**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review. observation, and resident and staff interview, it was determined the facility failed to ensure a resident's right for self-determination was honored. This was true for 1 of 2 residents (Resident #63) reviewed for choices. This deficient practice had the potential for Resident #63 to experience a decreased sense of well-being, lack of self-worth, and frustration when his preference for bed placement was not accommodated. Findings include: The facility's Resident Rights policy, undated, documented, Self-Determination: You have the right to self-determination through support of your choice, including the right to: make choices about aspects of your life in the facility that are significant to you. Resident #63 was admitted to the facility on [DATE], with multiple diagnoses including morbid (severe) obesity, pressure ulcer of the sacral (tailbone) region, spinal disc degeneration, and major depressive disorder. An MDS assessment, dated 4/9/24, documented was cognitively intact. During an interview on 6/3/24 at 11:18 AM, Resident #63 stated CNA #1 repositioned her bed without her consent. She stated she asked CNA #1 to turn her bed back up against the wall, and CNA #1 stated she repositioned the bed because it was easier for her to provide care for Resident #63. Resident #63 stated she liked her bed up against the wall because she usually leaned to the right side of her bed, and when lying in the bed in its current position she felt she was going to fall out of the bed. Resident #63 stated she told CNA #3 about CNA #1 repositioning her bed. During an interview on 6/4/24 at 2:57 PM, LPN #4 stated residents could have their beds positioned how they wanted in their rooms. LPN #1 stated she was unaware of why the bed was repositioned. LPN #1 stated she would have staff reposition the bed back to the way the resident liked it. During an interview on 6/6/24 at 10:32 AM, the SSD stated a resident had the right to self-determination; it was the staff's responsibility to explain the risk to the resident and family. During an interview on 6/6/24 at 2:42 PM, the DON stated a resident had a right to make their choices about their life while living in the nursing facility. The DON stated staff did not have the right to move a resident's bed without that resident's consent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** asBased on record review, policy review, observation, and resident and staff interview, it was determined the facility failed to implement storage of resident smoking materials as directed by residents' care plans. This was true for 2 of 2 residents (#57 and #67) whose care plans were reviewed for smoking. These failures placed residents in the facility at risk of negative outcomes if smoking materials were not stored safely due to lack of information in their care plan. Findings include: The facility's Smoking Policy, dated 10/15/22, documented Smoking paraphernalia is not permitted to be stored in the resident's room. This includes e-cigarettes and vaping devices/materials. 1. Resident #57 was admitted to the facility on [DATE], with multiple diagnoses including tobacco use. An MDS assessment, dated 4/18/24, documented Resident #57 was cognitively intact. Resident #57's Care Plan, dated 4/7/23, documented Resident #57 was an independent smoker and his smoking paraphernalia was stored in his room or in the nurse's cart. During an interview on 6/3/24 at 11:30 AM, Resident #57 stated he was an unsupervised smoker and had his own smoking products in his room. 2. Resident #67 was admitted to the facility on [DATE], with multiple diagnoses including nicotine dependence and use of cigarettes. An MDS assessment, dated 5/27/24, documented Resident #67 was moderately cognitively impaired. Resident #67's Care Plan, dated 4/7/23, documented Resident #67 a dependent smoker and his smoking paraphernalia was stored at the nursing station, in a locked box outdoors. During an interview on 6/3/24 at 11:30 AM, Resident #67 stated he smoked, and he kept his tobacco and lighter in his room. A red bag with tobacco in it was observed in his room. During an interview on 6/6/24 at 10:16 AM, LPN #5 stated residents that smoked were allowed to keep their smoking material in their rooms. During an interview on 6/6/24 at 10:19 AM, LPN #11 stated residents that smoked were not allowed to have smoking materials in their room. During an interview on 6/6/24 at 10:21 AM, CNA #6 stated if a resident were deemed a safe smoker, they could have smoking materials in their rooms. During an interview on 6/6/24 at 10:23 AM, RN #5 stated residents were not allowed smoking materials in their rooms. During an interview on 6/6/24 at 10:26 AM, RN #3 stated residents were not allowed smoking materials in their rooms and materials were kept somewhere at the nurses' station. During an interview on 6/6/24 at 10:28 AM, CNA #7 stated residents who smoked were not allowed smoking materials in their rooms. During an interview on 6/6/24 at 10:32 AM, the SSD stated he was not sure if residents could have smoking materials in their rooms. He further stated there were lockers outside at the smoking area for residents to keep their smoking materials. During an interview on 6/6/24 at 2:42 PM, the facility Administrator and DON both stated they were not familiar with the facility's smoking policy due to both being hired recently. They both agreed the facility's smoking policy and resident's care plan should be followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure: residents were assisted to formulate Advance Directives if necessary, residents' records included documentation of this process, and a copy of the residents' Advance Directives, or documentation of their decision not to formulate Advance Directives, was documented in their clinical record. This was true for 3 of 24 residents (#31, #35, and #44) whose records were reviewed for Advance Directives. These failures increased the residents' risk of not having their decisions honored and respected when unable to make or communicate health care preferences. Findings include: The facility's policy for Advanced Directives/Health Care Decisions, dated 10/1/17, documented the following: * Advance Directives include Living Wills and Durable Power of Attorney for Health Care. * The POST (Physician Orders for Scope of Treatment) is an order from a physician, nurse practitioner, or physician's assistant with instructions that complements an advanced directive by converting an individual's wishes regarding life-sustaining treatment and resuscitation into physician orders. * The facility would determine on admission whether the resident had an Advance Directive or other instructions to indicate the resident's wishes. * If the resident or their legal representative executed an Advanced Directive, the facility obtained a copy upon admission and incorporates and consistently maintains them in the same section of the resident's medical record readily retrievable for any facility staff. * If the resident had not executed an Advance Directive, the facility advised them of the right to formulate an Advance Directive, offered assistance if the resident wished to execute an Advance Directive, and advised the resident of their option to execute an Advance Directive but did not require the resident to do so. * The facility documented in the resident's clinical record discussions about Advance Directives and any healthcare decisions executed by the resident. * If the resident desired to develop an Advanced Directive, a nurse or social worker provided the resident with written information about their right under state law to make decisions about medical care. * The facility identified, clarified, and reviewed at least quarterly, after a life-altering event, and after returning from hospitalization, the resident's healthcare instructions and whether the resident desired to alter or continue the instructions. 1. Resident #44 was readmitted to the facility on [DATE] with multiple diagnoses including multiple sclerosis (a potentially disabling disease of the brain and spinal cord), muscle weakness, and hypertension (high blood pressure). Resident #44's admission MDS assessment, dated 12/24/18, documented he had moderate cognitive impairment. Resident #44's physician orders documented a code status of Full Code was ordered on 12/17/18. Resident #44's POST documented a code status of DNR and was signed by him on 9/29/18. Resident #44's care plan, initiated on 1/3/19, documented the code status on his POST was DNR. On 2/12/19 at 9:11 AM, Resident #44's POST documented a code status of DNR and the physician's order documented a conflicting code status of Full Code. There was no Advanced Directive, Living Will, or Durable Power of Attorney found in his clinical record. On 2/13/19 at 10:56 AM the LSW said she mailed a letter to Resident #44's family to request his Living Will. On 2/13/19 at 1:33 PM, the LSW provided a copy of a letter she sent to families to request a copy of residents' Living Will. The letter was dated 1/30/19 and did not have a resident's name, family member's name, or address. There was no documentation in Resident #44's clinical record the letter was mailed to his family. On 2/14/19 at 9:04 AM, the LSW said she previously requested Resident #44's Living Will from his family and she did not document it. The LSW said prior to this year (2019) it was not a facility policy for facility staff to request the Living Will from residents on admission. On 2/15/19 at 9:00 AM, the CNO said Resident #44's code status physician's order was updated to DNR as of 2/12/19, after the facility did an audit and found it did not match the POST. 2. Resident #35 was readmitted to the facility on [DATE] with multiple diagnoses including muscle weakness, Type 2 diabetes mellitus, and hepatic (liver) failure. Resident #35's quarterly MDS assessment, dated 12/21/18, documented she was cognitively intact. Resident #35's POST documented her code status was Full Code, and it was signed by her on 1/5/16. Resident #35's care plan, initiated on 5/10/18 and revised on 1/30/19, documented she had a physician's order for Full Code, and did not wish to have a Power of Attorney, Resident #35's Progress Notes documented Quarterly Care Conferences were held on 12/9/17, 6/5/18, 9/4/18, and 12/11/18. There was no documentation an Advanced Directive was offered or discussed during the care conferences. There was no documentation in Resident #35's clinical record of an Advanced Directive. On 2/14/19 at 9:08 AM, the LSW said she had been talking about Durable Power Of Attorney with Resident #35, and there was no documentation of the discussion. The LSW said there was only a POST in Resident #35's record. 3. Resident #31 was admitted to the facility on [DATE], with multiple diagnoses including chronic kidney disease, Type 2 diabetes mellitus, and paroxysmal atrial fibrillation (irregular heart rhythm). Resident #31's quarterly MDS assessment, dated 12/25/18, documented severe cognitive impairment. Resident #31's physician orders, documented a code status of Do Not Resuscitate (DNR) was ordered on 4/3/18. Resident #31's POST documented a code status of DNR, and was signed by her representative on 4/4/18. Resident #31's clinical record documented a Durable Power of Attorney For Financial Management only. Resident #31's care plan, initiated on 6/27/18 and revised on 2/6/19, documented she had a code status of DNR on her POST and a copy of Durable Power of Attorney for Health Care/Living Will was requested. Resident #31's Progress Notes documented Care Conferences were held on 4/5/18, 5/15/18, and 11/20/18. There was no documentation an Advanced Directive was offered or discussed. There was no documentation in Resident #31's clinical record of an Advanced Directive or Living Will. On 2/14/19 at 9:09 AM, the LSW said she requested the Living Will and Power of Attorney from Resident #31's son on 1/30/19, and it was documented on the care plan that she requested it. On 2/15/19 at 10:12 AM, the CNO provided a copy of Resident #31's Power of Attorney, and said it was for financial Power of Attorney only.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, review of grievances, and resident, family, and staff interview, it was determined the facility failed to ensure grievances were responded to, investigated, and prompt corrective action was taken to resolve the grievances. This was true for 1 of 17 residents (Resident #30) reviewed for grievances. This failure created the potential for harm if the resident grievance, both verbal and written, was not acted upon and the resident did not receive appropriate care. Findings include: The facility's Filing Grievances/Complaints policy and procedure, undated, directed staff to assist residents, their representatives, other interested family members, or advocates in filing grievances or complaints when such requests were made. Concerned persons were encouraged to assist the facility to overcome any shortcomings by calling attention to anything that failed to meet their expectations. The resident, or person filing the grievance and/or complaint on behalf of the resident, would be informed of the findings of the investigation and the actions that would be taken to his or her designee. A written summary of the report would also be provided to the resident, and a copy would be filed in the facility. 1. Resident #30 was admitted to the facility on [DATE] with multiple diagnoses including depression, dementia, contractures, and age-related physical debility. Resident #30's quarterly MDS assessment, dated 12/21/18, documented her cognition was severely impaired and required extensive assistance with two-person assist with ADLs. Resident #30's care plan, dated 6/27/18, documented she had an ADL self-care deficit and she required the assistance of two people, and needed encouragement to participate to the fullest extent possible with each interaction. The care plan documented she resisted ADLs and directed staff to reassure her, leave and return, and try again. Resident #30's ADL flowsheets, dated 1/27/19 from 6:00 AM to 2:00 PM, did not document Resident #30's acceptance, refusal or declination, or staffs' encouragement or offerings of ADLs. On 2/12/19 at 8:15 AM, Resident #30's daughter was interviewed by phone. She said she had planned a birthday party for Resident #30 on 1/27/19. She said she called ahead to let staff know as she wanted to make sure her mother was up and ready to have a party and celebrate her birthday. Resident #30's daughter stated when she showed up to the facility at 1:30 PM on 1/27/19, her mother was not dressed or groomed, had dirty pants, and had not been provided lunch or water. Resident #30's daughter stated a staff member came to Resident #30's room after she arrived and helped with getting her mother ready. Resident #30's daughter stated she called the facility and filed a grievance with the LSW on 1/28/19. Resident #30's daughter stated the LSW assured her this would not happen again and she would follow up with her regarding the incident. Resident #30's daughter said the facility did not follow up with her related to the incident on 1/27/18. On 1/28/19, Resident #30's daughter filed a grievance with the facility. The grievance was not available in the grievance binder record. The grievance documented on 1/27/19, Resident #30 was not out of bed until 1:30 PM, was dirty, was not provided with water or lunch, and was in her pajamas. The grievance documented Resident #30's daughter had called ahead because she was having a birthday party for Resident #30. On 2/13/19 at 9:40 AM, the LSW stated she did not follow up with Resident #30's daughter related to the grievance made on 1/28/19. The LSW stated she assured Resident #30's daughter on the day the grievance was made, the facility would ensure staff provided care and services to Resident #30. The LSW stated the care plan was not updated, but staff met as a group and addressed the incident. The LSW stated she would provide the documentation related to the incident. On 2/13/19 at 1:30 PM, the LSW stated Resident #30's daughter was not contacted for follow up related to the incident on 1/27/19. The LSW provided the grievance form document and stated there was no other documentation. The LSW stated she did not know why the grievance form was not part of the grievance binder record and stated the CNO said the incident was followed up with the LSW. The LSW stated the facility did follow up with the staff, and they were educated. On 2/14/19 at 9:30 AM, the CNO stated she did not follow up with Resident #30's family related to the grievance made on 1/28/19, and the issue had been resolved with the LSW the day of the grievance. The CNO stated the facility followed up with staff and provided education. The CNO stated she did not provide a plan to prevent the incident from reoccurring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure the required documentation was completed and the appropriate information was communicated to the receiving facility when a resident was transferred to the hospital. This was true for 1 of 3 residents (Resident #35) reviewed for transfer to the hospital, and had the potential to cause harm if the resident was not treated appropriately or in a timely manner due to a lack of information. Findings include: The facility's policy for Transfer and Discharge, dated 11/28/17, documented the following: Information provided to the receiving facility should include, at a minimum, contact information of the responsible medical practitioner and the resident's representative, Advance Directive information, special instructions and/or precautions for ongoing care, the resident's care plan goals, all information necessary to meet the resident's needs . and additional information as indicated in the transfer agreement. The required information should be communicated as close as possible to the time of transfer. Resident #35 was readmitted to the facility on [DATE], with multiple diagnoses including Type 2 diabetes mellitus. A physician's order, dated 12/19/18 at 12:35 PM, documented to send Resident #35 to the ER for evaluation and treatment because she did not feel well and felt dehydrated. A Progress Note, dated 12/19/18 at 3:42 PM, documented Resident #35 was transferred to the hospital due to increased confusion, not feeling well, and she thought she was dehydrated. The note also documented Resident #35's vital signs were not within normal parameters. The note also documented the physician was notified and a message was left for Resident #35's family member. There was no documentation of the information that was communicated to the receiving facility or any other information regarding the transfer to the hospital in Resident #35's clinical record. On 2/14/19 at 10:41 AM, the CNO said she would look for all the required documentation regarding Resident #35's transfer to the hospital. On 2/15/19 at 9:05 AM, the CNO said there was no transfer form completed for Resident #35's transfer to the hospital on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #35 was readmitted to the facility on [DATE], with multiple diagnoses including Type 2 diabetes mellitus. A physician's order, dated 12/19/18 at 12:35 PM, documented to send Resident #35 to the ER for evaluation and treatment because Resident #35 felt dehydrated and did not feel well. A Progress Note, dated 12/19/18 at 3:42 PM, documented Resident #35 was transferred to the hospital due to increased confusion, not feeling well, and she thought she was dehydrated. The note also documented Resident #35's vital signs were not within normal parameters. The note documented the physician was notified and a message was left for Resident #35's family member on her cell phone. There was no documentation of written notification being provided to Resident #35 or her representative regarding her transfer to the hospital on [DATE]. On 2/14/19 at 10:41 AM, the CNO said she would look for all the required documentation regarding Resident #35's transfer to the hospital. On 2/15/19 at 9:05 AM, the CNO said there was no written notice of transfer provided to Resident #35 or her representative regarding her transfer to the hospital on [DATE]. Based on record review, policy review, observation, and staff interviews, it was determined the facility failed to ensure there was documented evidence for 3 of 3 residents (#35, #45, and #74) reviewed for hospital transfers, that the resident, and/or the resident's representative, was provided a written transfer notice when the resident was transferred to the hospital. This failure created the potential for harm if residents were not made aware of or able to exercise their rights related to transfers. Findings include: The facility's Transfer and Discharge policy, dated 11/28/17 documented: * For residents who are discharged or transferred, the resident and, if known, the family member, surrogate or legal representative, are notified at least 30 days prior to the transfer, unless the transfer is effected when: - There is endangerment to the health or safety of others in the facility - The resident has urgent medical needs requiring more immediate transfer - For exceptions to the 30-day notice rule, notice is given as soon as practicable. * The written notice of transfer/discharge includes: - Reason for transfer/discharge - Effective date of transfer/discharge - Location to which the resident is transferred/discharged - Statement that the resident has the right to appeal the action to the state - Name, address, and telephone number of the state long term care ombudsman - As applicable, mailing address and telephone number of the agency responsible for protection and advocacy of developmentally disabled or mentally ill individuals 1. Resident #74 was admitted to the facility on [DATE] with medical diagnoses that included spina bifida (a birth defect where the bones in the vertebral column do not fully cover the spinal cord, leaving it exposed) and chronic pain syndrome. An attempt was made to interview Resident #74 on 2/11/19 at 3:37 PM and he was in bed and very lethargic, indicating he did not want to talk. On 2/12/19, at 8:34 AM, Resident #74 was not in his room and a staff nurse stated he was hospitalized on [DATE]. Resident #74's Progress Notes documented the following: On 2/11/19 at 5:29 PM: Resident transfer form completed. See form for details. On 2/11/19 at 6:45 PM: Resident #74 returned to the facility from being out with family for the weekend. When the nurse administered evening medications at approximately 4:30 PM, Resident #74 was difficult to arouse, had slurred speech, bloodshot eyes, and abnormal vital signs. Resident #74's blood pressure was 85/52 (normal blood pressure is 120/80) and respirations were 10 (normal respirations are 16 to 20 per minute). The CNA also noted red colored urine in the Foley catheter bag. The medical practitioner was notified and ordered to transfer Resident #74 to the hospital. He was sent by non-emergent transport to the hospital for further evaluation at approximately 6:30 PM on 2/11/19. The nurse called Resident #74's sister and left a message. On 2/12/19 at 6:45 AM: Resident #74 was admitted to the hospital. Resident #74's clinical record did not document he and his representative were provided a written transfer notice identifying the reason he was transferred to the hospital on 2/11/19. On 2/15/19 at 9:45 AM, the CNO stated the provided packet of papers was the packet sent to the hospital with Resident #74 and no written transfer notice was provided to him or his representative. 2. Resident #45 was admitted to the facility on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (obstruction of lung airflow that interferes with normal breathing) and cardiac arrhythmia (irregular heart rhythm). Resident #45's Progress Notes, dated 1/14/19 at 7:01 AM, documented the Resident #45 was found very lethargic, pale, and clammy and was difficult to arouse. The note also documented Resident #45 had a breathing treatment earlier without much effect. The note documented Resident #45's oxygen saturation was 88-89% on 3 liters of oxygen and the physician was called. The note documented a physician order was received to send Resident #45 to the ER for treatment and evaluation. The note also documented the daughter of Resident #45 was informed of his change in condition. Resident #45's clinical record did not document he and/or his representative were provided a written transfer notice identifying the reason Resident #45 was transferred to the hospital on 1/14/19. On 2/15/19 at 9:40 AM, the CNO stated there was no written transfer notice provided to Resident #45 and/or his representative. On 2/15/19 at 4:10 PM, LPN #3 stated when a resident was being transferred from the facility, she would tell the resident about their change of condition, talked about choice of hospitals, and clarified who the resident wanted to be called, but there was nothing in writing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, observation, and resident and staff interview, it was determined the facility failed to ensure the bed-hold policy was provided to residents. This was true for 2 of 3 residents (#35 and #74) reviewed for transfers to the hospital. This failure created the potential for harm if residents were not informed of their right to return to their former bed/room at the facility within a specified time. Findings include: The facility's policy for Transfer and Discharge, dated [DATE], documented the resident and their family member or representative would be provided written notice of the bed hold policy that identified the duration of the bed hold and criteria for readmission after the bed hold period expired. The facility's policy for Bed-Hold Readmission, dated [DATE], documented the following: * The first bed hold notice would be provided well in advance of any transfer . * The second bed hold notice would be provided to the resident and their representative, if applicable, at the time of transfer, or within 24 hours of transfer in case of an emergency transfer. * In case of an emergency transfer, the bed hold notice would be provided to the resident or their representative upon transfer and may be included in the papers sent to the hospital with the resident. * If the facility was unable to notify the resident's representative, they would continue attempts to notify the representative and document the attempts. 1. Resident #74 was admitted to the facility on [DATE] with medical diagnoses that included spina bifida and chronic pain syndrome. An attempt was made to interview Resident #74 on [DATE] at 3:37 PM and he was in bed and very lethargic, indicating he did not want to talk. On [DATE], at 8:34 AM, Resident #74 was not in his room and a staff nurse stated he was hospitalized on [DATE]. Resident #74's Progress Notes documented the following: On [DATE] at 5:29 PM: Resident transfer form completed. See form for details. On [DATE] at 6:45 PM: Resident #74 returned to the facility from being out with family for the weekend. When the nurse administered evening medications at approximately 4:30 PM, Resident #74 was difficult to arouse, had slurred speech, bloodshot eyes, and abnormal vital signs. Resident #74's blood pressure was 85/52 (normal blood pressure is 120/80) and respirations were 10 (normal respirations are 16 to 20 per minute). The CNA also noted red colored urine in the Foley catheter bag. The medical practitioner was notified and ordered to transfer Resident #74 out. He was sent by non-emergent transport to the hospital for further evaluation at approximately 6:30 PM. The nurse called Resident #74's sister and left a message. On [DATE] at 6:45 AM: Resident #74 was admitted to the hospital. Resident #74's clinical record did not document he and his resident representative were provided a bed hold notice when he was transferred to the hospital on [DATE]. On [DATE] at 9:45 AM, the CNO stated the provided packet of papers was the same packet sent to the hospital with Resident #74, and no bed hold policy was included or provided to Resident #74 and/or his representative. 2. Resident #35 was readmitted to the facility on [DATE], with multiple diagnoses including Type 2 diabetes mellitus. A physician's order, dated [DATE] at 12:35 PM, documented to send Resident #35 to the ER for evaluation and treatment because she did not feel well and felt dehydrated. A Progress Note, dated [DATE] at 3:42 PM, documented Resident #35 was transferred to the hospital due to increased confusion, not feeling well, and she thought she was dehydrated. The note also documented Resident #35's vital signs were not within normal parameters. The note also documented the physician was notified and a message was left for Resident #35's family member. There was no documentation in Resident #35's clinical record she and/or her family member was provided bed-hold policy information when she was transfer to the hospital. On [DATE] at 9:05 AM, the CNO said there was no notice of the bed-hold policy being provided to Resident #35 or her family member when she was transferred to the hospital on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents' care plans were updated to maintain consistency and accuracy. This was true for 1 of 18 residents (Resident #31) whose care plans were reviewed. This failure created the potential for harm if cares and/or services were not provided due to inaccurate information on the care plan. Findings include: The facility's policy for Care Plans, dated 11/28/17, documented the following: * A team of qualified individuals monitors the resident's condition and the effectiveness of the care plan. The team revises the care plan quarterly, annually, with significant change assessments, or more frequently as needed. * The care plan is reviewed following each assessment, except discharge assessments, and is revised according to the resident's changing goals, preferences, and needs. Resident #31 was admitted to the facility on [DATE] with multiple diagnoses, including chronic obstructive pulmonary disease and obstructive sleep apnea. Resident #31's physician orders, dated 2/14/18, documented the following: * CPAP (Continuous Positive Airway Pressure) at 15 cm water on room air with humidification. Start at bedtime, off in AM, ordered on 8/30/18. * CPAP Machine Daily Care, ordered on 8/31/18. * CPAP Machine Non-Disposable Tubing Care, ordered on 8/31/18. * CPAP Machine Weekly Care, ordered on 8/31/18. * CPAP/BiPap (Bilevel Positive Airway Pressure): Check skin under the mask for skin integrity with applying and removing the mask. Notify the physician as needed, twice a day, ordered on 8/31/18. Resident #31's current care plan did not document the use of CPAP or orders related to the CPAP machine. Resident #31's January 2019 and February 2019 MAR documented the CPAP and CPAP care was administered each day and each week as ordered. Resident #31's Progress Note, dated 1/23/19 at 10:01 AM, documented CPAP machine daily care was completed. On 2/14/19 at 2:58 PM, the CNO said Resident #31's CPAP was not documented on her care plan and it needed to be on the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, review of Incident and Accident Reports, and staff interviews, it was determined the facility failed to ensure professional standards of practice for completion of neurological assessments after a fall, medications were administered to residents prior to being documented as given, and pain medications were administered timely. This was true for 1 of 18 residents (Resident #31) reviewed for quality of care and 2 of 23 residents (#60 and #61) reviewed for medications. This failure placed residents at risk of a) adverse outcomes if medications were administered when contraindicated, b) increased pain due to delays in administering pain medication, and c) undetected neurological changes after falls. Findings include: The facility's General Dose Preparation and Medication Administration policy, dated [DATE], directed staff to verify each time a medication was administered it was the correct medication, the correct dose, the correct route, the correct rate, the correct time, and for the correct resident. The policy also directed staff to document necessary medication administration/treatment information, such as when medications were given on appropriate forms. The facility's Medication Management policy and procedure, dated [DATE], directed staff to develop policy, procedures and clinical practice guidelines to manage medications so they were safely provided and administered to residents. The policy documented authorized staff who administer medications were responsible for staying proficient in administering medication following evidenced-based practice guidelines. 1. Resident #60 was admitted to the facility on [DATE], with multiple diagnoses including hypertension, congestive heart failure, anxiety, depression, diabetes mellitus type 2, generalized muscle weakness, and difficulty walking. Resident #60's quarterly MDS assessment, dated [DATE], documented she was cognitively intact. Resident #60's care plan, dated [DATE] and [DATE], documented she had impaired visual function related to dry eyes and directed staff to administer ophthalmic medication as ordered. The care plan also documented she had altered cardiovascular status related to hypertension and directed staff to administer medications as ordered. a. A physician's order for Resident #60, dated [DATE], documented to instill Olopatadine hydrochloric acid solution 0.7%, instill one drop in both eyes one time a day for dry eyes On [DATE] at 11:10 AM, during medication administration, LPN #1 asked Resident #60 if she had received her eyedrops in the morning. Resident #60 stated she had received her eyedrops that morning. LPN #1 documented Resident #60 was administered her eyedrops. LPN #1 stated she did not administer eyedrops to Resident #60. LPN #1 stated she trusted what the resident had said about receiving her eyedrops and documented the eyedrops were given by the morning nurse. LPN #1 stated she should not have documented the administration of the eyedrops. b. A physician's order dated [DATE], documented to administer Hydralazine hydrochloric acid to Resident #60, one 10 mg tablet by mouth every 8 hours for hypertension. The order directed staff to hold the medication if SBP was less than 120. Resident #60's MAR, documented Hydralazine medication was administered when her SBP was less than 120, on the following dates: On [DATE] at 9:00 PM, SBP was 99 On [DATE] at 9:00 PM, SBP was 90 On [DATE] at 5:00 AM, SBP was 112 On [DATE] at 9:00 PM, SBP was 97 On [DATE] at 9:00 PM, SBP was 93 On [DATE] at 1:00, SBP was 96 On [DATE] at 9:00 PM, SBP was 117 On [DATE] at 11:51 AM, the CNO stated the February 2019 MAR documented Resident #60 was administered Hydralazine several times when her SBP was less than 120. The CNO stated she interviewed the nurses who administered the medication and they stated they did not administer the medication when Resident #60's SBP was less than 120 and the documentation was in error. The CNO stated the documentation errors were due to medications being documented as given before Resident #60's blood pressure was assessed. The CNO said the medication was then wasted when Resident #60's SPB was found to be less than 120. 2. Resident #61 was admitted to the facility on [DATE] and was readmitted on [DATE] with medical diagnoses that included multiple sclerosis (a potentially disabling disease of the brain and spinal cord), Type 2 diabetes mellitus, chronic pain syndrome, and low back pain. On [DATE] at 8:26 AM, Resident #61 stated It would be nice to get my pain medications on time instead of an hour or two hours late. She stated that even with her pain medication her pain level was a 7 to 8 (out of 10). Review of Resident #61's pain assessments documented she consistently rated her pain at 7 to 8 on a scale of 1 to 10. Resident #61's care plan documented she had acute/chronic pain related to arthritis, chronic back pain, history breast cancer, wounds, multiple sclerosis, history of cerebral vascular accident (stroke), and chronic pain syndrome. She often reported pain at a high level due to chronic pain. Staff were directed to administer medications as ordered, and monitor for effectiveness and side effects. Resident #61's MAR, dated February 2019, documented an order for an Oxycontin Tablet extended release 30 mg be given two times a day for chronic pain, ordered on [DATE]. The medication administration times were scheduled at 8:00 AM and 8:00 PM. Resident #61's MARs were requested with the documented times of her pain medications. The facility was not able to provide Resident #61's MARs. The facility provided the Narcotic Sign-out sheets for [DATE] through February 13, 2019. A review of the narcotic logs documented the following doses were signed out over an hour late from the scheduled administration time at 8:00 PM as follows: [DATE] at 9:16 PM [DATE] at 9:02 PM [DATE] at 9:24 PM [DATE] at 9:22 PM [DATE] at 9:08 PM [DATE] at 9:10 PM [DATE] at 9:51 PM [DATE] at 9:23 PM On [DATE] at 9:20 AM, Resident #61 stated she was still waiting for her 8:00 AM dose of pain medication. On [DATE] at 9:28 AM, LPN #3 stated she was getting a dose of pain medication for [a different resident name], who was getting a dressing change. LPN #3 noted the time on the electronic medical record MAR was 9:21 AM and said she was going to Resident #61 next. On [DATE] at 2:12 PM, the CNO stated the expectation was medications would be administered within one hour before to one hour after the scheduled administration time. 3. The facility's policy for Fall Response and Management, dated [DATE], documented neurological assessments should be done after an unwitnessed fall per the physician's order, or monitor every 15 minutes for one hour, every 30 minutes for one hour, then every hour for two hours or until the condition stabilizes. The resident's condition should be monitored for at least 72 hours after the fall. The website http://www.hcpro.com/LTC-287387-10704/Neurological-checks-for-head-injuries.html, accessed [DATE], documented the following: * Neurological assessments include (at a minimum) pulse, respiration, and blood pressure measurements; assessment of pupil size and reactivity; and equality of hand grip strength. * Neurological assessments should be performed every 15 minutes for two hours, every 30 minutes for two hours, every hour for four hours, every eight hours for 16 hours, and every eight hours for at least 72 hours and until the resident is stable. Resident #31 was admitted to the facility on [DATE] with multiple diagnoses, including dementia left leg amputation below the knee, muscle wasting and atrophy, and generalized muscle weakness. Resident #31's quarterly MDS assessment, dated [DATE], documented she had severe cognitive impairment. Resident #31's care plan documented she was at risk for falls due to deconditioning and directed staff to follow the facility's fall protocol, initiated on [DATE]. Resident #31's Progress Note, dated [DATE] at 11:02 PM, documented she was found sitting on the floor next to her bed. She attempted to self-transfer from bed to her wheelchair and fell onto her buttocks. The note documented the nurse assessed Resident #31 and would continue to monitor her. An Incident and Accident Report, dated [DATE] at 8:40 PM, documented Resident #31 was found on the floor next to her bed, and she was attempting to self-transfer from bed to her wheelchair. A Post Fall Investigation, dated [DATE] at 11:14 PM, documented Resident #31 had an unwitnessed fall on [DATE] at 8:30 PM. She was found in her room sitting on the floor next to her wheelchair. A Neurological Record documented Resident #31's eye opening, level of alertness, speech, and extremity movement were assessed on [DATE] at 8:30 AM and 12:30 PM, and on [DATE] at 12:30 AM. Her vital signs were documented on [DATE] at 10:00 PM, 10:30 PM, and 11:30 PM, on [DATE] at 12:30 AM, 4:30 AM, 8:30 AM, and 12:30 PM, and on [DATE] at 12:30 AM. A second page of the Neurological Record documented another resident's name that was crossed out and Resident #31's name was written in, and it documented her vital signs and neurological checks were completed at 15 minute intervals three different times, but there was no documented date or time. On [DATE] at 2:55 PM, the CNO said neurological checks should be done after any unwitnessed fall or when the resident hits their head. The CNO said the neurological checks were not completed appropriately for Resident #31. On [DATE] at 9:26 AM, LPN #5 said neurological checks should be performed anytime it was known the resident hit their head and anytime there was an unwitnessed fall. LPN #5 said she would have to look it up to see the required intervals and length of time neurological checks should be completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, policy review, and record review, it was determined the facility failed to consistently follow physician orders for treatment of a pressure ulcer for 1 of 3 residents (Resident #44) reviewed for pressure ulcers. The failure created the potential for Resident #44 to experience delayed healing, or further deterioration, of a Stage 4 pressure ulcer, and/or develop additional pressure ulcers. Findings include: The facility's policy for Prevention and Treatment of Pressure Ulcers and Other Skin Alterations, dated 11/28/17, documented basic or routine care to prevent pressure ulcers could include redistributing pressure, such as repositioning. The Lippincott Manual of Nursing Practice, tenth edition, documented measures to prevent pressure ulcers include repositioning every 2 hours. Resident #44 was readmitted to the facility on [DATE] with multiple diagnoses, including Multiple Sclerosis (a potentially disabling disease of the brain and spinal cord), muscle weakness, postprocedural wound closure, disruption of external surgical wound, and Stage 4 pressure ulcer of the sacral region (low back/upper buttock area). Resident #44's MDS assessment, dated 12/24/18, documented the following: * One unhealed Stage 4 Pressure ulcer. * He required extensive assistance for bed mobility and transfers. Resident #44's physician orders, dated 2/15/19, documented the following: * Ordered on 12/17/18: Avoid supine (lying on back) position. Position side to side using pillows and wedges. Bed flat. May elevate head of bed up to 30 degrees for meals and for 30 minutes after meals. * Ordered on 1/15/19: Bedrest with offloading by turning side to side until further evaluation by [a named physician]. * Ordered on 2/12/19: Dressing change twice a week and as needed, with wound vacuum on continuously to Resident #44's sacrum. Resident #44's care plan directed staff to follow the facility's protocols for treatment of his skin injury, initiated on 8/14/18, and to turn and reposition him every 2 hours, initiated on 2/13/19. On 2/12/19 at 7:54 AM, Resident #44 was observed lying in bed on his back. LPN #4 said Resident #44 had a pressure ulcer on his sacrum. On 2/12/19 at 8:45 AM, RN #2 was observed performing a dressing change to Resident #44's sacral wound. The pressure ulcer measured 2.5 cm by 4 cm. LPN #6, also present, said Resident #44 came from the hospital with the pressure ulcer, and he had a wound flap (a flap is a unit of tissue that can be moved to cover a wound while surviving on its own blood source) placed in November 2018 and it failed. Resident #44 was observed lying in bed on his back on 2/13/19 at 11:47 AM, 2:32 PM, and 3:59 PM, and on 2/14/19 at 2:17 PM. On 2/13/19 at 11:53 AM, LPN #4 said Resident #44's position was to be alternated from his right side and left side, unless the order changed it when the wound vacuum was resumed. LPN #4 said Resident #44 was not to be positioned on his back.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, policy review, and record review, it was determined the facility failed to ensure residents received proper treatment and care to maintain good foot health. This was true for 1 of 14 residents (Resident #7) reviewed for foot care. This failed practice created the potential for harm should residents experience complications from their medical condition related to the lack of proper foot care. Findings include: The facility's policy for Nail Care, dated 3/31/18, documented nail care would be provided to promote hygiene, comfort, neatness, wellbeing and prevent injuries and/or infections. Nail care would be provided by nursing personnel, and if the resident had a diagnosis of diabetes a licensed nurse must provide the nail care. Staff were directed to document refusal of nail care. Resident #7 was readmitted to the facility on [DATE] with multiple diagnoses, including primary osteoarthritis, lack of coordination, weakness, repeated falls, and varicose veins of the lower extremity with ulcer on another part of the lower leg. Resident #7's quarterly MDS assessment, dated 11/20/18 documented he required extensive assistance of one person with personal hygiene and extensive assistance of two persons with bed mobility. Resident #7's care plan documented the following: * He had potential issues with skin integrity related to edema of both legs with a history of venous stasis ulcers. There was a purple hue to the second, third, and fourth toes. The focus area was initiated on 12/8/16 and revised on 2/1/19. * He had a self care deficit with activities of daily living related to weakness, edema, wounds, and preferring to stay in bed. The focus area was initiated on 12/8/16 and revised on 1/28/19. On 2/11/19 at 9:47 AM, 2/12/19 at 7:13 AM, and 2/13/19 at 8:14 AM, Resident #7 was in bed and did not respond to verbal stimuli. His toenails on both feet were very long and in poor condition. The skin on his feet was scaling and his feet were discolored with a purple hue. On 2/13/19 at 8:57 AM, RN #1 said up until about 2 weeks ago Resident #7 would refused everything and it was documented on the MAR he refused cares. RN #1 said a CNA could trim Resident #7's nails. There was no documentation in Resident #7's clinical record nail care was offered or performed, and no documentation he refused nail care. On 2/13/19 at 9:10 AM, the CNO said Resident #7 was on the podiatrist list and he could not tolerate getting up, so the facility was trying to find a podiatrist who would come to the facility but was not able to find one. On 2/13/19 at 1:21 PM, the CNO said said it was not documented the last time Resident #7's nails were trimmed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and staff interviews, it was determined the facility failed to ensure residents received respiratory care as ordered by a physician. This was true for 1 of 5 residents (Resident #7) reviewed for oxygen therapy. This failure created the potential for harm if residents did not receive oxygen therapy to maintain adequate oxygen levels. Findings include: The facility's policy for Oxygen Therapy, dated 11/14/17, documented oxygen was indicated for documented or suspected hypoxia (low oxygen level) and directed staff to verify the physician's order prior to initiating oxygen therapy. Staff were also directed to monitor the resident for tolerating the oxygen, including relief of physical symptoms and improvement of oxygen saturation. According to the Mayo Clinic website for symptoms of hypoxemia (low oxygen level in the blood), accessed on 2/20/19, normal pulse oximeter readings are usually 95 to 100 percent, and less than 90% is considered low. Resident #7 was readmitted to the facility on [DATE], with multiple diagnoses including cerebral infarction (stroke) and pulmonary embolism (blood clot that has traveled to the lung) with acute cor pulmonale (dilation of the right side of the heart). Resident #7's quarterly MDS assessment, dated 11/20/18 documented he received oxygen while a resident. Resident #7's physician orders, dated 1/31/19, documented the following: * Monitor oxygen saturation/pulse oximetry every shift, ordered on 9/8/17. * Oxygen 3 liters per minute per nasal cannula as needed for shortness of breath, use for oxygen saturation less than 92%. Resident #7's care plan documented he had oxygen as needed and often refused, initiated on 8/25/17 and revised on 2/13/19. Resident #7's MARs from January and February 2019 documented his oxygen saturation was less than 92 percent on 43 out of 62 opportunities in January 2019 and on 23 out of 25 opportunities in February 2019. The oxygen saturation was not documented by the day shift on 2/2/19. There was no documentation oxygen was administered to Resident #7 or that he refused oxygen on any of the opportunities where his oxygen level was less than 92 percent. Resident #7 was observed lying in bed in his room on multiple occasions throughout the survey. He was not wearing oxygen and there was no oxygen equipment in his room at any time during the survey. On 2/13/19 at 8:57 AM, RN #1 said she noticed Resident #7's oxygen saturation was 88 percent a couple times, and she just checked it and it was 91 to 92 percent. RN #1 said Resident #7's oxygen saturation was checked daily, and he thought everything was poison and did not want the oxygen. RN #1 said she did not know whether it was documented Resident #7 refused oxygen. On 2/13/19 at 9:10 AM, the CNO said she would follow up about Resident #7's oxygen, and she acknowledged the order for oxygen and documentation his oxygen saturation had been less than 92 percent. On 2/13/19 at 1:21 PM, the CNO said Resident #7's physician was consulted and he said there should never have been an order for oxygen to be administered if the oxygen saturation was less than 92%, but the order should have been for oxygen if there were signs and symptoms of respiratory distress. Resident #7 did not receive oxygen as ordered by the physician when his oxygen level was less than 92 percent.

Based on policy review, observation, resident and staff interview, and review of the Facility's Assessment, it was determined the facility failed to ensure residents' clothing was appropriately separated by color, washed, sorted, and returned to residents in a timely manner. This was true for 7 of 13 residents (#4, #21, #27, #56, #60, #67, and #71) reviewed for laundry services. This failure placed residents at risk of diminished quality of life and lack of clean and appropriate clothing. The failure also had the potential to place a financial burden on residents if they had to buy new clothes because their clothes were lost or misplaced. Findings include: The facility's Work Practices - Linen & Laundry policy and procedure, dated 11/28/17, did not address laundry service practices for separating residents' clothes by color, washing clothes, sorting clothes, and returning residents' clothes in a timely manner. The policy also did not include processes to follow when a resident's clothing items were not returned to the resident and were missing. The Facility Assessment, dated 11/30/18, documented the purpose of the assessment was to determine what resources were necessary to care for residents competently during day-to-day operations. The assessment would help make decisions about direct care staff needs, as well as providing services to the residents in the facility. The assessment for laundry procedures directed staff to handle and keep clean and soiled laundry separate. The Facility admission Agreement, undated, recommended residents needed four to six complete changes of clothing during their stay at the facility, directed staff to provide quality care for laundry, and to wash personal clothing daily. a. Resident's voiced the following concerns regarding laundry services: * On 2/12/19 at 11:05 AM, Resident #4 stated she had not received two pairs of pants and her tank tops back from the laundry for a couple of weeks. On 2/13/19 at 9:15 AM, Resident #4 stated she had a couple of tank tops and a pair of pants returned to her from the laundry. At 3:30 PM she stated she still had missing items. * On 2/13/19 at 9:15 AM, Resident #21 stated she was told by housekeeping they were not able to separate her white undergarments with all the clothes. Resident #21 stated housekeeping told her they were not able to wash her sweaters and keep them from bleeding to other clothing, and her daughter would have to wash them. Resident #21 opened her drawers and pointed out her dark gray undergarments. Resident #21 stated since she did not have enough undergarments there were times she had to wear them two or three days in a row because the soiled undergarments had not returned from the laundry. * On 2/11/19 at 4:26 PM, Resident #67 was observed entering the laundry room and stated to Laundry Staff #2 he was missing two extra-large plaid pants for three days. Laundry Staff #2 told Resident #67 one of the washers had been broken and laundry services were behind. in catching up with Laundry Staff #2 also stated three big bins of clothing were clean and needed to be sorted. On 2/12/19 at 10:03 AM, Resident #67 stated he had not yet received his pants and he asked staff about it that day. Staff told him they would have to look for them in the bins and had not been able to do so. b. On 2/13/19 at 11:00 AM, during Resident Council Meeting, the residents stated concerns of missing clothing, clothing not being returned in a timely manner due to the washer being broken for two weeks, and whites and dark items being washed together. The residents' concerns included: * Resident #27 stated the whites were horrible and she was missing a white top undergarment. * Resident #56 stated she had been missing two pairs of pants for a while. * Resident #60 stated Laundry Staff #1 told her the facility could not bleach whites and told her they could not separate whites and colors to be washed because it would take too long to separate the items and get their work done. * Resident #60 stated she washed her own white undergarments. * Resident #67 stated he had not received his pants from laundry services. * Resident #71 stated he was tired of his white undergarments being gray. He also stated he was missing jackets and sweaters for three months to a year. He said staff did not pay attention when they returned laundry to residents and misplaced the items with other residents. On 2/11/19 at 4:26 PM, Laundry Staff #2 stated the washer had been broken for two weeks and the dryer broke down today, and both were fixed today. She stated the facility tried to catch up with laundry this past weekend and complete the linen and personal laundry for those residents who did not have extra clothing. Laundry Staff #2 stated they were unable to get caught up with all the personal laundry for residents. Laundry Staff #2 also stated housekeeping was short staffed, as there was one person doing laundry and one person in training. She stated she worked on the floor along with other staff who tried to help with the laundry. Laundry Staff #2 stated there were three big bins of clean resident clothing that needed to be sorted and returned to the residents. She also stated residents' personal laundry items were washed together whether they were white or colored clothes. On 2/12/19 at 2:28 PM, Laundry Staff #2 stated she was not aware of any concerns of residents who needed laundry items separated. Laundry Staff #2 stated residents had been receiving some of their clothes and stated the usual turnaround time for personal laundry was the next day. On 2/14/19 at 9:30 AM, the CNO stated she did not know there were problems with laundry. The CNO stated the Staff Development Coordinator did not provide competencies for housekeeping staff related to washing clothes. The CNO stated the washer had been broken for two weeks, and the parts were ordered and available to fix the washer. On 2/15/19 at 8:41 AM, Laundry Staff #1 stated she had been working for the facility and doing laundry the same way for nine years. She stated she received clothes from the CNAs in the bins numbered by floor, tried to keep the clothes together, and stuffed what she could in the washer. Laundry Staff #1 stated she did not separate the white and colored clothes. She stated residents had complained several times about the laundry. Laundry Staff #1 stated she told residents there was nothing she could do because there were not enough staff to separate the laundry. Laundry Staff #1 stated she did let the past administration know of residents' concerns over a year ago and she was told they were working on getting more staff. Laundry Staff #1 stated one washer broke two weeks ago, and after waiting for parts, was finally fixed this week. Laundry Staff #1 stated when residents had clothes missing, she instructed them to complete a grievance form.

Based on policy review, observation, review of the medication refrigerator temperature and maintenance logs, and staff interview, it was determined the facility failed to ensure expired medications were not available for administration, expired biological supplies were removed for resident use, multi-dose vials were dated when opened, and proper refrigerator temperature controls were within range for safe storage. This was true for 2 of 4 medication storage rooms and 2 of 3 refrigerators reviewed for safe storage and labeling medication. This failure created the potential for harm to all residents in the facility should residents receive medications with decreased efficacy, potency and safety. Findings include: The facility's Storage and Expiration of Medications, Biologicals, Syringes and Needles policy and procedure, dated 10/31/16, documented: * Staff were to ensure medications and biologicals having an expiration date on the label were stored separated from other medications until destroyed or returned to the pharmacy or supplier. * After any medication or biological package was opened, the facility should follow the manufacturer guidelines with respect to expiration dates. Staff should record the date opened on the medication container when the medication had a shortened expiration date after opened. * Staff were to ensure medications and biologicals were stored at appropriate temperatures according to the Unites States Pharmacopeia guidelines of temperature ranges and monitor the temperature of vaccines twice a day. The refrigerator temperatures should be 36-46 degrees Fahrenheit (F). The Centers for Disease Control and Prevention website (www.cdc.gov) accessed on 3/14/19, states: Medication vials should always be discarded whenever sterility is compromised or questionable. In addition, the United States Pharmacopeia (USP) General Chapter 797 [16] recommends the following for multi-dose vials of sterile pharmaceuticals: If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. On 2/14/19 at 9:00 AM, during medication storage review with the ADON, the following issues were noted: a. The Tuberculin Vaccine vial in the Unit #3 medication refrigerator was open and dated 1/3/19. The ADON stated the vaccine was opened 1/3/19 and past the 28 day of use, and should be discarded. b. Five Toothbrush/Suction Kits in the Unit #3 medication storage room had an expiration date of 12/3/18. The ADON stated the kits had expired and should be discarded. c. The Influenza Vaccine vial in the Unit #5 medication refrigerator was open and not dated. The ADON stated the vaccine was opened, not dated, and should be discarded. d. The facility's Medication Refrigerator Maintenance policy and procedure, dated 11/28/17, directed staff to review the functionality of medication refrigerators periodically and as needed to ensure acceptable temperature ranges and document corrective actions when applicable. The policy directed staff to implement preventive maintenance protocols when any of the recorded temperatures were outside the acceptable temperature range. On 2/14/19 at 9:00 AM, during medication storage review, the Unit #3 medication refrigerator/freezer temperature log documented 25 refrigerator temperature entries in January 2019, and 15 refrigerator temperature entries in February 2019, were outside the acceptable temperature range of 36 - 46 degrees F, as noted in the facility's policy. The dates included: January 2019 - - 1/5/19 = AM Check 28 degrees F - 1/6/19 = AM Check 26 degrees F - 1/14/19 = AM Check 34 degrees F - 1/15/19 = AM Check 34 degrees F - 1/16/19 = AM Check 32 degrees F - 1/17/19 = AM Check 32 degrees F, PM Check 28 degrees F - 1/18/19 = AM Check 34 degrees F - 1/19/19 = AM Check 30 degrees F, PM Check 32 degrees F - 1/20/19 = AM Check 30 degrees F, PM Check 32 degrees F - 1/21/19 = AM Check 32 degrees F, PM Check 48 degrees F - 1/22/19 = AM Check 32 degrees F - 1/23/19 = AM Check 32 degrees F, PM Check 62 degrees F - 1/24/19 = AM Check 30 degrees F, PM Check 32 degrees F - 1/26/19 = AM Check 32 degrees F, PM Check 32 degrees F - 1/25/19 = AM Check 32 degrees F - 1/29/19 = PM Check 32 degrees F - 1/30/19 = PM Check 30 degrees F - 1/31/19 = PM Check 50 degrees F February 2019 - - 2/2/19 = PM Check 34 degrees F - 2/3/19 = PM Check 28 degrees F - 2/4/19 = AM Check 32 degrees F, PM Check 32 degrees F - 2/5/19 = AM Check 32 degrees F, PM Check 32 degrees F - 2/6/19 = PM Check 54 degrees F - 2/8/19 = PM Check 32 degrees F - 2/5/19 = AM Check 30 degrees F, PM Check 30 degrees F - 2/10/19 = AM Check 30 degrees F, PM Check 32 degrees F - 2/11/19 = AM Check 31 degrees F, PM Check 30 degrees F - 2/12/19 = PM Check 32 degrees F The Maintenance Check Medication Room Refrigerator for Unit #3, dated on 1/7/19, 1/14/19, 1/21/19 and 1/28/19, did not document issues with the Unit #3 refrigerator. On 2/14/19 at 2:45 PM, the CNO stated the nurses documented the medication refrigerator temperatures two times a day at the beginning of each shift when they initially opened the refrigerator. The CNO stated the medication refrigerator was temperamental and when the temperatures were outside the temperature range, they adjusted the temperature to the correct temperature. She said they did not document the adjusted and corrected temperature.

Based on observation, staff interviews, and policy review, it was determined the facility failed to ensure: a) Clean mechanical lift slings were stored on the clean side of the laundry area, b) Staff personal protective equipment was stored on the dirty side of the laundry room, and c) Ventilation in the laundry area did not blow air from the contaminated laundry side to the clean side of the room. These failures created the potential for harm due to the increased the risk of cross contamination, and had the potential to affect all residents in the facility. Findings include: The facility's policy for Infection Prevention and Control, dated 10/31/17, documented the following: COMPONENTS: 1. The lnfection Prevention and Control Program include processes to minimize healthcare associated infection through an organization-wide program. These processes include but are not limited to the: a. As necessary, and at least annually, review and revise the infection control risk assessment. 1) New risks are identified 2) New services have been added, 3) New sites of care have been added, 4) Opportunities for improvement are identified 5) There are emerging or reemerging community healthcare problems b. Establishing facility wide engineering and work practice to reduce risk of exposure to and transmission of healthcare associated infections. On 2/14/19 at 10:20 AM, the laundry room was inspected with the Housekeeping and Laundry Manager (HLM). The HLM confirmed the division between dirty and clean was demonstrated by a difference in tile color (the clean side had a light (white/cream tile with a row of red tile, and the dirty side had grayish colored tile). There was no physical barrier separating the clean side from the dirty side. A fan was mounted approximately mid-way up the wall between dirty/clean areas (approximately 6 to 7 feet in height), blowing in an oscillating mode from dirty to clean. This increased the risk for cross contamination due to no barrier to prevent air flow from the dirty area to the area where clean laundry was stored. A rack with mechanical lift slings was mounted on the wall by the washing machine (on the dirty side). The HLM confirmed the slings were clean, but were stored on the dirty side of the laundry room. On the edge of the wall by the handwashing sink, a fire extinguisher hung with a gown and mask hanging over the extinguisher. The HLM confirmed the gown was hanging half on clean side, half on dirty side, and could not be considered clean. On 2/14/19 at 10:20 AM, the HLM stated all laundry for the facility (including all bed and bath linens) was done in that laundry room. On 2/15/19 at 12:51 PM, the Administrator stated he was not aware of laundry room issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to ensure the physician documented the necessity for discharge, or that resident information was made available to the receiving provider to ensure continuity of care. This was true for 1 of 2 discharged residents (#15) sampled. The deficient practice created the potential for harm if the resident's receiving caregivers were unaware of clinical or care needs. Findings include: Resident #15 was admitted on [DATE] with diagnoses including unspecified osteoarthritis, atrial fibrillation (irregular heartbeat), major depressive disorder, osteoporosis, muscle weakness, long term use of anticoagulants (blood thinners), and asthma. The 6/15/17 quarterly MDS (Minimum Data Set) assessment documented moderate cognitive impairment, presence of anxiety and depression, use of a wheelchair, and occasional bowel incontinence. The resident's 8/8/17 physician's Compliance Visit/Progress Note documented the resident had a fracture of a large bone spur in the left heel and generalized weakness that, makes the patient require long-term care .Restorative therapy and/or occupational therapy services were to continue. The note also documented the resident will remain in our facility for long-term care and will need followup with orthopedics or podiatry . Resident #15's interdisciplinary Progress Notes from 6/1/17 at 10:14 am through 8/30/17 at 8:15 am did not document a plan for the resident to discharge, or that the resident was discharged or transferred from the facility. Resident #15's clinical record did not include a physician's order to discharge the resident. On 9/1/17, a discharge MDS assessment for Resident #15 documented the resident had discharged from the facility and was not anticipated to return. On 9/7/17 at 2:50 pm, the DNS (Director of Nursing Services) said the resident went to a memory care unit at another facility, and she would look for additional documentation regarding the resident's discharge from the facility. No additional documentation was provided by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of Fall Investigation Reports, Incident and Accident Reports [I&As], and resident records, it was determined the facility failed to ensure the neurological (neuro) status of residents was assessed after unwitnessed falls. This was true for 1 of 2 residents (#5) sampled for falls. The deficient practice created the potential for harm if changes in residents' neuro status occurred. Findings include: Resident #5 was admitted on [DATE] and was readmitted on [DATE] and 7/22/17 with diagnoses including a history of falling. Resident #5's 5/5/17 annual and 8/2/17 quarterly MDS (Minimum Data Set) assessments documented severe cognitive impairment, extensive assistance required with bed mobility and transfers, and use of a wheelchair. On 4/29/17 at 4:30 am, Resident #5's Post Fall Investigation form documented the resident had an unwitnessed fall in her room. The resident was found crawling on the floor on her hands and knees. On 4/29/17 at 10:35 pm, Resident #5's Progress Note documented the resident was found half off the bed with her knees in contact with the blue protective mat. There were no documented neuro checks after the two falls on 4/29/17. On 5/11/17 at 4:45 am a Post Fall Investigation form documented Resident #5 had an unwitnessed fall in her room. The resident was found Lying on [a] padded mat in [the] fetal position on right side . Resident #5's Neurological Record form, dated 5/11 and 5/12/17, was blank at multiple time points in the areas of Pupil Response, Eye Response, Level of Consciousness, Speech, and Motor Response. The entire neuro check section of the 5/12, 5/13, and 5/14/17 Neurological Record was blank. On 9/617 at 3:30 pm, the resident was asleep in her bed with the bed in low position and blue fall mat on the floor next to her bed. On 9/7/17 at 2:40 pm, the DNS said the neuro checks should have been completed and documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #15 was admitted on [DATE] with diagnoses including unspecified osteoarthritis, atrial fibrillation (irregular heartbeat), major depressive disorder, osteoporosis, muscle weakness, fracture of one rib, long term use of anticoagulants (blood thinners), disease of the esophagus, and asthma. The 6/15/17 quarterly MDS (Minimum Data Set) assessment documented moderate cognitive impairment, presence of anxiety and depression, use of a wheelchair, and occasional bowel incontinence. A 6/27/17 Compliance Visit note documented the resident had swelling, bruising, and tenderness to her left foot. The resident reported the symptoms occurred after hitting her foot on a metal piece under her bed. The resident continued to need assistance with mobility and ADLs (activities of daily living), and an x-ray of her left foot was initiated. On 8/8/17, Resident #15's physician's progress notes documented the resident had a fracture of a large bone spur in the left heel, and generalized weakness that makes the patient require long-term care. The note also documented the resident will remain in our facility for long-term care and will need followup with orthopedics or podiatry . Resident #15's interdisciplinary progress notes between 6/1/17 through 8/30/17 did not document the resident was discharged or transferred from the facility, and no discharge summary or planning were documented. Resident #15's record did not contain an order to discharge from the facility. On 9/1/17, a discharge MDS assessment for Resident #15 documented the resident had discharged from the facility and was not anticipated to return. The 9/5/17 Stand-Up Meeting form, Previous Days Discharges, documented the resident was discharged from the facility on 9/1/17. On 9/7/17 at 2:50 pm, the DNS (Director of Nursing Services) said the resident went to memory care at another facility and she would contact the Social Worker to obtain discharge summaries for the resident. The facility provided no additional information. Based on record review and staff interview, it was determined the facility failed to develop and implement resident discharge plans. This was true for 2 of 2 sampled resident's (#14 and #15) reviewed for discharge from the facility. This failure created the potential for harm when the residents' discharge goals and participation was not included in the discharge process, which could result in a preventable readmission or an interruption in the continuity of care. Findings include: The facility's policy and procedure for Discharge Plan, dated 4/28/09, documented, The resident and interdisciplinary team set goals that the resident is capable of accomplishing prior to discharge from the center. The discharge plan is incorporated into the initial plan of care and the comprehensive plan of care. The Ready to Go Plan is a method of discharge planning. The facility's procedure for a resident discharge included the nurse or social worker to meet with the resident to discuss any questions or concerns prior to discharge and provide the resident with contact information that may be included in discharge planning, such as home health services, resident's health condition, medications, medical equipment, physician appointments, support groups, and a summary of resident's current health status upon discharge. 1. Resident #14 was admitted to the facility on [DATE] and was discharged on 6/15/17 with multiple diagnoses, including a hip fracture and pelvis fractures. A Nurse's Notes, dated 6/15/17 at 10:33 am, documented Resident #14 was discharged with a family member, ambulated with a front wheeled walker, narcotics were sent with the resident, and all the paperwork was signed. The Nurse's Notes did not document where the discharge location or what services were needed. A Home Evaluation form for Resident #14, dated 6/9/17, documented recommendation for a safe discharge for the resident included PT [Physical Therapy] and OT [Occupational Therapy] at home. Resident #14's record did not include a physician's order for discharge, follow-up therapy services,. There was no documentation the recommended follow-up services were offered or arranged for the resident, or that the resident declined the services. A Planned discharged Summary, dated 6/14/17 at 6:21 pm, contained an area to check where Resident #14 was discharging, what equipment needed for transfers, who accompanied Resident #14, and what referral services were needed for Resident #14. The Planned Discharge Summary form included an area to check reason for discharge, medication reconciliation with Resident #14 prior to discharge, and Resident #14 was to sign, date, and time of discharge with the original to be left in the clinical record. The areas were not checked and the signature was left blank. On 9/7/17 at 4:30 pm, the Social Services Assistant said the discharge summary should have been completed by a nurse and reviewed with Resident #14, with both signing the form. The Social Services Assistant stated a copy of the form should have been sent with Resident #14, and the original placed in the resident's clinical record. The Social Services Assistant confirmed the Planned Discharge Summary was incomplete and was unable to verify the medication list was reviewed, any medications needed to be ordered, or if a copy of the medication list was part of the paperwork that was sent home with Resident #14. The Social Services Assistant said Resident #14 discharged home without home health services because his son was a Physical Therapist, but was unable to provide documentation for the discharge plan of care for Resident #14.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record and policy review and staff interview, it was determined the facility failed to ensure care and services were provided to maintain residents' eating abilities. This was true for 1 of 9 residents (#2) sampled for Activities of Daily Living (ADL) maintenance. This deficient practice created the potential for harm when the resident was not appropriately assisted or cued during meals. Findings include: Resident #2 was admitted on [DATE] with diagnoses including convulsions, hypertension (high blood pressure), cerebral infarct (stroke), hemiplegia (weakness on one side of the body), and difficulty eating. The 4/25/17 quarterly and 7/25/17 quarterly MDS (Minimum Data Set) assessments documented Resident #2 was cognitively intact and required supervision-oversight, encouragement or cueing for eating. Resident #2's nutritional decline care plan documented RNA (Restorative Nursing Assistant) dining interventions were initiated on 1/27/17. Care planned interventions included physically and/or verbally cueing the resident, reminding the resident to swallow and take small bites and small sips. The facility's Restorative Dining Policy, Release Date 09/27/2016, documented, Maintenance and restorative dining programs are provided that contributes [sic] to the resident achieving and maintaining their highest practicable outcome in their ability to eat and drink by mouth. The Speech Therapy (ST) Plan Of Care, dated 10/3/2016, documented the resident was referred to speech therapy due to a choking episode that required evaluation in the emergency room. Resident #2's Swallowing Instructions documented the resident was to eat small bites at a slow pace, needed to alternate liquids with solids, needed encouragement to swallow twice after each bite, and needed cues to stay awake while eating for safety. The 6/27/2017 ST Progress & Discharge Summary documented the resident was at risk for aspiration (food or liquids going into the lungs) and to continue restorative dining assistance. Resident #2 was observed at a restorative dining table on 9/6/17 from 8:57 am through 9:13 am. Staff members brought a container of milk and poured most of it over the resident's cereal. No other liquids were on the table. No RNA staff were present and no other staff members cued the resident at any time during all the observed meals. The resident fed herself several bites of cereal in a row without taking a drink. She did not consistently swallow between bites. On 9/7/17 at 8:55 am, Resident #2 was sitting at the restorative table in the dining room. CNA (Certified Nursing Assistant) #3 served the resident's breakfast tray, but there were no staff cueing or assisting residents at the restorative table. CNA #3 said there was supposed to be RNA staff present, but he did not know where they were. On 9/7/17 at 9:28 am, CNA #2 said there was supposed to be RNA staff present, but she did not know where they were. On 9/7/17 at 12:47 pm, Therapy Staff #1 said Resident #2 should still receive cueing during meals and the RNA interventions were still applicable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to ensure that physician orders were transcribed accurately for 1 of 15 sample residents (#5). This deficient practice placed residents at risk of harm when medication orders were inaccurately transcribed. Findings include: Resident #5 was admitted on [DATE] and was re-admitted on [DATE] and 7/22/17 with diagnoses including malignant neoplasm of the breast (cancer), atrial fibrillation (irregular heartbeat), dementia, depression, and history of falling. Resident #5's Anesthesia Physician's Orders for Pre-Surgery admission form, dated 8/31/17 documented, Make sure all aspirin .have been discontinued for 7-10 days prior to surgery OR per Surgeon's orders. The form documented the resident was scheduled for an outpatient surgical procedure on 9/6/17. The September 2017 Medication Administration Record (MAR) documented Resident #5's aspirin tablet 81 mg (milligrams) was to be held from 9/1/2017 at midnight to 9/6/2017 at 7:59 am. It also documented the aspirin was given on 9/6/17 at 8:00 am, prior to her surgical procedure. On 9/7/17 at 12:00 pm, LPN #5 said the MAR documented the aspirin could be given as of 8:00 on 9/6/17 and that the order was transcribed incorrectly. LPN #5 stated the MAR should have documented the aspirin should be held until after the procedure was complete.

Based on document review and staff interview, it was determined the facility failed to ensure residents were provided notice prior to changes in facility charges, and that residents' private information was protected. This was true for all residents in the facility who signed the admission Agreement dated 01/2017. This failed practice had the potential for harm if residents had undue financial worry should the facility increase their rates, or their private information was shared inappropriately. Findings include: a. Page 6, section iv of the 01/2017 admission Agreement documented If a change in the Resident's level of care warrants an increase or decrease in the daily rate to reflect the Resident's new level of care, the Center may adjust the daily rate without prior notice. Any rate adjustment shall be considered as agreed to by the parties on the date the notice is mailed. On 9/7/17 at 3:15 pm, Administrative Staff #1 said the facility gives a 30 day notice to the Resident if the daily room rate changes, and acknowledged that the resident should be informed prior to any changes in room rates. On 9/7/17 at 7:23 pm, the Administrator said there is only one room rate, it's a flat rate and the rate won't change. When asked about the section of the admission Agreement that documents the Center may adjust the daily rate without prior notice, the Administrator said it was probably referring to a situation such as if the Resident moves to Assisted Living, then it would be under a different rate. b. Page 3, Attachment D of the 01/2017 admission Agreement documented that with few exceptions the facility may use resident Personal Health Information (PHI) for marketing purposes and may sell PHI. The agreement also documented that the facility may use limited health information to contact residents for fundraising efforts, unless the resident exercised one of the opt out methods we provide. There was no documentation regarding the exceptions where the facility may sell the Resident's health information without written authorization. The agreement did not describe the opt out methods for fundraising, specify which private information would be used for those efforts, or state whether the resident could still be admitted to the facility if they chose to opt out. On 9/7/17 at 3:15 pm, Administrative Staff #1 was asked about the exceptions where the facility may sell the Resident's health information without written authorization. Said she could not answer the question. On 9/7/17 at 7:23 pm, the Administrator said he thought it was an oversight that the admission Agreement contained this information.

Based on observation, interview and policy review, it was determined the facility failed to maintain accepted infection control standards with the sanitation of respiratory equipment for 2 of 15 sample residents (#4 & #10), and 3 random residents (#16, #17 & #18). The deficient practice created the potential for harm if residents experienced respiratory infections from unclean equipment. Findings include: On 9/5/17 at 9:15 am the nebulizer mist treatment (NMT) (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) set-ups for Resident #s 4, #10, #16, and #17 were observed still intact, with the masks and medication cups still attached to the tubing, not contained in closed plastic bags. Condensation was noted in the medication cups. On 9/6/17 at 9:00 am the NMT set-ups for Resident #s 4, #10, #16, and #17 were observed still intact, with the masks and medication cups still attached to the tubing, not contained in closed plastic bags. Condensation was noted in the medication cups. On 9/6/17 at 9:35 am, Resident #4 stated he received an NMT three times a day, the nurse put the medication in the medication cup and he started and stopped the NMT. He further stated when the NMT was completed, he puts the NMT mask on the machine. He stated he has not observed any of the nursing staff cleaning the NMT mask after use. Condensation was noted in the medication cup. On 9/6/17 at 10:30 am, Resident #18 was observed receiving an NMT. Licensed Practical Nurse (LPN) #1 was observed to enter Resident #18's room at the completion of the NMT and placed the intact mouthpiece on the NMT machine. The mouthpiece was not taken apart, rinsed out or placed in a protective plastic bag. Condensation was noted in the medication cups. On 9/6/17 at 2:00 pm, the NMT set-ups for Resident #s 4, #10, #16, #17, and #18 were observed still intact, with the masks or mouthpieces and medication cups still attached to the tubing, not contained in closed plastic bags. Condensation was noted in the medication cups. On 9/7/17 at 9:00 am, the NMT set-ups for Resident #s 4, #10, #16, #17 and #18 were still intact, with the masks and medication cups still attached to the tubing, not contained in closed plastic bags. Condensation was noted in the medication cups. On 9/7/17 at 9:30 am, Resident #10 was observed with an intact NMT mouthpiece laying on his lap. He stated he just finished his NMT and was waiting for someone to put it away. CNA #1 entered the room at 9:35 a.m., picked up the mouthpiece, placed it in a plastic bag and set it on his nightstand. Resident #10 stated the nurse puts the medication in the cup and he turned the machine on when he was ready and shut it off when he was done. He stated he has not observed any of the nursing staff clean it after he has used it. Condensation was noted in the medication cup. On 9/5/17 and 9/6/17 LPN #2 was observed caring for Resident #s 4, #10, #16 and #17 after their NMT treatments. The LPN was not observed to clean the residents' NMT masks or mouthpieces. On 9/7/17 LPN #3 who was caring for Resident #s 4, #10, #16 and #17 after their NMT treatments, was not observed to clean the NMT masks or mouthpieces. On 9/6/17 and 9/7/17 LPN #1, who was caring for Resident #18 was not observed to clean NMT mouthpiece after the treatment was administered. On 9/7/17 at 2:15 pm, LPN #1 stated he had been taught to clean, or rinse out, the NMT after completion, after which the mask, but not the mouthpiece, should be stored in a plastic bag. He stated the mouthpieces get stored, uncovered, on the NMT machine. On 9/7/17 at 11:00 am, the Director of Nursing (DNS) stated the NMT set-ups were to be changed weekly and we just had a house wide training on NMT maintenance earlier this year. The facility's training materials documented the training conducted during the week of March 2017 and first week of April 2017, and included cleaning and storage of NMT set-ups. Review of the Nebulizer Therapy competency checklist dated 10/31/09 documented, .Step 16 Clean nebulizer once treatment is completed. A. Dismantle and rinse under a strong stream of warm (sic); B. Allow to air dry on a paper towel; C. Reassemble and place in plastic storage bag. The facility's Nebulizer Therapy competency checklists documented LPN #1 had an undated competency checklist which was partially completed. Step 16 Clean nebulizer once treatment is completed, was checked satisfactory, however sub-parts A, B and C were not documented as complete. LPN #2's completed Nebulizer Therapy competency checklist, dated 4/3/17, documented LPN #2 had satisfactory competence in all parts of Step 16. LPN #3's completed Nebulizer Therapy competency checklist, dated 3/31/17, documented satisfactory competence in all parts of Step 16. On 9/7/17 at 1:00 pm, the DNS stated there was not a formal company policy on NMT's. They follow the NMT competency According to Air Care, NMT manufacturer's website, instructions for cleaning after each use were Rinse the mask or mouthpiece with warm water for at least half a minute. Shake off excess water and place parts on a clean towel for air-drying.