**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review it was determined the facility failed to treat one (1) of thirty-nine (39) sampled residents (Resident #28) with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life. Observation on 03/09/2020 revealed State Registered Nurse Aide (SRNA) #5 standing over Resident #28 during the lunch meal feeding him/her lunch in the resident's room. The findings include: Interview with the Director of Nursing (DON) on 03/11/2020 at 11:00 AM revealed the facility did not have a policy in regard to staff feeding residents. Review of the medical record for Resident #28 revealed the resident was readmitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Dysphagia, Dementia with Behavioral Disturbance and Muscle Weakness. Review of the quarterly Minimum Data Set (MDS) assessment, Section C, Cognitive Patterns, dated 01/12/2020, revealed the facility assessed the resident to be severely cognitively impaired and therefore a Brief Interview for Mental Status (BIMS) score could not be obtained. Further review of the MDS, Section G, Functional Status, revealed the resident required extensive assistance of one (1) person for eating. Review of the Comprehensive Plan of Care dated 07/05/2017 for Resident #28 revealed a focus area of Activities of Daily Living with an intervention that the resident was to be fed per staff. Observation of Resident #28 on 03/09/2020 at 1:03 PM revealed the resident lying in bed with the head of bed raised and SRNA #5 standing over the resident at bedside feeding the resident. Further observation revealed a chair in the room next to the resident's bed. Interview with SRNA #5 on 03/11/2020 at 5:01 PM revealed she should not have stood and fed the resident. The SRNA further revealed she was nervous with the surveyor in the room. The SRNA revealed she had been trained during orientation to not stand and feed residents. Interview with the DON on 03/11/2020 at 4:34 PM revealed the SRNA should not have been standing and feeding. The DON further revealed staff are educated during orientation on feeding residents. The DON also revealed she monitors residents being fed properly by making rounds and spot-checking and had not identified any concerns with residents being fed inappropriately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review it was determined the facility failed to complete an accurate assessment for one (1) of thirty-nine (39) sampled residents. Resident #53 had a urinary catheter; however, the facility failed to include the presence of the urinary catheter on the resident's admission Minimum Data Set (MDS). The findings include: Interview on 03/11/2020 at 12:43 PM with the Director of Nursing (DON) revealed the facility did not have a policy related to the accuracy of the MDS but used the Resident Assessment Instrument (RAI) manual. The RAI manual under Steps for Assessment in Section H: Bladder and Bowel reads: 1. Examine the resident to note the presence of any urinary or bowel appliances. Furthermore under Coding Instructions: Check next to each appliance that was used at any time in the past 7 days. Section H, 100 Appliances includes indwelling catheter as an option to be selected if the resident has an indwelling catheter. Review of Resident #53's medical record revealed the facility admitted the resident on 02/03/2020 with diagnoses of Obstructive Uropathy, Arthropathy, Urinary Tract Infection, Anxiety Disorder, Heart Disease, and Major Depressive Disorder. Further review of the medical record revealed the resident was admitted with an indwelling urinary catheter (an appliance inserted from outside the body through the urethra into the bladder to allow emptying of the bladder). Review of Resident #53's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10 indicating the resident had moderate cognitive impairment. Further review of the MDS revealed the resident was not marked on Section H as having an indwelling catheter, and was assessed to always be incontinent of bladder. Review of Resident #53's current Physician Orders revealed an order for Foley catheter care every shift and as needed. Review of Resident #53's care plan, dated 02/10/2020, revealed the resident was care planned with a Focus of: the resident has an indwelling Foley catheter due to diagnosis of obstructive uropathy. Observation on 03/08/2020 at 2:25 PM of Resident #53 revealed the resident was in bed with an indwelling catheter noted with yellow urine with no sediment in the tubing, and a dignity bag was in place. Observation on 03/11/2020 at 10:18 AM of catheter care for Resident #53 revealed no concerns. Interview with State Registered Nursing Assistants (SRNA) #1 and #2 who performed the catheter care revealed that the resident had the catheter ever since they have been here. Interview on 03/11/2020 at 10:47 AM with the MDS Coordinator revealed the resident was admitted to the facility from another facility. Per the MDS Coordinator, the resident was admitted with a Urinary Tract Infection, but she stated she did not remember if the resident had a catheter at that time. Upon reviewing the Indwelling Catheter Evaluation that was performed upon admission the MDS Coordinator agreed the resident must have had the catheter upon admission and that it should have been triggered on the MDS. Interview on 03/11/2020 at 4:17 PM with the Administrator revealed they had identified a concern with the accuracy of the MDS. The Administrator stated staff were making sure daily orders were put into the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review it was determined the facility failed to update the care plan for one (1) of thirty-nine (39) sampled residents (Resident #8). Resident #8's gastrostomy tube (G-Tube) (a tube inserted through the belly that brings nutrition directly to the stomach) was removed on 08/01/2019; however, the facility failed to revise the resident's care plan and remove the use of the G-tube for nutrition. The findings include: Review of a facility policy titled, Baseline Care Plan Assessment/Comprehensive Care Plans, not dated, revealed, As the resident remains in the Nursing Home, additional changes will be made to the comprehensive care plan based on the assessed needs of the resident . Further review of the policy revealed, The Comprehensive Care Plans will be reviewed and updated every quarter at a minimum. The facility may need to review the care plan more often based on changes in the resident's condition and/or newly developed health/psycho-social issues. Record review revealed the facility admitted Resident #8 on 06/13/2018 with diagnoses of Autistic Disorder, Encephalopathy, Aphasia, Major Depressive Disorder, and Epilepsy. Review of Resident #8's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident could not participate in the Brief Interview for Mental Status (BIMS) due to being rarely or seldom understood. Further review of the MDS revealed the resident was not marked as having a G-tube under Section K. Review of Resident #8's Care Plan, dated 01/17/2020, revealed the resident was care planned with a Focus: The resident requires tube feeding (thru G-tube) related to Diagnosis of Dysphagia. Further review of the resident's Care Plan revealed a focus on: I am at nutritional risk as I receive a mechanically altered-nectar thick liquids diet as ordered by my physician. Review of Resident #8's Physician Orders revealed a verbal order dated 08/01/2019 to clean G-tube site with soap and water, pat dry, and apply split dry dressing every shift. The reason for the order was listed as the tube was discontinued and the resident no longer had a G-tube. Observation of Resident #8 on 03/08/2020 at 2:22 PM revealed the resident was in bed lying on the right side with eyes open; attempted interview resulted in the resident not able to answer questions. No tube pump (equipment to administer feeding thru G-tube) was present. Other observations on 03/09/2020 revealed no tube pump present. Interview on 03/11/2020 at 9:08 AM with Licensed Practical Nurse (LPN) #1 revealed the resident did not have a G-tube and stated the resident had not had the tube in a while. Observation at this time revealed a small healed scar where the G-tube had been. She further stated the resident eats well and received the house supplement and drinks well. Interview on 03/11/2020 at 9:25 AM with the MDS Coordinator revealed she reviews the care plans and updates them when the MDS is due and as needed. She further stated that the nursing staff can also update care plans. Per the MDS Coordinator, I actually reviewed [Resident #8's] care plan yesterday, but I missed the G-tube feeding that was left on it. She further stated that the tube feeding should have been taken off of the care plan. Interview on 03/11/2020 at 4:21 PM with the Administrator revealed the care plan should have been updated after the G-tube was removed.

Based on observation, interview, and a review of facility policy it was determined the facility failed to ensure a resident who needs respiratory care was provided such care consistent with professional standards of practice for one (1) of thirty-nine (39) sampled Residents (Resident #82). A continuous positive airway pressure (CPAP) mask assembly for Resident #82 was observed stored uncovered hanging on the bulletin board in the resident's room. The findings include: A review of the facility policy for CPAP use titled, BIPAP/CPAP Home System Use, undated, revealed the policy did not address the storage of the CPAP machine or the CPAP mask/equipment. A review of the medical record for Resident #82 revealed the facility admitted the resident on 11/23/2018 with diagnoses that included Obstructive Sleep Apnea and Shortness of Breath. A review of the plan of care developed for Resident #82 revealed the resident utilized the CPAP machine from 10:00 PM to 6:00 AM for difficulty breathing and obstructive sleep apnea. Observations of Resident #82's CPAP machine on 03/08/2020 at 2:25 PM, 03/09/2020 at 9:23 AM, and 03/11/2020 at 9:55 AM revealed the CPAP mask apparatus was connected to the machine on a shelf by the resident's bed and the mask apparatus was hanging uncovered on a push pin on a bulletin board above the shelf. An interview with Licensed Practical Nurse (LPN) #2 on 03/11/2020 3:14 PM revealed the LPN was responsible for the care of Resident #82. According to the LPN she had placed the CPAP on the resident at 10:00 PM and removed the CPAP from the resident at 6:00 AM. Further interview with LPN #2 revealed she stored the CPAP mask in a plastic bag and was not aware why the CPAP was not stored in a plastic bag and was hanging on the resident's bulletin board uncovered. An interview with the Director of Nursing (DON) on 03/11/2020 at 10:21 AM revealed the facility did not have a policy addressing storage of the CPAP equipment/mask. However, the DON stated nurses were responsible for cleaning, applying, removing, and placing the mask in a plastic bag for storage when the CPAP was not in use. According to the DON, she made daily rounds to ensure resident equipment is stored correctly and had not identified any concerns with the storage of CPAP masks.