**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility policy, it was determined the facility failed to provide one (1) of fifteen (15) sampled residents with notification regarding bed hold upon transfer out of the facility. Resident #39 did not receive notifications regarding bed hold when transferred to an acute care hospital. The findings include: Review of the facility policy, Bed Hold Policy, dated 11/18/16, revealed the campus will properly inform residents in advance of their option to make bed-hold payments as well as the amount of the facility's charge to hold a bed. Record review of Resident #39 revealed the resident was admitted to the facility on [DATE] at 3:48 PM with diagnoses of Pneumonia, Malnutrition, Dehydration, Acute Kidney Failure, and Dementia. Further review of the resident's record revealed that on 09/20/19 at 11:24 AM the facility transferred the resident to an acute care hospital. Further review of the record revealed no documented evidence that the resident was given bed hold information when transferred to the hospital. Interview on 10/24/19 at 4:11 PM with the Director of Nursing (DON) revealed no bed hold was issued at discharge for Resident #39. The DON stated it was the floor nurse's responsibility to ensure the bed hold policy was given when residents left the facility via ambulance. Per the DON, the nursing staff had failed to issue Resident #39's bed hold notice on 09/20/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined the facility failed to revise an individualized care plan and nurse aide care plan based on the Minimum Data Set (MDS) assessment dated [DATE]. The assessment revealed the resident required extensive assistance of two (2) or more persons to perform bed mobility, transfer, dressing and toileting. However, the care plan did not include that the resident required two (2) or more persons' assistance to perform these tasks. The findings include: A care plan policy was requested of the facility but as of exit on 10/24/19 the policy was not provided. Review of the Resident Assessment Instrument 3.0 User Manual, Version 1.17.1, dated October 2019, revealed the completed MDS assessment must be analyzed and combined with other relevant information to develop an individualized care plan. Observation of Resident #21 on 10/24/19 at 9:51 AM, revealed State Registered Nurse Aide (SRNA) #2 transferred the resident from the bed to a motorized wheelchair using a mechanical lift. The SRNA performed the bed mobility of turning the resident from side to side to place the sling for the lift by herself. Further observation revealed the SRNA transferred the resident, via mechanical lift, from the bed to a motorized wheelchair without the assistance of another staff member. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] and had diagnoses of Acute on Chronic Diastolic Congestive Heart Failure, Acute and Chronic Respiratory Failure with Hypoxia, Morbid Obesity with Alveolar Hypoventilation, Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Neuromuscular Dysfunction of Bladder, Nonrheumatic Aortic Stenosis, Dependence on Supplemental Oxygen, and Chronic Atrial Fibrillation. Review of the Minimum Data Set (MDS) significant change assessment, dated 09/04/19, revealed the resident had a Brief Interview for Mental Status (BIMS) score of nine (9) which indicated the resident had moderate cognitive impairment. Further review of the MDS also revealed the resident required extensive assistance of two (2) or more persons to complete the tasks of bed mobility, transfers, dressing, and toileting. Review of the comprehensive care plan for Resident #21, dated 02/05/19, revealed the resident was to be transferred by the assistance of two (2) with a standing lift. Further review of the care plan revealed the resident required extensive assistance with bed mobility, transfers, and toileting, but without direction regarding the number of persons required per the MDS assessment. Review of the Aide Care Guide, undated, revealed the resident was to be transferred using the standing lift, without the number of persons required. In addition, the Aide Care Guide did not include the number of staff assistance required for bed mobility. Interview with SRNA #2 on 10/24/19 at 10:12 AM, revealed she always transferred Resident #21 by herself. She further stated the aides could find information regarding the amount of assistance and number of persons required by looking at the care guides located at the nurses' station. The SRNA found the care guide for Resident #21 and discovered the guide stated that the resident was to be transferred using the standing lift. The aide then stated they have been using a mechanical lift on him/her since the resident returned from the hospital. The records revealed the resident last returned from the hospital on [DATE]. Interview with SRNA #1 on 10/23/19 at 1:39 PM, revealed when transferring with a mechanical lift that sometimes one (1) person performs and sometimes two (2). SRNA #1 also stated resident requirements for assistance are found on the resident care guides at the nurses' station. Interview with the former Director of Nursing (DON) on 10/23/19 at 6:22 PM, revealed clinical care meetings are held daily, Monday through Friday, and changes and updates to the care plan are made at that time. Interview with the former DON on 10/24/19 at 3:23 PM, revealed she agreed that the MDS assessment, dated 09/04/19, showed Resident #21 to require extensive assistance of two (2) or more persons for the activities of bed mobility, transfers, dressing, and toileting. She also agreed that the comprehensive care plan, dated 02/05/19, did not reveal that the resident required two (2) or more persons for these activities. As well, the aide plan did not accurately reveal the resident's current level of required assistance for transfers, which was now per the use of a mechanical lift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility policy it was determined the facility failed to ensure oxygen therapy was provided as ordered for one (1) of fifteen (15) sampled residents. Resident #21 was observed receiving oxygen via nasal cannual and the oxygen concentrator was set on four and one-half (4.5) liters per minute (LPM) on 10/23/19 and on five (5) LPM on 10/24/19, which was not the ordered flow rate of three (3) LMP. The findings include: Review of the facility policy, Guidelines for the Administration of Oxygen, dated May 2018, revealed the physician's order for the oxygen should be verified and the oxygen setting must be set and adjusted by a licensed nurse. Observation of Resident #21 on 10/23/19 at 9:24 AM, revealed the resident was in bed and oxygen was being delivered via nasal cannula and the oxygen concentrator was set on four and one-half (4.5) LPM. Further observation on 10/23/19, at 5:01 PM, revealed the resident was up in a motorized wheelchair in the dining room and the portable oxygen canister was set at two (2) LPM. Observation of Resident #21 on 10/24/19 at 8:48 AM, revealed the resident was lying in bed and oxygen was being delivered via nasal cannula at five (5) LMP per oxygen concentrator. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] and had diagnoses of Acute on Chronic Diastolic Congestive Heart Failure, Acute and Chronic Respiratory Failure with Hypoxia, Morbid Obesity with Alveolar Hypoventilation, Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Neuromuscular Dysfunction of Bladder, Nonrheumatic Aortic Stenosis, Dependence on Supplemental Oxygen, and Chronic Atrial Fibrillation. Review of the Minimum Data Set (MDS) significant change assessment, dated 09/04/19, revealed the resident had a Brief Interview for Mental Status (BIMS) score of nine (9) which indicated the resident had moderate cognitive impairment. The MDS further revealed the resident required oxygen therapy. Review of the physician order summary, dated 10/24/19, revealed Resident #21 had an order, dated 08/16/19, that stated oxygen was to be provided at three (3) LPM per nasal cannula, continuously. Review of the comprehensive care plan for Resident #21, dated 08/28/19, revealed a risk of potential complications related to respiratory failure and the intervention to administer oxygen as per orders. Review of Resident #21's Aide Care Guide, undated, revealed in the comments section to ensure ear protectors are on while O2 (oxygen) is in use. Interview with Licensed Practical Nurse (LPN) #1 on 10/24/19 at 8:48 AM, revealed that the oxygen concentrator for Resident #21 should be set on three (3) LMP and stated she was not aware the concentrator was set on five (5) LPM. Further interview with the LPN, at 10:32 AM, revealed the previous shift had not reported to her any reason why the resident's oxygen would have been set on five (5) LPM, and at that time she set the concentrator to three (3) LMP as ordered. Interview with the former Director of Nursing (DON) and the DON on 10/24/19 at 5:21 PM, revealed residents receiving oxygen therapy are to have oxygen settings checked every shift to ensure it is being delivered as ordered. Both stated Resident #21's oxygen was not being delivered as ordered by the physician.

Based on observation, interview, and policy review it was determined that the facility failed to ensure that residents were provided meals with no greater than a 14-hour lapse between the evening meal and breakfast without the provision of a substantial nourishing evening snack. Observation on 10/23/19 at 6:30 PM revealed evening meal trays being sent to the floor. Observation on 10/24/19 at 9:30 AM revealed breakfast meal trays being sent to the floor, which is 15 hours between meals. Interview with one (1) unsampled resident and with the family of one (1) sampled resident revealed the residents had received supper on 10/23/19 at about 6:30 PM and received breakfast on 10/24/19 between 8:30 AM and 10:00 AM with no offering of an evening snack. The findings include: Review of facility policy titled Meal Service, effective date 05/31/16, revealed, Meal service will be no more than 16 hours between the evening meal and the breakfast meal if a substantial nourishing snack is provided at bedtime (14 hours if no snack is provided). Further review of the policy revealed, Meals will be served at the following hours: Breakfast Room Service: 7:30 AM and Dinner Room Service at 5:15 PM. Observation on 10/23/19 at 6:30 PM revealed supper trays being delivered to the floor. Observation on 10/24/19 at 9:30 AM revealed breakfast trays being delivered to the floor. Interview on 10/23/19 at 9:38 AM during resident council revealed unsampled Resident #22 stated he/she was never offered nighttime snacks. Interview on 10/24/19 at 9:57 AM with unsampled Resident #1 (end of 300 Hall) revealed he/she ate supper in the dining room on 10/23/19 at about 6:30 PM and had just received his/her breakfast in the room at 9:57 AM. Resident #1 stated he/she had not been offered a bedtime snack. Interview on 10/24/19 at 10:25 AM with the family of sampled Resident #187 (at the end of 100 hallway) revealed the resident had received the supper meal on 10/23/19 at about 6:30 PM and had received breakfast at 8:30 AM on 10/24/19. The family further revealed the family had spent every night with the resident and the resident had never been offered a bedtime snack. Furthermore, the Family Member stated there had been mornings when breakfast was as late as 9:30 AM. Per the family, Resident #187 had been in the facility since 10/05/19. Interview on 10/24/19 at 11:10 AM with Dining Support Service employee revealed the carts go out after the dining room is serviced. He further revealed the staff on the floor have access to the kitchen at all hours to fix snacks for the residents. He stated that snack carts are not sent out for nighttime snacks. He agreed that to go 15 hours without the offer of a meal was too long. He also mentioned there had been some recent turnovers in the staff in the kitchen. Interview on 10/24/19 at 5:12 PM with the former Director of Nursing revealed residents are not usually offered a night meal or snack unless the Registered Dietitian had made recommendations for the resident to have one. She further revealed the kitchen was always available for staff to make snacks for residents. She stated she had not identified a problem.

Based on observation and interview it was determined that the facility failed to ensure the food equipment cart was clean. Observation of the food delivery cart on 10/22/19 revealed the back of the food delivery cart was dirty. The findings include: Interview with a Dining Service Support Employee revealed they did not have policies on cleaning in the kitchen. The Dining Service Support Employee did offer a weekly cleaning checklist for the week of 10/13/19 and the week of 10/20/19. The employee further revealed the food delivery cart would fall under the category of Utility Carts cleaned & Sanitized. Review of the checklist revealed it was checked off as being cleaned the week of 10/13/19 but was not marked off as being cleaned for the week of 10/20/19. Observation of the food delivery cart on 10/22/19 at 12:42 PM revealed the back outside of the cart to be dirty. The cart was observed to have a dried substance that spread down the back of the cart and an object resembling foil stuck to the back of the cart. Interview on 10/23/19 at 3:40 PM with the Dining Service Support Employee revealed that it is the responsibility of the night shift kitchen staff to clean the kitchen and apparently they had missed the back of the cart. He agreed that the food delivery cart was dirty. He further revealed there had been a lot of turnover in the kitchen recently, and the facility had just terminated the night shift person who was responsible for cleaning. Interview on 10/23/19 at 9:00 AM with the former Director of Nursing revealed there was no cleaning policy and procedure for the kitchen. Per the DON, the facility followed manufacturer recommendations related to cleaning in the kithchen. She further revealed that she had seen the back of the food delivery cart and agreed it was dirty and should have been cleaned. Interview on 10/24/19 at 3:48 PM with the Infection Control Nurse revealed she does surveillance in the kitchen about once a week. She furthered revealed that she looks at the fridge, ensures everyone is wearing hair nets, and observes hand hygiene. She further stated that she had not identified any concerns with the kitchen.