Based on observation, interview, record review and a review of facility policies, it was determined the facility failed to provide privacy/dignity during medication administration for one (1) of twenty (20) sampled residents (Resident #9). Staff was observed to administer eye drops medication to Resident #9 while the resident was seated in the day room area with six (6) other residents. The findings include: Review of the facility policy titled, Resident's Rights-Federal Law, dated October 2007, revealed the residents had the right to personal privacy and confidentiality to include medical treatment. Review of the facility policy titled, Medication Administration General Guidelines for the Administration of Medications number 6.2, undated. revealed medications were supposed to be administered at the resident's bedside and if administration would expose the resident's skin, the curtain would be drawn for privacy. Review of Resident #9's medical record revealed the facility admitted the resident on 05/17/2021 with diagnoses including Alzheimer's Disease, and Glaucoma. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 02/10/2022, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) indicating severe cognitive impairment. Review of current Physician's orders, revealed orders for Combigan Solution eye drops (a medication to treat glaucoma) one (1) drop instilled in each eye twice daily. Observation of medication administration for Resident #9, conducted on 04/20/2022 at 8:28 AM, revealed Registered Nurse (RN) #1 administered Combigan Solution eye drops to the resident while he/she was sitting in a chair in the day room in view of six (6) other residents. Interview with RN #1, on 04/21/2022 at 10:12 AM, revealed she was unaware administering the eye drops to Resident #9 when the resident was in the day room with other residents was a dignity/privacy issue for the resident. Interview with the Director of Nursing (DON), on 04/21/2022 at 4:38 PM, revealed she was unaware eye drops were being administered to Resident #9 in the day room which could be a dignity or privacy issue. She stated the eye drops should be administered to residents in the privacy of the resident's room and not in front of other residents. Interview with the Administrator, on 04/21/2022 at 5:19 PM, revealed she monitored the treatment of residents daily and was unaware of staff administering eye drops to Resident #9 in the day room. According to the Administrator, performing treatments in view of others could be a privacy/dignity issue.

Based on observation, interview, record review, facility policy review, and review of the facility investigation, it was determined the facility failed to ensure residents were free from abuse for one (1) of twenty (20) sampled residents (Resident #7). On 04/11/2021, Licensed Practical Nurse (LPN) #6 was overheard by State Registered Nurse Aide (SRNA) #1 and SRNA #3, state she would smack Resident #7 in the face if he/she didn't calm down. Based on validation of the Quality Assurance (QA) Plan, the State Survey Agency determined the deficient practice represented past non-compliance, as it was identified and corrected regarding protecting residents from abuse, prior to initiation of the investigation by the State Survey Agency. The findings include: Review of facility policy, titled, Abuse, last revised 02/13/2019, revealed the facility would prohibit abuse, mistreatment, neglect, misappropriation of resident property and exploitation for all residents. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Verbal Abuse was the use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. The policy further revealed the facility would take appropriate actions to prevent abuse, and the facility would report any allegation of abuse immediately to the charge nurse on duty and the Director of Nursing or Facility Administrator, or to another nurse manager or licensed nurse who would ensure the alleged perpetrator immediately left the facility. Review of Resident #7's medical record revealed the facility admitted the resident on 02/18/2019 with diagnoses which included Alzheimer's Disease, Bradycardia, Major Depressive Disorder, Anxiety Disorder, Cardiac arrhythmia unspecified, Atherosclerotic Heart Disease of native coronary artery without angina pectoris. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 02/03/2022, revealed the facility assessed Resident #7 as having a Brief Interview for Mental Status (BIMS) score of two (2) out of fifteen (15) indicating severe cognitive impairment. Further review of the MDS Assessment, revealed the facility assessed the resident as exhibiting behaviors one to three (1- 3) days a week. including delusions, physical behavioral symptoms, and verbal behavioral symptoms, all of which were directed toward others. Review of the facility Long Term Care Facility-Self Reported Incident Form/Combined Report, revealed an alleged incident of verbal abuse occurred on 04/11/2021 at 1:20 PM. Per the allegation, LPN #6 stated to Resident #7, she would smack {him/her} in the face if {he/she} didn't calm down. The Administrator was informed of the allegation on 04/11/2021 at approximately 2:00 PM. Further review revealed LPN #6 was terminated from the facility on 04/16/2021. Review of the facility Investigation, dated 04/11/2021, signed by the Administrator, revealed an incident of verbal abuse related to Resident #7 allegedly occurred on 04/11/2021 at 1:20 PM, and the incident was reported on 04/11/2021 at approximately 1:45 PM, to LPN #7. Per the allegation, SRNA #1 and SRNA #3 informed LPN #7, they had witnessed LPN #6 tell Resident #7, she would smack him/her in the face if he/she didn't calm down. Additional review revealed an investigation was immediately initiated and resident skin assessments were initiated on 04/11/2021. Further, LPN #6 was suspended on 04/12/2021 from the facility pending investigation. LPN #6 was terminated on 04/16/2021 as the facility substantiated the allegation. Review of Resident #7's Progress note, on 04/12/2021 at 8:25 AM, revealed Resident #7's Responsible Party (RP) and Physician were notified of the incident on 04/12/2021 . Both parties were informed of the investigative process and procedures and contact information was given to both parties for additional questions or concerns. Review of Resident #7's Skin assessment, completed on 04/12/2021, after the incident was reported, revealed no evidence of injury and no other issues or concerns. Observation of Resident #7 on 04/19/2022 at 3:47 PM, revealed the resident was lying in bed fully dressed with call light in reach. No skin injuries were observed. Interview was attempted with the resident; however, he/she was non-interviewable. Review of SRNA #1's written Statement, dated 04/11/2021, revealed Resident #7 was being combative as they were trying to return the resident to his/her room for declamation. LPN #6 came from behind the nurse's station to assist SRNA #1 as SRNA #3 retrieved toileting supplies from the supply room. Resident #7 was attempting to smack LPN #6, when LPN #6 stated, I will smack you in the mouth. Interview with SRNA #1, on 04/21/2022 at 2:16 PM, revealed although the incident took place over a year ago, she remembered the day in question. She stated Resident #7 was agitated and being combative. Per interview, SRNA #1 was attempting to return Resident #7 to his/her room for one on one (1:1) activities and personal care to assist in de-escalating the resident. SRNA #1 stated Resident #7 was swatting at LPN #6 as she was attempting to assist with the resident. Per interview, LPN #6 screamed in the resident's face that she would smack him/her in the mouth. Further interview revealed SRNA #1 and SRNA # 7 then reported the incident to LPN #6 and left written statements under the Administrator's door at the end of their shift. Review of SRNA #3's written Statement dated 04/11/2021, revealed Resident #7 was combative and grabbing at the nurse's cart. SRNA #3 was retrieving items to provide peri-care for Resident #7 from the supply room. As she entered the supply room she heard LPN #6 state, I'll slap you in the mouth. SRNA #3 and SRNA #1 then took Resident #7 to his/her room and provided care. Interview with SRNA #3, on 04/21/2022 at 1:45 PM, revealed on 04/11/2021, SRNA #3 was retrieving supplies from the storage room when she heard Resident #7 state, I am going to slap you, to LPN #6. SRNA #3 stated she then heard LPN #6 state, I'll slap you back. SRNA #3 further stated she did not witness any physical abuse, but the nurse and resident were just threatening to slap one another. Further interview revealed afterwards she (SRNA #3) assisted SRNA #1 to transfer Resident #7 back to his/her room and then immediately informed LPN #7. Review of LPN #6's written Statement, dated 04/12/2021, revealed on 04/11/2021 Resident #7 was verbally and physically aggressive towards staff while also exhibiting exit seeking behaviors. Resident #7 stated, I will smack you. Further review revealed the resident was then returned to his/her room by SRNA #1 and SRNA #3 for redirection and personal care. Interview with LPN #6 could not be completed. Multiple attempts were made to contact LPN #6 on 04/19/22-04/21/2022, via phone and messages were left. Record review revealed LPN #6 was terminated by the facility on 04/16/2021 via telephone with the Administrator and Human Resources present. Interview with LPN #7, on 04/21/2022 at 1:20 PM, revealed she was informed by SRNA #1 and SRNA # 3, that LPN #6 had screamed in Resident #7's face, I'll smack you back. LPN #7 stated she immediately contacted the Administrator who instructed her to escort LPN #6 to the timeclock and out of the building. Interview with the Social Services Director, on 04/21/2022 at 2:40 PM, revealed a full investigation into the incident was completed. She stated during the investigation she was responsible for assisting with interviewing the interviewable residents related to abuse, and no concerns or issues were noted at that time. Interview with Director of Nursing (DON) #5, on 04/21/2022 at 5:10 PM, revealed she was not there the day of the incident; however, she was there the following day. DON #5 stated the investigation was started immediately after the Administrator was made aware of the allegation on 04/11/2021. Further, she could not recall any prior instances of grievances or abuse allegations for LPN #6. She recalled the facility substantiated the allegation involving Resident #7, and LPN #6 was terminated. , Review of the Administrators written Statement, dated 04/12/2021, revealed the incident was reported to her on 04/11/2021 by LPN #7. Immediate action was taken and LPN #6 was escorted out of the building pending investigation findings. She instructed LPN #7 to begin the investigation and to complete skin assessments. Further review revealed staff training and re-education were initiated. Interview with the Administrator, on 04/21/2022 at 5:45 PM, revealed she was informed on 04/11/2021, by LPN #7, of an allegation of abuse involving Resident #7 and LPN #6. Per interview, SRNA #1 and SRNA #3 had informed LPN #7, that LPN #6 used harsh tones and threatened to smack Resident #7 in the mouth. The Administrator stated she instructed LPN #7 to remove LPN #6 from all resident care and escort her to the timeclock and out of the building pending investigation results. She further stated she confirmed with staff that the resident was free of harm and away from potential abuse. Continued interview revealed she instructed staff on 04/11/2021 to begin the investigation and to complete skin assessments on residents who were not interviewable. Further, residents who were interviewable were interviewed, as well as staff were interviewed during the course of the investigation. Additional interview with the Administrator, revealed the investigation was completed on 04/16/2021 and the Kentucky Board of Nursing (KBN) was notified of the allegation and investigative findings. Per interview, the Administrator and Human Resources terminated LPN #6 via telephone on 04/16/2021 for abuse. *** The facility implemented the following actions to correct the deficient practice: 1. Record review revealed LPN #6 was suspended on 04/11/2021, immediately after the incident was reported to the Administrator on 04/11/2021. 2. Interviews with interviewable residents (BIMS of eight {8}) and above were conducted on 04/12/2021 by the Social Services Director (SSD) related to verbal and physical abuse with no concerns identified. 3. Skin assessments were conducted by the licensed nurses on non-interviewable residents (BIMS scores below eight {8}) on 04/11/2021 and 04/12/2021, for signs of abuse with no concerns identified. 4. Interviews with all staff was conducted 04/12/21 through 04/16/2021, by the Administrator and Staff Development Nurse, to determine if anyone had knowledge of abuse in the facility with no concerns identified. 5. Facility wide abuse education and retraining was initiated. Abuse education and post- tests were provided to all staff 04/13/2021- through 04/19/2021, by the Administrator and Staff Development Coordinator. 6. Staff Kindly Audits were conducted on ten percent (10%) of the residents weekly X four (4) weeks, then quarterly with MDS assessment. MDS Kindly Audits to be presented to Quality Assurance Process Improvement (QAPI) on a quarterly basis. 7. A Quality Assurance Process Improvement (QAPI) meeting was held on 04/12/2021 to discuss the incident. Following the Staff Kindly Audits, Quality Assurance Performance Improvement (QAPI) meetings will be held quarterly. 8. A Corporate Compliance Officer provided the Kentucky Board of Nursing a copy of the investigative findings regarding LPN #6 per regulations. **The State Survey Agency validated the corrective action taken by the facility as follows 1. Review of LPN #6's personnel record, revealed she was suspended on 04/11/20201 and terminated via telephone on 04/16/2021 by the Administrator and Human Resources. 2. Review of interview logs revealed all residents were interviewed on 04/12/2021 by the Social Services Director (SSD), about the care they received in the facility, and asked if they had ever been abused with no concerns identified or noted. 3. Review of resident skin assessment sheets, dated 04/11/2021 and 04/12/2021, revealed all non-interviewable residents (residents with a BIMS score of below eight (8) were observed for signs of abuse with no concerns identified or noted. 4. Review of questionnaires revealed all staff were interviewed on 04/12/2021 through 04/16/2021 to determine if the staff had ever witnessed a staff member verbally or physically abusing a resident. Staff were also questioned regarding reporting of abuse. Interviews on 04/21/2022 with SRNA #2 at 1:18 PM; SRNA #3 at 1:45 PM; LPN #4 at 2:00 PM; SRNA #1 at 2:16 PM; SRNA #4 at 2:38 PM; LPN #3 at 3:37 PM; Interim DON at 5:10 PM, and Administrator at 5:45 PM, revealed they were interviewed related to knowledge of the incident that occurred on 04/11/2021 as well as what to do if abuse was seen or suspected. 5. Review of an Abuse education sign in sheet revealed education was provided on 04/12/2021 through 04/19/2021 which reviewed the Abuse Prohibition policy and reporting expectations. Additional review revealed staff completed post- tests related to the education provided by the Administrator and Staff Development Nurse. 6. Review of the Log book, revealed Staff Kindly Audits were conducted on ten percent (10%) of the residents weekly X four (4) weeks, then monthly X two (2) weeks, then quarterly with MDS assessment. 7. Review of QAPI minutes for 04/12/2021, revealed a meeting was held to discuss the allegation of abuse. Per the discussion, going forward QAPI meetings to be held quarterly to discuss MDS Staff Kindly Audit results and recommendations. 8. Review of cover sheet sent to the Kentucky Board of Nursing Investigation on 04/16/2021, revealed full investigation attached with results.

Based on observation, interview, and review of facility policy, it was determined the facility failed to ensure all drugs and biologicals were stored in locked compartments for one (1) of three (3) facility medication carts. Observation on 04/19/2022, revealed the South hall medication cart was observed to be unlocked and unattended. The findings include: Review of the facility Medication Administration General Guidelines for the Administration of Medications policy number 6.2, undated, revealed the Nurse or Certified Medication Aide would ensure the medication cart was locked any time the cart was out of direct line of vision. Observation of the South hall medication cart, on 04/19/2022 at 5:10 PM, revealed the cart was fifteen(15) feet from the nurse's station and was unlocked with no staff present. Further observation revealed Registered Nurse (RN) #1 came to the cart at 5:20 PM and then walked away from the cart, leaving the cart unlocked. Further observation revealed at 5:23 PM, RN #1 returned to the cart and locked the cart. No wondering residents were identified, and no residents were observed in the hallway at the time the cart was unlocked. Interview with Registered Nurse (RN) #1, on 04/21/2022 at 10:12 AM, revealed the nurse forgot to lock the medication cart by mistake. The RN stated the carts were supposed to be locked when they were left unattended to ensure security of the medications. Interview with the Director of Nursing (DON), on 04/21/2022 at 4:38 PM, revealed staff should lock the medication cart if the cart was out of direct line of sight or had to be left unattended. According to the DON, she monitored the medication carts when she was on the floor making rounds to ensure they were locked and had not identified any recent concerns with staff leaving the carts unlocked. Interview with the Administrator, on 04/21/2022 at 5:19 PM, revealed she was not aware RN #1 had not locked the medication cart and had left the cart unattended on the South hall on 04/19/2022. According to the Administrator, the medication carts were to be locked when not in use by staff because unsecured medication carts could be a potential accident hazard for residents and a potential security risk for the medications.

Based on observation, interview, record review and review of facility policy, it was determined the facility failed to have an effective infection control program to prevent the spread of infection for two (2) of twenty (20) sampled residents (Resident #9 and #37). Nursing staff was observed to touch Resident #9 and #37's medications with bare hands prior to administration on 04/21/2022. The findings include: Review of the facility policy, titled, Medication Administration Infection Control Standards of Practice, undated, revealed the facility staff would provide safe medication administration to residents. However, the policy did not address the touching of resident's medications with bare hands. Observation of medication administration for Resident #9, on 04/20/2022 at 8:28 AM, revealed Registered Nurse (RN) #1 prepared Aspirin 81 milligram (mg) tablet (pain reliever, fever reducer), Losartan 50 mg tablet (medication used to treat hypertension), Metoprolol 25 mg tablet (medication to treat hypertension), and Vitamin B 12 500 microgram (mcg) tablet by removing the medications from the medication cards into her bare hand, then placing the medications into a medication cup for administration. RN #1 then proceeded to administer the medications to Resident #9 with applesauce. Observation of medication administration for Resident #37, on 04/20/2022 at 9:13 AM, revealed Licensed Practical Nurse (LPN) #1 prepared Tylenol 650 mg tablet (pain reliever and fever reducer), Atenolol 125 mg tablet (medication to treat hypertension), two (2)Crantabs 250 mg tablets, Eliquis 5 mg tablet (medications to prevent blood clots), Folic Acid 400 mcg tablet, Januvia 25 mg tablet (medication to treat Diabetes Mellitus), and Sertraline 25 mg tablet (antidepressant), by removing the medications from the medication cards into her bare hand, then placing the medications into a medication cup. The nurse then crushed the medications and administered them in applesauce to Resident #37. Interview with RN #1 on 04/21/2022 at 10:12 AM revealed the nurse was unaware she should not touch residents' medications with bare hands after the medications had been removed from packages. However, she stated touching the medications could potentially be an infection control issue. Interview with LPN #1, on 04/21/2022 at 1:29 PM, revealed the nurse was unaware she should not touch the residents' medications with bare hands when removing the medications from the packages. However, she stated she could see how touching the pills with her hands could be an infection control issue. Interview with the Director of Nursing (DON) on 04/21/2022 at 4:38 PM, revealed she was unaware nurses were touching residents' medications with their hands after opening the medication packages. Per interview, she had performed medications audits in the past and had not identified any problems. Further interview revealed touching the medications with bare hands could potentially spread germs to the resident and cause illness/infection. Interview with the Administrator, on 04/21/2022 at 5:19 PM, revealed she relied on the DON to monitor medication administration. Further, nurses were not to touch resident medications with bare hands because it was a potential infection control issue and could cause residents to become sick.

Based on observation, interview, and review of facility policy, it was determined the facility failed to ensure one (1) staff member who was unvaccinated for COVID-19 due to a religious exemption, wore the required mask when providing care to residents. Observation on 04/21/2022, revealed LPN #2, who was unvaccinated for COVID-19, and had a religious exemption was wearing a blue medical mask. The findings include: Review of the facility policy titled, Employee COVID-19 Vaccinations, reviewed/revised 04/2022, revealed the facility would implement additional precautions to mitigate the transmission and spread of COVID-19 for all staff who were not fully vaccinated (i,e., had not completed primary series yet, had a pending or granted religious/medical exemption, or vaccine was delayed for a certain reason, etc.) (CMS term) or up to date (CDC term) for COVID-19. (Facility precautions/mitigation actions to be taken, may include, but not limited to i.e., masking, social distancing, reassignment, weekly testing, use of N95 or higher-level respirator, etc.) Review of the listing of unvaccinated staff revealed Licensed Practical Nurse (LPN) #2 as unvaccinated. Observation on 04/21/2022 at 7:19 AM, of LPN #2, revealed she was wearing a blue medical mask. Interview with LPN #2, on 04/21/2022 at 7:19 AM, revealed she was not vaccinated, but had a religious exemption. She stated she was supposed to be wearing a N95 mask. However, she stated she was unable to wear a N95 mask due to fungus in her blood, although she had not been medically diagnosed. She further stated she told the Director of Nursing (DON)/Infection Control Nurse and the Administrator, and was instructed to make sure she wore a blue mask. Interview with the DON, who was also the Infection Control Nurse, on 04/21/2022 at 4:30 PM, revealed the facility required unvaccinated staff to wear the N95 mask and if staff could not wear the N95 mask, she would question the staff member as to the medical reason. Per interview, she was unaware LPN #2 who was unvaccinated, was not wearing a N95 mask. She stated, according to policy, LPN #2 should not be working if she could not wear the N95 mask. Interview with the Administrator, on 04/21/2022 5:19 PM, revealed it was her expectation for unvaccinated staff to wear the correct mask. She stated LPN #2 did tell her she had been wearing a regular blue medical mask because of a medical reason, but LPN #2 had not provided a medical excuse. Further interview revealed when LPN #2 contacted her on 04/20/2022, stating she would be working on 04/21/2022 and would not be able to wear the N95 mask, she did advise LPN #2 just to wear her blue medical mask instead of the N95. The Administrator stated she thought it would be okay as long as the nurse wore a mask.

**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 ensure a person-centered plan of care related to respiratory therapy was implemented for one (1) of twenty-six (26) sampled residents (Resident #35). Review of the care plan revealed an intervention for Resident #35 to get oxygen as ordered by the physician. Review of the physician orders revealed an order for oxygen at three (3) liters per minute (LPM). Observations of Resident #35 on 02/19/19, 02/20/19, and 02/21/19 revealed Resident #35 did not receive the physician-ordered oxygen flow rate. The findings include: Review of the facility's policy, Care Plan Interdisciplinary, dated 10/01/07 and reviewed on 10/01/18, revealed an individualized care plan would be developed for all residents admitted to the facility. The policy stated an updated and current individualized care plan was necessary to ensure each resident received the nursing care needed to treat identified problems that were specific to each resident. According to the policy, the care plan process would use the usual format: assess, plan, implement, evaluate, and reassess. Further review revealed the care plan was written using information from the Care Area Assessments (CAAs) as a guide to drive the care plan. Further review of the policy revealed an individualized plan would be developed on all residents admitted to the facility. Review of Resident #35's medical record revealed the facility admitted the resident on 01/26/19 with diagnoses of Atrial Fibrillation, Congestive Heart failure, Chronic Obstructive Pulmonary Disease, and Anxiety Disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35's Brief Interview for Mental Status (BIMS) score was thirteen (13), indicating the resident's cognition was intact. Review of Resident #35's physician orders dated 01/28/19, revealed an order for the resident to receive oxygen via nasal cannula at three (3) LPM. Review of the comprehensive plan of care (undated) revealed an intervention to give oxygen therapy as ordered and to monitor pulse oximetry and vital signs. Observation of Resident #35 on 02/19/19 at 4:03 PM, revealed the resident was receiving oxygen at two (2) liters per minute (LPM) via nasal cannula. Further observation on 02/20/19 at 10:45 AM and 11:00 AM, and on 02/21/19 at 8:21 AM, revealed the resident was receiving oxygen at 2.5 LPM via nasal cannula. Review of Resident #35's weekly oxygen saturation readings for 02/19/19 and 02/20/19 revealed the resident's oxygen saturation averaged 96%. Interview with Resident #35 on 02/19/19 at 4:05 PM revealed he/she utilized three (3) liters of oxygen at home. The resident stated he/she had never adjusted the oxygen settings at the facility. Observation and interview with Licensed Practical Nurse (LPN) #2 on 02/21/19 at 9:03 AM revealed the LPN confirmed Resident #35's oxygen was set to 2.5 LPM. Interview with the nurse revealed she was responsible for the resident's care that day and on 02/20/19. Further interview revealed she was responsible for ensuring the resident was receiving oxygen at the physician-ordered flow rate every shift, and stated the flow rate should have been set to three (3) LPM. A telephone interview conducted with LPN #1 on 02/21/19 at 10:39 AM revealed she was the nurse responsible for Resident #35's care on 02/19/19. LPN #1 stated she was not aware the resident's oxygen was set on two (2) LPM on 02/19/19. She stated she checked the resident's oxygen saturation at least once per shift and no concerns were identified. Interview with the Director of Nursing (DON) on 02/21/19 at 4:19 PM, revealed nurses were required to assess each resident's oxygen flow rate and review their plan of care every shift to ensure the resident was receiving the physician-ordered amount of oxygen. Further interview revealed she was not aware that Resident #35 was not receiving oxygen as ordered by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and review of the facility's policy, it was determined the facility failed to ensure one (1) of twenty-six (26) sampled residents (Resident #35) received respiratory care (oxygen therapy) according to the physician's orders and the comprehensive care plan. Resident #35 had physician's orders for oxygen at three (3) liters per minute (LPM) via nasal cannula; however, on 02/19/19, 02/20/19, and 02/21/19 the facility failed to provide Resident #35's oxygen as ordered. The findings include: Review of the facility's oxygen policy titled Oxygen and General Nursing, dated 10/01/07 (with a reviewed date of 10/01/18), revealed only licensed nurses and respiratory therapists were authorized to make changes in residents' oxygen administration and should instruct other staff not to change the oxygen flow rate. Review of Resident #35's medical record revealed he/she was admitted to the facility on [DATE] with diagnoses of Atrial Fibrillation, Acute and Chronic combined systolic (congestive) and diastolic (congestive) heart failure, chronic obstructive pulmonary disease, and anxiety disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35's brief interview for mental status (BIMS) score was thirteen (13) indicating his/her cognition was intact. Review of Resident #35's physician orders dated 01/28/19, revealed an order for the resident to receive oxygen via nasal cannula at three (3) LPM. Observation of Resident #35 on 02/19/19 at 4:03 PM, revealed the resident was receiving oxygen at two (2) LPM via nasal cannula; on 02/20/19 at 10:45 AM and 11:00 AM, the resident was receiving oxygen at 2.5 LPM via nasal cannula, and on 02/21/19 at 8:21 AM, the resident was receiving oxygen at 2.5 LPM via nasal cannula. Review of weekly oxygen saturation readings for 02/19/19 and 02/20/19 revealed the resident's oxygen saturation averaged 96%. Interview with Resident #35 on 02/19/19 at 4:05 PM revealed he/she wore oxygen at home prior to coming to the facility and the liter flow was on three (3) LPM. Further interview with Resident #35 revealed he/she never adjusted the oxygen settings. Observation and interview with Licensed Practical Nurse (LPN) #2 on 02/21/19 at 9:03 AM revealed the oxygen was set on 2.5 LPM. Further interview revealed the nurse was responsible to check Resident #35's oxygen flow regulator to ensure the resident was receiving the physician-ordered flow rate every shift. Continued interview revealed she confirmed the resident should be receiving oxygen at the physician-ordered rate of three (3) LPM. Additional interview revealed she was responsible for Resident #35 on 02/20/19 and 02/21/19. A telephone interview conducted with LPN #1 on 02/21/19 at 10:39 AM revealed she was the nurse responsible for Resident #35 on 02/19/19 and she was not aware the oxygen was on two (2) LPM. Further interview revealed she checked the oxygen saturations at least once per shift. Interview with the Director of Nursing (DON) on 02/21/19 at 4:19 PM, revealed nurses were required to assess each resident's oxygen flow rate every shift to ensure the resident was receiving the physician-ordered amount of oxygen. Further interview revealed she was not aware Resident #35 was not receiving the physician-ordered oxygen flow rate.

Based on observation, interview, and review of the facility policy, it was determined the facility failed to ensure food was palatable related to seasoning of the food. Six (6) residents in the Resident Council Meeting conducted at 9:30 AM on 02/20/19 complained that the food tasted like the facility had opened the can, heated, and served the food. The findings include: Review of the facility policy titled Food Preparation Guidelines, revised 10/01/18, revealed the facility would provide palatable food to include using spices or herbs to season food in accordance with recipes. In addition, the facility would honor resident preferences, as possible, regarding food and drinks. Observation at 11:48 AM on 02/20/19 of a test tray revealed there was no seasoning in the regular and pureed green beans. The Administrator accompanied the surveyor with the palatability test. The Administrator agreed that the green beans (regular and pureed) tasted like the can had been opened, heated, and served. Interview with the Dietary Manager (DM) at 11:53 AM on 02/20/19 revealed the facility did not season the food because of the No Added Salt (NAS) diets. The DM stated she did not realize they could add seasoning to the food during the cooking process for the NAS diets.

Based on observation and interview, it was determined that the facility failed to properly label biologicals stored in one (1) of three (3) medication carts, the North Hall medication cart. A storage type container was observed in the medication cart that contained a white powdery substance. The facility failed to ensure the container was labeled to identify the contents, instructions, and expiration date. The findings include: A policy on medication labeling and storage was requested; however, the facility did not provide a policy. On 12/14/17 at 9:00 AM observation of the North Hall medication cart revealed a plastic container with a lid in the bottom drawer that contained a white powdery substance. The container was not labeled with the contents of the container. Interview with the Licensed Practical Nurse (LPN) revealed that the white substance was thickener. She stated that the container should have been labeled with the contents and dated. On 12/14/17 at 4:55 PM interview with the Director of Nursing revealed that the container should have been labeled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Continued review of the Resident Assessment User Manual, revised October 2016, revealed the 30-day PPS assessment is required by Medicare and it authorizes payment for days thirty-one (31) thru sixty (60) of the Part A Medicare stay for nursing home facilities. Review of Resident #34's medical record revealed the facility admitted the resident on 10/31/17, following a hospitalization with diagnoses of Sepsis, Urinary Tract Infection, Infection/Inflammation related to Indwelling Urinary Catheter, Cerebral Infarction, Bradycardia, Hemiplegia/Hemiparesis, Dysphagia, and Hypertension. Review of Resident #34's MDS assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status score of twelve (12), which indicated the resident was cognitively intact. Review of Resident #34's 30-day Prospective Payment System (PPS) MDS assessment dated [DATE], revealed Section C (cognitive pattern assessment) and Section D (mood assessment) were not completed. Interview with the MDS Coordinator on 12/14/17 at 4:06 PM revealed she provided a weekly schedule of residents who required an MDS assessment to each department and kept a copy of the notification. The MDS Coordinator provided a copy of the schedule for the week of 10/01-10/17 that was sent to facility staff to remind them that resident assessments were due. A review of the schedule revealed that Residents #12 and #20 were on the list for an assessment to be completed during that timeframe. The MDS Coordinator also provided a copy of the MDS schedule for 09/15-22/17, which revealed Resident #38 required an assessment to be completed. Further interview with the MDS Coordinator revealed she keeps copies of all notifications she sends to each department responsible for completing sections on the MDS. Continued interview revealed the MDS Coordinator was off work when Resident #34's 30-day PPS assessment was due (11/28/17) and could not speak to the timeliness of staff notification. Interview with the Social Worker on 12/14/17 at 3:45 PM revealed she was responsible to complete Sections C and D of each resident's MDS. Further interview with the Social Worker revealed she was not aware that the quarterly assessment for Residents #12, #20, and #38 needed to be completed until after the Assessment Reference Date passed. Further interview with the Social Worker revealed she documented that Sections C and D were not assessed but signed the MDS as completed. Interview with the Director of Nursing (DON) on 12/14/17 at 4:17 PM revealed each department was responsible for completing their assigned section of each resident MDS. The DON stated she was responsible for signing MDS assessments when they were completed but did not review them for accuracy. Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Version 3.0 User Manual, it was determined the facility failed to assure the accuracy and completion of Sections C and D of the Minimum Data Set (MDS) assessment for two (2) of twelve (12) sampled residents (Residents #38 and #34) and two unsampled residents (Residents #12 and #20). The findings include: Review of the MDS 3.0 Manual, Chapter 3, Page C-1, dated October 2017, revealed the intent of Section C: Cognitive Patterns was to determine the resident's attention, orientation, and the ability to recall new information. According to the manual, these items were crucial factors in care planning decisions, identifying needed supports, and identifying possible delirium behaviors. The manual stated that the interview items were to be conducted the day before or the day of the Assessment Reference Date (ARD). Review of Section D: Mood revealed the items in this section address mood distress, a serious condition that is underdiagnosed and undertreated in the nursing home and is associated with significant morbidity. It is particularly important to identify signs and symptoms of mood distress among nursing home residents because these signs and symptoms can be treatable. The manual also stated that most residents who are capable of communicating can answer questions about how they feel. Continued review of the MDS 3.0 User Manual revealed a dash value indicates that an item was not assessed. Review of a memo issued by The Centers for Medicare and Medicaid Services (CMS) in June 2011 addressing the use of dashes revealed, Inappropriate use of a dash (-) has implications for the accuracy of quality measures and for communicating resident status at discharge to support coordination and continuity of care. Review of the facility's policy titled Electronic MDS Record, dated 06/08/11, revealed the MDS Coordinator, Social Services, Dietary, and Activities staff would input their information into the electronic Minimum Data Set (MDS) record. 1. Review of the record for Resident #12 revealed the facility admitted the resident on 02/13/17 with diagnoses that included Alzheimer's disease, Parkinson's disease, Chronic Fatigue, Hypertension, history of Peptic Ulcer, Anemia, and Anxiety Disorder. Review of Resident #12's quarterly MDS assessment with an Assessment Reference Date of 10/06/17 revealed that interviews for Section C: Cognitive Patterns and Section D: Mood were not completed and dashes were documented in the item sets. 2. Review of the record for Resident #20 revealed the facility admitted the resident on 02/04/13 with diagnoses that included Alzheimer's disease, Depression, Anxiety Disorder, Type 2 Diabetes, Chronic Atrial Fibrillation, and Parkinson's disease. Review of Resident #20's quarterly MDS assessment with an Assessment Reference Date of 10/06/17 revealed that Section C: Cognitive Patterns - Brief Interview for Mental Status (BIMS) and Section D: Mood interview had not been completed and dashes were documented in the assessment. 3. Review of the record for Resident #38 revealed the facility admitted the resident on 08/09/12 with diagnoses that included Alzheimer's disease, Hypertension, Chronic Obstructive Pulmonary Disease, Osteoporosis, and Type 2 Diabetes. Review of the resident's quarterly MDS assessment with an Assessment Reference Date of 08/18/17 revealed the facility documented dashes in the resident's assessment for Section C: Cognitive Patterns - Brief Interview for Mental Status (BIMS) and Section D: Mood interview and there was no evidence the interviews were completed.

Based on observation, interview, and record review, it was determined the facility failed to post the nurse staffing data daily at the beginning of each shift. Observation on 12/12/17, and review of staffing data that was posted from 06/19/16 through 12/11/17, revealed the facility failed to post the actual hours that licensed and unlicensed nursing staff worked each shift. In addition, the facility failed to maintain twenty-four (24) daily staffing schedules for the previous eighteen (18) months. The findings include: Interview with the Director of Nursing (DON) on 12/14/17 at 4:37 PM revealed the facility did not have a policy that addressed posting of licensed and unlicensed nursing staff at the facility. Observation on 12/12/17 at 11:42 AM revealed the facility posted the number of nursing staff that were present for the day, evening, and night shift on 12/12/17; however, the total number of actual hours worked were not completed for each shift. Review of the eighteen (18) months of staffing posted revealed the nurse staffing data that was posted from 06/19/16 through 12/12/17 did not show the actual hours worked for licensed and unlicensed staff. Staffing schedules were missing for the following dates: 08/02/16, 08/03/16, 08/04/16, 09/03/16, 09/17/16, 10/09/16, 11/22/16, 11/27/16, 12/16/16, 12/17/16, 12/18/16, 12/19/16, 03/10/17, 04/03/17, 04/04/17, 04/11/17, 04/13/17, 04/14/17, 04/26/17, 05/02/17, 05/12/17, 05/24/17, 05/27/17, and 07/31/17. Interview on 12/12/17 at 12:04 PM with the Director of Nursing (DON) revealed it was the night shift nurses' responsibility to post the 24-hour nurse staffing report. The DON stated that it was her responsibility to check the posting of staffing daily for accuracy, but she was not aware that the posting was required to show the actual hours worked. Interview with the Administrator on 12/12/17 at 12:31 PM revealed it was important to post staffing daily so that the visitors and family members could see that the facility was providing adequate staffing to care for the residents in the facility. The Administrator stated that she was not aware that the actual number of hours that staff worked must be posted daily.