Based on observation and staff interview it was determined the facility failed to ensure resident's privacy was maintained during medication administration and medical information was protected. This was true for 1 of 2 medication carts reviewed for privacy and confidentiality. This deficient practice placed residents at risk of embarrassment and loss of control over their personal information. Findings include: The facility's Patient Rights policy, revision date 12/1/22, documented the resident has the right to have personal and clinical records kept current and private. On 2/11/25 at 7:46 AM, observed on the south hall medication cart, the computer had the screen open to Resident #23's medical information. On 2/11/25 at 7:54 AM, observed on the south hall medication cart, the computer had the screen open to Resident #8's medical information. On 2/11/25 at 7:57 AM, observed on the south hall medication cart, the computer had the screen open to Resident #19's medical information. On 2/11/25 at 8:02 AM, LPN #1 stated she should have shut the screen to the computer before she left the medication cart.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure professional standards of nursing practice were followed for 1 of 12 residents (Resident #1) reviewed for quality of care. Resident #1 was at risk for adverse outcomes when she did not have a physician's order to provide oxygen as needed. This failed practice had the potential to adversely affect residents whose care and services were not followed according to accepted standards of practice. Findings include: The facility's Oxygen Administration policy revision date 10/13/22, documented oxygen was to be administered under orders of a physician, except in the case of an emergency. In such cases, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. Resident #1 was admitted to the facility on the 1/21/25, with multiple diagnoses including fracture of the right femur (thigh bone) and hypertension. On 2/10/25 at 9:00 AM, observed Resident #1 in her room with oxygen at 1 liter per minute via nasal cannula. Review of Resident #1's medical record did not document an order for oxygen. On 2/11/25 at 11:22 AM, LPN #2 stated Resident #1 did not have an order for the oxygen and she should have because she has been on a low flow oxygen since she was admitted .

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure medications available for residents were labeled, dated, and stored appropriately, this was true for 1 of 2 medication storage rooms inspected and 1 of 2 medication carts audited for labeling and storage of medications. This failure created the potential for residents to receive the wrong medication and to receive expired medications with decreased efficacy. Findings include: The CDC guidelines for Preventing Unsafe Injection Practices, dated 3/26/24, documented once a multi-dose vial is opened (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer states another date for that opened vial. The beyond-use-date should never exceed the manufacturer's original expiration date. The facility's Medication Storage policy revision date 10/12/22, documented the facility was to ensure all medications housed on the premises are stored in medication rooms or cart according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. On 2/11/25 at 10:07 AM, the facility's south side medication cart was inspected with LPN #1 present, observed in the third drawer on the left, a cup with multicolored tablets in it with a piece of tape across the top labeled Tums. On 2/11/25 at 10:12 AM, LPN #1 stated they did not have a container for the Tums, and they should have. On 2/11/25 at 10:16 AM, the facility's north side medication room was inspected with LPN #2 present, observed in the resident medication refrigerator, a vial of Tuberculin purified solution (a clear colorless solution used for detection of tuberculosis infection) vial with no opened date. On 2/11/25 at 10:17 AM, LPN #2 stated there was no open date on the bottle of Tuberculin purified solution or the box the solution was in. She stated the vial should have been dated when it was opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, record review, and, resident and staff interview, it was determined the facility failed to ensure a resident was assessed for safety to self-administer medication. This was true for 1 of 1 resident (Resident # 2) reviewed for self-administration of medications. This failure created the potential for adverse outcomes if Resident #2 received too much or too little of the medication. Findings include: The facility's Self- Administration of Medication policy, revised 10/12/22, stated the interdisciplinary team will determine which medication may be self-administered. The results of the interdisciplinary team assessment will be recorded on the Medication Self-Administration Assessment in the patient ' s medical record. Resident #2 was admitted to the facility on [DATE], with multiple diagnoses including Hypertension and removal of her pancreas. On 3/4/24 at 1:42 PM, Fluticasone Propionate nasal spray (nasal spray used to treat allergies) was observed on Resident #2's bedside table. Resident #2's care plan, dated 2/12/24, had no documentation Resident # was able to self-medicate. There was no Medicatioon Self-Adminisration Assessment in Resident #2's record. On 3/4/24 at 1:45 PM, Resident # 2 stated the medication on her bedside table was a nasal spray that she used for her allergies. On 3/5/24 at 9:06 AM, RN # 1 stated medications were not allowed to remain at a resident's bedside unless the resident was persistent on taking their own medication then an assessment was completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, and staff interview, it was determined the facility failed to ensure pertinent health information was provided to the receiving hospital. This was true for 1 of 2 residents (Resident #8) reviewed for transfers. This deficient practice had the potential to result in adverse outcomes if residents were not treated in a timely manner due to a lack of information provided upon transfer. Findings include: The facility's policy, Bed Hold Notice Before/Upon Transfer, revised 12/1/22, stated, Promontory Point Rehabilitation will provide the receiving provider the following: - Contact information of the practitioner responsible for the care of the patient. - Patient representative information, including contact information. - Advance Directive information. - All special instructions or precautions for ongoing care, as appropriate. - Comprehensive care plan goals. - All other necessary information including a copy of the patient ' s discharge summary, as applicable, and any other documentation to ensure a safe and effective transition of care. Resident # 8 was admitted to the facility on [DATE]. with multiple diagnoses including dementia and hypertension. A nurse's note dated 3/6/24 at 8:14 PM, documented Resident #8 was sent to the hospital earlier that day. The note documented there was no update and Resident #8 had not yet returned and his family and provider were aware. On 3/7/24 at 8:38 AM, RN #2 stated a transfer sheet and a medication list were sent with residents when they transferred to the hospital and the provider, family, and EMS were called. RN #2 stated this should have been documented in the progress note. On 3/7/24 at 8:48 AM, the DON and the ADON stated when a resident transferred to the hospital, the nurse notified and gave the physician a report, then made a progress note. They stated the facility sent a medication list, labs, and face sheet with the resident to the hospital. They further stated report was called to the hospital and family and should be documented in a progress note. Resident #8's record did not include documentation pertinent medical information was provided to the receiving hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, record review, and staff interview, it was determined the facility failed to ensure there was an on-going activity program designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident. This was true for 2 of 12 residents (#8 and #180) reviewed for activities. This failure created the potential for harm if residents experienced boredom and lack meaningful activities throughout the day. Findings include: The facility's Activities policy, revised 10/25/22, documented Promontory Point will provide an ongoing program to support patients in their choice of activities based on their preferences and include the following:. -Scheduled activities will be posted throughout the facility. - Special considerations will be made for developing meaningful activities for patients with dementia and/or special needs. - All staff will assist patients in and from activities when necessary. 1. Resident #180 was admitted to the facility on [DATE], with multiple diagnosis including fracture of the left tibia (the larger of the two bones in the lower leg) and hypertension. A care plan created on 2/21/24, documented Resident #180 was to be invited to scheduled activities, she was to be provided with an activities calendar, and she was to be assisted/escorted to activity functions. On 3/4/24 at 3:15 PM, Resident #180 was observed sitting in her wheelchair in her room. There was no activity calendar observed in her room. On 3/4/24 at 3:21 PM, Resident #180 stated she was not offered activities except therapy. She stated she had not received a calendar of the activities that were offered in the facility. 2. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including dementia and hypertension. Resident #8's care plan, revised 2/6/24,documented he liked to watch TV. The care plan documented Resident #8 was to be provided with simple, short activities, an activity calendar and reminded of upcoming activities. On 3/4/24 at 4:44 PM, Resident #8 was observed awake and sitting in his room. The TV was not on. On 3/4/24 at 4:50 PM, Resident # 8's wife stated he did not like activities other than watching TV. On 3/5/24 at 1:16 PM, the Administrator stated the activity director was let go, so activitties were not being offered according to resident care plans/preferences. He stated staff were going room to room offering activities. He stated Bingo wass offered at 2:00 PM in the dining room and there were no activity calendars in the Resident's rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents' dressing care was provided according to professional standards of nursing practice for 2 of 2 residents (#181 and #182) reviewed for quality of care. This failed practice had the potential to create infection in wounds or to Intravenous line sites. Findings include: The facility's Clean Dressing Change policy, revised 11/2/22, stated after securing a resident's dressing, staff were to mark the dressing with their initials and date. Dressing were to be changed per physician's order. The facility's PICC/Midline/CVAD (intravenous[IV] lines) Dressing Change policy revised 5/14/22, stated after the transparent semipermeable dressing was applied to the insertion site, staff were to label the dressing with the date and time the dressing was changed and their initials. 1. Resident #181 was admitted to the facility on [DATE], with multiple diagnosis including respiratory failure and thyroid cancer. On 3/4/24 at 4:34 PM, Resident #181 was observed lying in bed with an IV dressing on his left upper arm without a date or initials. The edges of the dressing were loose and light brown in color. On 3/4/24 at 4:40 PM, Resident #181 stated he could not remember the last time the dressing was changed. 2. Resident #182 was admitted to the facility on [DATE], with multiple diagnosis including respiratory failure and sepsis (when your immune system has a dangerous reaction to an infection). a. On 3/4/24 at 2:51 PM, Resident #181 was observed sitting in a chair in his room. The dressing to his left elbow did not have a date, time or initials. His IV site dressing on his left forearm did not have a date, time, or initials. b. On 3/6/24 at 9:42 AM, Resident # 182's IV site dressing on right hand was observed without date, time, or initials. On 3/6/24 at 12:09 PM, RN #2 stated all IV and wound dressings should be dated and initialed by the nurse, when they were changed. On 3/7/24 at 1:16 PM, the ADON stated all IV dressings and wound dressings should be dated and initialed when changed.

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure adequate care and treatment was provided to 1 of 1 resident (Resident #181) reviewed for feeding tube use. This created the potential for harm if complications developed from improper tube feeding practice. Finding include: The facility's Verifying Placement of feeding tube (a flexible plastic tube placed into the stomach to provide nutrition) policy, revised 6/14/21, directed staff to verify tube placement by gently tugging on the tube and taking note of the marking on the tube. A physician's order, dated 2/20/24, directed staff to change, date, and initial Resident #181's feeding bag and tubing every night shift. On 3/6/24 at 12:05, Resident #181 was observed in his room receiving Jevity 1.5 (a type of feeding formula that provides complete, balanced nutrition) via his feeding tube. The bottle of Jevity 1.5 was not labeled with Resident #181's name, start date or time, or rate of feeding to be delivered per hour. On 3/6/24 at 12:08 PM, RN #2 stated the bottle of Jevity 1.5 should have been labeled with Resident #181's name, the date it was started, along with the time and the rate it should be flowing at. On 3/6/24 at 12:11 PM, Resident #181 was lying in bed, with the head of the bed elevated. RN #2 was observed giving Resident #181's medication through his feeding tube. The feeding tube placement was not checked prior to giving the medication. On 3/6/24 at 12:17 PM, RN #2 stated she should have checked for tube placement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, record review, and staff interview, it was determined the facility failed to follow physician orders for the maintenance of supplemental oxygen This was true for 3 of 4 residents (#7, #181, and #182) reviewed for supplemental oxygen use. This placed residents at risk for respiratory infections when the supplemental oxygen and nebulizer tubing and humidifier bottle were not dated when changed. Findings include: The facility's Oxygen Concentrator policy revised 5/1/22, documented it was the nurse's responsibility to change the oxygen tubing weekly and as needed if it became soiled or contaminated. a. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including respiratory failure. A physician's order, dated 1/28/24, documented to change Resident #7's oxygen tubing and bag, clean the filter, and change the water (humidifier) bottle weekly. The order stated the staff were to initial and date the tubing when they were changed. A physician's order, dated 1/28/24, documented to change Resident #7's nebulizer (small machine that turns liquid medicine into a mist that can be easily inhaled) tubing weekly and as needed and initial and date the tubing every day shift, every Sunday. On 3/4/24 at 3:02 PM, Resident #7's oxygen concentrator tubing, water bottle, and nebulizer tubing were observed without dates. b. Resident # 81 was admitted to the facility on [DATE], with multiple diagnosis including respiratory failure and thyroid cancer. A physician's order, dated 2/20/24, documented to change Resident #182's oxygen tubing and bag, clean the filter, and change the water bottle weekly. The order directed staff to initial and date the tubing. On 3/4/24 at 4:28 PM, Resident #181 was observed lying in bed with his oxygen mask on. The oxygen mask and tubing were not dated. c. Resident #182 was admitted to the facility on [DATE], with multiple diagnosis including respiratory failure and sepsis (when your immune system has a dangerous reaction to an infection). A physician's order, dated 2/26/24, documented to change Resident #182's oxygen tubing and bag, clean the filter, and change the water bottle weekly. The order directed staff to initial and date the tubing. A physician's order, dated 2/26/24, documented to change Resident #182's nebulizer tubing set weekly and as needed and to initial and date the tubing every day shift, every Sunday. On 3/4/24 at 4:01 PM, Resident #182 was observed sitting in a chair with oxygen on. The oxygen tubing was not dated. The nebulizer set and tubing in his room were also not dated. On 3/5/24 at 12:54 PM RN #1 stated the oxygen tubing should be changed once a week and tubing is to be dated.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure residents were free from medication errors. This was true for 2 of 2 residents (#11 and #132) whose medication administration were observed. This failure created the potential for harm to residents who receive insulin using an insulin pen to experience low or high blood sugars when they received an incorrect amount of insulin. Findings include: The facility's Insulin Pen policy revised 10/12/22, documented the insulin pen is to be primed with 2 units of insulin after attaching the pen needle. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. When injecting the insulin, while pressing the plunger, keep the needle in the skin for up to 6-10 seconds and then remove the needle from the skin. On 3/5/24 at 7:41 AM, RN #2 was observed placing the insulin pen needle on the insulin pen and dialed the pen to the order dose of 14 units of Tresiba (long acting insulin) insulin. RN #2 injected the insulin and held the needle in Resident # 11's skin for 3 seconds. On 3/5/24 at 7:53 AM, RN #2 was observed placing the pen needle on the insulin pen and dialed the pen to the order dose of 4 units of Lispro (rapid acting insulin) insulin. RN #2 injected the insulin and held the needle in Resident #132's skin for 4 seconds. On 3/5/24 at 8:00 AM, RN #2 stated she primed the insulin pen needle with 1 unit of insulin and when injecting usually held the insulin pen in the resident's skin for 4 seconds. On 3/6/24 at 10:53 AM, the DON stated the insulin pen should be primed with 2 units of insulin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #7 was admitted on [DATE], with multiple diagnosis including respiratory failure and hypertension. An MDS admission assessment, dated 1/31/24, documented Resident #7 was cognitively intact. Resident #7's record did not include an advanced directive or documentation information about an advanced directive was provided and discussed with her. 4. Resident #182 was admitted to the facility on [DATE], with multiple diagnosis including respiratory failure and sepsis (when your immune system has a dangerous reaction to an infection). A MDS admission assessment, dated 3/1/24, documented Resident #182 was cognitively intact. Resident #182's record did not include an advanced directive or documentation information about an advanced directive was provided and discussed with her. On 3/6/24 at 11:38 AM, the SW stated he asked residents if they have had an advanced directive on admission and if they had one, he asked for a copy. If the resident did not have an advanced directive, he offered to help the resident formulate one or find a lawyer to help them formulate an advanced directive. The SW stated he did not document in the resident's chart if they had an advanced directive or if he offered to help them formulate one. Based on policy review, record review, and resident, and staff interview, it was determined the facility failed to ensure a residents' advance directive or POST were obtained and documented in their record. This was true for 4 of 12 residents (Resident #1, 130, #7, and #182) whose advance directives were reviewed. This deficient practice created the potential for harm or adverse outcomes if the residents' wishes regarding their advanced care plans were not followed or documented. Findings include: The facility's Residents' Rights Regarding Treatment and Advanced Directives policy, undated, stated: It is the policy of this facility to support and facilitate a resident's right to request, refuse, and/or discontinue medical or surgical treatment and to formulate an advance directive. 'Advance directive' is a written instruction such as a living will or durable power of attorney for health care, recognized under State law relating to the provision of health care when an individual is incapacitated (unable to speak for themselves). 1. On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive. 2. The facility will provide the resident or resident's representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advanced directive. 3. Upon admission, should the resident have an advance directive, copies will be made and placed in the chart as well as communicated to the staff. 4. Any decision-making regarding resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. The State Operation Manual Appendix PP defined an advance directive as a written instruction, such as a living will or durable power of attorney for health care, recognized under State law [whether statutory or as recognized by the courts or the State], relating to the provision of healthcare when the individual is incapacitated. Physician Order for Life-Sustaining Treatment, [POST], paradigm form is a portable form designed to improve patient treatments the patient wants in the event of a medical emergency, taking the patient ' s current medical condition into consideration. A POST is not an advance directive. 1. Resident #1 was admitted to the facility on [DATE] with diagnoses including surgical aftercare following placement of drain tubes post gallbladder surgery for blockage due to gallstones. An MDS assessment, dated 2/14/24, documented Resident #1 was cognitively intact. Resident #1's record did not include a copy of an advance directive, or documentation he was offered assistance to formulate an advance directive. On 3/7/24, at 10 AM, the SW confirmed Resident #1 was not offered assistance to formulate an advance directive and his record did not include documentation of further requests or follow up regarding an advance directive. 2. Resident #130 was admitted to the facility on [DATE], with multiple diagnoses including sepsis (when your immune system has a dangerous reaction to an infection). and chronic pressure ulcers of the buttocks. Resident #130's record did not include a copy of an advance directive, or documentation he was offered assistance to formulate an advance directive. On 3/5/24 at 11:34 AM, Resident #130 and his spouse stated they were interested in Resident #130 having an advance directive. Resident #130 and his spouse both stated they had not received information regarding advance directives since admission. On 3/7/24 at 10 AM, Resident #130's record was reviewed with the SW. The SW confirmed there was no documentation Resident #130 had an advance directive or that he was offered assistance in formulating one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. Resident #7 was admitted on [DATE], with multiple diagnosis including respiratory failure and hypertension. Resident #7 's record did not include documentation a baseline care plan was provided and discussed with her. d. Resident #181 was admitted to the facility on [DATE], with multiple diagnosis including respiratory failure and thyroid cancer. Resident #181's record did not include documentation a baseline care plan was provided and discussed with him or his wife. On 3/4/24 at 4:24 PM, Resident #181 stated no one had discussed the plan for his care and he did not remember signing a paper about it. e. Resident #184 was admitted on [DATE], with multiple diagnosis including respiratory failure, renal (kidney) failure, and congestive heart failure. Resident #184's record did not include documentation a baseline care plan was provided and discussed with him. On 3/4/24 at 4:59 PM, Resident #184 stated he did not receive papers about how the facility planned on caring for him. During an interview on 3/6/24 at 11:18 AM, the DON stated the baseline care plan was initiated when the patient was admitted . She stated there was no documentation the baseline care plan was reviewed with the above residents or their representative and there was no documentation one was signed by the residents' or their representative. Based on record review, policy review and resident staff interview, it was determined the facility failed to ensure a baseline care plan was reviewed and provided to residents' and their representative. This was true for 5 of 12 residents (#7, #16, #130, #181, and #184) whose records were reviewed. This failure placed residents at risk of not having their goals for care and services met. Findings include: A facility policy titled, Baseline Care Plan, undated, documented the facility would develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care that met professional standards of quality care. The guidelines stated the baseline care plan was developed within 48 hours of admission and included a minimum of healthcare information necessary to care for the patient and included the following: -initial goals based on admission orders -physician orders -dietary orders -therapy services -social services -PASARR [Preadmission Assessment and Resident Review) recommendation, if applicable -initial goals of resident -special needs, services, health or safety risk, wound care The guidelines further stated all care should be summarized and reviewed and signed by the patient and patient representative if applicable. a. Resident #16 was admitted to the facility 2/15/24, with multiple diagnoses including stroke and a post-surgical head wound. Resident #16's record did not include documentation a baseline care plan was provided and discussed with her. On 3/6/24, at 10:30 AM, Resident #16 stated she was uncertain of her plan of care. She stated she did not believe she had papers telling her what her care needs were at the facility. b. Resident #130 was admitted to the facility on [DATE], with multiple diagnoses including sepsis (when your immune system has a serious reaction to an infection) and chronic pressure ulcers of his buttocks. Resident #130'ss record did not include documentation a baseline care plan was provided and discussed with him. On 3/5/24, at 11:34 AM, Resident #130 and his spouse stated they remembered signing papers when he was admitted but did not remember what those papers stated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and staff interview, it was determined the facility failed to ensure infection control measures were consistently implemented and maintained to provide a safe and sanitary environment. This was true for 2 of 4 residents (#116 and #133) observed for infection control. This failure created the potential for harm by placing residents at risk for cross-contamination and infection. Findings include: 1. Resident #133 was admitted on [DATE], with multiple diagnoses including aftercare following total knee replacement. The facility's Personal Protective Equipment Policy (PPE), dated, 7/8/23, stated personal protective equipment appropriate to specific task requirements would be utilized per CDC guidelines. The policy stated equipment included but was not limited to: -gowns -gloves -masks -eyewear (googles and/or face shields The CDC website for isolation and standard precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, last reviewed 7/11/23, and accessed 3/14/24, states: Handwashing should be performed before having direct contact with patients; after contact with blood, body fluids or excretions, mucous membranes, nonintact skin, or wound dressings; after contact with a patient's intact skin; if hands will be moving from a contaminated-body site to a clean-body site during patient care; after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; after removing gloves. Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, nonintact skin, or potentially contaminated intact skin (e.g., of a patient incontinent of stool or urine) could occur. Wear a gown, that is appropriate to the task, to protect skin and prevent soiling or contamination of clothing during procedures and patient-care activities when contact with blood, body fluids, secretions, or excretions is anticipated. Use PPE to protect the mucous membranes of the eyes, nose and mouth during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions. Select masks, goggles, face shields, and combinations of each according to the need anticipated by the task performed. 1. On 3/4/24 At 5:35 PM, LPN #1 placed unopened testing supplies for admission testing of COVID-19, influenza, and PPD (purified protein derivative - skin injection to test for silent tuberculosis infection) on Resident #133's overbed table in front of her. LPN #1 then administered a nasal COVID-19 testing swab, a nasal influenza swab, and a PPD test to Resident #133. LPN #1 did not perform hand hygiene or wear PPE prior to administering the admission tests to Resident #133. On 3/4/24 at 5:55 PM, LPN #1 confirmed she did not perform hand hygiene or put on PPE during admission testing for COVID-19, influenza, and PPD. On 3/7/24 at 10:32 AM, the IP stated the facility policy was staff should be gowning and using PPE prior to completion of COVID-19 tests for all new admissions of unknown COVID-19 status. The IP further stated it was the facility's policy to use PPE for all new admissions. 2. On 3/4/24 at 5:35 PM, meal tray passes were observed in the facility's North Hall. a. LPN #1 entered Resident #133's room and placed a meal tray on her overbed table in front of her. LPN #1 did not perform hand hygiene prior to delivering Resident #133's meal. On 3/4/24 at 5:55 PM, LPN #1 confirmed she did not perform hand hygiene prior to delivering Resident #133's meal tray b. The Administrator delivered a meal tray to Resident #116. Resident #116 was not offered hand hygiene prior to receiving his meal tray. On 3/7/24 at 4:24 PM, the Administrator was asked if all residents should have hand hygiene offered prior to receiving their meal tray. The Administrator stated all residents should be offered hand hygiene prior to receiving their meal tray. The Administrator was asked if he offered hand hygiene to Resident #116 for his evening meal on 3/4/24. The Administrator stated he did not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and policy review, it was determined the facility failed to ensure residents were assessed to determine if they were safe to self-administer medications. This was true for 1 of 1 resident (Resident #17) reviewed for self-administration of medications. The failure created the potential for adverse effects if Resident #17 self-administered medications inappropriately. Findings include: The facility's policy Self-Administration of Drugs (undated), documented staff and/or the practitioner would assess whether a resident was capable of self-administering medications. The findings of the assessment would be presented to the Interdisciplinary Team (IDT) for final decision on appropriateness, and the facility would periodically, such as during quarterly MDS reviews, reevaluate the resident's ability to continue to self-administer medications. Resident #17 was admitted on [DATE], with diagnoses which included joint replacement, high blood pressure, and glaucoma. The MDS admission assessment, dated 2/28/19, documented Resident #17's was cognitively intact. On 3/13/19 at 11:44 AM, eye drops were observed in Resident #17's bedside refrigerator. On 3/13/19 at 12:01 PM, LPN #2 stated Resident #17 self-administered her medicated eye drops at night, and the nurses' documented in the medical record the time it was self-administered. On 3/13/19 at 12:05 PM, LPN #2 stated a self-administration assessment was not completed for Resident #17.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and policy review, it was determined the facility failed to ensure baseline care plans were developed to meet the needs of residents. This was true for 1 of 12 residents (Resident #1) reviewed for baseline care plans. The failure placed Resident #1 at risk of injury and/or medical complications due to the lack of information on his baseline care plan. Findings include: The facility's Baseline Care Plan policy (undated) documented the baseline care plan would be developed to properly care for the resident within 48 hours of a resident's admission. The baseline care plan would include the resident's stated goals and objectives and a copy of the baseline care plan summary provided to the resident. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including fractures of the lumbar spine, diabetes, and hypertension (high blood pressure), paroxysmal atrial fibrillation (a rapid, erratic heart rate begins suddenly and then stops on its own within 7 days), and long-term use of anticoagulant (blood thinning) medication. Resident #1's baseline care plan, initiated on [DATE], documented he also had a non-operable left tibial plateau (top of the shin bone) fracture for which he wore a leg brace. Resident #1's admission MDS assessment, dated [DATE], documented he was cognitively intact. Resident #1's physician orders, dated [DATE], documented the following: *2.5 mg of Apixaban (an anticoagulant used to reduce clot formation in the blood) twice daily *Humalog insulin KwikPen100 Unit/ML, inject per sliding scale for diabetes *Lantus insulin pen-injector 100 Unit/ML, inject 20 units subcutaneous two times a day *Monitor skin integrity under his knee brace *Non-weight bearing on his left lower extremity *Follow pressure sore prevention and/or care protocols *Resuscitation code status of Full Code, initiate CPR *Follow the bowel and bladder protocol *Complete an evaluation and initiate treatment for physical therapy, occupational therapy, and speech therapy *Fentanyl Patch for pain management, change every 72 hours *Hydrocodone-Acetaminophen 5-325 mg, 1-2 tablets every four hours, as needed, for pain *Ibuprofen 200 mg tablet every morning for inflammation Resident #1's baseline care plan did not include goals and interventions related to the following: *Insulin dependent diabetes *Fall prevention *Bowel and bladder care *Skin integrity and pressure sore prevention *Resuscitation code status *Pain management *Paroxysmal atrial fibrillation and use of anticoagulant medication *Therapy Services On [DATE] at 11:33 AM, the DON said the care plan was missing multiple components needed to care for Resident #1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, policy review, and Activity Calendar review, it was determined the facility failed to ensure there was a variety of activities, and the scheduled activities met the needs of residents. This was true for 2 of 2 residents (Resident #3 and Resident #173) reviewed for activities. This created the potential for residents to become bored and foster increased negative behaviors due to a lack meaningful and engaging activities throughout the day and evening. Findings include: The facility's undated Activity's policy documented residents' activities should be meaningful and individualized according to their needs. The March 2019 Activity Calendar was completed between 3/1/19 and 3/18/19, and it documented activities occurred seven days a week with minimal times set aside for activities. The Activity Calendar documented the following activities: * Sundays: activity cart upon request, puzzles in the dining room, Church services on television from 9:00 AM to 10:00 AM, and Sacrament in the afternoon * Mondays: activity cart upon request, puzzles in the dining room, [NAME] of the week, and Bingo at 4:30 PM * Tuesdays: Salon by appointment only, activity cart upon request, puzzles in the dining room, Tuesday 3/15/19 Wine and Cheese at 3:00 PM * Wednesdays: activity cart upon request, puzzles in the dining room, Wednesday 3/6/19 a board game at 4:30 PM * Thursdays: activity cart upon request, puzzles in the dining room, Thursday 3/15/19 St. Patrick's Day Craft at 5:00 PM * Fridays: Salon by appointment only, activity cart upon request, puzzles in the dining room, Dinner and a Movie on 3/1/19 and 3/16/19 (the movies were the same), and on 3/8/19 a different movie at 4:00 PM. * Saturdays: activity cart upon request, puzzles in the dining room The activity calendar from 3/1/19 through 3/18/19, did not include activities scheduled after 5:00 PM. The activity cart and puzzles were scheduled daily. The activity cart had the same items available of books, magazines, crosswords, word searches, and other games. There were 10 activities scheduled that were not the activity cart or puzzles, or that were not by appointment only. The activity Calendar instructed residents to contact their religions if they wanted religious services. a. Resident #173 was readmitted to the facility on [DATE], with diagnoses which included failure to thrive and pain. An admission MDS assessment, dated 3/1/19, documented Resident #173's activity preferences which were very important to her included pet visits, and activities that were important but she could no longer do included favorite activities and religious activities. An Activity Assessment, dated 3/1/19, documented Resident #173's activity preferences that were very important to her included pet visits. The assessment documented things somewhat important to her included listening to music, current events/news, reading, socials/parties, and group discussions. The assessment documented activities that were important to Resident #173, but she was no longer able to do, included religious services and favorite activities. The Activities care plan, dated 2/26/19, documented Resident #173 enjoyed activities where she played the piano or the organ and pet visits. The care plan did not document other activities she enjoyed, as documented in the 3/1/19 Activity Assessment. Resident #173's Activities Flowsheet, dated 2/1/19 through 2/28/19, did not include documentation of pet visits or playing the piano or organ. The flowsheet documented she actively participated in a social on 2/14/19, and she received a copy of the activities calendar four times. Resident #173 declined seven offers for activities such as bingo, crafts, activities cart, movie night, and a special event. Resident #173's flowsheet did not include other activities offered or provided. Resident #173's record was reviewed on 3/15/19 and did not include an Activities Flowsheet for March 2019. On 3/11/19 at 3:30 PM, Resident #173 stated the activities at the facility did not interest her and they were the same thing. Resident #173 stated she enjoyed playing the piano or organ and the facility did not have one. Resident #173 stated she stayed in her bed most of the day when she was not receiving therapy. b. Resident #3 was admitted to the facility on [DATE], with diagnoses which included pain and a fractured leg. An admission MDS assessment, dated 12/24/18, documented Resident #3's activity preferences which were very important to him included music and getting outside air. An Activity Assessment, dated 12/20/18, documented Resident #3's activity preferences that were very important to him were music and going outside for fresh air. The assessment documented it was not important to him to keep up with the current events/news, pet visits, read, socials/parties, and religious activities. The Activities care plan, dated 2/26/19, documented Resident #3 enjoyed activities of television, hunting, fishing, and vaping outside. The care plan did not include music and going outside as activities he enjoyed. Resident #3's Activities Flowsheet, dated 2/1/19 through 2/28/19, did not include documentation of being outside. The flowsheet documented he actively participated in a social on 2/6/19 and 2/14/19, a special event on 2/14/19, and he received a copy of the activities calendar four times. Resident #3 declined five offers for activities such as bingo, activities cart, and movie night. Resident #3's flowsheet did not include other activities offered or provided. Resident #3's record was reviewed on 3/15/19 and did not include an Activities Flowsheet for March 2019. On 3/11/19 at 1:46 PM, Resident #3 stated the activities provided by the facility did not pertain to a person of his age. On 3/13/19 at 10:06 AM, the Social Services Director stated the facility was currently working on updating the activities program due to resident complaints.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The Nursing 2018 Drug Handbook documented the following regarding digoxin (a heart medication): * Before administering the medication, measure the pulse for one minute, record the result and notify the prescribing provider of significant changes. * Excessively slow pulse rate (60 beats/minute or less) may be a sign of digitalis toxicity. Withhold drug and notify prescriber. Resident #126 was admitted to the facility on [DATE], with multiple diagnoses including atrial fibrillation (irregular heartbeat). Resident #126's physician orders documented an order on 3/9/19 for digoxin 125 mcg daily for heart failure. The order further instructed staff to hold the digoxin if Resident #126's heart rate less than 60 beats per minute. Resident #126's MAR documented digoxin 125 mcg was administered on 3/9/19, and the heart rate was 51. There was no documentation in Resident #126's record the digoxin was held on 3/9/19. On 3/13/19 at 2:17 PM, RN #1 said before giving digoxin, the nurse should check Resident #126's pulse and check the order. RN #1 said if the pulse was in the fifties then the medication should not be given, and the physician should be notified. On 3/13/19 at 2:55 PM, the DON said digoxin should not have been given to Resident #126 when his pulse was 51, and she did not see documentation the digoxin was held on that day. 3. Resident #13 was readmitted to the facility on [DATE], with diagnoses which included fractured prosthetic left hip joint, pain, and bacterial infection. An admission MDS assessment, dated 2/11/19, documented Resident #13 was cognitively intact and had a surgical wound. Resident #13's hospital History and Physical, dated 1/29/19, documented she had a pain pump in place on her left hip. Resident #13's physician orders, dated 2/4/19, included: - Cleansing the left hip with normal saline and gauze, applying skin prep to intact surrounding skin, and covering the surgical site with bordered gauze every three days. - Monitor the incision for signs and symptoms of infection and notify the physician if there was an increase in temperature, redness, swelling, drainage, etc., every shift. Resident #13's February 2019 MAR documented Resident #13's incision was monitored every shift as ordered, however, the documentation did not indicate if signs and symptoms of infection were found. The MAR documented her left hip dressing was changed as ordered. The following Progress Notes documented Resident #13's surgical incision was healing with Steri Strips (medical wound closure strips) in place and did not document a dressing was in place as ordered by the physician. The Progress Notes also identified Resident #13 had increased pain in her left hip area. Examples include: - Progress Notes, dated 2/23/19, 2/24/29, and 2/26/19, documented Resident #13's left surgical incision was healing and Steri Strips were in place. - A Progress Note, dated 2/27/19, documented Resident #13's left surgical incision was clean and healing. - A Progress Note, dated 3/1/19, documented Resident #13's left surgical incision was healing and Steri Strips were in place. - A Progress Note, dated 3/2/19, documented Resident #13's left surgical incision had Steri Strips in place and her left hip was throbbing with pain. - A Progress Note, dated 3/3/19, documented Resident #13's left surgical incision had Steri Strips in place and she had pain in her leg. - A Progress Note, dated 3/4/19, documented Resident #13's left hip hurts even more and was throbbing. - A Progress Note, dated 3/5/19 at 1:27 PM, documented Resident #13 had no changes to her skin integrity. The note documented her left leg hurt. - A Progress Note, dated 3/5/19 at 5:38 PM, documented Resident #13's left hip/pain pump site was swelling. - A Progress Note, dated 3/6/19, documented Resident #13's left hip surgical site was swollen, draining thick fluids, and pulling apart at the top of the incision. The note documented Resident #13's left hip hurt even more and was throbbing. Resident #13's March 2019 MAR documented the following: - Resident #13's incision was monitored every shift as ordered. There was no documentation of swelling, pain, or drainage to Resident #13's surgical incision. - Cleansing the left hip with normal saline and gauze, apply skin prep to intact surrounding skin, and cover with bordered gauze every three day was changed as ordered, except on 3/1/19 and 3/4/19. The MAR documented her left hip incision was cleansed and a dressing applied on 3/7/19 and 3/11/19. - The MAR documented Resident #13 had an appointment with her physician on 3/6/19 for increased swelling in her left hip incision. Resident #13's physician orders, dated 3/8/19, documented an order for 500 mg of cephalexin (antibiotic) three times daily for an infection to her left surgical hip site. Resident #13's MAR, dated 3/8/19 through 3/12/19, documented she received the cephalexin 500 mg as ordered. On 3/12/19 at 9:58 AM, Resident #13 stated her left hip incision did not have a dressing on it, and the facility stopped using a dressing and cleansing it except when she showered a while ago. Resident #13 stated her left hip incision did not have a dressing in place this week or last week. Resident #13 stated her incision was infected and started draining a few days ago. Resident #13 stated she noticed increased pain in her hip as well. On 3/13/19 at 11:54 AM, Resident #13's left hip incision was observed without a dressing. Resident #13's incision was intact with Steri Strips. There was redness and swelling along the incision line, and a green dried crusty exudate (mass of cells and fluid found during inflammation) along the entire incision line. On 3/13/19 at 2:14 PM, the DON stated she was unsure how Resident #13's left hip incision got infected. The DON stated the order to cleanse Resident #13's left hip and apply a bandage should have been discontinued on the first of March, and it was not. She stated nurses should follow all active physician orders. The DON stated she would try to find out why the nurses documented they cleansed the left hip incision and dressed the wound on 3/7/19 and 3/11/19 when Resident #13 stated it was not completed. The facility failed to follow physician orders for care and treatment of a surgical site incision. Based on observation, record review, policy review, and interviews with residents and staff, it was determined the facility failed to ensure professional standards were met for wound care, medication administration, treatment provided in a timely manner, and bowel care. This was true for 3 of 13 residents (#13, #73, and #126) reviewed for quality of care. These failures created the potential for harm should residents experience worsening of wounds, constipation or fecal impaction, and/or adverse effects from medications. Findings include: The Facility's Medication Therapy policy, dated April 2009, documented a resident's record must contain physician orders for all medications and treatments. 1. Resident #73 was admitted to the facility on [DATE], with diagnoses which included a fractured left femur (thigh bone), tobacco use, and stroke. a. Resident #73 developed a skin impairment on her left inner thigh. Resident #73's Total Skin and Body Assessment, dated 9/4/18, documented she had a raised area on the inside of her left thigh without drainage. A Physician Progress Note, dated 9/10/18 documented the physician examined a two-inch boil (infection of the hair follicle) on Resident #73's left inner thigh and it appears to have been opened by pressure at some point. The note documented the raised area was approximately four inches high. Resident #73's physician's order, dated 9/10/18, documented staff were to apply a warm pack three times a day to her left inner thigh. Resident #73's record did not include orders to monitor or treat the area to her inner left thigh between 9/4/18 and 9/10/18 (6 days). Resident #73's Total Skin and Body Assessment, dated 9/11/18, documented Resident #73 had a cyst on her upper inner thigh (previously referred to as a boil). The assessment did not document measurements for the area, a description of the wound bed, or include which leg it was on. A Wound Clinic Note, dated 9/13/18, documented Resident #73's left inner thigh abscess (i.e. boil, cyst) was initially evaluated, and she had eschar (dark dead tissue) measuring 0.4 cm long by 0.1 cm wide, which covered a fluid filled sack. The note documented the wound had a strong odor and the clinic removed a large amount of thick pus from the abscess. The note documented Resident #73's inner left thigh was not covered with a dressing on arrival. A Wound Clinic order, dated 9/13/18, documented an order for Resident #73's inner left thigh abscess to be cleansed with a cleansing agent, a barrier ointment applied to the surrounding skin, the wound packed with gauze, and an adhesive foam dressing applied every other day and as needed. Resident #73's physician orders, dated 9/17/18, (four days later) documented an order for staff to cleanse left thigh abscess with normal saline and gauze, apply skin prep to intact skin, pack the wound with gauze, and cover the wound with a foam dressing every other day. The order was entered into Resident #73's record four days after her wound clinic appointment (9/13/18 - 9/17/18). Resident #73's Total Skin and Body Assessment, dated 9/18/18, documented Resident #73's had a cyst on her upper inner thigh. The note documented there was an odor present with white drainage. The assessment did not document measurements for the area, a description of the wound bed, or which leg it was on. A Wound Clinic Note, dated 9/18/18, documented Resident #73's left inner thigh abscess was a full thickness wound with slough (a mass of dead tissue that separates from a wound bed) and eschar present on the wound bed. The note documented the area was warn to the touch, painful, and measured 1.2 by 1.6 by 0.4 cm. The note documented the Wound Clinic was unable to debride the area due to Resident #73's high pain level. A Wound Clinic order, dated 9/18/18, documented an order for Resident #73's inner left thigh abscess to be cleansed with a non-cytotoxic agent, Iodosorb (a sterile formula used to clean wound beds and assist with removing slough) applied to the wound bed, and a Tegaderm foam dressing applied every other day and PRN. Resident #73's physician orders for treatment of her left thigh abscess were changed to include the Iodosorb on 9/25/18, 7 days after the Wound Clinic order. The orders did not include the Tegaderm foam, as ordered by the Wound Clinic. Resident #73's Total Skin and Body Assessment, dated 9/25/18, documented she had a healing cyst to her left upper thigh. The assessment did not document measurements for the area and a description of the wound bed. A Wound Clinic Note, dated 9/25/18, documented Resident #73's inner left thigh abscess was healing and measured 0.7 cm by 1.50 cm by 0.2 cm. The note documented the wound bed had minimal slough with granular (new, healthy) tissue. A Wound Clinic order, dated 9/25/18, documented an order for Resident #73's inner left thigh abscess to be cleansed with a non-cytotoxic agent, Iodosorb applied to the wound bed, and a Mepilex dressing applied every other day and PRN. Resident #73's September 2018 MAR documented staff were to cleanse Resident #73 inner left thigh abscess with normal saline, apply skin prep to the intact area, apply Iodosorb, and cover the wound with Mepilex every other day and PRN, beginning on 9/25/18 and discontinued on 10/10/18. The dressing was changed as ordered by the physician, except on 9/28/18 when Resident #73 was unavailable and on 9/25/18. Resident #73's Total Skin and Body Assessment, dated 10/2/18, documented she had a healing cyst to her left upper thigh. The assessment did not document measurements for the area or a description of the wound bed. Resident #73's Total Skin and Body Assessment, dated 10/9/18, documented Resident #73's left upper thigh was in the healing stages. A Wound Clinic Note, dated 10/9/18, documented Resident #73's left upper thigh abscess remained open and was healing. A Wound Clinic order, dated 10/9/18, documented an order for Resident #73's inner left thigh abscess to be cleansed with a non-cytotoxic agent, a collagen gel applied to the wound bed, and a Mepilex dressing applied every other day and PRN. The order for the collagen gel was not added to Resident #73's physician orders. On 3/15/19 at 8:45 AM, the DON stated the wound treatment orders should be entered into the system by the nurse in charge of the resident's care. The DON stated the nurses should enter the orders as soon as possible, and if the orders were not sent with the resident, the nurses should contact the Wound Clinic to get the orders faxed. The DON stated Resident #73's thigh wound appeared to be an ingrown hair when it was first identified. The DON stated she could not find orders for its monitoring or treatment until 9/17/18; however, she recalled the facility provided a bandage for the abscess prior to 9/17/18. The DON stated Resident #73 was seen by the Wound Clinic when the wound opened. The facility failed to implement treatments as ordered by the Wound Clinic timely, and some were not implemented. The facility also failed to consistently assess Resident #73's left inner thigh abscess. b. The facility's undated Bowel Protocol documented when a resident did not have a bowel movement in three days or more, staff were directed to follow the protocol. The protocol documented the following: * Day 3 without a bowel movement - provide Milk of Magnesia, prune juice, or fiber. * Day 4 without a bowel movement - provide a suppository * Day 5 without a bowel movement - provide an enema * Day 6 without a bowel movement - contact the physician The facility failed to follow the bowel protocol as follows: Resident #73 was admitted to the facility on [DATE], with diagnoses which included a fractured left femur (thigh bone), tobacco use, and stroke. Resident #73 was discharged on 10/10/18. Resident #73's admission orders included: - Follow the bowel and bladder protocol, ordered on 7/23/18. - Colace (stool softener) two times a day for constipation, ordered on 7/23/18. - Polyethylene Glycol (laxative) 17 grams by mouth PRN one time daily for constipation, ordered on 7/23/18. - Bisacodyl Suppository 10 milligrams rectally PRN one time daily for constipation, ordered on 7/23/18. Resident #73's Nursing Admit Assessment, dated 7/23/18, documented her last bowel movement was on 7/19/18 (4 days prior to admission). Resident #73's July 2018 ADL Bowel Movement record documented the following: - There was no documented evidence she had a bowel movement between 7/23/18 and 7/28/18 (5 days). - The record documented Resident #73 had a bowel movement on 7/29/18. This bowel movement occurred 10 days after her last documented bowel movement on 7/19/18. A Progress Note, dated 7/28/18 at 4:27 PM, documented Resident #73 refused to eat her meals due to constipation. The note documented she declined to take medications to assist with constipation; however, the nurse encouraged her to take the medication and she did. A Progress Note, dated 7/29/18 at 9:59 PM, documented Resident #73 threw up a substance which looked and smelled like stool and the physician assessed the substance. The note documented Resident #73's last bowel movement was a while ago and she declined wanting to have a bowel movement. The note documented nursing received an order for a new laxative and Resident #73 agreed to take the medication. Resident #73's physician order, dated 7/29/18, documented she was to receive 300 mL (milliliters) of Magnesium Citrate (laxative) one-time daily PRN for constipation. Resident #73's July 2018 MAR documented the following bowel medications were provided: - Colace was administered as ordered, except on 7/30/18 and 7/31/18 when she refused. - One dose of Bisacodyl Suppository was administered on 7/27/18 and 7/29/18. The 7/27/18 dose was documented as ineffective. - 17 grams of Polyethylene Glycol was administered on 7/28/18 and it was ineffective. - 300 mL of Magnesium Citrate was administered on 7/29/18 and it was effective. The facility did not provide bowel care interventions between 7/23/18 and 7/27/18 (four days). Resident #73 received bowel care for the first time on 7/27/18, or eight days after her last bowel movement (7/19/18). The facility did not follow the protocol of initiating bowel care interventions on day 3 of no bowel movement. On 3/15/19 at 8:45 AM, the DON stated nurses were instructed to follow the bowel protocol after a resident went three days without a bowel movement. She stated they were instructed to start with day three interventions and continue onto the next intervention per residents' needs. The DON stated she was unable to find bowel care interventions provided to Resident #73 between 7/23/18 and 7/27/18. The DON stated if an intervention was ineffective she would expect staff to try something else or contact the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure an order was in place for CPAP machines and oxygen therapy. This was true for 2 of 4 residents (#19, and #123) reviewed for oxygen. These failures created the potential for harm should residents experience complications from CPAP machines and oxygen therapy being administered without physician directions. Findings include: The facility's undated Oxygen Concentrator policy documented the following: * Staff were directed to administer oxygen under physician orders, except in case of emergency. * The physician's order for rate, flow, and route of administration for oxygen were verified by the nurse. 1. Resident #19 was admitted to the facility on [DATE], with multiple diagnoses including aftercare following a joint replacement and obstructive sleep apnea (periods of cessation of breathing). Resident #19's care plan documented he had altered respiratory status and difficulty breathing and shortness of breath related to sleep apnea, initiated on 2/13/19. Resident #19's physician orders did not document an order for CPAP. Resident #19's Progress Notes, dated 2/27/19 at 12:24 PM, 2/28/19 at 6:14 PM, 3/5/19 at 9:20 AM, 3/9/19 at 12:46 PM, and 3/13/19 at 3:36 PM, documented he had shortness of breath on exertion and CPAP. On 3/11/19 at 3:17 PM, Resident #19 had a CPAP machine on his bedside table and the CPAP mask was under his pillow. On 3/13/19 at 11:20 AM, a CPAP machine, CPAP mask, and tubing were on Resident #19's bedside table. Resident #19 said he used the CPAP every night. On 3/13/19 at 11:32 AM, RN #1 said she expected an order for Resident #19's CPAP to document the settings used with the CPAP. On 3/13/19 at 11:36 AM, the DON said when a resident had a CPAP, the facility staff needed an order with the settings for the CPAP. 2. Resident #123 was admitted to the facility on [DATE], with multiple diagnoses including asthma. Resident #123's physician orders did not document an order for oxygen. Resident #123's Weights and Vitals Summary documented the following: * On 3/9/19 at 5:08 PM and 5:59 PM, the oxygen saturation ( a measurement of oxygen in the blood) was 94 percent on oxygen via nasal cannula. * On 3/10/19 at 11:18 AM, the oxygen saturation was 93 percent on oxygen via nasal cannula. * On 3/11/19 at 12:02 PM, the oxygen saturation was 96 percent on oxygen via nasal cannula. * On 3/12/19 at 12:29 PM, the oxygen saturation was 100 percent on oxygen via nasal cannula. Resident #123's Progress Notes documented the following: - On 3/10/19 at 4:26 PM, the oxygen saturation was 93 percent on oxygen via nasal cannula. - On 3/11/19 at 2:09 PM, the oxygen saturation was 96 percent on oxygen via nasal cannula. On 3/12/19 at 12:24 PM, Resident #123 was observed in her room with oxygen in place by nasal cannula. On 3/14/19 at 10:56 AM, an oxygen concentrator, tubing, and humidifier were in Resident #123's room. There was no active order for Resident #123 to receive oxygen. On 3/14/19 at 11:06 AM, RN #2 said Resident #123 kept removing the oxygen, so it was left it off, When RN #2 checked Resident #123's oxygen saturation it was 92 percent. RN #2 said she thought there was a standing order for oxygen and staff monitored Resident #123 for 48 hours before discontinuing the oxygen. On 3/14/19 at 3:46 PM, the DON said she could not find an order for Resident #123's oxygen, and a Hospital Progress Note documented she wore oxygen at night. The DON said staff needed an order for Resident #123's oxygen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, policy review, and record review, it was determined the facility failed to ensure prior to placement of side rails, residents were thoroughly assessed for the risk of entrapment, and a consent was in place. This was true for 3 of 6 residents (#8, #125, and #126) reviewed for side rail use and created the potential for harm from entrapment or injury related to the use of side rails. Findings include: The facility's Bed Safety policy, revised December 2018, documented the following: * Staff were directed to assess the sleeping environment, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding side rail safety assessment. * Staff were directed to obtain consent for side rails from the resident or their representative prior to using side rails. * Side rails may be used if the safety assessment determined they were necessary to assist with management of a medical symptom or condition, or to assist the resident with repositioning and transferring. * Staff were directed to complete the side rail safety assessment prior to using side rails and ensure the resident was able to use side rails safely. 1. Resident #8 was readmitted to the facility on [DATE], with multiple diagnoses including orthopedic aftercare and fusion of the lumbosacral spine (lower back). On 3/12/19 at 10:38 AM, bilateral 1/4 side rails were present on Resident #8's bed. Resident #8's record did not contain a side rails safety assessment or consent for the use of the side rails. Resident #8's care plan documented 1/4 side rails to assist with bed mobility, initiated on 2/4/19. On 3/13/19 at 9:37 AM, the DON said she could not find a side rail safety assessment, or a signed consent for the side rails in Resident #8's record. The DON said if a resident expressed a desire for side rails on admission, a side rails safety assessment was completed by the admitting nurse, the physician was contacted for an order, and the resident signed a consent for side rails. 2. Resident #125 was admitted to the facility on [DATE], with multiple diagnoses including aftercare following a joint replacement. On 3/12/19 at 10:14 AM and 3/13/19 at 4:05 PM, Resident #125 had bilateral 1/4 side rails on her bed. Resident #125's record did not contain a consent for side rails. Resident #125's Side Rail Assessment, dated 3/15/19 at 12:22 PM, documented she was evaluated for the use of bilateral 1/4 side rails and was determined to be safe, a physician's order was obtained prior to placing the side rails, and a consent was signed prior to placing the side rails. On 3/14/19 at 9:44 AM, the DON said she did not see an order or consent for Resident #125's side rails. 3. Resident #126 was admitted to the facility on [DATE], with multiple diagnoses including acute embolism and thrombosis (blood clot). On 3/11/19 at 4:16 PM and on 3/13/19 at 1:55 PM, Resident #126 had bilateral bed rails in place. On 3/11/19 at 4:16 PM, Resident #126 said a side rail safety assessment or consent form was not done, and the side rails were already in place when he arrived in the facility. Resident #126's record did not contain a consent for side rails. Resident #126's Side Rail Assessment, dated 3/15/19 at 12:15 PM, documented he was evaluated for the use of bilateral 1/4 side rails and was determined to be safe, a physician's order was obtained prior to placing the side rails, and a consent was signed prior to placing the side rails. On 3/13/19 at 2:49 PM, the DON said she did not see an order, consent, or care plan for Resident #126's side rails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, and staff interview, it was determined the facility failed to provide ongoing monitoring for appropriate, effective, and safe medication use. This was true for 1 of 5 residents (Resident #1) reviewed for unnecessary medications. This failure created the potential for harm if residents experienced adverse effects from medications administered without monitoring. Findings include: The facility's Medication Monitoring/Medication Management policy dated 11/2017, documented each resident's drug regimen was reviewed to ensure it was free from unnecessary drugs which included review of: * Excessive doses * Duplicate drug therapy * Excessive duration, without adequate monitoring * Adequate indications for its use * Adverse consequences which indicate the dose should be reduced or discontinued * Any combination of the above To optimize the therapeutic effect of the medication therapy and minimize or prevent potential adverse consequences. The facility policy documented the staff, the attending physician/prescriber, and the consultant pharmacist perform ongoing monitoring for appropriate, effective, and safe medication use. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including fractures of the lumbar spine and left tibia (shinbone), insulin dependent diabetes, hypertension (high blood pressure), and paroxysmal atrial fibrillation (a condition of the heart with sudden bursts of erratic heart beats). Resident #1's admission MDS assessment, dated 3/5/19, documented he was cognitively intact. A physician order dated 2/27/19, included the following medications to be administered to Resident #1: * apixaban 2.5 mg, give 1 tablet by mouth two times a day for atrial fibrillation * aspirin 81 mg, give 1 tablet by mouth one time a day for heart health * furosemide 40 mg, give 1 tablet by mouth one time a day for edema * ibuprofen 200 mg, give 1 tablet by mouth in the morning for inflammation Resident #1's MAR did not include monitoring of side effects for apixaban, aspirin, and ibuprofen. The Medical Director Report dated 2/28/19, documented observations and recommendations to increase apixaban to 5 mg twice a day. This form was signed on 3/11/19 by a nurse practitioner with a comment apixaban was ordered and monitored by the cardiologist. The admission MRR, unsigned by the physician, dated 3/5/19, documented monitoring for Resident #1 included signs and symptoms of bleeding and/or excessive bruising for apixaban use. The MMR also documented a potential drug interaction with concurrent use of the diuretic furosemide and nonsteroidal anti-inflammatory drugs (aspirin, and Ibuprofen) may result in reduced effectiveness and possible nephrotoxicity (poisonous type of effect that may cause kidney damage). Resident #1's care plan did not document for staff to monitor for side effects of apixaban from his date of admission on [DATE] until 3/12/19. A physician office visit dated 3/6/19, included a current list of Resident #1's medications. This list did not include Resident #1's apixaban or aspirin. The ibuprophen was documented as 600 mg rather than the current order of 200 mg. On 3/13/19 at 2:28 PM, the DON stated the Pharmacist completed the medication reviews. She said the reports were returned in a running format all together, not separated for each resident reviewed, and the reports were not included in the EMR because they are not separated. The DON said instead the Pharmacist made notations in the progress notes. On 3/13/19 at 3:04 PM, the DON stated the pharmacy recommendations were faxed to the facility which were placed in the providers box to review. If the provider made changes, they either provided a verbal or written order. On 3/15/19 at 11:50 AM, the DON stated side effect monitoring for apixaban, aspirin, and ibuprofen was not documented. On 03/15/19 at 11:33 AM, the DON stated the provider will write 'no changes' or verbalize to the nurse 'no changes'. The DON stated the provider did not routinely sign the pharmacy recommendations. 03/15/19 at 11:37 AM, the DON stated bruising, nose bleeds, blood in the urine, etc. were examples of signs and symptoms of side effects of apixaban. She stated the facility monitored symptoms or side effects for apixaban, but it was not documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, resident and staff interview, and record review, it was determined the facility failed to ensure a resident was provided dental services. This was true for 1 of 1 resident (Resident #173) reviewed for dental services. This failure created the potential for harm if residents experienced weight loss or increased mouth pain from poor fitting dentures. Findings include: The facility's Dental policy, undated, documented residents were assisted in obtaining routine and emergent dental care. Resident #173 was readmitted to the facility on [DATE], with diagnoses which included failure to thrive and pain. Resident #173's Nursing Admit Assessment, dated 2/23/19, documented she had full upper and lower dentures. A Nutrition Evaluation, dated 2/27/19, documented Resident #173 had full dentures and she did not wear them because they were uncomfortable. The evaluation recommended Resident #173 visit a denturist and for nursing to assess the fit of her dentures. An admission MDS assessment, dated 3/1/19, documented Resident #173 was cognitively intact and she had broken or loose-fitting dentures. Resident #173's Care Area Assessment, dated 3/8/19, documented Resident #173 had full dentures and she did not wear them because they were uncomfortable. The evaluation recommended Resident #173 visit a denturist and for nursing to assess the fit of her dentures. Resident #173's care plan did not include a care area for her dentures. Resident #173's record did not include documentation the facility followed up with Resident #173 regarding the fit of her dentures or placed a referral to a denturist. On 3/12/19 at 11:12 AM, Resident #173 stated she had full dentures and she did not wear them often because they caused her mouth pain. On 3/13/19 at 2:36 PM, the DON stated she was unsure if a referral was made to a denturist or if the fit of Resident #173's dentures was discussed with her. The DON stated she expected a referral to be made if the resident requested one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and policy review, it was determined the facility failed to ensure infection control measures were consistently implemented for equipment cleaning, laundry services, and avoiding cross-contamination during and after wound care. This was true for 3 of 12 residents (#6, #8, #13) reviewed for infection control. These deficient practices created the potential for harm by exposing residents to the risk of infection and cross contamination. Findings include: 1. The facility's Infecion Prevention and Control policy, undated, documented reusable equipment requiring cleaning, disinfection, or sterilization was cleaned in accordance with their current procedures governing the cleaning and sterilization of soiled or contaminated equipment. The Centers for Disease Control and Prevention website, accessed on 3/21/19, documented: * Clean medical devices as soon as practical after use (e.g., at the point of use) * Ensure at mininum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient or once daily or weekly). On 3/12/19 at 9:07 AM, CNA #3 moved the vital sign equipment from Resident #6's room, to Resident #13's room without cleaning the equipment between each use. On 3/12/19 at 9:21 AM, CNA #3 completed vital signs in Resident #74's room. The vital sign equipment was not cleaned after use, and the vital sign machine was then docked at the nurses' station. On 3/12/19 at 9:25, CNA #3 stated vital sign equipment should be cleaned after each resident use, and she stated she did not do this. 2. The facility's Infection Prevention and Control Program policy, undated, documented the following: * Laundry and direct care staff should handle, store, process, and transport linens to prevent spread of infection. * Linen should be stored on all resident care units on covered carts, shelves, in bins, drawers, or linen closets. On 3/13/19 at 3:33 PM, the residential laundry room was observed with the following: * PPE for handling soiled linen was hanging on the wall of the clean side of the room between the dryer and the folding table. * There was no covering on the clean linen rack. * Lost and found clothing and washed wool pads were stored on dirty side of the room. On 3/13/19 at 3:43 PM, the industrial laundry room was observed with the following: * A dirty bin of linens was positioned on the clean side of the wash room in front of industrial dryer. * There was no covering on the clean linen rack On 3/13/19 at 3:43 PM, the Laundry Manager stated he had not separated items between the clean and dirty areas of the laundry rooms. He said he did not realize he was cross contaminating the clean area when transporting the PPE used to handle soiled linen to where it was stored on the clean side of the laundry room. The Laundry Manager also said he did not realize he was cross contaminating when he stored the dirty linen bin on the clean side of the room. 3. The facility's Clean Dressing change policy, undated, documented: * Staff were to set up a clean field on the overbed table with needed supplies for wound cleansing and dressing application as follows: - Place a disposable cloth or linen saver under supplies - Place only the supplies to be used per wound on the clean field at one time Resident #8 was readmitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes mellitus, orthopedic aftercare, and fusion of the lumbosacral spine (low back). Resident #8's physician orders documented the following was ordered for wound care on 1/30/19: Cleanse wound with Normal Saline, apply SkinPrep to the surrounding skin, apply Santyl (an ointment used to help heal skin ulcers) to wound, apply Telfa (a guaze dressing) over Santyl, and cover with a 3M or similar adhesive dressing. On 3/12/19 at 10:49 AM, RN #2 entered Resident #8's room to change her dressing on her lower back. RN #2 placed a gray plastic tray containing dressing supplies on the foot of Resident #8's bed. RN #2 adjusted Resident #8's clothing and touched her multiple times while gathering supplies from the tray. While performing the dressing change as ordered, RN #2 touched clean items on the tray multiple times after touching the resident. On 3/12/19 at 11:02 AM, RN #2 left Resident #8's room with the tray and returned it to the medication room. RN #2 placed the gray tray on the top shelf in the medication room cupboard. RN #2 said sometimes the tray was used in other residents' rooms, and she should have taken the individual supplies out of the tray and left the tray in the medication room. On 3/13/19 at 9:33 AM, the DON said when a nurse performed a dressing change, she expected the nurse to review the order, gather the supplies and take them to the resident's room. The DON said the nurse only took what was needed into the room and put down a barrier to place the supplies on so the unused supplies could be taken back out of the room. The DON said taking the tray into Resident #8's room, placing the tray on her bed, and returning the tray to the shelf in the medication room was not the standard of practice and was not the facility's policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including fractures of the lumbar spine, diabetes, and hypertension (high blood pressure). Resident #1's admission MDS assessment, dated [DATE], documented he was cognitively intact. Resident #1's POST, dated [DATE], included a code status of Full Code. The Advanced Directive section was blank. The Medical Social Services Initial Comprehensive Assessment and Plan of Care, dated [DATE], included under the Advance Directives section a Living Will and POST were completed. Resident #1's record did not include a Living Will. On [DATE] at 11:03 AM, the DON was unable to provide a copy of Resident #1's Living Will. 8. Resident #11 was admitted to the facility on [DATE], with multiple diagnoses including hypertension (high blood pressure), anemia, and chronic renal disease (a gradual loss of kidney function over time). Resident #11's admission MDS assessment, dated [DATE], documented she was cognitively intact. Resident #11's POST, dated [DATE], documented her code status was DNR, and she had a Living Will. Resident #11's record did not include a Living Will. On [DATE] at 3:24 PM, the DON stated the Living Will was located; however, it was not included in Resident #11's record. 9. Resident #17 was admitted to the facility on [DATE] with multiple diagnoses including joint replacement, hypertension (high blood pressure), and glaucoma. Resident #17's admission MDS assessment, dated [DATE], documented she was cognitively intact. Resident #17's POST, dated [DATE], documented her code status was DNR, and she had a Living Will. The POST section B, regarding medical interventions, and section C, regarding artificial fluids and nutrition, and antibiotic and blood products, were not completed. Resident #17's record did not include a Living Will. On [DATE] at 3:39 PM, the DON stated the Living Will was not in Resident #17's record. Based on record review, policy review, and staff interview, it was determined the facility failed to ensure: a) residents were provided information regarding advance directives upon admission and were assisted to formulate an advance directive if necessary, and b) the residents' record included documentation of this process, a copy of the advance directive, or documentation the resident did not wish to formulate an advance directive. This was true for 9 of 12 residents (#1, #3, #11, #13, #17, #19, #123, #125, and #173) whose records were reviewed for advance directives. These failures created the potential for harm should residents not have their wishes documented and honored if they were unable to communicate their health care preferences. Findings include: The facility's undated policy for advance directives documented the facility would support and facilitate a resident's right to request, refuse, and/or discontinue medical or surgical treatment and to formulate an Advance Directive. Upon admission, the facility would determine whether the resident had an advance directive and would request a copy, place a copy in the clinical record, and communicate the advance directive information to staff. Decision making about the resident's choices would be documented in their record and communicated to the interdisciplinary team and staff involved in the resident's care. 1. Resident #19 was admitted to the facility on [DATE], with multiple diagnoses including aftercare following a joint replacement. Resident #19's admission MDS assessment, dated [DATE], documented he was cognitively intact. Resident #19's physician orders documented an order on [DATE] for CPR. Resident #19's POST documented Resuscitate (Full Code) and was signed by him on [DATE]. Resident #19's current care plan documented his code status was CPR, initiated on [DATE]. Resident #19's clinical record did not include an Advance Directive or documentation he had been provided information regarding formulating an Advanced Directive and offered assistance to do so, and declined the offer. On [DATE] at 9:24 AM, the Admissions Director said he did not see documentation of an advance directive for Resident #19 or that it was requested. On [DATE] at 9:36 AM, the Admissions Director said Resident #19's POST did not indicate he had an advance directive, so he did not request one from him. 2. Resident #125 was admitted to the facility on [DATE], with multiple diagnoses including aftercare following a joint replacement. Resident #125's physician orders documented an order on [DATE] for DNR. Resident #125's POST documented Do Not Resuscitate and was signed by her on [DATE]. Resident #125's current care plan documented her code status was DNR, initiated on [DATE]. Resident #125's clinical record did not include an Advance Directive or documentation she had been provided information regarding formulating an Advanced Directive and offered assistance to do so, and declined the offer. On [DATE] at 9:15 AM, the Admissions Director said he did not see documentation of an advance directive for Resident #125, and he did not recall asking her about it or offering it to her. The Admissions Director said upon admission to the facility, Social Services did an assessment, asked residents about their advance directives, and helped them fill one out if the family asked for assistance. On [DATE] at 9:22 AM, the Social Services Director said when a resident first arrived at the facility she asked them if they had an Advance Directive. The Social Services Director said her documentation indicated Resident #125 had a living will at home, and she was not sure whether the facility ever obtained a copy. The Social Services Director said she documented whether a resident had an advance directive, and the Admissions Director usually asked residents if they had an advance directive and for a copy of it during completion of the admission paperwork. 3. Resident #123 was admitted to the facility on [DATE], with multiple diagnoses including displaced bimalleolar (ankle) fracture and unspecified dementia without behavioral disturbance. Resident #123's physician orders documented an order for CPR on [DATE]. Resident #123's POST documented Resuscitate and was signed by her on [DATE]. Resident #123's clinical record did not include an Advance Directive or documentation she had been provided information regarding formulating an Advanced Directive and offered assistance to do so, and declined the offer. On [DATE] at 3:26 PM, the DON said there was no advanced directive documented for Resident #123. 4. Resident #13 was readmitted to the facility on [DATE], with diagnoses which included fractured prosthetic left hip joint, pain, and bacterial infection. Resident #13's physician's order, dated [DATE], documented her code status was Full Code and she wished to receive CPR. The care plan area addressing Resident #13's code status, initiated on [DATE], documented she wished to receive CPR. Resident #13's POST, dated [DATE], documented her code status was Full Code with limited interventions. The POST section C, regarding artificial fluids and nutrition, and antibiotic and blood product use, and section D, regarding advanced directives wishes, were not completed. An undated Social Services Initial Assessment documented Resident #13 had a living will and a POST. On [DATE] at 3:46 PM, the DON stated the advanced directives (living will) should be in the residents' records and she would attempt to locate them. 5. Resident #173 was readmitted to the facility on [DATE], with diagnoses which included failure to thrive, muscle wasting, falling, heart disease, chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs, making it hard to breathe), and pain. Resident #173's POST, dated [DATE], documented her code status was Full Code with comfort measures. The POST section D, regarding advanced directives wishes, documented she had a living will. Resident #173's physician's order, dated [DATE], documented her code status was DNR. The care plan area addressing Resident #173's code status, initiated on [DATE], documented her wishes of DNR. Resident #173's physician orders and POST were inconsistent. An undated Social Services Initial Assessment documented Resident #173 had a living will and a POST. On [DATE] at 9:24 AM, the Administrator stated Resident #173's wishes were for Full code and Staff would correct the order and the care plan. The Administrator stated the facility was waiting for Resident #173's family to bring in a copy of her living will. 6. Resident #3 was admitted to the facility on [DATE], with diagnoses which included pain and a fractured leg. Resident #3's physician's order, dated [DATE], documented his code status was Full Code and wished to receive CPR. The care plan area addressing Resident #3's code status, initiated on [DATE], documented he wished to receive CPR. Resident #3's POST, dated [DATE], documented his codes status was Full Code with comfort measures. The POST section C, regarding artificial fluids and nutrition, and antibiotic and blood product use, and section D, regarding advanced directives wishes, were not completed. An undated Social Services Initial Assessment documented Resident #3 had a living will and a POST. On [DATE] at 3:46 PM, the DON stated the advanced directives (living will) should be in the residents' records and she would attempt to locate them. The DON stated the POST should be filled out completely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including fractures of the lumbar spine, diabetes, and hypertension (high blood pressure). Resident #1's admission MDS assessment, dated [DATE], documented he was cognitively intact. Resident #1's POST, dated [DATE], documented a code status of Full Code. Resident #1's physician orders documented a code status of CPR, ordered on [DATE] . Resident #1's care plan, initiated on [DATE] through [DATE], did not contain documentation of his code status. On [DATE] at 3:29 PM, the DON stated there was not a code status addressed in Resident #1's care plan. 4. Resident #8 was readmitted to the facility on [DATE], with multiple diagnoses including Type 2 diabetes mellitus and hypertension (high blood pressure). Resident #8's physician orders documented CPR was ordered on [DATE]. Resident #8's POST documented Resuscitate (Full Code) and was signed by her daughter on [DATE]. Resident #8's care plan did not document her code status. On [DATE] at 2:03 PM, the DON said she did not see Resident #8's code status on her care plan. The DON said Resident #8 went home and then came back to the facility, and normally when a resident returned to the facility they were asked if they wanted to keep the same POST or if they wanted to make any changes. The DON said the admission Director obtained the POST and then it was documented on the care plan. The DON said it was overlooked and Resident #8's code status should have been on the care plan. 5. Resident #19 was admitted to the facility on [DATE] with multiple diagnoses, including aftercare following a joint replacement and obstructive sleep apnea (periods of cessation of breathing). Resident #19's care plan documented he had altered respiratory status and difficulty breathing/shortness of breath related to sleep apnea, initiated on [DATE]. The care plan interventions did not include or address the use of CPAP (a machine that is used to treat sleep apnea). Resident #19's Progress Notes, dated [DATE] at 12:24 PM, [DATE] at 6:14 PM, [DATE] at 9:20 AM, [DATE] at 12:46 PM, and [DATE] at 3:36 PM, documented he had shortness of breath on exertion and used a CPAP. On [DATE] at 11:20 AM, a CPAP machine, CPAP mask, and tubing were on Resident #19's bedside table. Resident #19 said he used the CPAP every night. On [DATE] at 11:36 AM, the DON said Resident #19's use of a CPAP machine should be on his care plan. Based on record review, policy review, and resident and staff interview, it was determined the facility failed to develop and implement comprehensive resident-centered care plans. This was true for 5 of 13 residents (#1, #8, #13, #19, and #173) whose care plans were reviewed. This failure created the potential for residents to receive inappropriate or inadequate care. Findings include: The facility's Comprehensive Care Plans policy, (no date, copyright 2018) documented a comprehensive person-centered care plan will be prepared by an interdisciplinary team for each resident within 7 days after the completion of the comprehensive MDS assessment, and it would be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 1. Resident #173 was readmitted to the facility on [DATE], with diagnoses which included failure to thrive, muscle wasting, falling, heart disease, chronic obstructive pulmonary disease (lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible), and pain. An admission MDS assessment, dated [DATE], documented Resident #173 was cognitively intact and required extensive assistance of 2 staff members for bed mobility and dressing, extensive assistance of one staff member for transfer and toilet use, and limited assistance of one with personal hygiene. The MDS documented she had broken or loose-fitting dentures. a. Resident #173's POST, dated [DATE], documented her code status was Full Code (resuscitate) with comfort measures. Resident #173's physician's order, dated [DATE], documented her code status was DNR (do not resuscitate). Resident #173's care plan, updated [DATE], documented her code status was DNR. Prior to [DATE] Resident #173's care plan did not include her code status. Resident #173's physician orders and care plan documented her code status as DNR. Her POST documented her code status as Full Code. On [DATE] at 9:24 AM, the Administrator stated Resident #173's wishes were for Full code and staff would correct the order and the care plan. On [DATE] at 3:46 PM, the DON stated she was unaware Resident #173's care plan did not document a code status prior to [DATE]. b. Resident #173's Nursing admission Assessment, dated [DATE], documented she had full upper and lower dentures. Resident #173's Care Area Assessment (CAA), dated [DATE], documented Resident #173 had full dentures and she did not wear them because they were uncomfortable. The evaluation recommended Resident #173 visit a denturist and nursing to assess the fit of her dentures. Resident #173's care plan did not contain a care area for her dentures. c. Resident #173 did not have a care plan area for her ADL function until [DATE], which documented she may require 1-2 staff members assistance with transfers, toilet use, personal hygiene, bed mobility, dressing, and bathing. The care plan was not consistent with the [DATE] MDS assessment which documented she required extensive assistance of 2 staff members for bed mobility and dressing, extensive assistance of one staff member for transfer and toilet use, and limited assistance of one with personal hygiene. On [DATE] at 11:12 AM, Resident #173 stated she required assistance from staff with all her cares except eating. On [DATE] at 3:46 PM, the DON stated Resident #173's care plan should have more details. The DON stated she was missing multiple areas which were identified on her CAA. 2. Resident #13 was readmitted to the facility on [DATE], with diagnoses which included fractured prosthetic left hip joint, pain, and bacterial infection. An admission MDS assessment, dated [DATE], documented Resident #13 was cognitively intact and had a surgical wound. Resident #13's Hospital History and Physical, dated [DATE], documented she had a pain pump in place on her left hip. The care plan area addressing Resident #13's pain, initiated [DATE], documented staff were to provide pain medications as ordered. The care plan did not document Resident #13 had a pain pump or address how staff were to manage the pain pump. On [DATE] at 9:58 AM, Resident #13 stated her incision was infected and started draining a few days ago. Resident #13 stated she had noticed increased pain in her hip as well. On [DATE] at 2:21 PM, the DON stated the care plan should contain information on Resident #13's pain pump.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview, record review, and policy review, it was determined the facility failed to ensure care plans were reviewed and revised after each comprehensive assessment, and as needed by, an interdisciplinary team for 4 of 13 residents (#13, #17, #19, and #73) whose care plans were reviewed. The failure created the potential for harm if care and services were not provided to residents as needed. Findings include: The facility's Comprehensive Care Plans policy, (copyright 2018) documented a comprehensive person-centered care plan would be prepared by an interdisciplinary team for each resident within 7 days after the completion of the comprehensive MDS assessment, and reviewed and revised by the interdisciplinary team after each comprehensive, and quarterly, MDS assessment. 1. Resident #17 was admitted to the facility on [DATE], with multiple diagnoses including joint replacement, hypertension (high blood pressure), and glaucoma. Resident #17's admission MDS assessment, dated 2/28/19, documented she was cognitively intact. On 3/12/19 at 10:28 AM, Resident #17 stated she was not involved in care plan meetings. Resident #17's record did not include documentation of care plan meetings with Resident #17. On 3/13/19 at 9:59 AM, the Social Services Director said the process for setting up care plan meetings was to first check with the resident to coordinate the meeting with other disciplines. The Social Services Director stated the initial care plan meeting was completed within a week of the resident's admission. The Social Services Director said a form, titled Initial Care Plan Conference (ICPC), was used to document the meetings and the follow up care conferences were documented in the progress notes. She stated the initial ICPC was not scanned into the resident's record. The Social Services Director stated Resident #17 declined attending care conference meetings. The Social Services Director confirmed there was not documentation in Resident #17's record of her declining participation in the meetings. The Social Services Director reported there was no set time scheduled for the interdisciplinary care conferences, and usually the facility only did them as needed. On 3/13/19 10:24 AM, the Administrator stated the initial ICPC documentation was not included in the residents ' records. The Administrator said he kept the documentation in his office. Resident 17's ICPC form was provided by, and reviewed with, the Administrator. The form documented the care plan conference was completed on 2/15/19. The form included the signatures of the Social Service Director and an occupational therapist. Other signatures were not documented. A box was checked on the form indicating the Patient participated, although as mentioned previously, Resident #17 and the Social Services Director stated Resident #17 did not attend. The contents of the care plan conference was not documented. The Administrator stated the facility did not document items covered in the care plan conferences. 2. Resident #19 was admitted to the facility on [DATE], with multiple diagnoses including aftercare following a joint replacement and obstructive sleep apnea (periods of cessation of breathing). Resident #19's record did not document a care plan conference occurred since his admission to the facility. On 3/11/19 at 3:08 PM, Resident #19 said he was not aware of a care plan conference being held since he was admitted to the facility. On 3/13/19 at 10:52 AM, the Social Services Director said documentation of care plan conferences were were kept in the Administrator's office. The Social Services Director said the initial care plan conference was done within a week of the resident's admission to the facility, and the Administrator, MDS nurse, Director of Therapy, and sometimes other staff attended the initial care plan conference. On 3/13/19 at 11:04 AM, the Administrator said he could not find the documentation of Resident #19's care plan conference. 3. Resident #13 was readmitted to the facility on [DATE], with diagnoses which included fractured prosthetic left hip joint, pain, and bacterial infection. An admission MDS assessment, dated 2/11/19, documented Resident #13 was cognitively intact and had a surgical wound. Resident #13's physician order, dated 3/8/19, documented she received 500 mg of cephalexin (antibiotic) three times daily for an infection to her left surgical hip site, until 3/21/19. Resident #13's March 2019 MAR documented the cephalexin 500 mg was administered three times a day as ordered from 3/8/19 through 3/12/19. On 3/12/19 at 9:58 AM, Resident #13 stated her incision was infected and it started draining a few days ago. The care plan area addressing Resident #13's infection and antibiotic use, was not initiated until 5 days after treatment was initiated. On 3/13/19 at 2:21 PM, the DON stated Resident #13's care plan was reviewed after discussions with the surveyors and care areas were added. The DON stated the use of the antibiotic was not added to the care plan as soon as possible. The DON stated she expected the care plan to be updated as soon as possible. The DON stated after a nurse received an order for something that required extra care, the nurse should initiate a care plan or update the care plan. 4. Resident #73 was admitted to the facility on [DATE], with diagnoses which included a fractured left femur (thigh bone), tobacco use, and cerebral infarction (stroke). An admission MDS assessment, dated 7/30/18, documented Resident #73 was cognitively intact and she required extensive assistance of two staff members for transfers, bed mobility, toilet use, and dressing. The MDS documented Resident #73 currently used tobacco. A Progress Note, dated 8/14/18, documented Resident #73 wanted to smoke, and the facility staff agreed to accommodate her request and assisted her with smoking at 10:00 AM and 4:00 PM. The care plan area addressing Resident #73's smoking, initiated on 7/27/18, did not document the agreed upon plan to assist her with smoking at 10:00 AM and 4:00 PM. On 3/15/19 at 8:45 AM, the Administrator stated Resident #73 was aware of the non-smoking policy upon admit, and the facility met with Resident #73 and her family to develop a plan to assist her with smoking. The Administrator stated he thought Resident #73's care plan included her smoking schedule. The care plan was not revised when changes occurred to Resident #73's care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including fractures of the lumbar spine and left tibia (shinbone), insulin dependent diabetes, hypertension (high blood pressure), and paroxysmal atrial fibrillation (a condition of the heart with sudden bursts of erratic heart beats). Resident # 1's physician orders, dated 2/27/19 included triazolam (medication to treat insomnia) 0.25 mg, give 1 tablet by mouth at bedtime for sleep. Resident #1's MAR documented nightly administration with hours of sleep documented each night. Residents #1's care plan dated 2/28/19 documented he used hypnotic medication related to insomnia. Care plan interventions/tasks documented the potential risks were incontinence, injury from fall, functional decline/decreased ability to ambulate, skin breakdown/abrasions, circulatory compromise, signs and symptoms of adverse reaction, decreased social contact/sedation, drowsiness, ataxia, drunk walk, and morning hangover. The care plan directed staff to notify the physician as needed if adverse side effects were observed. There was no documentation in Resident #1's record triazolam side effects were monitored. On 3/15/19 at 11:37 AM, the DON stated side effects were monitored but not documented in resident records. Based on record review, policy review, and staff interview, it was determined the facility failed to ensure there was adequate side effect monitoring for residents receiving psychotropic medications. This was true for 4 of 5 residents (#1, #8, #13, and #19) who were reviewed for unnecessary medications. This failed practice created the potential for harm should residents experience adverse effects from psychotropic medications. Findings include: The facility's policy for Medication Management, dated 11/2017, documented the following: * For residents who received psychotropic medications, the facility must assess the effectiveness of the medication and potential adverse consequences. * The facility ensured residents were adequately monitored for adverse consequences of psychotropic medications (a medication that affects brain activity associated with mental processes and behavior). If the psychotropic medication caused or contributed to adverse consequences, the facility and prescribing provider must decide whether to continue the medication. 1. Resident #8 was readmitted to the facility on [DATE], with multiple diagnoses including chronic pain syndrome and restless leg syndrome. Resident #8's physician orders documented the following: an order on 12/19/18 for clonazepam (anti-anxiety medication) 2 mg at bedtime for restless legs and sleep, and an order on 1/23/19 for escitalopram (antidepressant medication)10 mg in the morning for depression. Resident #8's care plan documented the following: * She used anti-anxiety medication, initiated on 1/21/19. Care plan interventions included monitor/document side effects. Anti-anxiety side effects included drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, disorientation, depression, dizziness, impaired thinking and judgment, memory loss, nausea, upset stomach, and blurry or double vision. * She used antidepressant medication, initiated on 2/4/19. Care plan interventions included monitor/document side effects as needed. Antidepressant side effects included dry mouth, dry eyes, constipation, urinary retention, and suicidal ideations. Resident #8's February 2019 MAR documented the clonazepam and escitalopram were administered each day from 2/1/19 through 2/28/19. The March 2019 MAR documented the clonazepam and escitalopram were administered each day from 3/1/19 through 3/11/19. Resident #8's February 2019 and March 2019 MARs and TARs did not include documentation of monitoring of side effects for clonazepam and escitalopram. There was no documentation in Resident #8's record side effects of clonazepam and escitalopram were monitored. On 3/13/19 at 10:11 AM, the DON said monitoring of signs and symptoms was documented in the MAR to see if the medicine helped. The DON said it was documented as needed if adverse effects or side effects were observed, and they were not typically listed on the MAR. 2. Resident #19 was admitted to the facility on [DATE], with multiple diagnoses including major depressive disorder. Resident #19's physician orders documented an order on 2/7/19 for bupropion ER (antidepressant medication)150 mg once a day for depression. Resident #19's care plan documented he used antidepressant medication, initiated on 2/8/19. Interventions included monitor/document side effects as needed. Antidepressant side effects included dry mouth, dry eyes, constipation, urinary retention, and suicidal ideations. Resident #19's February 2019 MAR documented the bupropion was administered each day from 2/8/19 through 2/28/19. The March 2019 MAR documented the bupropion was administered each day from 3/1/19 through 3/13/19. Resident #19's February 2019 and March 2019 MARs and TARs did not include documentation of monitoring for side effects of bupropion. There was no documentation in Resident #19's record side effects of bupropion were monitored. On 3/13/19 at 11:58 AM, RN #1 said when a resident received antidepressant medication, the nurse should monitor vital signs and check on their level of well-being. RN #1 said side effect monitoring should come up on the MAR/TAR and she did not see side effect monitoring for Resident #19's bupropion. RN #1 said if there were side effects she documented it in the progress notes. On 3/13/19 at 12:16 PM, the DON said when the care plan was created the side effect monitoring was created at the same time. She said monitoring for side effects for Resident #19's bupropion was not included. 3. Resident #13 was readmitted to the facility on [DATE], with diagnoses which included fractured prosthetic left hip joint, pain, bacterial infection and insomnia. The care plan area addressing Resident #13's insomnia, initiated 2/8/19, documented staff were to monitor Resident #13 for side effects of trazodone (medication used to decrease anxiety and insomnia related to depression) to include dry mouth, dry eyes, constipation, urinary retention, and suicidal ideations. Resident #13's physician orders, dated 2/4/19, included 100 mg of trazodone at bedtime for insomnia. Resident #13's March 2019 MAR documented staff were to administer trazodone at bedtime for insomnia. The medication was provided as ordered. Resident #13's record did not include monitoring of side effects for the psychotropic medication trazodone. On 3/13/19 at 2:27 PM, the DON stated monitoring of side effects was not documented for all of the residents on psychotropic medications.

Based on observation, policy review, review of the 2017 FDA Food Code, and staff interview, it was determined the facility failed to ensure food was maintained according to safe practices. This failed practice placed 3 of 3 residents (#13, #17, and #173) whose room refrigerators were assessed and the 26 other residents with refrigerators in their rooms, at risk for adverse health outcomes. This failed practice increased residents' risk of developing food borne illnesses. Findings include: The facility's Use and Storage of Family/Other Provided Foods policy, revised 1/2016, documented non-perishable foods were required to be labeled with a date, the resident's name, and what the food item was. The policy documented the food could be stored for 3 days, at which time the items needed to be discarded. The 2017 FDA Food Code, Chapter 3, Part 3-5, Limitation of Growth of Organisms of Public Health Concern, subpart 3-501.12 Time/Temperature Control for Safety Food, Slacking, documented, (A) Under refrigeration that maintains the food temperature at 5 C (41 F [Fahrenheit]) or less . On 3/13/19 at 11:38 AM, Resident #17's refrigerator was observed with milk, butter, cheese, nuts, and a food item wrapped in a napkin without a date, the resident's name, or description of what the food item was. On 3/13/19 at 11:48 AM, Resident #13's refrigerator was observed at 43 degrees F and contained potentially hazardous food which included cut melons. Other fresh fruits, including grapes, peaches, and oranges, and half of a sandwich were observed. The food items were covered with plastic wrap and were not labeled with dates or the resident's name. On 3/13/19 at 11:55 AM, Resident #173's refrigerator was observed at 30 degrees and had sandwiches, fruit, crackers, and milk. The food items were covered with plastic wrap and were not labeled with dates or the resident's name. On 3/13/19 at 12:15 PM, the Certified Dietary Manager (CDM) stated all the residents in the facility had a refrigerator in their room. The CDM observed the refrigerator in Resident #13's room and stated the temperature was 43 degrees F and it needed to be less than 41 degrees F. The CDM stated the food items should have dates and the residents' names on them. The CDM stated he had no way of telling how old the food items were without dates.