**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 a resident's representative and physician were immediately notified when the resident had a significant change in condition. This was true for 1 of 1 resident (Resident #352) reviewed for notification of change in condition. This deficient practice placed Resident #352 at risk for lack of advocacy and support from their representative, and deterioration of her health status. Findings include: The facility's Change in a Resident's Condition or Status policy, revised February 2021, stated the facility will promptly notify the resident, his or her attending physician and the resident representative of changes in the resident's medical/mental condition. This policy was not followed. Resident #352 was readmitted to the facility on [DATE], with multiple diagnoses including dementia with behavioral disturbances. A nurse's note, dated 1/15/22 at 4:32 AM, documented Resident #352 was repeatedly yelling help me and having visual hallucinations. The note also documented Resident #352 had a fever of 104.1 degrees (normal temperature is 98.6 - 100.4 degrees) Resident #352's record did not include documentation Resident #352's physician and representative were notified of her change in condition. A nurse's note, dated 1/16/22 at 2:17 AM, documented Resident #352 was yelling and calling out mother of God help. The nurse's note documented Resident #352's oxygen saturation (percentage of oxygen in the blood) was 88% (normal is 95% - 100%). Resident #352's record did not include documentation Resident #352's physician and representative were notified of her change in condition. On 11/30/23 at 2:38 PM, the Administrator stated the facility did not have documentation of notification for change in condition for Resident #352.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and resident staff interview, it was determined the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASRR) was completed when the resident had a clinical diagnosis of Post-Traumatic Stress Disorder (PTSD). This was true for 1 of 1 resident (Resident #16) whose PASRR record was reviewed. This deficient practice had the potential to cause harm if residents' specialized services for mental health needs were not provided due to a lack of updated screening. Findings include: The Medicaid (government entity that provides health coverage to Americans) long term care PASRR website accessed on 12/14/23, documented the following: PASRR is a federal requirement for Medicaid-certified nursing facilities to help ensure that individuals are not inappropriately placed in nursing homes for long term care. The PASRR procedures include: - Evaluate all applicants for serious mental illness (SMI) and intellectual disability (ID). - Offer all applicants the most appropriate setting for their needs (in the community, a nursing facility, or acute care settings). - Provide all applicants with the services they need in those settings. The PASRR procedure further documented the nursing facilities would conduct a Level I screen, a preliminary assessment to determine whether a resident might have SMI or ID when admitted to the facility. Those individuals who tested positive at Level I would then be evaluated in depth, called Level II PASRR. The PASRR screening results were to determine needs and appropriate health care settings and a set of recommendations for services to inform the individual's plan of care. The facility's policy titled, admission Criteria, revised 3/2019, documented all new admissions were screened for mental disorders and other related disorders (RD). The policy further documented all potential admissions would have a Level I PASRR completed to determine if the resident met the criteria. If the Level I screen documented that the individual may have met the criteria for RD, then they would be referred to the state PASRR representative for the Level II (evaluation and determination) screening process. The policy further documented the admitting nurse should notify the social services department when a resident was identified with a possible RD. The policy documented the social worker was responsible for the referral to the state authority. After the Level II evaluation was completed, the state PASRR representative would determine if a physical or mental condition was present and what specialized services the resident needed. The determination would be provided to the facility. The interdisciplinary team would determine if the facility could meet the needs of the resident. These requirements and policy were not followed. Resident #16 was admitted on [DATE], with multiple diagnoses including PTSD (a mental health condition that is triggered by a terrifying event). An admission MDS assessment, dated 5/13/22, documented Resident #16 was cognitively intact. The assessment documented his onset for the diagnosis of PTSD was 5/11/22. Resident #16's Care Plan, revised 4/27/23, documented Resident #16 had depression related to PTSD and medical issues. Resident #16's goal was to exhibit indicators of depression, anxiety, or sad mood less than daily. The interventions included administration of medications, as ordered, and monitor and document any risk for self-harm or suicide plan. Resident #16's Idaho Level I PASRR Screen, dated 5/9/23, documented PTSD had not been checked for the question, Does the resident have any of the following Major Mental Illness, which included PTSD. The Level I PASRR was signed by the physician and the resident. There was no indication a Level II PASRR was completed. Resident #6's history and physical, dated 5/9/22, did not include his PTSD diagnosis. During an interview on 11/28/23 at 3:05 PM, Resident #16 stated he had PTSD from his military service. Resident #16 stated he was shot several times while in the military. Resident #16 further stated he had a Veterans' counselor that he could talk to. During an interview on 11/30/23 at 9:29 AM, LPN #5 and LPN #6 stated they were not aware of the diagnosis of PTSD. During an interview on 11/30/23 at 10:40 AM, LPN #6 stated a PASRR was a preadmission screening tool for mental disorders that may require additional care. LPN #6 further stated the screening was based on the history and physical given to the facility. The Level I PASRR was completed by her with the information provided by the history and physical, which did not include a diagnosis of PTSD. LPN #6 stated she was not sure when the diagnosis was added but a new Level I PASRR should have been initiated and sent to the health and welfare agency to be screened for a Level II PASRR.

**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' care plans were revised to reflect current needs and interventions. This was true for 1 of 23 residents (Resident # 26) whose care plans were reviewed. This deficiency placed residents at risk of adverse outcomes if care and services were not provided due to care plans not being revised as residents ' needs changed. Findings include: The facility's Care Plan policy, revised March 2022, documented the comprehensive, person-centered care plan described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility's Change in a Resident's Condition or Status policy, revised February 2021, documented the interdisciplinary team reviewed and updateded the care plan when there was a significant change in the resident's condition, when the desired outcome was not met, when the resident was readmitted to the facility from a hospital stay, and at least quarterly, in conjunction with the required quarterly MDS assessment. These policies were not followed. Resident # 26 was admitted on [DATE] and readmitted on [DATE], with multiple diagnoses including Type 2 diabetes with kidney disease, and dependence on renal dialysis. Resident # 26's care plan, dated 9/20/21, documented daily weights were to be measured at the same time and same scale each day. The care plan directed staff to notify Resident 26's Nephrologist if she had weight gain greater than or equal to 5 pounds in 3 days. The Weights and Vital Signs Summary report for November 2023, documented a weight for Resident #26 on 11/2/23 at 2:00 PM and 11/6/23 at 8:11 AM. The report did not document daily weights each day at the same time as directed by the care plan. On 11/29/23 at 11:49 AM, LPN # 1 stated the order for daily weights for Resident #26 was discontinued and the care plan should have been revised at that time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview, record review, and facility policy review, it was determined the facility failed to assess, monitor, and identify potential triggers for 1 of 1 resident (Resident #16) reviewed for trauma-informed care. This failure created the potential for . Findings include: The facility's policy Trauma-Informed and Culturally Competent Care Level III, revised 8/2022, stated the purpose of the policy was to guide staff in providing care that was culturally competent and trauma-informed in accordance with professional standards of practice, and to address the needs of trauma survivors by minimizing triggers and/or re-traumatization. The policy further defined Trauma results from an event, series of events, or set of circumstances that was experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being. The policy defined Trauma-informed care as an approach to delivering care that involved understanding, recognizing, and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognized the widespread impact and signs and symptoms of trauma in residents, and incorporated knowledge about trauma into care plans, policies, procedures, and practices to avoid re-traumatization. The policy defined Trigger as a psychological stimulus that prompted recalled previous traumatic event, even if the stimulus itself was not traumatic or frightening. The policy stated all staff were provided with training in trauma and trauma-informed care. The policy stated nursing staff were to be trained in trauma screening and assessments, including evaluating the presence of symptoms with the trauma and the identification of triggers. The care planning section of the policy stated staff were to identify and decrease exposure to triggers that may re-traumatize the resident. The policy stated an individualized care plan was to be developed. The initial screening was to be utilized to identify the need for further assessment and care. Resident #16 was admitted on [DATE], with multiple diagnoses including Post-Traumatic Stres Disorder (PTSD - a mental health condition that is triggered by a terrifying event), paraplegia (paralysis), and major depressive disorder. Resident #16's quarterly MDS assessment, dated 10/10/23, documented he had feelings of being down, depressed, bad about himself, let himself down, and that he might be better off dead nearly every day. Further review of the MDS documented Resident #16 would refuse care frequently. Resident #16's care plan, with a revised date of 4/27/23, documented a problem with depression related to PTSD and medical issues. Resident #16's goal was to exhibit indicators of depression, anxiety, or sad mood less than daily. The interventions included administration of medications as ordered, and monitor and document any risk for self-harm or suicide plan. Resident #16's care plan, revised 4/27/23, further documented his use of antidepressant medications. The goal was for Resident #16 to be free of discomfort and adverse reactions. The interventions included monitoring for adverse reactions and allowing Resident #16 to call the Veterans Administration (VA) counselor when he felt he needed. During an interview on 11/28/23 at 3:05 PM, Resident #16 stated he was diagnosed with PTSD from when he was in the military in Afghanistan. Resident #16 stated he had been shot several times. Resident #16 stated his wife wanted a divorce after he returned home, and he tried to commit suicide. During an interview on 12/1/23 at 8:45 AM, the Complex Care Unit (CCU) Coordinator stated she conducted the social services aspect for residents. The CCU Coordinator further stated Resident #16 had PTSD and had tried to commit suicide in the past when he lived at his home. The CCU Coordinator stated she did not know what Resident #16's triggers were from PTSD. She further stated she had spoken to Resident #16 on numerous occasions, but they had not discussed triggering events for PTSD. She stated she had encouraged Resident #16 to get outside counseling, but he preferred to talk to the VA counselors and for God to help him through. She stated behavior monitoring was not done for Resident #16's PTSD triggers. The CCU Coordinator stated she did the initial social services documentation, but the trauma informed care was done by nursing. She stated there were no interventions in the care plan for triggers from PTSD and there should have been. During an interview on 12/1/23 at 9:29 AM, LPN #5 stated she and LPN #6 completed the resident assessments for Resident #16. LPN #5 stated they were not aware of Resident #16's PTSD and did not assess for any triggers. LPN #5 further stated Resident #16 should have been assessed for triggers. During an interview on 12/1/23 at 9:34 AM, the MDS Coordinator stated Resident #16 was depressed and self-isolating. She stated she had talked to him on admission, but he did not tell her he had PTSD. She stated a physician's note and a quarterly summary alerted her to the PTSD diagnosis. The MDS Coordinator stated she did not do the trauma informed care assessments and care plan, LPN #5 or CCU Coordinator did. She reviewed the care plan and stated there was a problem for depression that was added on 4/19/23 and PTSD was added as a diagnosis, however no interventions or triggers were initiated. She stated triggers for Resident #16's PTSD should have been addressed and care planned. She stated she did not know what Resident #16's triggers were. The MDS Coordinator stated the necessity of identifying triggers were to ensure Resident #16 did not have suicidal ideation and he did not put himself in a triggered situation. During an interview on 12/1/23 at 9:59 AM, CNA #3 stated she had training on trauma informed care. CNA #3 stated the CNA book and the care plan was where potential triggers for residents were documented. CNA #3 stated she was not aware of any residents who had identified triggers related to PTSD.

**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 and prevention practices were maintained to provide a safe and sanitary environment when providing wound care. This was true for 1 of 1 resident (Resident #2) observed during wound care. This failure put Resident #2 at risk for infection due to cross contamination and potential exposure to bacteria and other pathogens. Findings include: The facility's Dressings, Dry/Clean policy, revised September 2013, documented after a soiled dressing was removed, to pull the soiled glove used over the dressing and discard. If gauze was used to clean the wound, use clean gauze for each cleansing stroke. The policy stated staff were to initial the clean dressing and label it with the date and time the dressing was changed. This policy was not followed. Resident #2 was admitted [DATE], with multiple diagnoses including an open wound of the abdominal wall. On 11/28/23 at 12:09 PM, LPN #1 was observed providing wound care to Resident #2. LPN #1 donned gloves, positioned Resident #2 in bed, adjusted her blankets, and set up wound care supplies on the bedside table. LPN did not perform hand hygiene, change her gloves or cleanse the bedside table before setting up the wound supplies. She then removed Resident #2's soiled wound dressing without performing hand hygiene and changing her gloves. She changed one glove after removing the soiled dressing without performing hand hygiene. She cleansed Resident #2's abdominal wound with one gauze pad to clean multiple areas of the wound. LPN #1 then applied a clean dressing to Resident #2's abdominal wound without performing hand hygiene and changing her gloves. LPN #1 did not label the dressing with the date, time, or her initials. On 11/28/23 at 12:35 PM, LPN # 1 stated she should have cleansed Resident #2's wound with multiple gauze pads. She stated she should have changed her gloves before removing Resident #2's soiled dressing and after completing wound care. LPN # 1 stated she should have completed hand hygiene each time she removed her gloves. She stated she was not aware of the need to date, time, and initial dressings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the State Agency's Long Term Care Reporting Portal, record review, incident reports, and staff interview, it was determined the facility failed to ensure allegations of resident abuse were reported to the State Survey Agency within 2 to 24 hours. This affected 2 of 5 residents (#7 and #8) who were reviewed for abuse, and for additional unidentified residents referenced in 2 incident reports. This failure created the potential for residents to be subjected to ongoing abuse without detection and protective measures implemented by the facility. Findings include: The facility's policy, Reducing the Threat of Abuse and Neglect, revised 12/21/23, stated allegations of abuse were to be reported to the State Survey Agency Long Term Care reporting Portal within 2-24 hours of the event, and report the results of an investigation within 5 working days from the date of the incident. Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including dementia with agitation, depression, and conduct disorder. An admission MDS assessment, dated 10/19/23, documented Resident #4's cognitive skills for daily decision making were severely impaired. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease and dementia with psychotic disturbances. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease and dementia. Resident #10 was initially admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including bipolar disorder and dementia. 1. A facility incident report, dated 1/31/24, documented Resident #4 was opening and slamming another resident's door, punching into the air, walls, and other residents' doors. When the staff attempted to redirect him, he began yelling out at no one then aimed attention toward sleeping resident in recliner. he [sic] attempted to swing at that resident. Other residents were removed from common area to accommodate this resident. A Staff Statement, dated 1/31/24, documented, during the incident, Resident #4 entered the room shared by Resident #7 and Resident #8 and slammed the door closed. When staff members tried to open the door, he attempted to hit them and punched the door 4-5 times, resulting in injuries to his hands and small cuts on his forearm. Resident #4 then came further out of the room in an attempt to hit the staff members and the staff were able to block him from reentering the room. The Statement documented Resident #4 became a danger to himself, the women in the room, and us [staff]. Review of the State Agency's Long Term Care Reporting Portal did not include a report of the above incident. 2. Resident #4's medical record included a Behavior Note, dated 2/2/24. The note documented Resident #4 was opening and slamming another resident's door, punching other residents' doors, yelling, and punching walls and into the air. He then attempted to swing at a sleeping resident in the common area. The staff removed other residents from the common area. A facility incident report, dated 2/2/24, documented Resident #4 was yelling in the direction of other residents and staff intervened when he tried to swing. Review of the State Agency's Long Term Care Reporting Portal did not include a report of the above incident. On 2/7/24 at 2:00 PM, the Administrator and the DON were interviewed together. When asked if the 1/31/24 and 2/2/24 incidents were investigated for potential abuse, they stated they were not. When asked if the incidents were reported to the State Agency Portal, the Administrator stated they were not since he thought that abuse was to be reported only when physical contact was made.

Based on facility document review and staff interview, it was determined the facility failed to ensure they employed an RN as the full-time DNS. The failure to have a full-time RN/DNS placed residents at risk of inadequate care and supervision of their medical status for a census of 44 residents. Findings include: The facility's job description for the Director of Nursing Services, approved by the Administrator on 3/9/20, documented Responsible for the management of the nursing services in the long-term care facility and directs nursing activities . The essential duties and responsibilities included the following: The DNS has knowledge of the state and federal regulations in the delivery of resident care, is informed of residents' conditions, determines the facility capacity for the care of potential new admissions, maintains the Quality Assurance program, ensures medications, treatments and plans of care are provided to the residents, evaluates nursing care by making daily rounds of the facility, and ensures adequate staff are available for resident care. During an interview on 11/29/23 at 10:10 AM, the Administrator stated there was no full-time RN designated to be the DNS working full-time at the facility and involved in resident care. During an interview on 11/30/23 at 10:30 AM, the Corporate Human Resources Director confirmed the facility did not have a full-time DNS.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure food items were dated and labeled and hygiene practices followed. This failure had the potential to affect 44 of 44 residents residing in the facility who consumed food prepared by the facility at risk of adverse health outcomes, including food-born illnesses. Findings include: 1. The facility's Food Storage policy, undated, stated once products were opened, a use by date label must be added. This policy was not followed. On 11/27/23 at 4:00 PM, during a kitchen inspection, 7 of 18 seasoning containers appeared cloudy and moist. 7 of the 18 opened seasoning containers did not have a use by date on the container. On 11/27/23 at 4:09 PM, The Dietary Manager stated the opened seasoning containers should have a use by date, and they did not. 2. The facility's Preventing Foodborne Illness policy, revised November 2022, stated hair caps and beard restraints were worn when cooking, preparing, or assembling food to keep hair from contacting exposed food, clean equipment, and utensils. This policy was not followed. On 11/28/23 at 10:52 AM, the Dietary Aid was observed in the kitchen assembling meal trays with no cover over his mustache. On 11/28/23 at 11:15 AM, the Dietary Aid stated he was never told the beard restraint should be worn to cover his mustache. On 11/28/23 at 11:17 AM, the Dietary Manager stated the beard restraint should be worn above the mustache to prevent hair from falling onto the meal trays.

Based on interview and document review, it was determined the facility's administration failed to ensure a full-time DNS was on staff. This failure had the potential to affect the care of the 44 residents in the facility and the assistance and care needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Findings include: During an interview on 11/29/23 at 10:10 AM, the Administrator stated there was no full-time RN designated to be the DNS working full-time at the facility and involved in resident care. The Administrator admitted knowledge of the need for a full-time DNS. The personnel file of the Interim DNS did not include a signed form of her job description. During an interview on 12/01/23 at 11:00 AM, the Interim DNS stated she was not in the facility on a full-time basis and had other job duties on the facility campus. The Interim DNS also stated she was not involved in resident care planning and in the provision of nursing services in the facility on a daily basis.

Based on staff interview and document review, it was determined the facility failed to report accurate Payroll Based Journal (PBJ) information for the facility as required for a census of 44 residents. Findings include: The facility's PBJ report, for 7/1/23 through 9/30/23, documented a full time RN functioned as the DNS in the facility. During an interview on 11/29/23 at 10:10 AM, the Administrator confirmed the facility did not employ a full time RN to serve as the DNS, as reported in the PBJ report. During an interview on 11/30/23 at 10:55 AM, the facility's Corporate Human Resources Representative confirmed the facility replaced the previous DNS with the Interim DNS on 5/8/23. Additionally, she confirmed the Interim DNS's employee file did not include an accepted and signed DNS job description defining job duties. During an interview on 12/1/23 at 11:00 AM, the Interim DNS stated she was not in the facility on a full-time basis and had other job duties on the facility campus, specifically in the assisted living facility, which was in another building. The Interim DNS also stated she was not involved in resident care planning and in the provision of nursing services in the facility on a daily basis.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure employees were trained on abuse. This was true for 43 of 79 employees whose records were reviewed for abuse training. This failure had the potential to place all residents in the facility for unidentified or continued abuse if an employee was unable to identify and report abuse. Findings include: The facility's Reducing the Threat of Abuse and Neglect policy, revised December 2022, stated the facility would implement and maintain an effective training program on abuse prohibition. This policy was not followed. During a review of employee abuse training, it was identified 43 of 79 employees did not complete training for abuse and neglect. On 12/1/23 at 10:32 AM, the Resident Care Coordinator stated 43 of 79 employees did not complete training for abuse and neglect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, policy review, and review of Incident and Accident reports, it was determined the facility failed to ensure all allegations of potential abuse or neglect were reported to the Administrator and State Survey Agency within 2 hours for 1 of 2 residents (Resident #40) reviewed for abuse/neglect. This had the potential to adversely affect all residents residing in the facility. The deficient practice created the potential for harm if abuse was not reported and investigated completely. Findings include: The facility's Abuse policy, revised on 11/22/16, stated all reports of abuse, neglect, and injuries of unknown origin, were to be thoroughly investigated. All employees observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator, DNS, or charge nurse. The supervisor or charge nurse should complete a Report of Incident/Accident form and submit the original to the DNS within 24 hours of the incident or accident. This policy was not followed. Resident #40 was admitted to the facility on [DATE], with multiple diagnoses including dementia and stroke. A quarterly MDS assessment, dated 11/29/18, documented Resident #40 had severe cognitive impairment and required the assistance of one to two staff persons with his ADLs. Resident #40's Self Deficit care plan, dated 2/23/18, documented he required extensive assistance of one to two staff members with toileting, incontinence care, bed mobility, and transfers. An I&A report, documented an allegation of staff abuse occurred on 12/29/18, and it was reported to the administration on 12/31/18, two days later. The report documented Resident #40 was combative during nursing care and CNA #5 shouted at Resident #40, and said Resident #40 needed to knock it off and grow up. The I&A report documented CNA #5 pointed her finger at Resident #40's face when he continued to be aggressive and told Resident #40 to stop and she was going to write a report about him to get him kicked out of the facility. The I&A report also documented CNA #4 heard CNA #5 telling Resident #40 I can't believe you are a grown man acting like that. A Staff Statement completed by LPN #5 documented on 12/29/18 at 6:00 PM CNA #4 reported the incident to her. LPN #5 stated she told CNA #4 to report it and put the report under the Administrator's door because they, LPN #5 and CNA #4, were getting off shift. LPN #5 also documented if CNA #4 ever felt that way again to get the resident's nurse and .let us decide what to do. On 1/17/19 at 2:59 PM, the DNS said any allegation of potential abuse should be reported to her or the Administrator within 2 to 24 hours and the written report should be completed within 5 days. The DNS said CNA #5 was terminated upon completion of their investigation. The DNS said she educated LPN #5 and CNA #4 regarding timely reporting and prevention of potential abuse. The DNS said she enrolled LPN #5 and CNA #4 in a course Abuse Prevention in Persons with Dementia: The Basics and asked them to complete the course within 7 days of their enrollment to the course.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, Incident and Accident (I&A) report review, and policy review, it was determined the facility failed to ensure allegations of verbal abuse reported by staff were thoroughly investigated for 1 of 2 residents (Resident #40) reviewed for abuse/neglect. This deficient practice placed all residents residing in the facility at risk for harm from undetected physical and/or verbal abuse. Findings include: The facility's Abuse policy, revised on 11/22/16, stated all reports of abuse, neglect, and injuries of unknown source, were to be thoroughly investigated. All employees observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator, DNS, or Charge Nurse. The policy defined verbal abuse as any use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents or their families. The policy stated the nurse should assess the individual and document related findings. The policy stated the individual conducting the investigation should at a minimum: *Interview the person(s) reporting the incident. *Interview any witnesses to the incident. *Interview the resident (as medically appropriate). *Interview staff members (on all shifts) who have contact with the resident during the period of the alleged incident. *Interview the resident's roommate, family members, and visitors. *Interview other residents to whom the accused employee provides care or services. This policy was not followed. Resident #40 was admitted to the facility on [DATE], with multiple diagnoses including dementia and stroke. A quarterly MDS assessment, dated 11/29/18, documented he had severe cognitive impairment and he required the assistance of one to two staff members for his ADLs. Resident #40's Self Deficit care plan, dated 2/23/18, documented he required extensive assistance of one to two staff members with toileting, incontinence care, bed mobility, and transfers. An I&A report, documented an allegation of staff abuse occurred on 12/29/18, and it was reported to the administration on 12/31/18, two days later. The report documented Resident #40 was combative during nursing care and CNA #5 shouted at Resident #40, and said Resident #40 needed to knock it off and grow up. The I&A report documented CNA #5 pointed her finger at Resident #40's face when he continued to be aggressive and told Resident #40 to stop and she was going to write a report about him to get him kicked out of the facility. The I&A report also documented CNA #4 heard CNA #5 telling Resident #40 in the dining room I can't believe you are a grown man acting like that. CNA #4 reported the incident to LPN #5. A Staff Statement completed by LPN #5 documented on 12/29/18 at 6:00 PM, CNA #4 reported the incident to her. LPN #5 stated she told CNA #4 to report it and put the report under the Administrator's door because they, LPN #5 and CNA #4, were getting off shift. LPN #5 also documented if CNA #4 ever felt that way again to get the resident's nurse and .let us decide what to do. The I&A report documented CNA #5 was placed on leave during the investigation. Attached to the report were written statements from CNA #5, CNA #4, LPN #5, and the Administrator. The Administrator documented he was unable to interview Resident #40 due to his cognitive impairment. The I&A report did not include statements or interviews of Resident #40's roommate or of other residents who were under the care of CNA #5. The I&A report concluded the abuse by CNA #5 was substantiated and no psychosocial harm was noted to Resident #40. The report was signed by the Administrator on 1/4/19 at 5:50 PM. Resident #40's record did not include documentation he was assessed or observed for signs of psychosocial harm. On 1/17/19 at 2:59 PM, the DNS said the I&A report did not include interviews of Resident #40, his roommate, and other residents who were under the care of CNA #5. The DNS said Resident #40 should have been placed on alert charting and monitored for 72 hours. On 1/18/19 at 10:00 AM, the Administrator said he interviewed Resident #40 and he remembered Resident #40 telling him I will kick his ass. The Administrator said he did not formally write a report of his interview of Resident #40. The Administrator said Resident #40 had a roommate and he did not interview Resident #40's roommate or the other residents who were under the care of CNA #5. The Administrator said it was an oversight.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, it was determined the facility failed to ensure the MDS was completed timely for 1 of 15 residents (Resident #2) reviewed for MDS completion. The failure created the potential for harm if care and services provided did not meet resident needs. Findings include: Resident #2 was admitted to the facility on [DATE], with multiple diagnoses including heart failure, chronic pain, difficulty walking, macular degeneration, hypertension, and lower back pain. An admission MDS assessment, dated 10/29/18, documented Resident #2 was independent with decision making and a resident interview was not completed. The MDS was signed on 1/15/19, which was 78 days after it was initiated. On 1/16/19 at 3:33 PM, the MDS RN stated Resident #2's 10/29/18 MDS was started and not completed until 1/15/19. The MDS RN stated she did not know what happened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #21 was admitted to the facility on [DATE], with multiple diagnoses which included stroke with left hemiplegia (paralysis). A quarterly MDS assessment, dated 10/26/18, documented Resident #21 was cognitively intact and had functional range of motion impairment to his upper and lower extremities on one side. A physician's order, dated 4/5/18, documented Resident #21 was discharged from PT and caregivers were trained to put on/remove his left upper extremity arm support. On 1/14/19 at 2:30 PM, Resident #21 said he received PT three times a week for his lower extremities. Resident #21 said he was not receiving PT for his left upper arm. Resident #21 stated he could not move his left upper arm since he had a stroke. Resident #21 said he used a splint whenever he was up in his wheelchair. On 1/15/19 at 11:29 AM, Resident #21 was observed in bed and he was wearing a brace on his lower left leg. On 1/15/19 at 11:38 AM, Resident #21 was observed in his power wheelchair wearing a splint on his left upper arm. On 1/15/19 at 12:24 PM, Resident #21 was observed in the smoking area with a splint on his left upper extremity. Resident #21's care plan, dated 8/1/18, did not address his brace and splint. On 1/6/19 at 12:12 PM, the Physical Therapist said Resident #21 had left sided hemiplegia and complained of pain to his left shoulder. The Physical Therapist said Resident #21 should wear his splint when he was up in his power wheelchair to provide support of his left arm otherwise, his left arm hung down and put stress on his shoulder causing pain. On 1/17/19, at 11:15 AM, RN #3 said Resident #21 was admitted to the facility with his leg brace and splint on his left upper arm. RN #2 said Resident #21's left upper splint should be on when he was up in his wheelchair and off when he was in bed. RN #3 said Resident #21's AFO and splint should have an order and should have been addressed in his care plan. Based on observation, resident interview, staff interview, record review, and policy review, it was determined the facility failed to ensure a comprehensive care plan was developed for 2 of 15 residents (#12 and #21) whose records were reviewed. This failure created the potential for harm if residents did not receive adequate care and treatment to meet their needs. Findings include: The facility's Care Plans, Comprehensive Person-Centered policy, revised 12/2016, documented a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident. This policy was not followed. 1. Resident #12 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's disease, seizure disorder, anxiety, and depression. Resident #12's record included physician orders, dated 2/19/18, for Norco (a narcotic pain medication) 7.5mg of by mouth three times a day, and daily PRN for pain. A quarterly MDS assessment, dated 10/1/18, documented Resident #12 was severely cognitively impaired. The assessment documented Resident #12 received scheduled and PRN pain medication, but no non-medication interventions for pain. The MDS documented Resident #12 received opioid pain medication on seven days out of seven during the look back period. Resident #12's December 2018 MAR, documented Resident #12 received routine pain medication three times a day every day of the month and required as needed pain medication an additional eight times during the month. Resident #12's MAR for January 2019, documented Resident #12 received routine pain medication three times a day from 1/1/19 to 1/16/19, and required as needed pain mediation an additional three times. Resident #12's care plan did not include a section on pain management to include his use of the routine and PRN pain medication, nor for attempting any non-pharmacological interventions for pain management prior to administering pain medication. On 1/17/19 at 2:30 PM, LPN #1 stated a care plan for Resident #12 was not developed related to the administration of routine and PRN pain medication, nor for the implementation of non-pharmacological pain management interventions.

**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 residents' care plans were revised as care needs changed for 1 of 15 residents (Resident #46) whose care plans were reviewed. This failure had the potential for harm if care and services were not provided due to inaccurate information. Findings include: Resident #46 was admitted to the facility on [DATE], with diagnoses including dementia, difficulty in walking, muscle weakness, and repeat falls. A quarterly MDS assessment, dated 12/12/18, documented Resident #46 was cognitively intact and required extensive assist of one staff person with all cares except eating. On 1/16/19 at 11:05 AM, the RSM stated Resident #46 had behavioral issues which included being accusatory towards staff. The RSM stated one of the identified practices used to keep Resident #46 safe, required the assistance of two staff persons when physical contact was required. Resident #46's AROM and ADL care plan areas were not updated with the appropriate level of care identified by the RSM for two person assistance with physical contact as follows: a. The care plan area addressing Resident #46's AROM, dated 6/29/18, documented one staff member assisted Resident #46 with AROM to her upper and lower extremities seven days a week. The care plan documented the staff person was to assist Resident #46 with AROM exercises of two to three sets of 10 repetitions for her knee and hip flexion, two to three sets of 10 repetitions to her ankle and shoulder, and 10 repetitions of trunk flexion and extension. b. The care plan area addressing Resident #46's ADLs, dated 12/16/18, documented one staff member assisted Resident #46 with transfers, bed mobility, ambulation, dressing, and personal hygiene. On 1/16/19 at 2:14 PM, RNA #2 stated Resident #46's care plan did not reflect her current need for two staff persons when physical contact was necessary. On 1/16/19 at 2:45 PM, LPN #2 stated Resident #46 required two staff members to complete her RNP due to behavioral issues and safety concerns. On 1/16/19 at 11:05 AM, the RSM stated Resident #46's ADL care plan was not updated when Resident #46's behavioral issues presented and she required two staff when physical contact was required.

**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 evening activities scheduled to meet the needs of residents with cognitive impairment who resided in the non-locked behavioral unit. This was true for 3 of 3 residents (#41, #46, and #60) reviewed for activities and resided in the unlocked behavioral unit. This created the potential for residents to become bored and foster an increase in negative behaviors when not provided with meaningful engaging activities throughout the day and evening. Findings include: The facility's Activity's Evaluation policy, dated 5/2013, documented residents' activities should be meaningful and individualized according to their needs. The January 2019 Activity Calendar for the residents documented activities occurred seven days a week with different times of the day when activities were provided. The Activity Calendar documented the following times: - Sundays 9:00 AM to 3:00 PM or 4:00 PM - Mondays 9:00 AM to 4:00 PM or 4:30 PM - Tuesdays 9:00 AM to 4:00 PM or 4:30 PM - Wednesdays 8:30 AM or 9:00 AM to 4:30 PM or 6:30 PM - Thursdays 9:00 AM to 3:00 PM, 4:00 PM or 5:30 PM - Fridays 10:00 AM or 10:30 AM to 2:00 PM, 3:30 PM, 4:00 PM or 6:30 PM - Saturdays 10:00 AM or 11:30 AM to 2:00 PM or 3:30 PM. The activity calendar documented six days during the month of January 2019 where an activity was scheduled after 5:00 PM. 1. Resident #60 was admitted to the facility on [DATE], with diagnoses including dementia with behavioral disturbances, depression, and anxiety. An annual MDS assessment, dated 6/27/18, documented Resident #60's activity preferences were having books and magazines she liked, listening to music, pet visits, keeping up with the news, and participating in favorite activities. A quarterly Activity Assessment, dated 9/27/18, documented Resident #60's activity preferences were listening to music, pet visits, family and friend visits, going to the beauty parlor, and walking/wheeling around the facility in her wheelchair. The assessment documented Resident #60 had no interest in movies/videos, writing, group discussions, and exercise. The care plan area addressing Resident #60's Activities, documented she enjoyed activities involving balls, because she was a professional softball player, she enjoyed assisting staff when they were writing statements, she enjoyed trivia, she enjoyed socializing in common areas, but would only join in the conversation when asked a question, she enjoyed music, and watching all [NAME] movies. The care plan did not include the interests identified as very important to her on the MDS or quarterly activities assessment and included some activities that Resident #60 had identified as no interest or past interests on her care plan. Resident #60's Activities Flowsheet, dated 12/1/18 through 1/16/19, documentation did not include documentation of pet visits, going to the beauty parlor, books and magazines, or walking and/or wheeling around. The flowsheets documented Resident #60 participated in a music activity on 12/7/18, 12/14/18, 12/21/18, 12/28/18, and 1/7/19. The flowsheets documented she did not watch [NAME] movies, participate in trivia, or participate in activities involving balls. The flowsheet documented she was actively socializing with other residents in the common area from 1/1/19 through 1/16/19. Resident #60 had minimal participation in activities that were identified on her care plan and her activities were not individualized with her identified interests. On 1/14/19 at 12:50 PM, Resident #60 was observed near the nurses' station sitting in her wheelchair with her back to the TV and her eyes were closed. Other residents were sitting quietly in the same area. Resident #60 was observed from 12:50 PM through 1:47 PM without changes until staff assisted her to the restroom and then into her bed. Resident #60's TV in her room was not turned on or music turned on when CNA #7 left the room. On 1/15/19 at 11:00 AM, Resident # 60 was observed in the hallway near the nurses' station sitting quietly and other residents around her were sitting quietly. On 1/15/19 at 11:45 AM, Resident #60 was observed as staff assisted her in her wheelchair into the dining room for lunch. On 1/15/19 at 1:12 PM, Resident #60 was observed in bed with no TV or music playing. On 1/15/19 at 4:33 PM, Resident #60 was observed sitting in a lounge chair near the nurses' station. The TV was observed playing a show that was not [NAME]. Resident #60 was observed sitting quietly with her eyes closed. Resident #60 was observed from 4:33 PM to 5:28 PM in the same position with her eyes periodically closed until staff assisted her into her wheelchair and assisted her to the dining room for dinner. On 1/16/19 at 11:00 AM, Resident #60 was observed asleep in bed with the TV on and a show that was not [NAME] was playing. On 1/17/19 at 11:51 AM, the Activities Director stated Resident #60 enjoyed activities involving balls and watching kids' arts and craft demonstrations. The Activities Director stated Resident #60 enjoyed [NAME] movies in the fireside room. The Activities Director stated she was aware that individualized activities were not provided consistently for Resident #60. The fireside room was a room that contained movies (including [NAME]), books, games, puzzles, and various other activities. Resident #60 was not observed to enter the fireside room for the duration of the observations. The fireside room was empty for the majority of the survey with the exception of use during voting and when a family visited a resident. 2. Resident #41 was admitted to the facility on [DATE], with diagnoses including dementia and behavioral disorder. An admission MDS assessment, dated 3/6/18, documented Resident #41's activity preferences which were very important to her included having books and magazines she liked, pet visits, group activities, participating in favorite activities, fresh air, and religious activities. A quarterly Activity Assessment, dated 12/3/18, documented Resident #41's activity preferences that were very important to her were listening to music, pet visits, family and friend visits, going to the beauty parlor, bingo, current events/news, western movies, outdoor time, religious services, socials/parties, and talking to others. The assessment documented it was somewhat important to her to read. The assessment documented Resident #41 used to enjoy arts and crafts, cooking demonstrations, gardening, puzzles/word games, and coloring. The assessment documented Resident #41 had no interest in board games, group discussions, and educational programs. The assessment documented staff offered coloring, word searches, and 1:1 conversation with staff. The Activities care plan, dated 2/27/18, documented Resident #4 enjoyed activities with music, walking outside, word searches, ice cream and cookies. The care plan did not include the interests identified as very important to her on the MDS or quarterly activities assessment and included some activities that Resident #41 had identified as a past interest on her care plan. Resident #41's Activities Flowsheet, dated 12/1/18 through 1/16/19, did not include documentation of pet visits, family and friend visits, going to the beauty parlor, bingo, current events/news, western movies, religious services, socials/parties, and talking to others. The flowsheets documented Resident #41 participated in a music activity on 12/7/18, 12/11/18, 12/14/18, 12/21/18, 12/22/18, and 12/28/18. The flowsheet documented she actively discussed the weather on 12/7/18, 12/14/18, 12/21/18, 12/28/18, 1/4/19, and 1/10/19. The flowsheet documented staff read to her on 1/4/19 and 1/10/19. Resident #41 had minimal participation in activities that were identified on her care plan and her activities were not individualized with her identified interests. On 1/14/19 from 12:17 PM to 2:15 PM, Resident #41 was observed sitting in the hallway with her back to the nurses' station and facing the back side of the TV. Resident #41 had a staff member standing next to her or sitting next to her periodically throughout the observation. Resident #41 was observed groaning and moaning when staff was not by her side, from 12:41 PM to 12:53 PM, at 1:04 PM and 1:06 PM, and from 1:11 PM to 1:43 PM. On 1/15/19 from 10:51 AM to 12:25 PM, Resident #41 was observed sitting with her back to the nurses' station and periodically staff sat next to her. Resident #41 was observed periodically moaning, groaning, and crying softly to herself. On 1/15/19 from 12:35 PM to 2:43 PM, Resident #41 was observed in bed with her eyes closed. Resident #41's TV was off, and no music was playing. On 1/15/19 from 4:32 PM to 5:32 PM, Resident #41 was observed sitting in her wheelchair with her back to the nurses' station and periodically crying and moaning. On 1/15/19 at 5:36 PM, Resident #41 was assisted into bed. On 1/16/19 at 10:18 AM, Resident #41 was observed in bed and cried out, Help, help, help. On 1/16/19 at 12:19 PM, Resident #41 was observed in her wheelchair with her back to the nurses' station and cried out, Help, help, help, help, help. On 1/17/19 at 11:00 AM, Resident #41 was observed in her wheelchair with her back to the nurses' station moaning and crying, Help, help, help, help, help. On 1/17/19 at 11:36 AM, the Activities Director stated Resident #41 spent most of her day at the nurses' station people watching. The Activities Director stated Resident #41 liked weather reports. The Activities Director stated Resident #41 appeared to have increased fear and she could benefit from 1:1 interaction and music playing. The Activities Director stated she had sensory stimulation books for residents with dementia and she encouraged staff to utilize these tools. The Activities Director stated Resident #41 may benefit from this type of sensory stimulation. The Activities Director stated she knew Resident #41's activities could be better suited to her current level of function. 3. Resident #46 was admitted to the facility on [DATE], with diagnoses including dementia, difficulty in walking, muscle weakness, and repeated falls. An admission MDS assessment, dated 5/10/18, documented Resident #46's activity preferences that were very important to her were listening to music, pet visits, keeping up with the news, participating in favorite activities, and outside activities. A quarterly Activity Assessment, dated 12/11/18, documented Resident #46's activity preferences that were very important to her were listening to music, pet visits, family and friend visits, going to the beauty parlor, current events and news, educational programs, outdoor time, having conversation in person and on the phone, and watching the news or Dr. Oz. The assessment documented Resident #46 used to enjoy shopping, gardening, and arts and crafts. The assessment documented Resident #46 had no interest in computers, group discussions, puzzles and word games, the radio, socials/parties, and sports. The Activities care plan, dated 5/7/18, documented Resident #46 enjoyed daily guided walks in the facility, evening prayer with another resident, 1:1 visits with staff, a family member suggested offering gardening, organizing her belongings, having extra pudding and yogurt in her room, and going outdoors, which Resident #46 declined. The care plan did not include all the interests identified as very important to her on the MDS or quarterly activities assessment and included some activities that Resident #46 had identified as a past interest on her care plan. Resident #46's Activities Flowsheet, dated 12/1/18 through 1/16/19, did not include documentation of pet visits, listening to music, going to the beauty parlor, current events/news, watching TV, and educational programs. The flowsheet documented Resident #46 participated in organizing her belongings and having extra yogurt and cookies in her room from 12/1/18 through 12/31/18. The flowsheet documented she was provided 1:1 visits on 12/4/18, 12/9/18, 12/16/18, 12/18/18, 12/27/18, 12/31/18, and 1/4/19. The activities flowsheet documented she was actively prayed with another resident each day from 12/1/18 to 1/16/19. The activities flowsheet documented Resident #46 participated in guided walks around the facility with Restorative nursing from 12/1/18 through 12/31/18. Resident #46 had minimal participation in activities that were identified on her care plan and her activities were not individualized with her identified interests. The care plan area addressing Resident #46's ROM Program, dated 6/29/18, documented two staff members were to ambulate with Resident #46 with her front wheeled walker for 25-200 feet. On 1/16/19 at 11:30 AM, the Activities Director stated she documented the walking program provided by restorative as guided walks. The Activities Director stated she was unaware the RNP for walking was not consistently provided to Resident #46. On 1/14/19 at 12:59 PM, Resident #46 was observed sleeping in a recliner chair in her room. On 1/14/19 at 2:14 PM, Resident #46 stated she wanted to walk around the facility and it was difficult at times to find two staff members for walking assistance. On 1/15/19 at 9:46 AM, Resident #46 was observed sitting in her recliner chair eating. Resident #46 was observed in the same position on 1/15/19 at 10:09 AM, 10:37 AM, 11:25 AM, 12:15 PM, 2:46 PM, and 4:37 PM. Resident #46 stated no one came to visit her unless she used her call light to request something. Throughout the observation period Resident #46's TV was off, and she slept periodically. On 1/16/19 at 10:12 AM, Resident #46 was observed tearful and crying and stated she did not understand why two staff members had to assist her with everything she did. Resident #46 stated if she wanted assistance with water two staff members entered her room to assist. Resident #46 stated she felt like staff did not want to help her or visit her because of this. On 1/16/19 at 11:30 AM, the Activities Director stated Resident #46's 1:1 visits should be completed one to two times a week. The Activities Director stated this was not done and Resident #46 required the assistance of two staff members with all cares. On 1/16/19 at 11:05 AM, the RSM stated Resident #46 had behavioral issues which included being accusatory towards staff. The RSM stated one of the identified practices used to keep Resident #46 safe, required two staff members assistance when physical contact was required. The RSM stated Resident #46 did not require the assistance of two staff members with all her needs. The RSM stated one staff member could complete a 1:1 visit for activities. On 1/17/19 at 11:51 AM, the Activities Director stated she stayed late on Mondays and Wednesdays to provide activities later into the day. The Activities Director stated she was aware the activities calendar did not have many activities after 5:00 PM and she was working on scheduling more activities. The Activities Director stated she did not have many night activities because residents went to bed early. The Activities Director stated there were two activities personnel for all residents. The Activities Director stated she could use more staff to assist with meeting the residents' activities needs. On 1/17/19 at 4:00 PM, the DNS stated the facility was in the process of hiring more staff in general. The DNS stated she was aware the Activities Program could use more staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, it was determined the facility failed to ensure residents received respiratory care as ordered by a physician. This was true for 2 of 3 residents (#2 and #162) reviewed for oxygen therapy. This deficient practice had the potential for harm if residents received unnecessary, excessive, or insufficient oxygen to maintain stability. Findings include: 1. Resident #162 was admitted to the facility on [DATE] and was readmitted on [DATE], with multiple diagnoses including aspiration pneumonia. A significant change in status MDS assessment, dated 1/3/19, documented Resident #162 was cognitively intact and required oxygen therapy. On 1/15/19 at 10:10 AM, Resident #162 was observed in her wheelchair in the Bistro (a multipurpose room) receiving oxygen via nasal cannula. On 1/16/19 at 10:18 AM, Resident #162 was observed sleeping in her bed receiving oxygen via nasal cannula. The flow rate of oxygen was at two liters per minute (LPM). Resident #162's record did not include a physician order for oxygen use. On 1/18/19 at 10:53 AM, RN #2 said Resident #162 was on oxygen therapy prior to her discharge to the hospital in December 2018. RN #2 said it was the nurse consultant who transcribed the physician's orders from the hospital and the orders should have been reviewed the following morning during their daily meeting and oxygen therapy should have been ordered. 2. Resident #2 was admitted to the facility on [DATE], with multiple diagnoses including heart failure. A physician order, dated 10/22/18, documented Resident #2 was to receive oxygen to maintain her oxygen saturation level at greater than 90%, but did not specify a flow meter paramater. On 1/14/19 at 1:23 PM, Resident #2 was observed sitting in her recliner with the nasal cannula on her lap. Resident #2 said she used oxygen most of the time but was unsure if she was using her oxygen correctly. On 1/15/19 at 12:45 PM, Resident #2 was observed in her recliner leaning forward receiving oxygen via nasal cannula at 2 LPM. On 1/16/19 at 8:43 AM, LPN #5 said Resident #2 received continuous oxygen. On 1/16/19 at 8:48 AM, CNA #2 entered Resident #2's room to check the resident's vital signs. CNA #2 said Resident #2 had her oxygen flowing from the oxygen concentrator at 3 LPM. On 1/16/19 at 2:06 PM, Resident #2 was sitting in her recliner wearin her nasal cannula. On 1/17/19 at 12:05 PM, Resident #2 was observed sleeping in bed and receiving oxygen via a nasal cannula. On 1/17/19 at 3:13 PM, Resident #2 was observed in her recliner receiving oxygen via nasal cannula at 3 LPM. On 1/17/19 at 3:47 PM, RN #2 reviewed Resident #2's physician's order and said the oxygen order did not have a parameter and it should have one. RN #2 and the Surveyor then went to Resident #2's room and checked her oxygen flow rate, and it was at three LPM. RN #2 said the evening shift nurse should not have adjusted the resident's oxygen flow rate.

Based on observation, staff interview, and record review, it was determined the facility failed to ensure medication error rate was less than 5%. This was true for 2 of 30 medications (6.67%) which affected 2 of 6 residents (#6 and #45) whose medication administration was observed during medication pass. This failed practice placed residents at risk of not receiving medications as ordered by the physician and had the potential to lessen the effectiveness of the medications administered. Findings include: 1. On 1/16/19 at 3:15 PM, RN #1 was observed applying triamcinolone cream 0.1% to Resident #45's bilateral cheeks (face) and bridge of her nose. Resident #45's record included physician orders for hydrocortisone cream 1% to cheeks twice a day and triamcinolone cream 0.1% to ankle rash twice a day. The pharmacy label on the triamcinolone documented the medication was to be applied to Resident #45's ankle twice a day. After the triamcinolone cream was applied to Resident #45's face RN #1 reviewed the label. RN #1 reread the triamcinolone label and then looked through several tubes of medication in her medication cart. RN #1 stated the triamcinolone was the same as the hydrocortisone cream and the triamcinolone was what they were using. On 1/18/19 at 12:55 PM, the Pharmacist said during a telephone interview, triamcinolone and hydrocortisone were not the same. The Pharmacist said they were both corticosteroids but triamcinolone was more potent and they were not interchangeable. 2. On 1/17/19 at 11:50 AM, LPN #4 was observed to administered ten oral medications to Resident #6, including Clearlax powder (a laxative) 17 grams mixed in a small amount of water. LPN #4 reviewed Resident #6's Clearlax order after administering it. LPN #4 read the order and said the Clearlax was to be mixed in four to six ounces of fluid but she had mixed it in less than four ounces of water.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, it was determined the facility failed to ensure pharmacy labels matched the physician's order. This was true for 1 of 30 medications for 1 of 6 residents (Resident #6) whose medication passes were observed. The failure created the potential for Resident #6 to receive a wrong dose and experience an adverse effect. Findings include: Resident #6 was admitted to the facility on [DATE], with mulitple diagnoses including epilepsy (seizure disorder). Resident #6's physician orders included depakote (an anti-seizure medication) 500 mg twice a day for mood disorder with depression, ordered on 7/6/18. On 1/17/19 at 11:50 AM, LPN #4 was observed administering 10 oral medications to Resident #6, including depakote 500 mg. The pharmacy label for the depakote documented take one tablet by mouth every morning and take two tablets by mouth at bedtime (2 tabs = 1000 mg). On 1/17/19 at 12:05 PM, RN #2 reviewed Resident #6's physician order for depakote and said it did not match the pharmacy label. RN #2 said they had informed the pharmacist about Resident #6's depakote order the last time they sent the medication. RN #2 said she will notify the pharmacy again.

**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 residents received treatment and services to prevent further decrease in ROM. This was true for 5 of 6 residents (#18, #21, #41, #46, and #60) who were reviewed for treatment and services related to ROM. This deficient practice placed residents at increased risk of experiencing a decrease in mobility and function due to lack of AROM or passive ROM (PROM) services. Findings include: The facility's Restorative Nursing Services policy, revised April 2018, documented residents' restorative goals and objectives were individualized per their needs and outlined in their care plans. 1. Resident #60 was admitted to the facility on [DATE], with diagnoses including dementia with behavioral disturbances, hemiplegia (paralysis) affecting the right side, and gout. A quarterly MDS assessment, dated 12/24/18, documented Resident #60 had moderate cognitive impairment and she required extensive assistance from one to two staff members with all cares. The MDS assessment documented Resident #60 received AROM two days, splint or brace placement four days, and walking program two days during the 7 day look back period. The care plan area addressing Resident #60's AROM Program, dated 2/28/16, documented she was to participate in group activities with RNAs or activity aides 7 days a week for 15 minutes, or open gym from 3:30-4:30 PM. Resident #60's Restorative Program flowsheet, dated 12/1/18 through 1/16/19, documented RNA staff completed AROM for a minimum of 15 minutes on 12/18/18, 12/20/18, 1/1/19, and 1/5/19-1/8/19. Resident #60 did not receive AROM from the RNAs 40 days out of 47 days. The AROM/ROM flowsheets also documented CNAs completed an unknown amount of time of AROM for 34 days of the 47 days during the time frame. The care plan area addressing Resident #60's left hand brace, dated 4/17/18, documented staff provided gentle stretching of her third and fourth digit and applied a sheepskin palm protector to her left hand after washing her hands. The care plan documented the brace could be worn day and night and to replace the brace the next day if Resident #60 removed it. The Restorative Program flowsheet for Resident #60, dated 12/1/18 through 1/16/19 documented staff completed gentle stretching of her third and fourth digits and applied a sheepskin palm protector to her left hand on 12/2/18, 12/3/18, 12/5/18, 12/6/18, 12/9/18, 12/10/18, 12/12/18, 12/13/18, 12/18/18, 12/20/18, 12/23/18-12/25/18, 12/30/18-1/1/19, 1/4/19-1/9/19, 1/11/19, 1/12/19, 1/14/19, and 1/15/19. Resident #60 did not receive her left-hand brace 20 days out of 47. There was no documentation why the brace was not applied on the 20 days. The care plan area addressing Resident #60's ROM Program, dated 9/3/16, documented staff were to ambulate Resident #60 to the dining room and back to the hall three times daily, and from her room to the common room as needed with her front wheeled walker, six to seven days a week. The care plan directed the RNAs to document the total number of feet walked each day. Resident #60's Restorative Program flowsheet, dated 12/1/18 through 1/16/19, documented staff completed ambulation with Resident #60 on 12/2/18, 12/3/18, 12/5/18, 12/6/18, 12/9/18, 12/10/18, 12/12/18, 12/13/18, 12/18/18, 12/20/18, 12/23/18-12/27/18, 12/30/181/1/19, 1/3/19-1/9/19, 1/12/19, and 1/15/19. Resident #60 did not receive assistance with walking on 20 days out of 47. The Restorative Program flowsheet for Resident #60 documented Restorative Aides were not available on 12/1/18, 12/7/18, 12/18/18, 1/2/19, and 1/13/19, and documented restorative services were not offered to Resident #60 on 12/17/18 and 1/16/19. On 1/14/19 from 12:50 PM through 2:02 PM, Resident #60 was observed sitting near the nurses' station without a brace on her left hand. Resident #60 was observed again without her hand brace on 1/15/19 from 11:00 AM through 4:33 PM and on 1/16/19 at 9:00 AM through 2:14 PM. On 1/15/19 at 11:45 AM, Resident #60 was observed being wheeled into the dining room by staff for lunch. On 1/15/19 at 5:28 PM Resident #60 was observed being assisted into her wheelchair and wheeled to the dining room for dinner. On 1/16/19 at 2:14 PM, RNA #2 stated Resident #60 had multiple programs and it was difficult to complete these daily. RNA #2 stated one of Resident #60's programs included a brace to her left hand. RNA #2 stated Resident #60 was to wear the brace before breakfast and keep it on as long as she could tolerate it. RNA #2 stated she knew Resident #60's brace was not always placed on her hand. RNA #2 stated on days when she did not have time to place the brace, she would document RA services were unavailable or not offered and document a zero for the time completed. RNA #2 stated she did not document how long Resident #60 wore her brace and did not know if the brace was effective or not. RNA #2 stated Resident #60 did not have her brace on 1/16/19, and RNA #2 did not have time to place it on her hand. RNA #2 stated on occasions Resident #60 participated in exercise programs or a CNA provided AROM with Resident #60 and RNA #2 stated she documented CNA on the ADL AROM/ROM flowsheet. RNA #2 stated she did not know how long CNAs worked with Resident #60 or everything they did. RNA #2 stated she sometimes saw CNAs doing something with Resident #60 and that was how she knew they had completed the AROM. On 1/16/19 at 2:45 PM, LPN #2 stated Resident #60 should wear the brace during the day for as long as possible or as tolerated. LPN #2 stated Resident #60 removed the brace herself or asked staff to remove it. She was unsure how long Resident #60 wore the brace or if it was effective because the RNP did not capture this information. LPN #2 stated she was unaware if Resident #60's walking program for meals was completed three times a day or not. LPN #2 stated the RNAs documented how many total feet Resident #60 walked for the day. On 1/16/19 at 3:20 PM, the Therapy Director stated Resident #60's hand brace should be on for 8 hours and off for 8 hours. The Therapy Director stated Resident #60's orders did not specify what type of brace to use or how long she required the brace. He stated Resident #60 needed a sheepskin brace. 2. Resident #46 was admitted to the facility on [DATE], with diagnoses including dementia, difficulty in walking, muscle weakness, and repeat falls. A quarterly MDS assessment, dated 12/12/18, documented Resident #46 was cognitively intact and she required extensive assistance of one staff members with all cares except eating. The MDS assessment documented Resident #46 received AROM and restorative walking four days during the look back period of 7 days. The care plan area addressing Resident #46's ROM Program, dated 6/29/18, documented two staff members were to ambulate with Resident #46 with her front wheeled walker for 25-200 feet daily. Resident #46's Restorative Program flowsheet, dated 12/1/18 through 1/16/19, documented staff completed her walking program of 25-200 feet on 12/2/18, 12/5/18, 12/6/18, 12/9/18-12/13/18, 12/16/18, 12/20/18, 12/23/18, 12/24/18, 12/26/18, 12/27/18, 12/30/18, 12/31/18, 1/3/19, 1/4/19, 1/6/19, and 1/10/19. Resident #46 did not receive her walking program 27 days out of 47. The care plan area addressing Resident #46's AROM, dated 6/29/18, documented she was to do AROM to her upper and lower extremities 7 days a week. The care plan documented the staff was to assist Resident #46 with AROM exercises of two to three sets of 10 repetitions for her knee and hip flexion, two to three sets of 10 repetitions to her ankle and shoulder, and 10 repetitions of trunk flexion and extension. Resident #46's Restorative Program flowsheet, dated 12/1/18 through 1/16/19, documented staff completed AROM to her upper and lower extremities on 12/2/18, 12/5/18, 12/6/18, 12/9/18-12/13/18, 12/16/18, 12/20/18, 12/23/18, 12/24/18, 12/26/18, 12/27/18, 12/30/18, 12/31/18, 1/3/19, 1/4/19, 1/6/19, 1/9/19, and 1/10/19. Resident #46 did not receive AROM 26 days out of 47. The Restorative Program flowsheet for Resident #46 documented Restorative Aides were not available on 12/1/18, 12/7/18, 12/8/18, 12/14/18, 12/15/18, 1/2/19, and 1/13/19, and documented restorative services were not offered to Resident #41 on 12/4/18, 12/17/18, 1/1/19, 1/5/19, 1/7/19, 1/8/19, 1/11/19, and 1/14/19. On 1/16/19 at 11:05 AM, the RSM stated Resident #46 had behavioral issues which included being accusatory towards staff. The RSM stated one of the identified practices used to keep Resident #46 safe included requiring two staff members to assist when physical contact was required. On 1/16/19 at 2:14 PM, RNA #2 stated Resident #46 had multiple programs and it was difficult to complete these daily. RNA #2 stated Resident #46 required two staff members for all her cares and this included the RNP because physical contact occurred. RNA #2 stated it was difficult to obtain a second person to complete Resident #46's RNP consistently. RNA #2 stated the RNAs were not scheduled to work at the same time and this meant she had to find a CNA to assist her or the RNP would not be completed. On 1/16/19 at 2:45 PM, LPN #2 stated Resident #46 required two staff members to complete her RNP due to behavioral issues and safety concerns. 3. Resident #41 was admitted to the facility on [DATE], with diagnoses including dementia, behavioral disorder, adult failure to thrive, and rheumatoid arthritis. A quarterly MDS assessment, dated 12/3/18, documented Resident #41 was severely cognitively impaired and she required extensive assistance from one to two staff members with all cares. The MDS assessment documented Resident #41 received PROM five days during the look back period of 7 days. The care plan area addressing Resident #41's Restorative Program flowsheet, dated 9/19/18, documented staff were to provide her with gentle PROM to her joints for 15 minutes a day, six to seven days a week. The care plan did not document which joints staff were to provide the PROM to, how to perform the task, or document if they were to spend 15 minutes on each joint or take 15 minutes for all joints. Resident #41's Restorative Program flowsheet, dated 12/1/18 through 1/16/19, documented staff completed PROM for a minimum of 15 minutes on 12/2/18- 12/6/18, 12/918, 12/11/18, 12/12/18, 12/18/18, 12/20/18, 12/23/18, 12/26/18, 12/30/18-1/1/18, 1/3/19-1/6/19, 1/8/19, 1/9/19, 1/12/19, 1/15/19, and 1/16/19. Resident #41 did not receive PROM 20 days out of 47. The Restorative Program flowsheet for Resident #41 documented Restorative Aides were not available on 12/1/18, 12/7/18, 12/8/18, 12/14/18, 12/15/18, 1/2/19, and 1/13/19, and documented restorative services were not offered to Resident #41 on 12/17/18, 12/25/18, 1/7/19, and 1/14/19. On 1/16/19 at 2:04 PM, RNA #2 stated if Resident #41's RNP was completed in the morning she tolerated it better. RNA #2 stated Resident #41's RNP program did not specify what joints to provide the PROM to or for how long. RNA #2 stated LPN #2 knew more details about which joints the program dealt with for Resident #41. On 1/16/19 at 2:45 PM, LPN #2 stated PROM for Resident #41's upper and lower extremities should be completed daily. LPN #2 stated the current directions did not specify which joints to target and she would correct this. 4. Resident #21 was admitted to the facility on [DATE], with multiple diagnoses which included stroke with left hemiplegia (paralysis). A quarterly MDS assessment, dated 10/26/18, documented Resident #21 was cognitively intact, required extensive assistance of one to two staff members for his ADLs and had impairment to one side of his upper and lower extremities. Resident #21's ROM care plan, dated 8/1/17, documented he was to receive passive ROM on his left upper and left lower extremities as he can tolerate and active ROM exercises on his right upper and right lower extremities. Resident #21's Restorative Program flowsheet, dated 12/1/18 through 1/16/19, documented staff completed his PROM on 12/2/18-12/6/18, 12/9/18-12/13/18, 12/16/18, 12/20/18, 12/23/18-12/27/18, 12/30/18, 12/31/18, 1/1/19, 1/3/19, 1/4/19, 1/6/19-1/12/19, 1/10/19, and 1/14/19-1/16/19. The flowsheet documented Resident #21 did not receive PROM on 15 days out of 47. The Restorative Program flowsheet documented Restorative Aides were not available on 12/1/18, 12/7/18, 12/8/18, 12/14/18, 12/15/18, and 1/13/19, and restorative services were not offered on 12/17/18 and 1/5/19. On 1/14/19 at 2:30 PM, Resident #21 said he received PT three times a week for his lower extremities. Resident #21 said he was not receiving PT for his upper left arm. When asked to move his left upper arm, Resident #21 said he could not move his left upper arm. Resident #21 then used his right hand to lift his left upper arm. Resident #21 said he wanted to have PT for his left upper extremity to make it stronger. On 1/16/19 at 12:24 PM, the Therapy Director said Resident #21 had a muscle strengthening program in the past and he plateaued (state of little or no change). Resident #21 was then referred to the RNP. The Therapy Director said if Resident #21 did not receive his restorative therapy consistently as ordered, he will have further decrease on his ROM and possible increase in pain to his left shoulder. On 1/16/19 at 2:20 PM, LPN #2 who was the RNP Supervisor confirmed Resident #21 did not receive his ROM exercises. LPN #2 said the facility needed three RNAs to meet the residents' ROM exercise/needs. LPN #2 said the facility had only one RNA during that time to do all the ROM exercises. LPN #2 said the facility recently hired a new RNA and was still looking for another one. LPN #2 also stated the RNAs were required to document on the back of the Restorative Program flowsheet the reason why ROM exercises were not performed. On 1/17/19, at 1:08 PM, RNA #2 said she was the only RNA in the facility and she was unable to meet the residents' ROM exercises/needs. 5. Resident #18 was admitted to the facility on [DATE], with multiple diagnoses which included dementia. A quarterly MDS assessment, dated 10/19/18, documented Resident #18 was cognitively impaired and he required extensive assistance of two staff members for his activities of daily living. The MDS assessment documented Resident #18 had impairment of his upper extremity on one side and both of his lower extremities. Resident #18's ROM care plan, dated 8/23/18, documented he was to receive passive ROM exercises 6-7 days a week, 15 minutes per day. Resident #18's Restorative Program flowsheet, dated 12/1/18 through 1/16/19, documented he received his passive ROM exercises on 12/2/18-12/4/18, 12/9/18-12/13/18, 12/20/18, 12/23/18-12/27/18, 12/30/18, 12/31/18, 1/1/19, 1/3/19, 1/4/19, 1/6/19-1/12/19, and 1/14/19-1/16/19. The flowsheet documented Resident #18 did not receive his restorative therapy on 15 days out of 47. The Restorative Program flowsheet documented restorative services were unavailable on 12/1/18, 12/7/18, 12/8/18, 12/14/18, 12/15/18, 1/2/19, and 1/13/19, and were not offered on 12/17/18 and 1/5/19. On 1/15/19 at 12:10 PM, Resident #18 was observed sitting in his Broda (tilting wheelchair) chair with his arms folded on his chest. CNA #2 asked Resident #2 to open his arms but Resident #18 just kept his arms on his chest. LPN #5 said she believed Resident #18 had participated in the RNP once a day, 5 days a week. On 1/15/19 at 2:47 PM, Resident #18 was observed in bed with his both upper arms folded on his chest. On 1/15/19 at 3:05 PM and 3:26 PM, Resident #18 was observed in the same position. On 1/16/19 at 2:20 PM, LPN #2 who was the Restorative Nursing Program Supervisor, said the facility needed 3 RNAs to meet the residents' ROM exercises/needs. LPN #2 there was only one RNA during that time to do all the ROM exercises. LPN #2 said the facility just hired a new RNA and was still looking for another one. LPN #2 also stated the RNAs were required to document at the back of the flow sheet the reason why a resident did not perform their ROM exercises. On 1/17/19, at 1:08 PM, RNA #2 said she was the only RNA in the facility and she was unable to meet the residents' ROM exercises/needs. On 1/16/19 at 2:04 PM, RNA #2 stated she was one of two RNAs currently employed by the facility and the facility needed a minimum of three RNAs to ensure all residents received their RNP. RNA #2 stated there were two shifts for the RNP a morning and an evening shift. RNA #2 stated residents should receive their RNP seven days a week and LPN #2, who was the restorative nurse, scheduled the RNAs and assisted in determining what residents required RNP and what their programs entailed. RNA #2 stated it was difficult to complete the current caseload of residents every day and not all residents received their RNP daily. RNA #2 stated there were currently 30 residents on her caseload and some residents had two to three programs each. RNA #2 stated the different programs included AROM, PROM, transfer programs, braces, exercises, and walking programs. RNA #2 stated when she was unable to complete a residents' RNP, she would document RA services unavailable or not offered and document a zero for the time completed. RNA #2 stated sometimes she would see CNAs doing some sort of activity with a resident and she would count that as her restorative and documented CNA on the ADL ROM flowsheet. On 1/16/19 at 2:45 PM, LPN #2 stated currently the facility needed a minimum of three RNAs to complete residents' RNPs. LPN #2 stated the facility was in the process of trying to obtain a third RNA. LPN #2 stated activities aides and CNAs provided an open gym activity where they use balls and balloons with residents and completed other exercise activities a few days a week. LPN #2 stated the RNA should not document what the CNAs and activities aides were providing for exercises. LPN #2 stated if CNAs or activities aides completed exercises they should document what and how long of an exercise they completed for the residents. LPN #2 stated she was unaware the RNAs were documenting CNA when other staff provided some type of activity. On 1/17/19 at 4:00 PM, the DNS stated she was unaware residents' RNP were not completed as scheduled. The DNS stated the facility was in the process of hiring more staff in general. The DNS stated the restorative aides were rarely pulled to work the floor. The DNS stated she was aware the RNP could utilize more staff.