrator that would be used. This deficient practice had the potential to affect all residents in the facility. Findings include: Review of the facility's Conditions of Service and Consent for Treatment located within the admission Agreement included a section titled Agreement to Alternative Dispute Resolution, which was the facility's arbitration agreement. The document read, The arbitration of any claim or dispute hereunder shall be administered by [name of organization] in Tifton, Georgia . 1.Review of the untitled, undated admission record provided by the facility revealed R25 was admitted to the facility on [DATE]. Review of R25's Agreement to Alternative Dispute Resolution dated 8/23/2024 revealed it was signed on 8/23/2024 by R25's family member (F)25. 2. Review of the untitled, undated admission record provided by the facility revealed R80 was admitted to the facility on [DATE]. Review of R80's Agreement to Alternative Dispute Resolution dated 8/12/2024 revealed the document was signed on this date by F80. The agreement documented the arbitration of any claim or dispute would be administered by [name of organization] in Tifton, Georgia. 3. Review of the untitled, undated admission record provided by the facility revealed R44 was admitted to the facility on [DATE]. Review of R44's Agreement to Alternative Dispute Resolution dated 8/12/2024 revealed the document was signed on this date by F44. The agreement documented the arbitration of any claim or dispute would be administered by [name of organization] in Tifton, Georgia. During an interview on 9/13/2024 at 3:20 pm, the Admissions Director verified the Agreement to Alternative Dispute Resolution identified the arbitrator that would be used, located in Tifton Georgia. The Admissions Director stated she implemented the hospital's arbitration agreement (part of the same organization) about two years ago and did not know the requirement for an arbitrator to be selected who was agreed upon by both parties and the requirement for an agreed upon venue/location. During an interview on 9/13/2024 at 5:29 pm, the Administrator stated the arbitration agreement was hospital based and that was why the arbitrator and venue were specified in the agreement. The Administrator stated he had not been aware of the discrepancy between the requirement for an agreed upon arbitrator and venue.

Based on observations, staff interviews, record review, and review of the facility policy titled, Storage of Medication (SHR), the facility failed to ensure that one resident of 18 residents (R15) was administered insulin that was not expired; failed to ensure that one resident of 18 residents (R16) had prescribed Novolog insulin available for coverage; failed to ensure that two of three medications storage room were free of expired medications. The facility census is 80. Findings include, Review of the facility policy Storage of Medication (SHR) dated October 23, 2023, Proacedure: The following procedure is used to store medications: 1. All medications and any components used in their preparation are labeled with the contents, expiration date and any applicable warnings. Those medications not previously labeled with an expiration date shall be labeled on the vial and not the box. 3. All expired, damaged, mislabeled, and/or contaminated medications are removed from the storage area for medications available for administration and stored separately. 5. When a multi-dose vial has been opened or accessed, the vial is dated and discarded within twenty-eight (28) days unless the manufacturer specifies a different date for that opened vial. If a multi-dose vial has not been opened or accessed, it is discarded according to the manufacturer's expiration date. 1. An observation on 11/27/2023 at 12:15 pm observed with Licensed Practical Nurse (LPN) BB revealed that R15 vial of Humalog (Lispro) insulin vial had an open date of 10/10/2023. The Lispro insulin expired on 11/7/2023. Review of the Medication Administration Record (MAR) dated 11/15 revealed R15 was administered Lispro insulin on 11/15/2023 at 6:58 pm, 11/17/2023 at 9:00 am, 11/17/2023 at 12:00 pm, 11/18/2023 at 9:00 am, 11/18/2023 at 12:00 pm, 11/19/2023 at 12:00 pm, 11/21/2023 at 8:30 am, 11/21/2023 at 5:10 pm, 11/22/2023 at 8:30 am, 11/22/2023 at 1:12 pm, 11/23/2023 at 7:54 am, 11/24/2023 at 11:54 am, 11/24/2023 at 6:33 pm, 11/25/2023 at 1:34 pm, 11/25/2023 at 6:00 pm, and 11/26/2023 at 5:45 pm. Review of the physician order revealed that R15 had an order for the Humalog (Lispro) insulin to administer eight units before meals three times a day. There was no evidence that R15 had an adverse outcome with the expired Lispro insulin. An interview on 11/27/2023 at 12:15 pm, LPN BB revealed that R15 had refused her lunch time insulin. She continued to state that the nurses are responsible for discarding expired medications and that she checks once a week for expired medications. 2. An observation on 11/28/2023 at 11:43 am, observed LPN AA obtained blood glucose (sugar) finger stick on R16 who had a result of 329 mg/dl which required five units of Novolog insulin coverage. There was no evidence of Novolog insulin in the medication cart for R16. LPN AA went into the medication storage room to a pixel and pharmacy stock box, there was no Novolog insulin. Review of the physician order revealed that R16 had an as need order for insulin aspart (Novolog correctional dose Low) with a start date of 11/6/2023. The Novolog insulin has parameter to administer subcutaneous injection for hyperglycemia as needed. An observation on 11/28/2023 at 12:05 pm, LPN AA and Registered Nurse (RN) CC verify that a vial of Novolog insulin that was labeled with another resident (R14) name. LPN AA withdrew five units of the Novolog insulin and administered the Novolog insulin to R16. An interview on 11/28/2023 at 2:12 pm. LPN AA revealed that they had spoken to RN CC about not having any Novolog insulin coverage in the medication cart and wanted permission to use R14 Novolog insulin because of the high result of R16. She continued to state that RN CC had ordered the Novolog insulin for R16 but, it would not get delivered until that night. RN CC told her it was okay to give the Novolog from R14 insulin vial. An interview on 11/28/2023 at 2:34 am RN CC revealed that they went to the Director of Nursing (DON) and informed her that there was no Novolog insulin for R16 coverage. And that it would take a while to get insulin from the pharmacy. The DON gave permission to pull from R14 insulin vial because R16 needed insulin coverage. And was instructed to verify the insulin order. She and LPN AA verify the Novolog insulin order. Normally, there is a lock box in the medication storage room that would have the extra insulin in the lock box, but she did not check behind the LPN. She continued to state that the Novolog insulin had been ordered from the pharmacy. An interview on 11/30/2023 at 9:52 am, the DON revealed that she gave the staff nurses permission to use another resident (R14) Novolog insulin for coverage. And that the multiple vial had not been in the resident's (R14) room. 3. During an observation on 11/27/2023 at 11:33 am, observed with LPN DD on the Live Oak Hall, the Medication Storage room revealed one unopened bottle of Ibuprofen 100 mg with an expiration date of 10/23. An interview on 11/27/2023 at 11:33 am, LPN DD stated that the nurses on the hall are responsible for removing expired medication from the shelf. 4. During an observation on 11/27/2023 at 12:10 pm, observed with RN CC, the Day Lilly Hall medication storage room revealed one unopened bottle of B-2 100 mg with an expiration date of 5/23. An interview on 11/27/2023 at 12:10 pm, RN CC revealed that the charge nurses, or supervisors are responsible for rotating the stock medications and removing any expired medications. And that she will dispose of the expired medication.

Based on family and staff interviews, record review, and review of the facility policy titled, Informing Resident of Health Status, the facility failed to notify the family of a physician's order for one of 14 residents (R) R A. Specifically, the facility failed to notify the family of the results of a bladder scan for RA. Findings include: Review of the facility policy titled Informing Resident of Health Status dated June 17, 2013, indicated the resident and, when appropriate, the family/representative are given clear, concise explanation of: The resident's condition and any changes in the condition. Any proposed treatments(s) or procedure(s). The potential benefit(s), risk(s), and alternative(s) of the proposed treatment(s) or procedure(s) and potential risks or refusal of care. Review of the 10/19/2022 Nurse's Notes for R A documented the overnight sitter reported the resident had not voided all night. The physician was made aware and ordered a bladder scan. Review of the 10/19/2022 bladder scan results showed an impression of large postvoid residual and possibly enlarged prostate. Further review of the clinical record revealed there was no documentation the family was made aware of the physician's order for the bladder scan nor were they notified of the results of the bladder scan. During an interview with the family member on 3/23/2023 at 3:00 p.m., they stated no one from the facility had informed them of the physician's order for a bladder scan. During an interview with the Director of Nursing on 3/23/2023 at 12:45 p.m., she confirmed there was no documentation the family was notified of the physician's order for a bladder scan nor the results of the scan.

Based on record review, staff and family interviews, and review of the facility policy titled, Care Plans, the facility failed to provide a copy of the summary of the baseline care plan to the responsible party for one of 14 residents (R) (RA). Findings include: Review of the policy titled Care Plans dated December 5, 2022, indicated the facility provides the resident and his/her representative, if applicable, with a written summary of the Baselines Care Plan that includes the following: a. Initial goals for the resident. b. A list of current medication and dietary instructions. c. Services and treatments to be administered by the facility and personnel acting on behalf of the facility. The policy further noted Baseline Care Plans are documented in the Electronic Medical Record (EMR). During an interview with the family of R A on 3/23/2023 at 3:00 p.m., she stated that they never received a copy of the baseline care plan for the resident. Review of the EMR, revealed there was no indication a baseline care plan had been done and no evidence a copy of the summary of the baseline care plan had been given to the family. During an interview with the Director of Nursing (DON) on 3/23/2023 at 12:45 p.m., she stated there was no documentation the family had received a copy of the summary of the baseline care plan. During an interview with the Survey Accreditation Manager on 3/22/2023 at 2:45 p.m., she stated they have identified problems with the current system used for electronic charting. They have realized once a resident is discharged from the facility the comprehensive care plan is no longer available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy titled, Care Plans, the facility failed to implement the care plan interventions to provide wound care as ordered for three of 14 residents (R)(R#4, R#5 and R#6) with pressure ulcers. The deficient practice had the potential to affect the progression of the residents' wounds by not providing wound care as ordered by the physician for R# 4, R#5, and R#6. Findings include: Review of the facility policy titled Care Plans dated December 5, 2022, noted the following under Purpose: The purpose of this Policy is for [NAME] Health and Rehabilitation staff to develop and implement a Baseline Care Plan for each resident that includes instructions needed to provide effective and person-centered care of the resident upon admission. Policy: [NAME] Health and Rehabilitation will develop and implement a Comprehensive Person-centered Care Plan for each resident within 21 days of admission or within seven days of completion of the Comprehensive Assessment. The Comprehensive Care Plan includes interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that are implemented. 1. Resident #4 was admitted to the facility on [DATE] with the following but not limited to diagnoses of: Stage 4 pressure ulcer left buttock, hypertension, coronary atherosclerosis, peripheral vascular disease, cerebrovascular disease, hemiplegia, and mental disability. Review of R#4 care plan updated on 12/12/2022 revealed a pressure ulcer with an intervention to provide wound care as ordered. Review of the Nursing Narrative note dated 12/7/2022 documented the resident had an unstageable decubitus to her left ischium that measured 3.5 centimeter (cm) wide 2.9cm long 0.2 cm deep. The physician was notified on 12/7/2022 and an order was obtained to clean the unstageable decubitus to the left ischium with anasept spray and apply Santyl ointment and medihoney every two days and as needed. However, review of the December 2022 treatment documentation revealed there was no documentation the treatment was done until 12/9/2022 and there was no documentation the dressing was changed every two days as ordered from 12/15/2022 to 12/21/2022. On 12/21/2022 a new physician's order was obtained to clean wound to left ischium with normal saline or anasept, pack wound with anasept moistened gauze and cover with dry dressing daily. Review of the December 2022 treatment documentation revealed there was no documentation the dressing was changed daily as ordered from 12/28/2022 to 12/30/2022. A physician's order was obtained on 1/5/2023 to begin negative pressure wound therapy wound vac continuously at 125mm/hg (millimeter of mercury) pressure, apply white foam in base then apply black foam. Apply anasept spray 10 minutes prior to each dressing change three times weekly and as needed Tuesday/Thursday/Saturday. Review of the 1/2023 treatment documentation revealed there was no documentation the treatment was done as ordered from 1/5/2023 to 1/17/23. A physician's order was obtained on 1/17/2023 to clean sacrum wound with anasept spray and apply anasept spray-soaked gauze everyday as needed and cover with a mepilex dressing if wound vac is off and only until the wound vac is reapplied. Review of the 1/2023 treatment documentation revealed there was no documentation the treatment was done 1/19/2023 to 2/5/2023. A physician's order was obtained on 2/6/2023 to clean left ischium with anasept spray and pack with 1/4-inch packing strip and leave at least two inches outside of the wound and cover with Telfa and Mepilex daily. Review of the 2/2023 and 3/2023 treatment documentation revealed the treatment was documented as done 14 of 28 days in February and 10 of 16 days in March. Refer to F686. 2. Resident #5 was admitted to the facility on [DATE] with the following but not limited to diagnoses of: aortic stenosis, peripheral artery disease, cerebrovascular accident, hypertension, hypothyroidism, atrial fibrillation, chronic pain, and neuropathic pain. Review of R#5 care plan for pressure ulcer with a revision date of 2/21/2023 had an intervention for wound care according to MD orders. Review of the Nursing Narrative note dated 10/8/2022 revealed documentation of a wound to posterior right leg noted to be oozing dark red puss looking drainage. Area was cleaned with anasept spray and anasept gel was applied with Xeroform and ABD pads and netting. MD was notified and stated to continue to clean and monitor. Review of the Physician's orders dated 10/8/2022 noted to clean posterior right leg with anasept spray and apply anasept gel and cover with Xeroform and ABD pads and netting daily and as needed. However, review of the 10/2022 treatment documentation revealed there was no documentation the treatment was done until 10/28/2022. During an interview with the Director of Nursing on 3/15/2023 at 2:30 p.m., she clarified the wound identified on 10/8/2022 as the posterior right leg was actually on the right heel. Review of the physician's orders dated 11/1/2022 noted to clean right heel with normal saline or anasept, apply Santyl ointment and cover with dry dressing daily. Review of the 11/2022 treatment documentation revealed the treatment was documented as done 13 of 30 days. Review of the physician orders dated 12/26/2022 noted to clean right heel with normal saline or anasept, apply Santyl covered by Medihoney, cover with dry dressing every two days. Review of the treatment documentation for 1/2023 through 2/2/2023 revealed there was no documentation treatment had been done as ordered for this timeframe. During this time, the treatment order was changed on 1/12/2023 to clean right heel wound with anasept cleanser and apply Medihoney then a hydrogel sheet covered with 4x4 then cover with Allevyn heel cup then wrap in Kerlix on Thursday and Sunday each week. There was no evidence this was done until 2/5/2023, 2/9/2023, 2/19/2023 and 2/24/2023. Review of the physician order dated 2/24/2023 noted to clean right heel with anasept or normal saline, apply gentamicin and cover with opticell alginate and dry dressing every 2 days. Review of the 2/2023 and 3/2023 treatment documentation revealed the treatments were only documented as done on 2/24/2023, 2/28/2023, 3/2/2023, 3/4/2023 and 3/8/2023. 3. Resident #6 was admitted to the facility on [DATE] with the following but not limited to diagnoses of: catatonic disorder, epilepsy, hypertension, peripheral vascular disease, diabetes, contracture of bilateral upper and lower extremities, morbid obesity and spasticity. Review of R# 6 care plan dated 5/11/2022 revealed a pressure ulcer with an intervention for wound care as ordered. Review of the 1/30/2023 Phone Message to the physician noted the wound to the resident's right outer ankle was reassessed by the Registered Nurse and noted to be a Stage 3 with full thickness tissue loss, but no tendon or bone exposed. The wound measured 6cm x 4cm x 0.1cm. Review of the physician order dated 1/30/2023 noted to clean right outer ankle with anasept spray and apply anasept gel with Mepilex dressing every three days and as needed. Review of the 1/2023 and 2/2023 treatment documentation revealed there was no documentation the treatment was done until 2/4/2023. Review of the 2/4/2023 physician order noted to clean wound to right dorsal foot with anasept or normal saline, apply Medihoney, cover with foam dressing every two days. Review of the 2/2023 and 3/2023 treatment documentation revealed the treatment was only documented as done two of 28 days in February and there was no documentation it had been done between 3/4/2023 and 3/10/2023. During an interview with the DON on 3/15/2023 at 2:30 p.m., she stated that in November 2022 she identified that the previous treatment nurse told Registered Nurse (RN) EE, the current treatment nurse, that they didn't have to chart the treatments being done every day. Refer to F686.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review and review of the facility policy titled Wounds and Pressure Ulcers, the facility failed to thoroughly assess pressure ulcers and failed to consistently document pressure ulcer treatments for three of 14 sampled residents (R) (R#4, R#5, and R#6). Findings include: Review of the policy titled Wounds and Pressure Ulcers dated December 5, 2022, Monitoring and Documentation: [NAME] Health and Rehabilitation personnel should monitor and evaluate the following at each dressing change or at least weekly and should also document in the resident's medical record the determinations of such evaluation: Location and staging Size including width, length, and depth. Exudate, if present: type, color, odor, approximate amount Pain, nature, and frequency of pain Wound bed: color and type of tissue Wound edges and surrounding tissue Type and amount of dressing used. If the wound has packing, the amount removed and the amount replaced. The presence, location and extent of any undermining or tunneling. Description of wound drainage Response to current treatment Compliance or non-compliance to plan of care. Pressure reduction devices Physician and responsible party notification 1. Resident #4 was admitted to the facility on [DATE] with the following but not limited to diagnoses: Stage 4 pressure ulcer left buttock, hypertension, coronary atherosclerosis, peripheral vascular disease, cerebrovascular disease, hemiplegia, seizure disorder and mental disability. Review of the Nursing Narrative note dated 12/7/2022 documented R#4 had an unstageable decubitus to her left ischium that measured 3.5 centimeter (cm) wide 2.9cm long 0.2 cm deep. However, there was descriptive documentation of the wound bed that would have indicated the pressure ulcer was unstageable. The physician was notified on 12/7/2022 and an order was obtained to clean the unstageable decubitus to the left ischium with anasept spray and apply Santyl ointment and medihoney every two days and as needed. However, review of the December 2022 treatment documentation revealed there was no documentation the treatment was done until 12/9/2022 and there was no documentation the dressing was changed every two days as ordered from 12/15/2022 to 12/21/2022. On 12/21/2022 a new physician's order was obtained to clean wound to left ischium with normal saline or anasept, pack wound with anasept moistened gauze and cover with dry dressing daily. Review of the December 2022 treatment documentation revealed there was no documentation the dressing was changed daily as ordered from 12/28/2022 to 12/30/2022. A physician's order was obtained on 1/5/2023 to begin negative pressure wound therapy wound vac continuously at 125mm/hg (millimeter of mercury) pressure, apply white foam in base then apply black foam. Apply anasept spray 10 minutes prior to each dressing change three times weekly and as needed Tuesday/Thursday/Saturday. Review of the 1/2023 treatment documentation revealed there was no documentation the treatment was done as ordered from 1/5/2023 to 1/17/2023. A physician's order was obtained on 1/17/2023 to clean sacrum wound with anasept spray and apply anasept spray-soaked gauze everyday as needed and cover with a mepilex dressing if wound vac is off and only until the wound vac is reapplied. Review of the 1/2023 treatment documentation revealed there was no documentation the treatment was done 1/19/2023 to 2/5/2023. A physician's order was obtained on 2/6/2023 to clean left ischium with anasept spray and pack with 1/4-inch packing strip and leave at least two inches outside of the wound and cover with Telfa and Mepilex daily. Review of the 2/2023 and 3/2023 treatment documentation revealed the treatment was documented as done 14 of 28 days in February and 10 of 16 days in March. 2. Resident #5 was admitted to the facility on [DATE] with the following but not limited to diagnoses: aortic stenosis, peripheral artery disease, dementia, cerebrovascular accident, hypertension, hypothyroidism, atrial fibrillation, chronic pain, and neuropathic pain. Review of the 10/8/2022 Nursing Narrative note revealed documentation of a wound to posterior right leg noted to be oozing dark red puss looking drainage. There was no descriptive documentation of the wound to indicate the type of wound, wound bed appearance or measurements on 10/8/2022. Review of the Physician's orders dated 10/8/2022 noted to clean posterior right leg with anasept spray and apply anasept gel and cover with Xeroform and ABD pads and netting daily and as needed. However, review of the 10/2022 treatment documentation revealed there was no documentation the treatment was done until 10/28/2022. Review of the Weekly Wound Report for 10/16/2022 noted the wound was an unstageable pressure ulcer on the right heel that measured 3.5x3.5x0.1cm with no descriptive documentation of the wound bed. During an interview with the Director of Nursing on 3/15/2023 at 2:30 p.m., she clarified the wound identified on 10/8/2022 as the posterior right leg was actually on the right heel. Review of the physician's orders dated 11/1/2022 noted to clean right heel with normal saline or anasept, apply Santyl ointment and cover with dry dressing daily. Review of the 11/2022 treatment documentation revealed the treatment was documented as done 13 of 30 days. The 12/26/2022 physician orders noted to clean right heel with normal saline or anasept, apply Santyl covered by Medihoney, cover with dry dressing every two days. Review of the treatment documentation for 1/2023 through 2/2/2023 revealed there was no documentation treatment had been done as ordered for this timeframe. During this time, the treatment order was changed on 1/12/2023 to clean right heel wound with anasept cleanser and apply Medihoney then a hydrogel sheet covered with 4x4 then cover with Allevyn heel cup then wrap in Kerlix on Thursday and Sunday each week. There was no evidence this was done until 2/5/2023, 2/9/2023, 2/19/2023 and 2/24/2023. Review of the physician order dated 2/24/2023 noted to clean right heel with anasept or normal saline, apply gentamicin and cover with opticell alginate and dry dressing every 2 days. Review of the 2/2023 and 3/2023 treatment documentation revealed the treatments were only documented as done on 2/24/2023, 2/28/2023, 3/2/2023, 3/4/2023 and 3/8/2023. Per review of the Weekly Wound Report, the facility documented weekly wound measurements since 10/16/22. However, there was no consistent descriptive wound documentation of the wound bed. 3. Resident #6 was admitted to the facility on [DATE] with the following but not limited to diagnoses: catatonic disorder, epilepsy, hypertension, peripheral vascular disease, diabetes, schizophrenia, dementia, asthma, contracture of bilateral upper and lower extremities, morbid obesity, and spasticity. Review of the physician order dated 1/30/2023 noted to clean right outer ankle with anasept spray and apply anasept gel with Mepilex dressing every three days and as needed. Review of the 1/2023 and 2/2023 treatment documentation revealed there was no documentation the treatment was done until 2/4/2023. Review of the 2/4/2023 physician order noted to clean wound to right dorsal foot with anasept or normal saline, apply Medihoney, cover with foam dressing every two days. Review of the 2/2023 and 3/2023 treatment documentation revealed the treatment was only documented as done two of 28 days in February and there was no documentation it had been done between 3/4/2023 and 3/10/2023. Review of the Weekly Wound Report from 2/5/2023 to 3/5/2023 revealed there were weekly measurements documented but the documentation did not include descriptive documentation of the wound bed. During an interview with the DON on 3/15/2023 at 2:30 p.m., she stated that in November 2022 she identified that the previous treatment nurse told Registered Nurse (RN) EE, the current treatment nurse, that they didn't have to chart the treatments being done every day. During an interview with RN EE on 3/21/2023 at 11:30 a.m., he stated that he does a weekly wound report with the measurements, but it did not include descriptions of the wound bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed ensure the Minimum Data Set (MDS) assessments were accurate for two ((R) R#1 and R#35) of eight residents receiving oxygen therapy. Findings Include: 1.Record review for R#1 revealed resident was admitted to the facility on [DATE] with diagnoses of Catatonic disorder, encephalopathy, epilepsy, chronic anticoagulation, Essential hypertension, Dysphagia, peripheral vascular diseases, asthma, diabetes mellitus, anemia, gastroesophageal reflux disease, schizophrenia, decubitus of the right ankle, gastrostomy status, peripheral vascular disease, major depressive disorder, sleep bruxism, and spasticity. Further review reveald orders for oxygen at 2 liters per minute (LPM) per nasal cannula routinely. Review of the MDS Quarterly assessment dated [DATE] revealed oxygen therapy was not indicated as in use for R#1. On 10/26/22 at 4:02 p.m. Interview with Registered Nurse (RN) BB MDS Director confirmed the MDS quarterly assessments that were completed on 7/01/22 and 9/28/22 should have captured oxygen use on the MDS for both assessments that were completed. 2. Record Review (RR) of the clinical record revealed R#35 admitted to the facility on [DATE] with diagnoses that included but not limited to, emphysema-admitting diagnosis with onset date 2/1/21, chronic obstructive pulmonary disease (COPD), chronic congestive heart failure (CHF), essential (primary) hypertension (HTN), pulmonary hypertension, chronic atrial fibrillation (A-Fib), and cerebral infarction. Review of R#35 's current physician orders included but not limited to, oxygen (O2) at 2 liters per minute (LPM) via nasal cannula as needed (prn)-order date 9/3/21. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed oxygen therapy was not checked under special treatments at Section O-0100C. Review of the quarterly MDS assessment dated [DATE] revealed oxygen therapy was not checked under special treatments at Section O-0100C. Review of the quarterly/5-day reentry MDS assessment dated [DATE] under health conditions at Section J-1100 revealed no shortness of breath or trouble breathing, with exertion, when sitting at rest, or when lying flat; and under special treatments at Section O-0100 oxygen therapy was not checked. Observations on 10/25/22 at 2:09 p.m., on 10/26/22 at 8:33 a.m., and on 10/26/22 at 2:22 p.m. confirmed R#35 using oxygen at 2 LPM via n/c. During an interview on 10/27/22 at 2:15 p.m. with the MDS Director she confirmed an order for R#35's oxygen with start date 9/3/21. MDS Director was unsure why the MDS assessment had not been coded to address the oxygen usage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and review of policy titled Respiratory Therapy, the facility failed to ensure that oxygen therapy was administered as ordered by Physician for one resident ((R) R#1) of eight residents receiving oxygen. Findings include: Review of facility policy titled Respiratory Therapy (dated July 3, 2013), under Procedure: Oxygen Administration revealed - Set oxygen regulator to administer as ordered. Record review for R#1 revealed resident was admitted to the facility on [DATE] with diagnoses of Catatonic disorder, encephalopathy, epilepsy, chronic anticoagulation, Essential hypertension, Dysphagia, peripheral vascular diseases, asthma, diabetes mellitus, anemia, gastroesophageal reflux disease, schizophrenia, decubitus of the right ankle, gastrostomy status, peripheral vascular disease, major depressive disorder, sleep bruxism, and spasticity. Further review of the record revealed Minimum Data Set (MDS) Quarterly assessment dated [DATE] with Section O (Treatments/Procedures) not indicating oxygen therapy use for resident. Review of orders revealed oxygen at 2 liters per minute (L/M) per nasal cannula routinely. Observation on 10/25/22 at 9:57 a.m. Resident receiving oxygen therapy current setting is on 1 L/M there was no date noted on oxygen tubing. Observation on 10/26/22 at 8:16 a.m. oxygen therapy current setting is on .5 liters per nasal cannula resident is positioned on her back and has eyes closed. Interview on 10/26/22 at 8:22 a.m. with Licensed Practical Nurse (LPN) AA confirmed that R#1 oxygen was set at .5 liters and should have been on 2 Liters. Further interview also revealed that the residents that have oxygen are checked every two hours to ensure that their oxygen is on the correct setting. LPN AA also confirmed that when rounds were made at 7:00 a.m. they did not notice that R# 1 oxygen was not on the correct setting. Interview on 10/26/22 at 4:27 p.m. with Director of Nursing (DON) revealed that there are currently 8 residents in the facility currently receiving oxygen therapy and should have a care plan in place that indicates the use of oxygen along with any interventions as appropriate. During interview it was confirmed that R#1 has been on oxygen therapy since 11/22/20 at 2 L/M and it should have been noted in their care plan as well as on the MDS assessments. Further interview also revealed that they would expect for the Unit Managers and nurse management to ensure that the residents care plans are person centered and addressed all their medical needs and that the residents are checked daily to ensure that their oxygen settings are as ordered by physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to ensure two of two staff implemented standard precautions when providing care for one of 13 sampled residents as evidenced by staff failing to perform handwashing or hand hygiene with glove changes and sanitizing equipment after use. Findings include: Record review included R#77 admitted on [DATE] with diagnosis of critical polytrauma. Brief interview for mental status (BIMS) reveals a score of 15 indicating intact cognition. Observation of wound care on 10/26/2022 at 9:30 a.m. with Licensed Practical Nurse (LPN) CC and Registered Nurse (RN) DD revealed LPN CC and RN DD took measurements of left heal, posterior left calf, and left knee. Left heel outer dressing removed by RN DD with clean gloves. Removed gloves and clean gloves donned. After completing removal of dressing to left heel he donned clean pair of gloves but failed to perform hand hygiene with glove change. LPN CC placed a waterproof pad under left leg. Clean gloves donned but she failed to perform hand hygiene with glove change. CC applied gauze to left lower leg, applied tape to secure gauze. After completing she removed gloves and donned a clean pair of gloves but failed to perform hand hygiene with the glove change. After completing wound care, RN DD removed scissors from clean area of equipment to be used. Scissors taken out of room and put in scrub top front pocket. After he removed scissors from the room, he failed to perform cleaning of equipment. Interview on 10/27/2022 at 1:10 p.m. with RN DD who stated you must sanitize hands prior to entering resident room and before you leave the room. RN DD reported that if gloves are intact, it is not necessary to have to sanitize hands between glove use. It was clarified that sanitizing hands between glove use if only if entering, exiting, and if there is a tear in the glove. It was further reported that supplies are thrown away if left over from wound care unless they belong to the resident. Scissors are to be cleaned with Cavi Wipes before and after use. In between use if used more than once then use Cavi wipes to clean. RN DD acknowledged putting scissors in pocket after use and should not have done so. Interview with Director of Nurses (DON) on 10/27/2022 at 2:00 p.m. who stated anytime gloves are removed the expectation is that hands are sanitized prior to putting on clean gloves. DON further stated that hands should be sanitized prior to putting on gloves and after taking off gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to develop a comprehensive care plan for two residents ((R) R#1 and R#35) receiving oxygen therapy, and the facility failed to develop a care plan for psychotropic drug use for one resident R#60. This effected three of 38 sampled residents. Findings include: 1.Record review for R#1 revealed resident was admitted to the facility on [DATE] with diagnoses of Catatonic disorder, encephalopathy, epilepsy, chronic anticoagulation, Essential hypertension, Dysphagia, peripheral vascular diseases, asthma, diabetes mellitus, anemia, gastroesophageal reflux disease, schizophrenia, decubitus of the right ankle, gastrostomy status, peripheral vascular disease, major depressive disorder, sleep bruxism, and spasticity. Review of orders indicated oxygen at 2 liters per minute (L/M) per nasal cannula routinely. On 10/26/22 at 4:02 p.m. Interview with Registered Nurse (RN) BB revealed that the charge nurse would complete the baseline care plan and update it as needed, Social Services, dietary, and Wound care initiate and update their own care plans specific to the resident's needs. During interview it was also disclosed that the Minimum Data Set (MDS) staff is responsible for ensuring that the care plans are correct and are person centered to the residents' needs. Continued interview also confirmed that R # 1 did not have a care plan that addressed the use of oxygen. On 10/26/22 at 4:27 p.m. Interview with Director of Nursing (DON) revealed that there are currently 8 residents in the facility currently receiving oxygen therapy and should have a care plan in place that indicates the use of oxygen along with any interventions as appropriate. During interview it was confirmed that R#1 has been on oxygen therapy since 11/22/20 at 2 L/M and it should have been noted in the care plan as well as on the MDS assessments. Further interview also revealed that they would expect for the Unit Managers and nurse management to ensure that the residents care plans are person centered and addressed all their medical needs. Further interview also confirmed that the facility did not have a care plan policy for reviewing. 3. Record Review (RR) revealed R#60 admitted facility on 5/31/18, top three diagnoses were Alzheimer's dementia, epilepsy, Diabetes Mellitus type 2. Additional diagnoses included frailty, generalized anxiety, insomnia, bedbound, and cerebral aneurysm-onset 5/16/19. A Brief Interview of Mental Status (BIMS) was not conducted because resident was rarely/never understood, indicating severe cognitive decline. RR of current Physician Orders revealed R #60 had an order for Lorazepam 2 milligrams per milliliter (ml) (2mg/ml) injectable solution 0.5 ml intramuscular (IM) every six hours (q6h) as needed (prn) seizure activity, first dose 8/29/18. RR of the current care plan revealed there was no care plan for the medication Lorazepam. Further review revealed Ativan (Lorazepam) 1mg IM q6h prn seizure activity was discontinued from the Psychotropic medication use care plan, with last updated date of 3/14/22. Interview on 10/27/22 at 3:30 p.m. with the Administrator and the Director of Nursing (DON). DON confirmed a current order for lorazepam 2mg/1ml, administer 0.5ml IM q6h prn seizure activity, first dose 8/29/18. The Administrator confirmed the care plan had lorazepam discontinued and said that was not correct. R#60 had a current order for lorazepam prn for seizure activity, it should still be on the care plan, and she did not know why it had been removed. Cross refer 758 2. Record Review (RR) of the clinical record revealed R#35 admitted to the facility on [DATE] with diagnoses that included but not limited to, emphysema-admitting diagnosis with onset date 2/1/21, chronic obstructive pulmonary disease (COPD), chronic congestive heart failure (CHF), essential (primary) hypertension (HTN), pulmonary hypertension, chronic atrial fibrillation (A-Fib), and cerebral infarction. RR of R#35 's current physician orders included but not limited to, oxygen (O2) at 2 liters per minute (LPM) via nasal cannula as needed (prn)-order date 9/3/21, Advair hydrofluoroalkane (HFA) 115 micrograms (mcg)-21 mcg inhalation aerosol metered dose inhaler 2 puffs twice a day (bid)-order 2/2/2021. RR on 10/25/22 of the current Care Plan for R#35, revealed there was no oxygen therapy or interventions on the care plan. Observation on 10/25/22 at 2:09 p.m., on 10/26/22 at 8:33 a.m., and on 10/26/22 at 2:22 p.m. confirmed R#35 using oxygen at 2 LPM via nasal cannula. Interview at that time revealed she had to wear it almost continuously but removed it occasionally for a few minutes to eat. R#35 complained of having shortness of breath with fluid retention and revealed she had been sent to the hospital ER recently because she couldn't breathe. Interview on 10/27/22 at 2:15 p.m., the MDS Director confirmed the care plan for oxygen therapy was initiated on 10/26/22. She confirmed an order for R#35's oxygen with start date 9/3/21. Further review of the care plan confirmed oxygen was not initiated prior to 10/26/22, she didn't know why it was not initiated at the time the oxygen was started but it should have been. Interview with the Director of Nursing (DON) revealed her expectation was that care plans should reflect the residents' diagnoses and conditions, include appropriate interventions, and should be reviewed and revised as indicated. Cross refer F641

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure psychotropic drug use was limited to 14 days unless the physician felt it was appropriate for the as needed (PRN) order to be extended beyond 14 days, documented the rational, and indicated the intended duration for the prn order, for two residents ((R) R#60 and R#81) of five reviewed for unnecessary medications, that had an order for PRN antianxiety medication beyond 14 days. Findings include: 1. Record Review (RR) revealed R#60 admitted facility on 5/31/18, top three diagnoses were Alzheimer's dementia, epilepsy, Diabetes Mellitus type 2. Additional diagnoses included frailty, generalized anxiety, insomnia, bedbound, and cerebral aneurysm-onset 5/16/19. A Brief Interview of Mental Status (BIMS) was not conducted because resident was rarely/never understood, indicating severe cognitive decline. RR of current Physician Orders revealed R #60 had an order for Lorazepam 2 milligrams per milliliter (ml) (2mg/ml) injectable solution 0.5 ml intramuscular (IM) every six hours (q6h) as needed (prn) seizure activity, first dose 8/29/18. Additionally, there was no end date, was not ordered for a specific number of days, and no rational to continue past 14 days. RR of the current care plan revealed there was no care plan for Lorazepam. Further review revealed Ativan (Lorazepam) 1mg IM q6h prn seizure activity was discontinued from the Psychotropic medication use care plan, with last updated date of 3/14/22. Interview on 10/27/22 at 3:30 p.m. with the Director of Nursing (DON) confirmed a current order for lorazepam 2mg/1ml, administer 0.5ml IM q6h prn seizure activity, first dose 8/29/18. The administrator confirmed the Lorazepam was ordered for R#60 prn for seizures, had no end date, was not ordered for a specific number of days, and had no rational to continue past 14 days. The Administrator's expectation was because the medication was ordered for seizure activity, the prn order was acceptable as written. 2. R#81 was admitted to the facility on [DATE] with diagnoses of but not limited to Alzheimer's dementia, major depressive disorder and altered mental status. Review of R#81's admission Minimum Data Set (MDS) revealed Section N-Medications -received an antipsychotic, antianxiety, antidepressant and opioids. Review of R#81's medications revealed but not limited to: clonazepam 0.5 milligrams (MG) one (1) tablet by mouth (PO) two (2) times a day (BID) as needed (PRN) ordered on 9/12/22 for a diagnosis of anxiety. The order did not include a stop date. Review of the Pharmacy Consultant Activity Report dated 9/29/22 revealed: A recommendation to evaluate the current clonazepam order. Review of a scanned document revealed the recommendation was signed by the Physician on 10/4/22 to include a duration of 90 days. Review of the Physicians orders as of 10/27/22 the orders still did not include that duration of 90 days. An interview held on 10/27/22 at 1:47 p.m. with the Director of Nursing (DON) revealed the resident was admitted with the order for the PRN clonazepam. Her order should have had a stop date or parameter added to the order. The nurse should have clarified the order on admission. When she receives a Pharmacy recommendation they are given to the Physician. When recommendations are received from the Physician, the DON or designee will transpose the orders. She does not know why the recommendation was not followed through with. Her expectations would be to write the orders within a 24-hour period after receiving them from the Physician. She verified the recommendation was not followed through with after the Physician signed the recommendation to add a time limit of 90 days to the clonazepam order. She indicated they do not have a policy on PRN antipsychotic medications use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review revealed R#11 was admitted to facility 9/13/13. R#11 had the following diagnoses of hypertension, plantar fasciitis, asthma, hyperlipidemia, nutritional anemia, chronic obstructive pulmonary disease, transient cerebral ischemic attack, osteoarthritis, arthropathy, epilepsy, convulsions, pacemaker, and peripheral vascular disease. The last care plan review was completed on 11/1/19. R#11's Comprehensive Assessment was completed on 11/1/19 but review of the MDS Transmission Results indicated the assessment was not transmitted to CMS within 14 days of completion. Record review revealed R#7 was admitted to facility 2/15/18. R#7 had the following diagnoses of hypertension, dementia with behavioral disturbances, hyperlipidemia, idiopathic gout, type two diabetes, viral hepatitis, gastro-esophageal reflux, and altered mental status. The last care plan review was completed on 10/31/19. R#7's Comprehensive Assessment was completed on 10/31/19 but review of MDS Transmission Results indicated the assessment was not transmitted to CMS within 14 days of completion. Record review revealed R#9 was admitted to facility 6/13/19. R#9 had the following diagnoses of vitamin D deficiency, coronary artery disease, hyperlipidemia, hypertension, diabetes mellitus type two, insomnia, and hypothyroidism. The last care plan review was completed on 10/31/19. R#9's Comprehensive Assessment was completed on 11/5/19 but review of MDS Transmission Results indicated the assessment was not transmitted to CMS within 14 days of completion. 3. Record review revealed R#17 was admitted to the facility on [DATE]. R#17 had the following diagnoses of age-related osteoporosis without fracture, pain, chronic obstructive pulmonary disease, cough, macular degeneration, glaucoma, and Epilepsy. The last care plan review was completed on 11/11/19. R#17's Comprehensive Assessment was completed on 11/11/19 but review of MDS Transmission Results indicated the assessment was not transmitted to CMS within 14 days of completion. Record review revealed R#8 was admitted to the facility on [DATE]. R#8 had the following diagnoses of acid reflux, acquired absence of leg below knee, anemia of renal disease, dependence on renal dialysis, diabetes mellitus type 2 with complications, essential familial hypercholesterolemia, glaucoma, hyperlipemia, hypothyroidism, mild hypertension, and end stage renal disease. The last care plan review was completed on 11/9/19. R#8's Comprehensive Assessment was completed on 11/4/19 but review of MDS Transmission Results indicated the assessment was not transmitted to CMS within 14 days of completion. Record review revealed R#3 was admitted to the facility on [DATE]. R#3 had the following diagnoses of vitamin D deficiency, osteoporosis, hypertension, hypo-albuminemia, glaucoma, bilateral lower extremity edema, dysphagia, and pressure injury of deep tissue of sacral region. The last care plan review was completed on 7/18/19. R#3's Comprehensive Assessment was completed on 12/16/19. The assessment was completed greater than 120 days from the previous Comprehensive assessment completed on 7/18/19. Based on record review and staff interview, and review of the facility policy titled, Comprehensive Assessment, Minimum Data Set (MDS) the facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted timely within 14 days of completion to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System for 15 of 15 residents reviewed (R#5, R#13, R#15, R#16, R#12, R#14, R#17, R#8, R#3, R#11, R#7, R#9, R#4, R#2, R#10). The facility census was 93. Findings include: Review of the facility policy titled, Comprehensive Assessment, Minimum Data Set (MDS) dated effective January 2017, revealed; B. 1. The facility will use the Resident Assessment Instrument (RAI) specified by the state of Georgia. 1. A record review revealed R#5 was admitted to the facility on [DATE] with the diagnoses of chronic kidney disease, atrial fibrillation, chronic anticoagulant use, mood disorder, glaucoma, hypertension, debility, constipation, osteoarthritis, glaucoma, stroke, and left shoulder pain. R#5 had a comprehensive MDS completed on 10/30/19, 8/8/19, 5/16/19, and 2/22/19. R#5's care plans were reviewed and updated on 10/31/19. R#5 Comprehensive Assessment was completed on 10/30/19 but review of MDS Transmission Results indicated the assessment was not transmitted to CMS within 14 days of completion. A record review revealed R#13 was admitted to the facility on [DATE] with the diagnoses of dysarthria, dementia, hyperlipidemia, anemia, antidepressant, bipolar depression, constipation, anxiety, and tremor. R#13 had a comprehensive MDS completed on 11/7/19, 8/16/19, 5/22/19, 2/28/19, and 11/28/18. R#13's care plans were reviewed and updated on 11/17/19. R#13's Comprehensive Assessment was completed on 11/7/19 but review of MDS Transmission Results indicated the assessment was not transmitted to CMS within 14 days of completion. A record review revealed R#15 was admitted to the facility on [DATE] with the diagnoses of hypertension, chronic obstructive pulmonary disease, glaucoma, gastro-esophageal reflux, dementia, and chronic respiratory failure. The last care plan review was completed on 11/7/19. R#15's Comprehensive Assessment was completed on 11/5/19 but review of MDS Transmission Results indicated the assessment was not transmitted to CMS within 14 days of completion. 5. Record review revealed R#4 was admitted to facility 9/13/13. R#4 had the following diagnoses of Alzheimer's dementia, chronic obstructive bronchitis, anxiety, hypertension, insomnia, obesity, diabetes, and hyperlipidemia. The last care plan review was completed on 10/25/19. R#4's Comprehensive Assessment was completed on 11/15/19 but review of MDS Transmission Results indicated the assessment was not transmitted to CMS within 14 days of completion. Record review revealed R#2 was admitted to facility 9/13/13. R#2 had the following diagnoses of anemia, benign prostatic hyperplasia, dementia, depression, glaucoma, and hyperlipidemia. The last care plan review was completed on 11/15/19. R#2's Comprehensive Assessment was completed on 11/15/19 but review of MDS Transmission Results indicated the assessment was not transmitted to CMS within 14 days of completion. Record review revealed R#10 was admitted to facility 9/13/13. R#10 had the following diagnoses of Alzheimer's dementia, anxiety, hypertension, insomnia, anemia, and hip pain. The last care plan review was completed on 11/5/19. R#10's Comprehensive Assessment was completed on 11/5/19 but review of MDS Transmission Results indicated the assessment was not transmitted to CMS within 14 days of completion. An interview on 12/17/19 at 9:14 a.m. with the Director of Nursing (DON) revealed, with MDS staff present, that she only knew about the issue two days ago and she reported it to their Information Technologist (IT) Department with the health system. Everything is in transition since the October 1 when the facility changed names and location, but she had not contacted CMS. An interview on 12/17/19 at 2:20 p.m. with the MDS Coordinator AA revealed that she used the CMS Resident Assessment Instrument (RAI) Manual for guidelines on transmission of MDS's. She indicated she sends the completed assessments as a zip/batch file directly to the state when completed. She revealed they have not changed provider numbers or changed the system in which they complete the assessments since the facility changed names and moved into a new facility on October 2019. She revealed she does not look at the missing assessment report on a regular basis to see if there were any assessment past due. She was not aware the assessments were not transmitted to CMS within 14 days of completion. She had not contacted CMS Interview on 12/17/19 at 4:06 p.m. with the Administrator revealed they think they had a glitch within the system. Further interview with the Corporate Registered Nurse (RN) Director of Survey Investigations (CC) stated she will discuss the missing MDS Transmissions with the DON and MDS Coordinators to get some answers. 2. Record review revealed R#16 was admitted to the facility on [DATE] with the diagnoses of dysarthria, schizophrenia, mild intellectual disability, hyperlipidemia, anemia, hypertension, cataracts, bilateral lower extremity edema, anxiety, insomnia, breast cancer, osteoarthritis, and colon cancer. R#16 had a comprehensive MDS completed on 11/21/19, 8/16/19, 6/2/19, 3/11/19, and 12/7/18. R#16's care plans were reviewed and updated on 11/21/19. R#16's Comprehensive Assessment was completed on 11/21/19 but review of the MDS Transmission Results indicated the assessment was not transmitted to CMS within 14 days of completion. Record review revealed that resident R#12 was admitted to the facility on [DATE]. R#12 had the following diagnoses of cerebral palsy, hypertension, and hyperuricemia. The last care plan review was completed on 11/11/19. R#12's Comprehensive Assessment was completed on 11/11/19 but review of MDS Transmission Results indicated the assessment was not transmitted to CMS within 14 days of completion. Record review revealed that resident R#14 was admitted to the facility on [DATE]. R#14 had the following diagnoses of dementia, hypertension, colon cancer, and colectomy. The last care plan review was completed on 11/6/19. R#14's Comprehensive Assessment was completed on 11/6/19 but review of MDS Transmission Results indicated the assessment was not transmitted to CMS within 14 days of completion.