Based on interview, record review, and review of the facility instructions for completion of the Center for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) CMS-10055, revealed that the facility did not provide the SNFABN document to one of one resident (Resident (R)52) who remained in the facility after receiving skilled Medicare part A services. This failure could lead a resident or responsible party to not make an informed decision about remaining in the facility after Medicare A services ended. The findings include: Review of the directions for completion of the Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) Form CMS-10055 directed, Medicare requires SNFs to issue the SNFABN to Original Medicare, also called fee-for-service (FFS), beneficiaries prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is: not medically reasonable and necessary; or considered custodial. The SNFABN provides information to the beneficiary so that she/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. SNFs must us the SNFABN when applicable for SNF Prospective Payment services (Medicare Part A). Review of R52's electronic medical record (EMR) revealed the Face Sheet located in the Profile tab indicated the facility originally admitted the resident on 05/09/2024 for therapy. The resident's last covered day (LCD) was 07/31/2024 and she remained in the facility for long-term care (LTC). The facility issued a Notice of Medicare Non-Coverage (NOMNC) on 07/29/2024 that was signed by her representative. She was not issued a SNFABN although she remained in the facility for LTC. R52 had 16 days of Medicare A remaining. Review of the Medicare Part A, PPS (Prospective Payment System) Minimum Data Set (MDS) with an Assessment Review Date (ARD) of 07/31/24, completed at the end her of Medicare Part A services, revealed R52 had a Brief Interview of Mental Status score of 09 out of 15 which indicated R52 had moderately impaired cognition. During an interview with the Business Office Manager (BOM) on 10/24/2024 at 4:06 PM, she stated she was responsible for issuing the liability notices to residents whose Medicare A services were ending. When asked about the CMS-10055 SNFABN she stated, we give those to residents when their Medicare Part B services were ending. When asked if she had ever issued one to a resident who was coming off Medicare A services, her reply was no. She stated was unaware that a CMS-10055 SNFABN was required for Medicare A residents remaining in the building for long-term care. She stated the facility did not have a policy. Per BOM, the facility used the CMS directions to complete and issue the notices. A copy of the directions that she followed was requested. On 10/24/2024 at 4:30 PM, the BOM provided the directions for the CMS-10123 NOMNC however she did not provide a copy of the directions for the CMS-10055 SNFABN form. The Administrator provided two pages that she printed from the CMS website on 10/24/2024 at 5:00 PM and stated, We don't have to complete them until the end of the month because it is not mandatory yet.The surveyor reviewed the pages the Administrator printed and informed the the Administrator the CMS-1055 had been in use for years but CMS had recently revised the form to make it easier to understand and complete. Additionally, the pages printed were from the CMS website were in reference to the revised CMS-1055 and when they new form was to be used. The Administrator did not provide the directions for completion of the current version of the CMS-10055. Interview on 10/25/2024 at 10:00 AM, the Administrator made multiple attempts to stated that the SNFABN was not required if there was no expectation of liability for the resident. She stated the company that owned the facility until 11/01/2024 never went after bad debt and always wrote it off. During an interview on 10/25/2024 at 03:15 PM, the Administrator stated her expectation was that they were going to follow Medicare guidelines.

Based on record review, interviews, and policy review, the facility failed to verbally explain the contents of the binding arbitration agreement for one resident (Resident (R)24) of three residents reviewed for binding arbitration agreements. The findings include: Review of the facility's policy provided by the facility titled, Binding Arbitration Agreement dated 10/01/2022, revealed Policy Explanation and Compliance Guidelines: I. When explaining the arbitration agreement, the facility shall: a. Explicitly inform the resident or his or her representative of his or her right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at, this facility. b. Explain to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands. c. Ensure the resident or his or her representative acknowledges that he or she understands the agreement. Review of R24's quarterly Minimum Data Set (MDS), located in the electronic medical record (EMR) under the MDS tab and with an Assessment Reference Date (ARD) of 08/10/2024, revealed R24 was admitted to the facility with diagnoses of Alzheimer's disease with late onset, depression, unspecified, personal history of transient ischemic attack (TIA), and cerebral infarction. The MDS indicated R24 had a Brief Interview for Mental Status (BIMS) score of 99, indicating severe cognitive impairment. During a telephone interview with R24's family member (F)1 on 10/24/2024 at 9:00 AM, he stated he had signed R24's binding arbitration agreement for the resident. F1 stated he did not recall anyone explaining the contents of the agreement to him. He stated that he wanted R24 to be admitted and that he signed whatever was presented to him. F1 stated he was unsure of what legal rights he was giving up by signing the arbitration agreement. During an interview on 10/23/2024 at 3:45 PM, the Admissions Director (AD) stated during the admission process, his process for obtaining a binding arbitration agreement was to ask the resident or their representative if they knew what the binding arbitration agreement was. If they say no, he goes on to explain that arbitration was when a serious allegation was filed against the facility,and it goes to arbitration. A neutral lawyer would be brought in to listen to both sides, to mediate and to come to a conclusion. The AD stated that he assured the resident that they would still be treated in the facility regardless of whether they signed the arbitration agreement or not. The AD stated he would ask if the resident or their representatives wanted to read through the binding arbitration document first and most of them said, no. The AD stated he never told residents or their representatives that they could take the arbitration to be reviewed by their attorney before signing but gave them a copy of the entire admission packet after they have signed. When asked if he told residents of their right to rescind the arbitration agreement before thirty days, he stated, No. The AD stated he did not know how many days residents had to rescind the arbitration agreement and that no one had ever told him about the resident's right to rescind nor did he inform residents of that right. The AD stated he did not inform residents of the right to a neutral choice of venue. The AD stated he was not aware that residents could not change their minds after thirty days had passed. During an interview with the Administrator on 10/25/2024 at 3:15 PM, she stated it was her expectation that the AD explains the binding arbitration agreement to residents before they sign.

Based on observation, interview, and policy review, the facility failed to ensure infection control practices had been followed by two of six staff (Licensed Practical Nurse (LPN)2 and LPN4) while dispensing medications for two of 11 residents (Resident (R)59 and R39) observed during medication administration. This deficient practices has the potential to contaminate the medications taken by the residents. The findings include: Review of the undated facility policy titled Medication Pass Procedure included, .medications were to have been opened without contamination. Wasted or dropped medication would have been destroyed and documented. During an observation on 10/23/2024 at 3:23 PM, while putting medications into plastic medication cups and filling a small plastic cup with water, LPN4 touched the inside of the medication and plastic cup. LPN4 proceeded to give R59 the medication cup and R 59 dropped a capsule from the cup onto her shirt. LPN4 picked up the medication and gave the capsule to R59 with her bare hands. During an observation and interview on 10/24/2024 at 3:41 PM, LPN2 stated that she used her fingernail to open the foil covering on the back of the blister pack before she pushed the medication out of the blister pack. LPN2 was observed to touch R39's blister packs with her fingernail and open the foil on the back of the pack for seven medications. During an interview on 10/25/2024 at 9:31 AM, LPN2 denied she had used her fingernail to open the foil covering before she pushed the medication out of the blister pack. During an interview on 10/25/2024 at 9:28 AM, LPN4 confirmed that she had touched the insides of the medication and water cups. Per LPN4, she knew she should not have touched the cups in that manner. LPN4 stated she should have used a glove or disposed of R59's capsule medication when it fell on R59's shirt. She stated she could have also asked the resident if she would have wanted to pick the pill up herself. During an interview on 10/25/2024 at 11:38 AM, Staff Development Nurse confirmed LPN2 and LPN4 had both failed to ensure infection practices during the medication passes. Staff Development stated each nurse had competency observations as part of their orientation and on an annual basis. During an interview on 10/25/2024 at 2:42 PM, the Director of Nursing (DON) revealed she was aware of the incidents by the nurses. The DON stated both LPN's breached infection control practices while passing medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and facility policy review, the facility failed to properly store medications. Specifically, there were several loose tablets in three of six medication carts (Peach unit, Cherry unit and Maple unit). This failure increased the risk for drug diversion from three of six medication carts. The findings include: Review of the undated facility policy titled, Review of Unused Drugs revealed, All unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations (refer to any state-specific requirements). Policy Explanation and Compliance Guidelines: 1. Drugs will be destroyed in a manner that renders the drugs unfit for human consumption and disposed of in compliance with all current and applicable state and federal requirements . During interview on [DATE] at 2:42 PM, with Licensed Practical Nurse (LPN)2 and observation of the Peach Unit medication cart, revealed when the drawers of the cart were opened there were two loose tablets (one round pink tablet and one round white tablet) in the first large drawer, three loose tablets (one pink round tablet, one round white tablet, and one green tablet) in the second large drawer, and three and a half tablets (partial white tablet, one round brown tablet, one oval pink tablet, and one round white tablet) in the third large drawer. LPN2 stated that when a nurse finds loose pills in the medication cart, they are to put them in the sharps container, otherwise the night nurse cleans out the carts on a routine basis and throws away any loose pills. LPN2 stated that she had not seen the loose tablets in the cart, and she did not know who they belonged to. During interview on [DATE] at 3:02 PM, with LPN3 and observation of the Cherry Unit medication cart, revealed when the drawers of the cart were opened there was one loose tablet (one round white tablet) in the first large drawer, and two loose tablets (one round white tablet and one oval tan tablet) in the second large drawer. LPN2 stated that whoever notices loose pills in the cart was responsible for discarding them in the sharps container. LPN2 stated that she had not seen the loose tablets in the cart, and she did not know who they belonged to. During interview on [DATE] at 03:29 PM, with LPN1 and observation of the Maple Unit medication cart, revealed when the drawers of the cart were opened there was one loose tablet (one round yellow tablet) in the first large drawer. LPN1 stated that she had not noticed the loose tablet, but the facility protocol was for any nurse finding loose pills should discard of them in the sharps container. Otherwise, the Medical Records nurse (MR) does cart audits once a week and discards any loose pills. During an interview on [DATE] at 2:28 PM, the Director of Nurses (DON) stated that the MR nurse does cart audits on Monday or Tuesday every week. The DON stated that her expectation was for any loose pills to be disposed of in the sharps container. Any nurse may dispose of loose pills in the sharps box, and they don't record this information. The facility has a new pharmacy consultant group, and they haven't done cart audits. Additionally, the DON did not think the facility had a policy that directly addressed medication storage. During an interview on [DATE] at 2:43 PM, the MR nurse confirmed that she performed cart audits on Mondays, but the last audit was on Sunday ([DATE]). She stated sometimes she finds loose pills, and sometimes she doesn't. Per the MR nurse, any nurse may dispose of loose pills in the sharps container when they find them. During an interview on [DATE] at 3:30 PM, the Administrator stated that she was aware that three of the six medication carts were observed having loose pills on [DATE]. She stated her expectation was for the MR nurse to do an audit at the beginning of the week to ensure the carts were clean and loose pills were disposed of. She felt that she had practical expectations and that from time-to-time pills were going to fall out of the blister packs. The Administrator stated when nurses see loose pills, the expectation was for them to destroy the medications, and any loose narcotic medications were to be given to the DON for destruction.

Based on observation, interview, and policy review, the facility failed to provide food storage in a safe and consistent manner. Specifically, food items were observed open and unlabeled/ undated as to when the package/bottle/bags/boxes was opened. This had the potential to affect 78 of 79 residents who consumed food from the kitchen. The findings include: Review of undated policy provided by the facility titled, Guidelines for Storage subtitle Date Your Products with Use by Dates revealed use-by date for flour and syrup was one year, and two years for vinegar. The policy further revealed the use by date for frozen potatoes was eight months. During an observation and initial kitchen walk through with the Dietary Manager (DM) on 10/22/2024 beginning at 9:48 AM, the following was observed: 1. In the general kitchen area - four bags of flour were in an uncovered bin. The bags of flour were unsealed and unlabeled with the open date and expiration dates. At the time of this observation, the DM stated she was waiting on a replacement lid for the flour bin. The DM also stated she was unsure of how long the flour was good for before it had to be discarded. 2. In the general kitchen area there was an open, unlabeled bottle of Reliance brand pancake and waffle syrup. At the time of the observation, the DM stated the bottle did not belong to the kitchen and had been left there by another department. DM acknowledged the bottle was the responsibility of the kitchen staff. 3. In the dry product storage room, there were three open, unlabeled one-gallon bottles of white vinegar. At the time of the observation, the DM stated the vinegar was not used for patient food, but to clean the steamer. The DM acknowledged that since the vinegar was stored in the in the resident food area, it could be used in resident's food. 4. In the dry food storage area, there was a toolkit box containing cake decorating items and flavors. All items in the kit were undated and unlabeled. At the time of the observation, the DM stated she had no idea what the box was and what it was doing in the resident food storage area. 5. In the walk-in freezer, there was one open, unlabeled bag of cookie dough; two open, unlabeled bags of garlic bread; and one open bag of unlabeled hash browns. At the time of the observation, the DM acknowledged the food items should have been labeled with the open dates and should have been stored in their original boxes. During an interview with the Administrator on 10/25/2024 at 3:15 PM, she stated it was her expectation that all open food items should be labeled with the date opened and with an expiration date.

Based on observations, interviews and document review, the facility failed to ensure the call light systems annunciator was operating at two of two nurses' stations (Transition and Orchard). This deficient practice could result in residents being unable to obtain assistance with their activities of daily living. The findings include: During an observation on 10/22/2024 at 4:59 PM at the Transition nurse's station, the call light system did not alarm at the nurses' station. Interview at that time with Licensed Practical Nurse (LPN) 1 and the Assistant Director of Nursing (ADON) revealed the annunciation system had been damaged during a storm, which had occurred in the spring. Both stated the lights above the doors still worked so staff could watch when a resident put on their call light requesting assistance. During an observation on 10/23/2024 at 4:00 PM at the Orchard nurse's station, the call light system did not alarm at the nurses' station when activated. Observation on the Oak hallway of the Transition unit on 10/22/2024 at 5:30 PM revealed a light was on above R59's door indicating the resident's call light had been activated, R59's call light appeared outside of her room; however, did not ring or light the annunciation system at the nurses station. During an interview on 10/23/2024 at 4:12 PM with Certified Nursing Assistants(CNA)1, CNA3, and LPN5, they revealed the residents alert staff when they required assistance by activating their call lights. The light above the door would light up but did not ring at the nurses' stations. Usually someone is down the hall watching and could respond to the light. The residents who were able to understand had been given small hand bells to use to also alert staff if they required assistance. During an interview on 10/25/2024 at 9:53 AM, CNA2 and Certified Medication Technician (CMT) 1 stated that they have been doing 30-minute rounds on each hall to ensure the residents needs had been met. Both stated the residents who had a hand bell were able to understand how to use it. Review of the facility's Call Light Audits from October 2023 through September 2024 revealed the audits were conducted by various department supervisors. One resident room was observed per day. There were no documented times for what time of the day the audit had been completed. During an interview on 10/25/2024 at 2:42 PM, the Director of Nursing (DON) confirmed the Call Light Audits were only being conducted one day a week in one room each day. The DON stated that the Call Light Audits did not cover all different times of the day and the weekends. During an interview on 10/25/2024 at 2:50 PM, the Administrator revealed the call light annunciators had been damaged by a storm in July 2024. Per the Administrator, the current owner was aware of the damage but had not fixed the call light system. The Administrator stated the facility did not have a policy regarding call lights.

Based on observations and interviews, the facility failed to ensure two of two (Transition and Orchard) living room couches used by residents were maintained in a safe manner. The unrepaired couches could be a fall risk and possible risk for physical injury. This deficient practice has the potential to affect all 79 residents and their visitors in the facility. The findings include: During an observation on 10/23/2024 at 12:30 PM the Transition wing living room had a half-circle couch that had recliners at each end. The recliner on the right side was in the reclined position. A dining chair was positioned behind the back of the recliner and was holding the back in a more upright position. When the chair was removed, the recliner back would not stay upright. During an interview on 10/24/2024, Licensed Practical Nurse (LPN) 1 and the Assistant Director of Nursing (ADON) stated that the couch had only been broken for a week. They were not sure if the maintenance department had been notified. During an observation on 10/25/2024 at 9:34 AM, the Orchard living room had a half-circle couch. There was a two-cup holder on the left-hand side of the couch. The metal liners for those cup holders were missing. One of the two cup holders had exposed wood that was rough to the touch and could cause injury to a residents' hands and/or fingers. During an interview on 10/25/2024 at 9:34 AM, the Activity Director thought the couch in the Transition wing had broken about a week ago. The AD stated that a request for items to be fixed would be entered in the TELS (Building Management System) and then maintenance would fix the item. During an interview on 10/25/2024 at 9:54 AM, the Maintenance Director revealed he had not been notified of the condition of the couches. He reviewed the TELS system and did not see where the two couches had been reported. He stated the Transition living room couch recliner was broken. Per the Maintenance Director, he had not been notified of the metal liners missing from the Orchard couch. During an interview on 10/25/2024 at 2:42 PM, the Director of Nursing (DON) and the Administrator stated that the Transition living room couch had been broken for about a week. Both stated they were unaware of the missing metal liners for the Orchard living room couch.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Manual, it was determined the facility failed to ensure a quarterly Minimum Data Set (MDS) assessment was completed no less than every three (3) months for one (1) of eighteen (18) sampled residents (Resident #5). Review of Resident #5's medical record revealed the facility completed the resident's Quarterly MDS assessment on 01/14/19; however, the facility failed to open a quarterly assessment until 06/25/19 (date of the survey), approximately five (5) months later. The findings include: Interview with the MDS Coordinator on 06/27/19 at 1:30 PM, revealed the facility did not have a policy related to completing MDS assessments, but the facility followed the Resident Assessment Instrument (RAI) guidelines. Review of the RAI 3.0 User's Manual revealed a quarterly assessment must be completed at least every ninety-two (92) days following the previous OBRA (Omnibus Budget Reconciliation Act) assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. Review of Resident #5's medical record revealed the facility admitted the resident on 10/31/18 with diagnoses including Unspecified dementia without behavioral disturbances, Recurrent depressive disorder, muscle weakness, Atherosclerotic heart disease, Essential hypertension, chronic kidney disease stage III, and history of falling. Continued Review of Resident #5's medical record revealed the facility completed an admission MDS assessment dated [DATE]. Further review of the medical record revealed the next assessment the facility completed of Resident #5 was a Quarterly MDS assessment on 01/14/19. There was no documented evidence that the facility completed another assessment for the resident within 92 days of the 01/14/19 assessment. Interview with the MDS Coordinator, on 06/27/19 at 1:30 PM, revealed she had been working as the MDS Coordinator since 05/03/19 and had not received training on MDS for over ten (10) years. Additionally, she was responsible for completing the MDS assessments. Per interview, she used the RAI Manual Guidelines to know when an assessment was due to be completed. Further, she did not know why the Quarterly assessment was missed for Resident #5. Interview with the Director of Nursing (DON), on 06/27/19 at 4:06 PM, revealed the MDS Coordinator was responsible for completing resident MDS assessments. Per interview, she was unaware that the assessment for Resident #5 was not completed after the 01/14/19 Assessments and before the 06/25/19 Assessment. Additionally, the RAI Manual Guidelines was used to know timeliness of assessments. Continued interview revealed the facility had no audit process in place until June to ensure MDS Assessment were completed per RAI Guidelines. Further, Resident #5's Quarterly Assessment should have been completed per the RAI Guidelines. Interview with the Administrator, on 06/28/19 at 10:28 AM revealed she expected the RAI Manual to be followed related to completing MDS Assessments, for timeliness and accuracy of resident assessments.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined the facility failed to submit the Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) within the required timeframe for two (2) of eighteen (18) sampled residents (Residents #3 and #5) The findings include: Interview with the MDS Coordinator, on 06/27/19 at 1:30 PM, revealed the facility did not have a policy related to completing MDS assessments, but the facility followed the RAI guidelines. Review of the RAI 3.0 User's Manual, Version 1.16, dated October 2018, Chapter 5 Submission and Correction of MDS Assessments, revealed comprehensive assessments must be transmitted electronically within fourteen (14) days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within fourteen (14) days of the MDS Completion Date (Z0500B + 14 days). Entry and Death in Facility tracking records, information must be transmitted within fourteen (14) days of the Event Date (A1600 + 14 days for Entry records and A2000 + 14 days for Death in Facility records). Review of the CMS Submission Report, MDS 3.0 NH Final Validation Report, dated 06/21/19, revealed five (05) of thirteen (13) MDS records were transmitted late. The facility received warning error message -3749c, care plan completed late, V0200C2 (CAAA care plan signature date) is more than seven (7) day after V0200B2 (CAA process signature date) for Resident #3 and #5. Interview with MDS Coordinator, on 06/27/19 at 1:30 PM, revealed she had been working as MDS at this facility since 05/13/19 and had not received training on MDS for over ten (10) years. Per interview, she used the RAI Manual 3.0 Guidelines to know when to complete and submit MDS Assessments. However, continued interview revealed since working as MDS at the facility she had never submitted MDS assessments. Further, the assessments should have been closed, completed and submitted per the RAI manual. Interview with Director of Nursing, (DON), on 06/27/19 at 4:06 PM, revealed the RAI Guidelines was used to know the timeliness and completion of assessments, and submission timeframes. Per interview, she was unaware that the assessments above were completed or submitted late; however, the Assessments should be completed per the RA I guidelines to ensure accuracy. Continued interview revealed the facility had no audit process in place until June to ensure MDS Assessment were completed per RAI Guidelines. Interview with the Administrator, on 06/28/19 at 10:28 AM, revealed she expected the RAI Manual to be followed related to completing and submitting MDS Assessments, for timeliness and accuracy of resident assessments

The facility failed to ensure each resident's assessment was coordinated by and certified as complete by a registered nurse, to the accuracy of the portion of the assessment he or she completed for two (2) ResidentS (Residents #4 and #55). The findings INCLUDE: Review of the facility policy titled Accurate MDS Assessment, implemented date 03/10/19, revealed the facility would ensure all participates in the assessment process have the requisite knowledge to complete an accurate MDS. Further, a Registered Nurse (RN) would conduct or coordinate each assessment with the appropriate participation of health professions and was responsible for certifying that the assessment was completed. Review of CMS's RAI Version 3.0 Manual, chapter 5: Submission and Correction of the MDS Assessment revealed for an admission assessment the MDS Completion date (Z0500B) must be no lo later than thirteen (13) days after the Entry Date (A1600). Further, all non-admission OBRA and PPS assessments and other comprehensive MDS assessments, the MDS Completion date (Z0500B) must be no later than fourteen (14) day after the the Assessment Reference Date (A2300). 1. Review of the CMS Submission Report, MDS 3.0 NH Final Validation Report, dated 06/21/19 revealed a warning error message -3749a, Annual Assessment completed late, Z0500B was more than fourteen (14) day after A2300 (Assessment reference date) for Resident #55. 2. Review of the CMS Submission Report, MDS 3.0 NH Final Validation Report, dated 06/27/19, revealed a warning error message -3810d, record submitted late, more than fourteen (14) days after Z0500B on this new (A0050 equal 1) Quarterly Assessment, for Resident #4. Interview with MDS Coordinator, on 06/27/19 at 1:30 PM, revealed she had been working as MDS at this facility since 05/13/19 and had not received training on MDS for over ten (10) years. Per interview, she used the RAI Manual 3.0 Guidelines to know when to complete and MDS Assessments. Further, the assessments should have been certified/completed by a RN after completion of the Assessment. Interview with Director of Nursing (DON), on 06/27/19 at 4:06 PM revealed the MDS Coordinator, RN used the RAI Guidelines to know the timeliness and completion of assessments. Per interview, she was unaware that the assessments above were completed late; however, the Assessments should be completed per the RA I guidelines to ensure accuracy. Continued interview revealed the facility had no audit process in place until June to ensure MDS Assessments were completed per RAI Guidelines. Interview with the Administrator, on 06/28/19 at 10:28 AM revealed she expected the RAI Manual to be followed related to certifying and completing MDS Assessments, timely and accurately of resident assessments

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility Policy, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs for one (1) of eighteen (18) sampled residents (Resident #77). Resident #77 had a urinary catheter; however, review of the Comprehensive Care Plan revealed no documented evidence of a plan of care for the urinary catheter. Review of Resident #77's physician's orders revealed a Physician's Order, dated 6/7/19, to start bladder retraining; however, there was no documented evidence the bladder retraining occurred and no documented evidence of a plan of care for the bladder retraining. The findings include: Review of the facility's Policy Care Plan Revisions Upon Status Change, implemented 03/01/19, revealed the purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Per the policy, the comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. Continued review revealed upon identification of a change in status, the nurse would notify the MDS coordinator, the physician, and the resident representative, if applicable. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. The team meeting discussion will be documented in the nursing progress notes. The care plan will be updated with the new or modified interventions. Staff involved in the care of the resident will report resident response to new or modified interventions. Further review revealed the Care Plan would be modified as needed by the MDS Coordinator or other designated staff member. Additional review revealed the Unit Manager or other designated staff member would communicate care plan interventions to all staff involved in the resident's care. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs. The MDS Coordinator will determine whether a Significant Change in Status Assessment is warranted and if so, the assessment will be completed according to established procedures. Record review revealed the facility admitted Resident #77 to the facility on [DATE]. Resident #77 had diagnoses, which included Dementia, Coronary Artery Disease, and Clostridium Difficile. Continued review of the record revealed the facility assessed Resident #77 per the most recent MDS assessment, and annual assessment, dated 04/16/19, as having a Brief Interview Mental Status (BIMS) score of thirteen (13) out of fifteen (15), the resident was assessed as always incontinent of urine and bowel, and was not assessed as having a urinary catheter at the time of the assessment. Record review revealed a Comprehensive Care Plan for Resident #77 with a problem onset date 04/19/19 that the resident has bowel and bladder incontinence, with a goal that the resident will not experience impaired skin integrity due to incontinence and the resident will remain free of urinary tract infection for ninety (90) days with a target date documented 07/18/19. Continued review revealed approaches, which included to provide frequent skin care, keep the resident clean and dry, and check and change the resident every two (2) to three (3) hours or per individual program. There was no documented evidence of a plan of care to address the resident's use of a urinary catheter and no documented evidence the plan of care addressed bladder retraining. Review of the Physician's Orders for Resident #77 revealed an order, dated 05/13/19, for a Foley urinary catheter to bedside drain, size eighteen (18) French, balloon ten cc (10 cubic centimeter) with the diagnosis for the urinary catheter as urinary retention. Continued review of the Physician's Orders revealed a Telephone Order, dated 06/07/19, for the following: start bladder retraining. Continued review of the order revealed to Clamp the F/C (Foley catheter) for two (2) hours then unclamp for one (1) hour for twenty-four (24) hours; then on day two (2), clamp the catheter for four (4) hours and unclamp for one (1) hour for twenty-four (24) hours; then day three (3), to clamp the catheter for eight (8) hours and unclamp for one (1) hour, then to discontinue the urinary catheter. However, review of the clinical record for Resident #77 revealed no documented evidence the Physician orders, dated 06/07/19, to start bladder retraining were implemented. Observation of Resident #77, on 06/26/19 at 9:50 AM and 06/27/19 at 10:35 AM, revealed the resident was observed with a urinary catheter bag to bedside drainage, with yellow urine observed in the tubing. Interview with the Director of Nursing (DON), on 06/27/19 at 5:50 PM, revealed she reviewed Resident #77's record and stated she cannot find anything in the record as to whether the physician orders, dated 06/07/19, for bladder retraining and discontinuing the urinary catheter was done or not done; but stated the resident obviously still has the catheter. Continued interview with the DON revealed she reviewed Resident #77's plan of care and indicated there was nothing in the care plan regarding the bladder retraining or for the urinary catheter. Interview with Licensed Practical Nurse (LPN) #7, on 06/28/19 at 10:58 AM, revealed she was the nurse who documented the Telephone Order, dated 06/07/19, to start bladder retraining for Resident #77. LPN #7 further stated the facility was going through transition with the computer system and she indicated she could not get on the electronic record for the Treatment Administration Record (TAR) so she passed the order along to the next nurse. LPN #7 stated she should have followed up on this and stated she did not. LPN #7 stated she only works on Fridays, Saturdays, and Sundays and when she returned to work, Resident #77 had moved from one unit to another unit when she came back and the order for bladder retraining got lost in this time. LPN #7 stated her DON has educated her on this and said what she should have done was to transfer the order to the Medication Administration Record (MAR), since she was unable to get in to the TAR. LPN #7 further stated she does not think the bladder retraining for Resident #77 occurred. Continued interview with LPN #7 revealed potential outcomes for continued urinary catheter use could be UTI (Urinary Tract Infection). In addition, LPN #7 stated she thought they update Care Plans from what she understood but she was not familiar with that, and stated she was supposed to get some training on that. LPN #7 stated she did not update anything with Resident #77's care plan because they are on the computer. LPN #7 exited the interview but returned a couple minutes later and reported there is a green binder on the unit with each resident's Care Plan and staff should go there and update the Care Plan and also put updates on the Certified Nurse Aide (CNA) sheet so they would know. LPN #7 stated none of this was done for Resident #77 for the bladder retraining orders. Interview with State Registered Nurse Aide (SRNA) #4, on 06/28/19 at 9:46 AM, revealed she knew what care to provide residents by referring to her CNA guide. In reviewing Resident #77, the CNA guide documented Resident #77 was incontinent of bowel and bladder, large briefs, and there was nothing documented regarding the resident having a catheter. SRNA #4 did say the resident has a catheter and she provided catheter care for the resident when she goes into the room to rotate him every two (2) to three (3) hours. Interview with the MDS Coordinator, on 06/28/19 at 10:35 AM, revealed she took the role as MDS Coordinator on 06/23/19 and the prior MDS Coordinator was no longer employed at the facility. Continued interview revealed the MDS Coordinator explained the process. She indicated a new admission gets a baseline Care Plan and the nurse starts the baseline care plan and then it was reviewed the following day during the IDT (Interdisciplinary Team) meeting and updated. The MDS Coordinator stated after the initial MDS admission assessment the comprehensive care plan was developed, with CAA's, and it would address any diagnoses issues. The MDS Coordinator indicated other disciplines such as social services and the dietitian complete their parts. Continued interview revealed the nurses on the floor would often address new issues and place interventions on the Care Plan. The MDS Coordinator further stated the IDT reviews orders in the clinical meeting every morning. She stated she looked at Resident #77's care plan when it was brought to her attention, and she did not find anything addressing urinary catheter care in the resident's care plan. She indicated she would have to find out about the Nurse Aide sheets to see what documentation was on the document. Continued interview with the MDS Coordinator revealed she did not know anything about the bladder retraining order for Resident #77; however, she stated they take the yellow copy of orders to the morning meeting and usually a copy of the orders was provided to MDS coordinator to review. Additional interview with the MDS Coordinator revealed there should have been a plan of care to address the urinary catheter and a care plan regarding the bladder retraining, for Resident #77, and the reason was to ensure the resident did not have complications from the urinary catheter or infections. Interview with the DON, on 06/28/19 at 11:33 AM, revealed she did not find any additional information regarding Resident #77's bladder retraining in the medical record. Further interview with the DON revealed reasons to do the bladder retraining were to remove the catheter and increase independence. Per interview, possible complications for having a urinary catheter if it was not necessary could be a risk of infection. The DON revealed prior to 06/27/19, there was no care plan to address the catheter for Resident #77, and she would expect the care plan to include catheter care and stated the bladder retraining should have been on the care plan as well for Resident #77. The DON stated the facility process was with new orders such as an order for a urinary catheter or bladder retraining, the information would go on the resident's care plan, CNA care guide, and would be documented on the TAR as a treatment. The DON stated it was her expectation that staff follow this process and the facility policies and procedures. Interview with the Administrator, on 06/28/19 at 11:55 AM, revealed there was no evidence the physician's orders, dated 06/07/19, for bladder retraining and discontinuation of the urinary catheter for Resident #77 were implemented. Further interview with the Administrator revealed it was her expectation that facility staff would follow physician's orders and update the resident's plan of care accordingly. She stated Resident #77 should have had a care plan to address the urinary catheter. Per interview, possible outcome with continuing the urinary catheter use was a risk for infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility's policy, it was determined the facility failed to revise the Comprehensive Care Plan for one (1) of eighteen (18) sampled residents (Resident #47). Resident #47 had a skin tear to the right upper arm and review of Resident #47's Comprehensive Plan of Care revealed no documented evidence the Care Plan was revised to include the skin tear to the right upper arm. The findings include: Review of the facility policy Care Plan Revisions Upon Status Change, date implemented 03/01/19, revealed the purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Per the policy, the comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. Continued review of the Care Plan Revisions Upon Status Change, revealed upon identification of a change in status, the nurse will notify the MDS coordinator, the physician, and the resident representative, if applicable. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. The team meeting discussion will be documented in the nursing progress notes. The care plan will be updated with the new or modified interventions. Staff involved in the care of the resident will report resident response to new or modified interventions. Care Plan will be modified as needed by the MDS Coordinator or other designated staff member. Continued review of the policy Care Plan Revisions Upon Status Change, revealed the Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in then resident's care. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs. The MDS Coordinator will determine whether a Significant change in status Assessment is warranted and if so, the assessment will be completed according to established procedures. Review of the facility policy titled Green Meadows Physician's Orders, date implemented 03/01/19, revealed verbal orders should be received only by licensed nurses, or pharmacists, and confirmed in writing by the physician, on the next visit to the facility. Continued review of the policy revealed the nurse should document an order by telephone or in person on the physician's order sheet, transmit the appropriate copy to the pharmacy for dispensing, and place the signed copy on the designated page in the resident's medical record. Continued review of the Green Meadows Physician's Orders policy revealed Documentation of Medication Orders, which noted each medication order should be documented with the date, time, and signature of the person receiving the order. The order should be recorded on the physician order sheet, and the Medication Administration Record (MAR). Clarify the order. Enter the order on the medication order and receipt record. Call or fax the medication order to the provider pharmacy. Transcribe newly prescribed medications on the MAR or treatment record. Notify the resident's sponsor/family of new medication order. Review of the clinical record revealed the facility admitted Resident #47 to the facility from an acute hospital on [DATE] with diagnoses which included Acute Kidney Injury, Hypertension, Gastroesophageal Reflux Disease, Heart Failure, Cystitis, and Anemia. Review of the admission MDS Assessment, dated 04/24/19 revealed the facility assessed Resident #47 as having a BIMS (Brief Interview Mental Status) score of twelve (12) of fifteen (15). Continued review of the MDS assessment revealed the facility assessed Resident #47 as at risk of developing pressure ulcers/injuries, had two (2) stage two (2) pressure ulcers present on admission, and was documented as having skin tears. Review of the CAA's (Care Area Assessment Summary) revealed Resident # 47 has multiple diagnoses that can affect skin integrity and the family is aware of the resident's delicate skin and the risk for increased skin injuries at this time. Review revealed the resident was admitted with two stage two pressure injuries and a venous stasis ulcer and these put the resident at risk for additional complications such as additional skin injuries, and care plan will be developed. Review of the Physicians Telephone Orders for Resident #47 revealed an order dated 06/21/19 to cleanse right upper arm with NS (normal saline), cover with non stick dressing BID (two times a day) until healed. Review of the Nurse's Notes for Resident #47 revealed a note dated 06/21/19 at 1:20 PM, which documented the physician was at the facility and saw the resident and new order to cleanse right upper arm skin tear with NS (normal saline) apply bactroban, non adherent pad and border gauze every shift until healed. Review of the TAR (Treatment Administration Record) for Resident #47 revealed no evidence of a treatment in place for Resident #47's right upper arm/extremity. Review of Resident #47's Comprehensive Care Plan revealed a plan of care with the problem Fragile skin (high risk for skin tears/bruising with on-set date on 04/30/19 and goal that the resident will be free from new bruises times ninety (90) days with target date 07/29/19; a goal the resident will be free from skin tears times ninety (90) days with a target date of 07/29/19; and a goal skin tear to left upper extremity will heal without complications with a begin date of 06/13/19 and a target date of 07/13/19. Further review of the plan of care revealed approaches which included treatment to skin tear to LUE (left upper extremity) as ordered, observe for signs and symptoms of infection, and notify physician as needed. Record review revealed there was no documented evidence the care plan was revised to indicate Resident #47 encounted a skin tear on 06/21/19 and no documented evidence of interventions to address the skin tear to the resident's right upper extremity. Interview with Licensed Practical Nurse (LPN) #8 on 06/27/19 at 10:12 AM revealed Resident #47 has skin tears to both arms, has paper thin skin, and they clean and used petroleum then wrap them. She reported the resident did not have any pressure ulcers, the care plan should be revised to include the skin tear. Interview on 06/27/19 at 05:48 PM with the Director of Nursing (DON) revealed she did not find any documented treatment to the skin tear to the right upper extremity on Resident #47's TAR and did not find anything documented on Resident #47's Care Plan to address the skin tear to the right upper extremity. Interview with the MDS Coordinator on 06/28/19 at 10:35 AM revealed she took the role as MDS Coordinator on 06/23/19. Per interview, the prior MDS Coordinator was no longer employed at the facility. Continued interview revealed the facility process for a newly admitted resident was for the nurse to start the baseline care plan and then it was reviewed the following day during the IDT (Interdisciplinary Team) meeting and updated. The MDS Coordinator stated after the initial MDS admission assessment the comprehensive care plan was developed, with CAA's, and also it would address any diagnosis issues, then nurses on the floor would address new issues and place interventions on the Care Plan. The MDS Coordinator further stated the IDT reviews orders in clinical meeting every morning. Per interview, Resident #47 had fragile skin and the resident's plan of care should have been revised to include the treatment/interventions for the right upper extremity (RUE) skin tear. During an interview with the DON on 06/28/19 at 11:39 AM, the DON stated she wasn't able to locate any documentation prior to yesterday with regards to Resident #47's RUE skin tear. Per interview, the DON indicated she would expect the physician treatment order to be on the resident's Treatment Administration Record (TAR) and Care Plan. Further interview revealed it was her expectation that nurses follow facility Policy and Procedures from obtaining the physician's order, to documenting on the TAR, and updating the plan of care for the resident. The DON stated if a resident has a change of condition, new orders should be transcribed and carried out, and followed through to the care plan. Interview with the Administrator on 06/28/19 at 11:51 AM revealed she had been made aware Resident #47 had a treatment order for the RUE with no evidence the treatment was documented on the TAR and no evidence the plan of care was revised. Continued interview with the Administrator revealed a resident with a change of condition should have treatments documented on the TAR and the care plan should be updated. Per interview, a possible outcome could be failure to follow the plan of care; and if the treatment is not documented on the TAR, there could be failure to ensure the order was carried out. The Administrator further stated it was her expectation that staff follow physician's orders, update MAR's (Medication Administration Record), TAR's and Care Plans according to the resident's plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility policy it was determined the facility failed to provide services to meet professional standards of quality for one (1) of eighteen (18) sampled residents (Resident #47). Review of Resident #47's Treatment Administration Record (TAR), for June 2019, revealed no documented evidence of the treatment for which there was a physician order, dated 06/21/19, for treatment to a skin tear to the right upper arm. The Findings Include: Review of the facility policy titled Green Meadows Physician's Orders, date implemented 03/01/19, revealed verbal orders should be received only by licensed nurses, or pharmacists, and confirmed in writing by the physician,on the next visit to the facility. Continued review of the policy revealed the nurse should document an order by telephone or in person on the physician's order sheet, transmit the appropriate copy to the pharmacy for dispensing, and place the signed copy on the designated page in the resident's medical record. Continued review of the Green Meadows Physician's Orders policy revealed Documentation of Medication Orders, which noted each medication order should be documented with the date, time, and signature of the person receiving the order. The order should be recorded on the physician order sheet, and the Medication Administration Record (MAR). Clarify the order. Enter the order on the medication order and receipt record. Call or fax the medication order to the provider pharmacy. Transcribe newly prescribed medications on the MAR or treatment record. Notify the resident's sponser/family of new medication order. Record review of the clinical record revealed the facility admitted Resident #47 to the facility from an acute hospital on [DATE] with diagnoses which included Acute Kidney Injury, Hypertension, Gastroesophageal Reflux Disease, Heart Failure, Cystitis, and Anemia. Review of the admission MDS Assessment, dated 04/24/19 revealed the facility assessed Resident #47 as having a BIMS (Brief Interview Mental Status) score of twelve (12) of fifteen (15). Continued review of the MDS assessment revealed the facility assessed Resident #47 as at risk of developing pressure ulcers/injuries, had two (2) stage two (2) pressure ulcers present on admission, and was documented as having skin tears. Review of the CAA's (Care Area Assessment Summary) revealed Resident # 47 was recently hospitalized due to a fall with injury and weakness, and was found to have a UTI (urinary tract infection). Continued review revealed the resident has multiple diagnoses that can affect skin integrity and the family is aware of the resident's delicate skin and the risk for increased skin injuries at this time. Review revealed the resident was admitted with two stage two pressure injuries and a venous stasis ulcer and these put the resident at risk for additional complications such as additional skin injuries, and care plan will be developed. Review of the Physicians Telephone Orders for Resident #47 revealed an order dated 06/21/19 to cleanse right upper arm with NS (normal saline), cover with non stick dressing BID (two times a day) until healed. Review of the Nurse's Notes for Resident #47 revealed a note dated 06/21/19 at 1:20 PM, which documented the physician was at the facility and saw the resident and new order to cleanse right upper arm skin tear with NS (normal saline) apply bactroban, non adherent pad and border guaze every shift until healed. Review of the TAR (Treatment Administration Record) for June 2019 for Resident #47 revealed no documented evidence of a treatment in place for Resident #47's right upper arm/extremity. Review of the Comprehensive Care Plan for Resident #47 revealed a plan of care with the problem Fragile skin (high risk for skin tears/bruising with on-set date on 04/30/19 and goal that the resident will be free from new bruises times ninety (90) days with target date 07/29/19; a goal the resident will be free from skin tears times ninety (90) days with a target date of 07/29/19; and a goal skin tear to left upper extremity will heal without complications with a begin date of 06/13/19 and a target date of 07/13/19. Further review of the plan of care revealed approaches which included treatment to skin tear to LUE (left upper extremity) as ordered, observe for signs and symptoms of infection, and notify physician as needed. There was no documented evidence of a plan of care or approaches to address the skin tear to the resident's right upper extremity. Interview with Licensed Practical Nurse (LPN) #8 on 06/27/19 at 10:12 AM revealed Resident #47 had skin tears to both arms, had paper thin skin, and they cleaned then use petroleum then wrap them. She stated she didn't htink there was anything on the TAR about this treatment. Interview with Registered Nurse (RN) #5/Wound Nurse on 06/27/19 at 10:14 AM revealed she only did documentation on pressure ulcers. Continued interview revealed she didn't do wound documentation on skin tears, and treatments were done by the nurses on the unit. She further stated any treatment should be documented on the TAR. Interview with the Director of Nursing (DON) on 06/27/19 at 05:48 PM revealed she did not find any documented treatment to the skin tear to the right upper extremity on Resident #47's TAR and did not find anything documented on Residednt #47's Care Plan to address the skin tear to the right upper extremity. The DON stated any physician's ordered treatment should be record on the TAR. Subsequent interview with LPN #8 on 06/28/19 at 10:18 AM to inquire about the documentation regarding the skin tear to Resident #47's right upper arm, the physician's order, and the Nurse's Note, dated 06/21/19, revealed she did not recall what the order was for Resident #47's right upper extremity, but that is sould be on the TAR. Interview with the MDS Coordinator on 06/28/19 at 10:35 AM revealed she took the role as MDS Coordinator on 06/23/19 and the prior MDS Coordinator was no longer employed at the facility. Interview with the Director of Nursing (DON), on 06/28/19 at 11:39 AM revealed she was unable to locate any documentation prior to 06/27/19 with regards to Resident #47's RUE skin tear. Per interview, the DON indicated she would expect the physician treatment order to be on the resident's TAR and Care Plan. Further interview revealed it was her expectation that nurses follow facility Policy and Procedures from obtaining the physician's order, to documenting on the TAR, and updating the plan of care for the resident. Interview with the Administrator on 06/28/19 at 11:51 AM revealed she had been made aware Resident #47 had a treatment order for the RUE with no evidence the treatment was documented on the TAR and no evidence the plan of care was revised. Continued interview with the Administrator revealed a resident with a change of condition should have treatments documented on the TAR and the care plan should be updated. Per interview, a possible outcome could be failure to follow the plan of care; and if the treatment was not documented on the TAR, there could be failure to ensure the order was carried out. The Administrator further stated it was her expectation that staff follow physician's orders, update MAR's (Medication Administration Record), TAR's and Care Plans according to physician's orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility's Policy, it was determined the facility failed to ensure that a resident who enters the facility without an indwelling catheter was not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; was assessed for removal of the catheter as soon as possible; and received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (1) of eighteen (18) sampled residents (Resident #77). Review of Resident #77's physicians orders, revealed a Physician's Order dated 6/7/19 to start bladder retraining and discontinue the use of a catheter. However, there was no documented evidence the bladder retraining occurred or the urinary catheter was discontinued. Further, observations and interviews revealed the resident continued to have a urinary catheter throughout the survey. The Findings Include: Review of the facility's Policy titled Physician's Orders, date implemented 03/01/19, revealed verbal orders should be received only by licensed nurses, or pharmacists, and confirmed in writing by the physician on the next visit to the facility. Continued review of the policy revealed the nurse should document an order by telephone or in person on the physician's order sheet, transmit the appropriate copy to the pharmacy for dispensing, and place the signed copy on the designated page in the resident's medical record. Review of the facility's Policy titled Catheter Care Policy, date implemented 03/01/19, revealed it is the policy of the facility to provide catheter care to all residents that have an indwelling catheter in an effort to reduce bladder and kidney infections. Record review revealed the facility admitted Resident #77 to the facility on [DATE]. Resident #77 had diagnoses, which included Dementia, Coronary Artery Disease, and Clostridium Difficile. Continued review of the record revealed the facility assessed Resident #77 per the most recent MDS assessment, and annual assessment, dated 04/16/19, as having a Brief Interview Mental Status (BIMS) score of thirteen (13) of fifteen (15), the resident was assessed as always incontinent of urine and bowel, and was not assessed as having a catheter at the time of the assessment. Record review revealed a Comprehensive Care Plan for Resident #77 with a problem onset date 04/19/19 that resident has bowel and bladder incontinence, with a goal that the resident will not experience impaired skin integrity due to incontinence and the resident will remain free of urinary tract infection for ninety (90) days with a target date documented 07/18/19. Continued review revealed approaches included to provide frequent skin care, keep the resident clean and dry, and check and change the resident every two (2) to three (3) hours or per individual program. There was no documented evidence of a plan of care to address the resident's use of a urinary catheter and no evidence the plan of care addressed bladder retraining. Review of the Physician's Orders for Resident #77 revealed an order, dated 05/13/19, for a Foley urinary catheter to bedside drain, size eighteen (18) French, balloon ten cc (10 cubic centimeter) with the diagnosis for the urinary catheter as urinary retention. Continued review of the Physician's Orders revealed a Telephone Order, dated 06/07/19, for the following: start bladder retraining. Continued review of the order revealed to Clamp the F/C (Foley catheter) for two (2) hours then unclamp for one (1) hour for twenty-four (24) hours; then on day two (2), clamp the catheter for four (4) hours and unclamp for one (1) hour for twenty-four (24) hours; then day three (3), to clamp the catheter for eight (8) hours and unclamp for one (1) hour, then to discontinue the urinary catheter. However, review of the clinical record for Resident #77 revealed no documented evidence the Physician orders, dated 06/07/19, to start bladder retraining were implemented. Observation of Resident #77, on 06/26/19 at 9:50 AM and 06/27/19 at 10:35 AM, revealed the resident was observed with a urinary catheter bag to bedside drainage, with yellow urine observed in the tubing. Interview with the DON, on 06/27/19 at 5:50 PM, revealed she reviewed Resident #77's record and stated she cannot find anything in the record as to whether the physician order, dated 6/7/19, for bladder retraining and discontinuing the catheter was done or not done; but stated the resident obviously still has the catheter. Continued interview with the DON revealed she reviewed Resident #77's plan of care and indicated there was nothing in the care plan regarding the bladder retraining or for the urinary catheter. Interview with Licensed Practical Nurse (LPN) #8, on 06/28/19 at 10:05 AM, revealed she had only worked with Resident #77 for about three (3) days, and stated the resident was on another unit when the bladder retraining was ordered. Interview with LPN #7, on 06/28/19 at 10:58 AM, revealed the resident's family thought the catheter was causing Urinary Tract Infections and this was the reason for the bladder retraining order. LPN #7 further stated the reason Resident #77 had the urinary catheter to begin with was for urinary retention. Continued interview with LPN #7 revealed the facility was going through transition with the computer and she indicated she could not get on the electronic record for the Treatment Administration Record (TAR) so she passed the order along to the next nurse. LPN #7 stated she should have followed up on this; however, she did not. LPN #7 stated she only works on Fridays, Saturdays, and Sundays and when she returned to work, Resident #77 had moved from one unit to another unit. She stated when she came back to work, the order for bladder retraining got lost. LPN #7 stated her DON has educated her on this and said what she should have done was to transfer the order to the Medication Administration Record (MAR), since she was unable to get in to the TAR. LPN #7 further stated she does not think the bladder retraining for Resident #77 occurred. Continued interview with LPN #7 revealed potential outcomes for continued catheter use could be UTI (Urinary Tract Infection). In addition, LPN #7 stated she thought they update Care Plans from what she understood but she was not familiar with that, and stated she was supposed to get some training on that. LPN #7 stated she did not update anything with Resident #77's care plan because they are on the computer. LPN #7 exited the interview but returned a couple minutes later and reported there is a green binder on the unit with each resident's Care Plan and staff should go there and update the Care Plan and also put updates on the Certified Nurse Aid (CAN) sheet so they would know. LPN #7 stated none of this was done for Resident #77 for the bladder retraining orders. Interview with the MDS Coordinator, on 06/28/19 at 10:35 AM, revealed she took the role as MDS Coordinator on 06/23/19 and the prior MDS Coordinator was no longer employed at the facility. Continued interview revealed the MDS Coordinator explained the process. She indicated a new admission gets a baseline Care Plan and the nurse starts the baseline care plan and then it was reviewed the following day during the IDT (Interdisciplinary Team) meeting and updated. The MDS Coordinator stated after the initial MDS admission assessment, the comprehensive care plan was developed, with CAA's, and it would address any diagnosis issues. The MDS Coordinator indicated other disciplines such as social services and the dietitian would complete their parts. Continued interview revealed the nurses on the floor would often address new issues and place interventions on the Care Plan. The MDS Coordinator further stated the IDT reviews orders in the clinical meeting every morning. She stated she looked at Resident #77's care plan when it was brought to her attention, she did not find anything addressing catheter care in the resident's care plan. She indicated she would have to find out about the nurse aid sheets to see what documentation was on the document. Continued interview with the MDS Coordinator revealed she did not know anything about the bladder retraining order for Resident #77; however, she stated they take the yellow copy of orders to the morning meeting and usually a copy of the orders was provided to MDS coordinator to review. Continued interview with the MDS Coordinator revealed Resident #77 should have had a plan of care to address the catheter and a care plan regarding the bladder retraining, and the reason was to ensure the resident did not have complications from the catheter or infections. Interview with the DON, on 06/28/19 at 11:33 AM, revealed she did not find any additional information regarding Resident #77's bladder retraining in the medical record. Further interview with the DON revealed reasons to do the bladder retraining were to remove the catheter and increase independence. Per interview, possible complications for having a catheter if it were not necessary could be risk of infection. Additional interview with the DON revealed prior to 06/27/19, there was no care plan to address the catheter for Resident #77, and she would expect the care plan to include catheter care and stated the bladder retraining should have been on the care plan as well for Resident #77. The DON stated the facility process was with new orders such as the order for a catheter or bladder retraining, the information would go on the resident care plan, CNA care guide, and would be documented on the TAR as a treatment. The DON stated it was her expectation that staff follow this process and the facility policies and procedures. Interview with the Administrator, on 06/28/19 at 11:55 AM, revealed there was no evidence the physician's orders, dated 06/07/19, for bladder retraining and discontinuation of the Foley catheter for Resident #77 were carried out. Further interview with the Administrator revealed it was her expectation that facility staff would follow physician's orders and update the resident's plan of care accordingly. She stated Resident #77 should have had a care plan to address the catheter. Per interview, possible outcome with continuing the urinary catheter use was risk for infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of the facility's policy, it was determined the facility failed to provide routine and emergency drugs and biologicals and failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for one (1) of eighteen (18) sampled residents (Resident #49). Per interview on 06/25/19, with the Resident and the resident's representative, Ranitine (Zantac) medication was ordered by an out of facility provider and given to the facility's nursing staff on 06/17/19. Record review of Resident #49's physician's orders revealed no documented evidence of an order on 06/17/19 for Ranitidine. However, investigation revealed the Ranitidine had been prescribed for Resident #49 on 06/17/19 but was not made available to the resident until 06/26/19. Additionally, facility nursing staff interviews revealed the order for Ranitidine was sent to the pharmacy on 06/17/19, was not received, and follow up was made to the pharmacy on two (2) separate days attempting to get the medication to the facility. However, the medication was not received by the facility until 06/26/19. The findings Include: Review of the facility policy titled Green Meadows Physician's Orders, date implemented 03/01/19, revealed medications should be administered only upon the signed order of a person lawfully authorized to prescribe. Verbal orders should be received only by licensed nurses, or pharmacists, and confirmed in writing by the physician, on the next visit to the facility. Continued review of the Green Meadows Physician's Orders policy revealed Documentation of Medication Orders, which noted each medication order should be documented with the date, time, and signature of the person receiving the order. The order should be recorded on the physician order sheet, and the Medication Administration Record (MAR). Clarify the order. Enter the order on the medication order and receipt record. Call or fax the medication order to the provider pharmacy. Transcribe newly prescribed medications on the MAR or treatment record. Notify the resident's sponsor/family of new medication order. Further review of the Green Meadows Physician's Orders policy revealed Handwritten Order Signed by the Physician section of the policy which documented the charge nurse on duty at the time the order is received should note the order and enter it on the physician's order sheet, if not written by the physician. If necessary, the order should be clarified before the physician leaves the nursing station whenever possible. Continued review of the policy revealed Verbal Orders section, which documented the nurse should document an order by telephone or in person on the physician's order sheet, transmit the appropriate copy to the pharmacy for dispensing, and place the signed copy on the designated page in the resident's medical record. Physician orders should be signed per state specific guidelines. Per the policy, the section titled Written Transfer Orders (sent with a resident by a hospital or other health care facility), documented implement a transfer order without further validation if it is signed and dated by the resident's current attending physician, unless the order is unclear or incomplete, or the date signed is different from the date of admission. If the order is unsigned, or signed by another physician, or the date is other than the date of admission, the receiving nurse should verify the order with the current attending, before medications are administered. The nurse should document verification on the admission order record by entering the time, date, and signature. Record review revealed the facility admitted Resident #49 to the facility on [DATE]. Per the medical record, Resident #49 had diagnoses which included Cerebrovascular Accident; Type 2 Diabetes Mellitus; Chronic Renal Disease; and Nausea. Review of the most recent MDS Assessment, a Quarterly assessment dated [DATE], revealed Resident #49 was assessed by the facility as having a BIMS (Brief Interview for Mental Status) score of fifteen (15) out of fifteen (15). Continued review of the assessment revealed the resident received a therapeutic diet. Review of the Comprehensive Care Plan for Resident #49 revealed a plan of care/problem dated 03/23/18 for potential for weight loss related to being on a therapeutic diet, DM (Diabetes Mellitus), decreased mobility with left sided weakness, GERD (Gastroesophageal Reflux Disease), food allergies. Further review of the plan of care revealed a goal documenting the resident will maintain current weight plus/minus five (5) pounds until next review with a goal date of 07/30/19. Per the care plan, approaches included weigh and record as ordered or as deemed appropriate; offer HS (bedtime) snack; and an approach dated 06/18/19 to administer medications for GERD/DM (Gastroesophageal Reflux Disease/Diabetes Mellitus) as ordered. Interview with Resident #49 and the resident's Representative on 06/25/19 at 3:50 PM revealed the resident representative took the resident to an outside physician appointment for the resident's stomach on 06/17/19. The resident was given a prescription for Ranitidine (Zantac) and the resident representative stated he/she brought it back to the facility and was advised by facility staff they would have the medication in a couple days; however, the representative stated he/she had asked about 4 times since they returned with the prescription on 06/17/19, and the resident still had not received the medication. The resident Representative stated she had asked a facility nurse about the medication on the date of interview, 06/25/19, and was told by the nurse, she had to call the doctor to verify the time the medication would be administered. Review of the Physician's Orders dated June, 2019, revealed a telephone order dated 06/25/19 to discontinue current Zantac order and restart Zantac 150 mg (milligrams) PO BID (by mouth two times a day). Continued review of the telephone orders revealed an order dated 06/26/19 for Zantac 150 mg one PO (by mouth) now (one time only) for GI (gastrointestinal). Review of the Treatment Assessment Report Nurse's Note dated 06/26/19 revealed a note which documented late entry on 06/25/19, which documented the Physician was contacted related to previous Zantac order. New order obtained to discontinue order from 06/17/19 and administer Zantac BID (twice a day) at 6:00 AM and HS (hour of sleep). The documentation further stated the daughter was in the facility and aware. Continued review of the Nurse's Notes revealed a note dated 06/26/19 which documented physician contacted, new order obtained for Zantac 150 mg PO (by mouth) Now (one time only). Although requested, the facility did not provide a written documentation of the prescription for Zantac for Resident #49, that was originally prescribed on 06/17/19. Interview on 06/26/19 at 1:18 PM with the Director of Nursing (DON) revealed Resident #49's prescription for Zantac that came from the outside physician office on 06/17/19, should have been faxed to pharmacy; however, the pharmacy said they didn't receive it. Continued interview with the DON revealed the facility physician was notified on 06/25/19 that the medication didn't get started on the 06/17/19, and obtain orders. The DON further stated the order for Zantac from 06/17/19 was discontinued and new order for Zantac was obtained, and the medication arrived today (06/26/19). The DON further stated Resident #49 received a now dose on 06/26/19 and stated the Zantac was in the medication cart. The DON stated she was notified by a nurse about the Zantac on 06/25/19, and she was not sure why the medication wasn't ordered on 06/17/19. Further interview with the DON revealed it was not acceptable for Resident #49 to have to wait from 06/17/19 to 06/26/19 to receive the ordered Zantac. Per interview, possible outcomes could be the resident could have stomach issues. Interview on 06/26/19 at 3:52 PM with Licensed Practical Nurse (LPN) #6 revealed she thought LPN #7 read the orders to her on 06/17/19 for Resident #49's new prescription for Zantac on that date, 06/17/19, and LPN #6 indicated she told LPN #7 she would put it on the MAR. LPN #6 stated LPN #7 told her she would do the rest; and LPN #6 stated she did not know if the order for Zantac was sent to pharmacy or not. Telephone interview with LPN #7 on 06/27/19 at 4:15 PM revealed Resident #49 went for an appointment with outside family doctor and dentist on 06/17/19 and the resident returned with a prescription for Zantac (Ranitidine). LPN #7 indicated she had to write the order for it because it was an outside provider, and stated she did write the order, but didn't contact the resident's physician. She indicated she didn't call the resident's facility physician. Continued interview revealed she faxed the order and script to the pharmacy. LPN #7 stated she wrote the order because Resident #49 didn't have any empty orders and the LPN stated she wrote it on a brand new Physician order sheet, on the top, and faxed to the pharmacy. LPN #7 indicated conformation usually just came out on the bottom of the document and they put that in a basket next to the fax machine; however, LPN #7 said this couldn't be located. LPN #7 indicated she put the outside physician's name on the order, but should have contacted the physician at the facility. LPN #7 stated she followed up with pharmacy twice on the Zantac for Resident #49, on 06/22/19 and 06/23/19; however, she stated she did not document this. Interview on 06/27/19 at 4:55 PM with the pharmacy's Regional Director of Customer Success, revealed the pharmacy received a faxed order for Resident #49's Zantac on 6/25/19 at 2:25 PM, and the pharmacy delivery ticket indicated the medication was delivered to the facility on 6/26/19 at 2:17 AM. Continued interview with the Regional Director revealed he would check to see if the pharmacy received calls from facility staff regarding the medication. The Regional Director stated he did not have any dispense for Zantac for Resident #49 on for 06/17/19. Per interview, Zantac typically was used for heartburn and acid reflux and potential outcome of a resident not having the medication could be discomfort, persistent heartburn or acid reflux. Subsequent information received via email from the pharmacy's Regional Director of Customer Success on 06/28/2019 at 2:06 PM revealed the following: Communication was initiated by the pharmacy on 06/18/19, requesting that an order be sent via the facility electronic health record software. The Regional Director indicated the facility did not use electronic software and would not have been able to send an order electronically. The Regional Director indicated a hospital order was sent, but the pharmacy could not accept those as valid orders; and indicated the pharmacy needed an order, written on a telephone order form, faxed from the facility to the pharmacy. The Regional Director further indicated once the pharmacy received the telephone order form, the medication was dispensed. The Regional Director stated there was communication between the facility and the pharmacy. He further documented the pharmacy customer service would have directed the nurse to fax an order, opposed to using the electronic health record (which the facility does not use), then the medication (Zantac for Resident #49) would have been received much sooner. He further indicated the pharmacy had escalated this incident to their QA department. On 06/28/19 at 11:43 AMn interview with the facility DON revealed Zantac was ordered on 6/17/19 for Resident #49 and the medication was not received by the facility until 06/26/19. The DON stated this was not an acceptable amount of time, and that it was her expectation that facility policy and procedures be followed regarding obtaining medication for residents. The DON indicated a possible outcome for the resident was upset stomach. The DON further indicated the facility audited physician's orders and observed medication carts to ensure medications were in the cart; however, she indicated the facility had no physician's telephone order to alert that there was a new medication, Zantac, for Resident #49. Interview on 06/28/19 at 11:47 AM with the facility Administrator revealed Resident #49 waiting from 06/17/19, when the Zantac was ordered by an outside physician, to 6/26/19 to receive the medication at the facility was not an acceptable amount of time. Continued interview with the Administrator revealed the resident not having the prescribed stomach medication could possibly cause upset stomach. Per interview it was her expectation that facility policy and procedures be followed regarding obtaining medication for residents, and that the facility follow physician orders.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure the medication error rate for the facility was not five (5) percent or greater. Observation of the medication pass revealed twenty-four (24) medication opportunities with five (5) medication errors to result in a twenty-one (21) percent medication error rate. The findings include: Review of the facility's policy titled Medication Errors, implemented date of 03/01/19, revealed the facility would provide care and services safely, free of medication errors. Per policy, medication error was defined as the administration not in accordance with the physician's order; manufacture specifications; or accepted professional standards. Additional review revealed the facility would ensure medication error rate below five (5) percent. Further, crushing do not crush medications was not in accordance with manufacturer's specifications. Review of the facility's pharmacy reference sheet titles Medications Not to be Crushed, located in the Medication Administration Record (MAR), revealed Potassium Chloride should not be crushed. Review of Resident #55's Physician Orders revealed no order to crushed medications. Observation of the medication administration, on 06/26/19 at 8:30 AM, revealed Licensed Practical Nurse (LPN) #1 to prepare one (1) Vitamin C, five hundred (500) milligram (mg); one (1) Calcium Carbonate, six hundred (600) mg; one (1) Furosemide twenty (20) mg; one (1) Potassium Chloride Extended Release twenty (20) millequivalets (mEq); and one (1) Tab A Vitamin. Continued observation revealed LPN #1 crushed together Vitamin C, Calcium Carbonate, Furosemide, Potassium Chloride and Tab A Vitamin. Further observation revealed, she mixed all of the five (5) crushed medications together with applesauce in a medication cup, the LPN #1 administered all medications together to Resident #55. Interview with LPN #1, on 06/26/19 at 9:00 AM revealed she was not aware of a facility resource to aide in knowing what medications were allowed to be crushed. Additionally, she was not aware if the Resident #55 had a physician's order to crush medications. Continued interview revealed she knew Resident #55 required his/her medication crushed from experience working with the resident and that he/she would not take the medications unless they were crushed. Further interview revealed she would research a medication if she was not aware if it was safe to crush; however, had no concerns about the medications for Resident #55 that she crushed. Additionally, medication should be administered per physician orders to ensure residents received medication the safest way and to ensure residents got the most therapeutic effect from their medications. Interview with Director of Nursing (DON), on 06/27/19 04:06 PM revealed medication administration should be free or error. Additional interview revealed crushing medications required a physician's order. Per interview, crushing medication that were not safe to crush would interfere with effectiveness the of the medication. Continued interview revealed the facility did not have a current process in place to ensure those residents who required crushed medication had an order in place, nor a resource guide for nurses to refer to about medications that were unsafe to crush. Further, she stated, it was important that residents received medication per physician orders and in the safest manner to ensure medication had the most desirable effect on residents. Interview with Pharmacy Consultant, on 06/27/19 at 4:45 PM revealed certain medication should not be crushed, such as Extended Release medications and proper administration of medication to patients ensured they received medication over time, not all at once. Further interview revealed, Potassium Chloride Extended Release should never be crushed because it changed the way the medication would disperse in the body and crushing Potassium would change the medication delivery and cause gastrointestinal upset. Per interview, patients who need their medications crushed, require a physician's order and collaboration with the Consultant Pharmacist to review and ensure all medications crushed with others was medication specific and safe. Interview with the Administrator, on 06/28/19 at 10:19 AM revealed she expect physician orders to be followed and medication administration to be accurate and timely. Per interview, she expected Nurses to maintain the five rights of medication administration including patient, drug, route, dose, and time. Additionally, she expect residents who required crushed medications to have a physician's order to crush medication. Continued interview revealed she expected nurses to follow guidelines related to what medications could be crushed safety. Further, she stated medication administration should be person centered and residents should receive medications accurately to ensure the most therapeutic benefit from medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of eighteen (18) sampled residents (Resident #77). Observation of lunch meal service, on 06/25/19 revealed a nurse entered Resident #77's room without donning PPE, to deliver a meal tray and exit the room without proper hand hygiene. Additionally, observation of wound care, on 6/27/19 revealed a nurse failed to practice proper hand hygiene during a non-sterile dressing change for Resident #77. The findings include: Review of the facility's policy titled Green Meadows Transmission-Based Precautions, which was without date, copyright 2019 The Compliance Store, LLC, revealed it was facility policy to take appropriate precautions to prevent transmission of infectious agents, based on the agents' modes of transmission. Continued review of the policy revealed Contact Precautions were intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the resident or the resident's environment. Per the policy, Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. The policy further documented donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g. C. difficile). Review of the facility policy titled Green Meadows Hand Hygiene, dated implemented 03/01/19, revealed all staff will perform proper hand hygiene procedures to prevent the spread of infectioin to other personnel, residents,, and visitors. This applies to all staff working in all locations within the facility. Continued review of the policy revealed the use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves. Review of the facility policy titled Green Meadows Clean Dressing Change, dated implemented 03/01/19, revealed it is the policy of the facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Continued review of the policy revealed the following: wash hands and apply gloves; loosen the tape and remove the existing dressing; remove gloves, pulling inside out over the dressing; and discard into appropriate receptacle. Wash hands and put on clean gloves. Record review revealed the facility admitted Resident #77 to the facility on [DATE]. Resident #77 had diagnoses which included Dementia, Coronary Artery Disease, and C. difficile. Continued review of the record revealed the facility assessed Resident #77 per the most recent MDS assessment, and annual assessment dated [DATE] as having a BIMS (Brief Interview fo rMental Status) of thirteen (13) of fifteen (15), the resident was assessed as always incontinent of urine and bowel, and was not assessed as having a catheter at the time of the assessment. Record review revealed a Comprehensive Care Plan for the resident with a problem C-difficile infection, potential for complications with an onset date of 06/11/19 and a goal that the D-Diff infection will resolve within ninety (90) days and adequet hydration will be maintained for ninety (90) days with target date of 09/09/19. Interventions included administer antibiotics as ordered, contact precautions/isolation will be maintained per facility protocol. Review of the physician's Orders for Resident #77 revealed an order dated 06/11/19 to initiate contact isolation effective 06/10/19 and may discontinue isolation three (3) days after Flagyl and Vancomycin discontinued if no further loose stools and the diagnosis documented was C. Diff positive. 1. Observation of meal tray pass on the hall on 06/25/19 at 12:18 PM revealed Licensed Practical Nurse (LPN) #5, Unit Manager Orchard unit, took Resident #77's food tray into the resident's room without donning PPE and exited and used hand sanitizer. Observation of Resident #77's door revealed PPE was available on the door of the resident's room. Interview with LPN #5 directly after the incident revealed when asked the reason she didn't don PPE for Resident #77 who was on contact precautions, LPN #5 stated she didn't realize the resident was on contact precautions and was not sure why the resident was on contact precautions. The surveyor reported to LPN #5 that per the facility matrix provided by the facility, Resident #77 was on contact precautions due to C. Difficile infection and LPN #5 stated she needed to go wash her hands. LPN #5 stated the risk from not wearing the proper PPE would be contamination. 2. Obsevation of wound care of a non-sterile dressing change for Resident #77 on 06/27/19 at 10:35AM revealed LPN #8 was assisted by the ADON (Assistant Director of Nursing) during the wound care to the resident's left heel. Continued observation during the wound care revealed LPN #8 removed the prior dressing from Resident #77's heel, and removed her gloves. LPN #8 then was observed as she retied the neck tie of her PPE gown, pulled out additional gloves from a glove box, and opened saline vials and applied to guaze after removing the soiled gloves and prior to washing her hands. Interview with LPN #8 directly after the wound care revealed she should have washed her hands after removing soiled gloves and before touching other items such as her gown ties, gloves, and saline and the reason was to prevent cross contamination. Interview with the Patient Care Coordinator/ADON, on 06/27/19 at 11:27 AM revealed she was present with LPN #8 during the wound care for Resident #77. Continued interview with the Patient Care Coordinator/ADON revealed LPN #8 should have washed her hands after she removed the dressing and removed her gloves, prior to touching new gloves, tying her gown, and opening the saline and applying to the guaze and the reason was for infection control. The ADON stated LPN #8 will be educated. Interview on 06/28/19 at 11:33 AM with the DON revealed PPE should be donned at the door for resident's on contact precautions and handwashing should be done after removing soiled gloves. Continued interview with the DON revealed it was her expectation staff follow process and the facility's policies and procedures. Interview with the Administrator on 06/28/19 at 11:55 AM revealed the staff delivering the meal tray to Resident #77, who was on contact precautions for C. difficile infection without donning PPE was not in accordance with facility's policy. The Administrator stated her expectation was for staff to adhere to infection control policies and procedures. Continued interview with the Administrator regarding Resident #77's wound care revealed it was her expectation that staff adhere to infection control policy and would follow standards of practice of anytime you remove gloves, wash your hands. Further interview with the Administrator revealed without PPE use and proper handwashing, there was potential risk for increase in infection.

Based on observation, interview and review of the facility's policy, it was determined the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles. Observations revealed three (3) of five (5) medications carts to contain opened medications without labels or expiration dates. The findings include: Review of the facility's policy, titled Medication Storage, implemented on 03/01/19, revealed the facility would ensure all medications would be stored in accordance to the manufacturer's recommendations. Observation of the Transitional unit Medication Cart #1, on 06/26/19 at 8:45 AM, revealed the following items located in stock and available for resident use: one (1) Humalog (insulin) Pen, with no open date, or expiration date; one (1) Fluticasone Nasal Spray, with no open date, or expiration date; and one (1) Ipratropium Nasal Spray, with no open date, or expiration date. Interview with Licensed Practical Nurse (LPN) #1, who was assigned to Transitional unit Medication Cart #1, on 06/26/19 at 9:00 AM revealed all multi-dose medications should be dated with an open and/or an expiration dated, by the nurse who opens the medication. Per interview, dating a multi-dose medication ensures all nurses know when a medication would expire and when to not use the medication. Additionally, it was important to administer medications safely to residents because medication should have the therapeutic effect. Continued interview revealed the Unit Manager and a staff from the Pharmacy audited the medication carts periodically to ensure medication were stored appropriately. Further, she was responsible to ensure medications were labeled with open dates and expiration dates before administering the medication, when the medication cart was assigned to her. Observation of the Apple Orchard unit Medication Cart #2, on 06/26/19 at 9:40 AM, revealed the following items located in stock and available for resident use: one (1) Vial of Lantus (insulin), with no open date, or expiration date. Interview with LPN #2, who was assigned to Apple Orchard unit Medication Cart #2, on 06/26/19 at 9:45 AM revealed all multi-dose vials of insulin should be dated with an expiration date to ensure the resident received medication not expired. Additionally, the assigned nurse was responsible to ensure all multi-dose medications were dated with opened and/or expiration dates. Further, expired medication would not have the most therapeutic effect. Observation of the Peach Orchard unit Medication Cart #3, on 06/26/19 at 9:50 AM, revealed the following items located in stock and available for resident use: two (2) Novolog (insulin), with no open date, or expiration date; two (2) Humalog (insulin) Pens, with no open date, or expiration date; two (2) Baslar (insulin) Pens, with no open date, or expiration date; one (1) Levimir (insulin) pen, with no open date, or expiration date; two (2) Symbicort inhalers, with no open date, or expiration date; one (1) Ventolin HFA inhaler, with no open date, or expiration date; two (2) Fluticasone salmeterol inhalers, with no open date, or expiration date; one (1) Lantaprost eye drop, with no open date, or expiration date; and one (1) Neomycin polymyixin eye ointment, with no open date, or expiration date. Interview with LPN #3, who was assigned to Peach Orchard unit Medication Cart #3, on 06/26/19 at 10:00 AM revealed, he/she was responsible to ensure multi-dose medications were labeled with open dates when assigned to the medication cart. Continued interview revealed nursing leadership also audited medication carts for proper medication storage and labeling routinely. Further, it was important that medications were administered to residents' safely and not expired to decrease the risk for adverse reactions. Interview with LPN #4, Unit manager of the Transition unit, on 06/26/19 at 9:15 AM revealed she expected medications to be stored per the facility policy and standards of practice. Additionally, all multi-dose mediations should be dated when opened by the assigned nurse. Per interview, she completed medication storage audits yesterday and did not identify any concerns. Further, she missed the medications that did not have open dates. Interview with LPN #5, Unit Manager Orchard, on 06/27/19 at 3:37 PM revealed when medications came in the facility from the pharmacy, the nurse assigned to the medications cart was responsible to label all medications with an open date. Per interview, eye drops, inhalers and insulins were multi-dose medications and required an open date and/or an expiration date. Additionally, it was important to know open dates and expiration dates of medications, to ensure medications were administered safely. Continued interview revealed she did not have a process in place to audit behind the floor nurses to ensure multi-dose medications were dated with open and expiration dates. Further, she was uncertain of the facility policy but expected nurses to know the facility policy and store and label medications appropriately. Per interview, all multi-dose medications identified during state inspectors observations of the Orchard Medication carts should have been labeled and dated per facility policy. Interview with Director of Nursing (DON), on 06/27/19 at 4:02 PM revealed multi-dose medications were dated when put on medication carts with an open date or expiration date, per facility policy. Per interview, audits of the medication carts for proper storage and labeling per facility policy was not currently completed. However, it was important to store and label medication appropriately to ensure standards of practice was maintained for medication administration. Additionally, proper labeling of medication would decrease the risk for administration of expired medications. Continued interview revealed expired medications would not have the most beneficial effect for the residents. Further, she expected all multi-dose medications identified by the state inspector, on the medication carts, to be labeled with open dates and expiration dates. Interview with Pharmacy Consultant, on 06/27/19 at 4:45 PM revealed the she had identified there was a need for correction at the facility earlier in the month, related to date opening on multi-dose mediations. Additional interview revealed a plan of action to implement correction was in progress for next month. Per interview, it was important for medications such as insulin, eye drops and inhalers to be dated with open dates to ensure sterility of the medications and to keep the product close to manufacturing standards. Interview with Administrator, on 06/28/19 at 10:24 AM revealed medication should be stored, labeled, and dated per facility policy. Per interview, multi-dose medication should have open dates and/or expiration dates on them once they are in the medication carts. Additionally, nursing staff should maintain the facility policy and process; each medication should have an open date and expiration date. Further, it was important for residents to receive medication that were not expired to ensure the have the most therapeutic effect from their medications.

Based on observation, interview and review of the facility's policies, it was determined the facility failed to store foods in accordance with professional standards for food service safety. Observations of the kitchen on 06/29/19 revealed frozen food products, outside original boxes without labels with food names, received dates, or use by dates. The findings include: Review of the facility's policy titled Date Labeling for Food Safety, revised 03/01/19' revealed the facility would adhere to a date marking system to ensure the safety of food. Additional review revealed food should be clearly marked to indicate the date or day by which food should be consumed or discarded by the individual opening a food. Continued review revealed the marking system consist of color-coded labels, the day/date of opening, and the day/date the item should be consumed or discarded. Further, the cook was responsible for checking the food items for expiration, and discarding accordingly; the Dietary Manager was responsible to spot check weekly for compliance. Observations of the walk-in freezer, on 06/29/19 at 12:40 PM revealed two (2) bags of frozen broccoli, with no food name label and no opening or consumed/discarded day/date. Further observations revealed one (1) bag of frozen breaded meat patties, one (1) bag of frozen peas, and one (1) bag of frozen diced chicken cubes, with no food name label and no opening or consumed/discarded day/date. Interview with Dietary Manager, on 06/25/19 at 12:44 PM revealed the [NAME] completed an audit tool daily, which included checking stock for correct labeling. Per interview, the Dietary Manager made daily rounds in the kitchen to validate the Cooks audit was completed accurately. However, the current audit system did not identify concerns with frozen food item and she could not state where the failure of the audit process was. Continued interview revealed, once a food product was removed from the original package a label should be added to the food to include the food name, open date and use by date. Further, it was important to have food products labeled per the facility policy to ensure food was safe for use per food standards. Interview with [NAME] #1, on 06/27/19 at 3:14 PM revealed when a food product was opened or take out of the original box a label should be added to the bag with the food name, the open date and the date the food goes bad. Additionally, she would look at all food items at least twice a day to ensure they were labeled per the facility policy. Further, it was important to know what food items were and what dates they were good until, to ensure residents were given the right food and the food was not bad. Interview with Administrator, on 06/28/19 at 10:15 AM revealed her expectation for food storage and labeling was for food products in the freezer to be labeled with a common food name and dated with a receive date, open date, and expiration date. Per interview, the Dietary Manager was to ensure facility policy was maintained. Additionally, the Administrator performed walk thoughts to ensure food was labeled in accordance to facility policy. Further, it was important food products were labeled accordingly to ensure foods served to Residents was safe food and meet their nutritional needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's abuse policy, it was determined the facility failed to protect two (2) of nineteen (19) sampled residents, Residents #10 and #14, from physical abuse by Resident #73. The findings include: Review of the facility's Abuse Prohibition Policy, dated 03/13/17, revealed the facility would monitor residents and identify potential signs and symptoms of abuse. In addition, the facility would monitor occurrences, patterns, and trends that constituted abuse. The facility would protect residents from alleged offenders by providing a safe, protected environment during the investigation. The alleged perpetrator would be immediately removed to ensure resident protection. 1. Interview with Resident #10, on 04/25/18 at 11:12 AM, during Group Interview, revealed earlier in the day he/she was in North Unit TV area, when Resident #73 started beating him/her on the back with his/her fist. Resident #10 stated it hurt and her/his back continued to feel sore. Resident #10 stated she/he reported the incident to Licensed Practical Nurse (LPN) #1 after it occurred. Observation and continued interview with Resident #10, on 04/26/18 at 9:53 AM, revealed the resident in bed and continued to complain of pain in the upper back area. Resident #10 put on the call light, LPN #1 entered the room, and Resident #10 requested pain medication for the back pain. Review of the clinical record for Resident #10 revealed the facility admitted the resident on 11/11/17, with diagnoses of Hypertension, Type 2 Diabetes, and Gastro-Esophageal Reflux. Review of Resident #10's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) and determined the resident interviewable. Review of LPN #1's Nursing Note, dated 04/26/18 at 10:30 AM, revealed the resident complained of pain in his/her back and right knee, and had a headache. Tylenol was administered. Review of the clinical record for Resident #73 revealed the facility admitted the resident on 08/05/17, with diagnoses of Insomnia, Anxiety, and Alzheimer's Dementia. Review of Resident #73's Quarterly MDS, dated [DATE], revealed the facility did not conduct a BIMS because he/she was rarely/never understood, and his/her cognitive skills for daily decision-making were severely impaired. The facility assessed the resident did not display physical behavior symptoms toward others. Review of Resident #73's Nursing Note, dated 03/11/18, revealed the resident exhibited behaviors of hitting, kicking, spitting, and swinging at staff. Review of Resident #73's Care plan, dated 03/08/18, revealed the resident continued to be combative with staff with an intervention for staff to offer diversional activities as needed. Interview, on 04/26/18 at 1:49 PM, with Certified Nursing Assistant (CNA) #2 revealed Resident #73 did not do well in crowds, a lot of activity angered him/her, and he/she might swing at someone. The CNA stated while providing care for Resident #73 earlier in the day, he/she swung at her and tried to hit her and another CNA working with her. She stated the resident tried to hit CNAs daily, and struck CNA #2 in the stomach about two (2) weeks prior. She stated she reported the incident to a male nurse who no longer worked at the facility. According to the CNA, she reported the incident immediately to the nurse when the resident hit her, but nothing was done about it. Interview, on 04/26/18 at 2:10 PM, with Restorative Aide #1 revealed Resident #73 was strong and did not talk much. The Aide stated on 04/25/18 at about 7:15 AM, she was getting ready to walk Resident #10 and the resident stated Resident #73 hit him/her on the back earlier in the morning. The Aide stated she immediately reported Resident #10's report to the Director of Nursing (DON) and requested she speak to the resident. She stated the DON discussed the incident with Resident #10. Interview, on 04/26/18 at 4:02 PM, with LPN #1 revealed she had not personally witnessed Resident #73 hit another resident. However, she had seen him/her roll in a wheelchair up and down the halls and go into other residents' rooms. She stated earlier in the day (on 04/25/18), Resident #10 told her Resident #73 hit her/him on the back. However, she did not put interventions in place to protect the resident from further harm. Interview, on 04/26/18 at 5:24 PM, with the DON revealed she became aware about 7:15 AM on 04/25/18 that Resident #73 had hit Resident #10; however, she did not identify the incident as resident-to-resident physical abuse. In addition, she did not put actions in place to monitor Resident #73 for additional resident-to-resident altercations. Interview with the Administrator, on 04/26/18 at 6:10 PM, revealed Resident #10 reported to the DON that Resident #73 hit him/her in the back. However, the facility did not identify the incident as physical abuse. The Administrator stated after the report, staff should have put measures in place to protect residents from potential resident-to-resident abuse perpetrated by Resident #73. 2. Interview, on 04/25/18 at 4:55 PM, with Resident #14 revealed on 04/20/18, Resident #73 lifted the stop sign on his/her doorway, entered his/her room and made a fist and hit Resident #14's wrist down on the table. Resident #14 stated it hurt when Resident #73 hit his/her hand and it left a bruise and made him/her very mad. Resident #14 stated he/she later in the day reported the incident to a CNA, name unknown, and LPN #1. Resident #14 stated on 04/25/18, Social Services came to see him/her and he/she told Social Services about Resident #73 having hit him/her. In addition, Resident #14 stated he/she spoke with Social Services regarding the incident; however, the worker acted as if she did not believe the incident happened. Review of the clinical record for Resident #14 revealed the facility admitted the resident on 11/23/16, with diagnoses of Chronic Obstructive Pulmonary Disease, Hypertension, and Chronic Kidney Disease. Review of Resident #14's Annual MDS, dated [DATE], revealed the facility assessed the resident with a BIMS score of fifteen (15) out of fifteen (15) and determined the resident interviewable. Review of the resident's Care Plan, dated 11/23/17, revealed the facility placed a stop sign in the resident's doorway to deter wandering residents from entering. Review of Resident #14's Nursing Note, dated 04/25/18, revealed the resident had petechiae (red or purple spots on the skin caused by a minor bleed from broken capillary/blood vessels) on both hands. The notation did not mention the potential cause of the petechiae. Interview, on 04/26/18 at 1:49 PM, with CNA #2 revealed stop signs on residents' doors were to keep wandering residents out of the rooms and Resident #73 wandered into other resident's rooms. She stated staff was to monitor and protect residents from resident-to-resident altercations. Interview, on 04/26/18 at 4:02 PM, with LPN #1 revealed she assessed the petechiae on Resident #14's hand the previous day and stated she did not remember any complaints from Resident #14. However, if she had known Resident #73 had struck Resident #14's hand, she would be required to put interventions in place to protect residents from further abuse. Interview, on 04/26/18 at 4:25 PM, with the Social Services Director revealed she knew Resident #73 had been combative with staff. However, was not aware he/she had hit residents before 04/25/18. She stated although she had been aware Resident #73 had hit staff intentionally, she did not recognize his/her hitting another resident was abuse requiring the facility to put effective measures in place to provide protection from further abuse. Interview, on 04/26/18 at 5:24 PM, with the DON revealed Resident #14 reported to staff he/she was hit on the arm days ago by Resident #73. However, the facility did not identify the need to implement interventions to protect the resident from further harm. Interview with the Administrator, on 04/26/18 at 6:10 PM, revealed staff made him aware of allegations related to Resident #73 hitting other residents on 04/25/18. He stated he would need to reeducate staff on the abuse policy and procedure intervention related to confused residents hitting other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's abuse policy, it was determined the facility failed to implement its policy to report allegations of physical abuse for two (2) of nineteen (19) sampled residents, Residents #10 and #14. The findings include: Review of the facility's Abuse Prohibition Policy, dated 03/13/17, revealed the facility would monitor residents and identify potential signs and symptoms of abuse. In addition, the facility would monitor occurrences, patterns, and trends that constituted abuse. The facility would report all injuries of unknown source, and all allegations of abuse immediately, but no later than two (2) hours after the allegation was made, to the State Survey Agency and Adult Protective Services in accordance with State law through established procedures. 1. Interview with Resident #10, during Group Interview, on 04/25/18 at 11:12 AM, revealed earlier in the day, he/she was in North Unit TV area and Resident #73 started beating him/her on the back with his/her fist. Resident #10 stated it hurt and his/her back continued to feel sore. The resident stated he/she reported the incident to Licensed Practical Nurse (LPN) #1 after it occurred. Record review revealed the facility admitted Resident #10 on 11/11/17, with diagnoses of Hypertension, Type 2 Diabetes, and Gastro-Esophageal Reflux. Review of Resident #10's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) and determined the resident interviewable. Observation of and continued interview with Resident #10, on 04/26/18 at 9:53 AM, revealed the resident in bed with pillows under his/her back and continued to complain of pain in the upper back area. LPN #1 entered the room and Resident #10 requested pain medication for the back pain. Review of a Nursing Note by LPN #1, dated 04/26/18 at 10:30 AM, revealed Resident #10 complained of pain in his/her back and right knee, and of a headache. Tylenol was administered. Review of Resident #73's clinical record revealed the facility admitted the resident on 08/05/17, with diagnoses of Insomnia, Anxiety, and Alzheimer's Dementia. Review of the Quarterly MDS for Resident #73, dated 03/03/18, revealed the facility did not conduct a BIMS due to the resident was rarely/never understood and his/her cognitive skills for daily decision-making were severely impaired. Review of a Nursing Note, dated 03/11/18, revealed Resident #73 was hitting, kicking, spitting, and swinging at staff. Review of Resident #73's Care plan, dated 03/08/18, revealed the resident continued to be combative with staff and staff was to offer diversional activities as needed. Interview with Certified Nursing Assistant (CNA) #2, on 04/26/18 at 1:49 PM, revealed while providing care for Resident #73 earlier in the day, the resident swung at her and tried to hit her and another CNA helping her. CNA #2 stated Resident #73 did not do well in crowds, as a lot of activity angered him/her and he/she might take a swing at someone. The CNA stated the resident tried to hit CNAs daily and struck CNA #2 in the stomach about two (2) weeks ago. She revealed she reported the incident immediately to a nurse, who no longer worked at the facility, but nothing was done about it. Interview with Restorative Aide #1, on 04/26/18 at 2:10 PM, revealed on 04/25/18 around 7:15 AM, Resident #10 told her Resident #73 hit him/her on the back earlier in the morning. The Aide stated she immediately reported the allegation to the Director of Nursing (DON) and requested the DON speak to the resident and the DON discussed the incident with the Resident #10. Restorative Aide #1 revealed Resident #73 was strong and did not talk much. Interview with LPN #1, on 04/26/18 at 4:02 PM, revealed Resident #73 self-propelled in his/her wheelchair up and down the halls and went into other residents' rooms. She stated earlier in the day on 04/25/18, Resident #10 reported to her that Resident #73 hit her/him on the back and she reported the allegation to the DON. She stated she did not know if the allegation was reported to the State Survey Agency. She stated the facility abuse policy required staff to report allegations of resident abuse. Interview with the DON, on 04/26/18 at 5:24 PM, revealed she was aware Resident #73 hit Resident #10; however, she did not identify the incident as physical abuse. In addition, she did not report the allegation of abuse to the State Survey Agency or other agencies per facility policy and State regulations. Interview, on 04/25/18 at 12:15 PM, with the Administrator revealed he was not aware of any resident-to-resident abuse incidents that included Resident #73. The administrator stated when staff was made aware of any allegation of abuse, it must be reported per State regulations immediately, but no later than two (2) hours, to the State Survey agency and other agencies. Continued interview on 04/26/18 at 6:10 PM, revealed Resident #10 reported Resident #73 hit him/her to the DON. However, the facility did not identify the incident as physical abuse and did not report the allegation of abuse to the State Survey Agency or other entities per the facility policy and State law. 2. Interview with Resident #14, on 04/25/18 at 4:55 PM, revealed on 04/20/18, Resident #73 entered his/her room and Resident #14 offered to shake hands with Resident #73; however, instead of shaking hands, Resident #73 made a fist and hit Resident #14's wrist down on the table. Resident #14 stated it hurt when Resident #73 hit his/her hand and it left a bruise and made him/her very mad. Resident #14 stated he/she reported the incident to a CNA, name unknown, and LPN #1. Resident #14 stated on 04/25/18, he/she told Social Services about Resident #73 hitting him/her but Social Services acted as if she did not believe the incident happened. Record review for Resident #14 revealed the facility admitted the resident on 11/23/16, with diagnoses of Chronic Obstructive Pulmonary Disease, Hypertension, and Chronic Kidney Disease. Review of the Annual MDS, dated [DATE], revealed the facility assessed the resident with a BIMS score of fifteen (15) out of fifteen (15) and determined the resident interviewable. Review of Resident #14's Nursing Note, dated 04/25/18, revealed the resident had petechiae (red or purple spots on the skin caused by a minor bleed from broken capillary/blood vessels) on both hands. Interview with LPN #1, on 04/26/16 at 4:02 PM, revealed she cared for Resident #14 on 04/20/18 and did not remember any complaints from the resident. However, if she had known Resident #73 had struck Resident #14's hands, she would have reported the incident of abuse. Interview with the Social Services Director, on 04/26/18 at 4:25 PM, revealed she knew Resident #73 had been combative with staff. However, was not aware he/she had hit residents before 04/25/18. She stated Resident #73 was capable of voluntary movement and although she was aware Resident #73 hit staff intentionally, she did not recognize his/her hitting another resident was abuse, and did not assure the incident was reported to appropriate agencies per regulations. She stated she was responsible for training all new staff on the prohibition of abuse, including reporting allegations. Interview with the DON, on 04/26/18 at 5:24 PM, revealed Resident #14 reported to staff Resident #73 hit him/her on the arm days ago. However, the facility did not identify the need to report the allegation. Interview with the Administrator, on 04/26/18 at 6:10 PM, revealed staff made him aware of allegations related to Resident #73 hitting other residents on 04/25/18. He stated he would need to reeducate staff on the abuse policy and procedure intervention related to confused residents hitting other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's abuse policy, it was determined the facility failed to investigate allegations of physical abuse for two (2) of nineteen (19) sampled residents, Residents #10 and #14, after the residents reported abuse by Resident #73 to staff. The findings include: Review of the facility's Abuse Prohibition Policy, dated 03/13/17, revealed the facility would monitor residents and identify potential signs and symptoms of abuse. In addition, the facility would monitor occurrences, patterns, and trends that constituted abuse and investigate. The facility would investigate all injuries of unknown source to determine if they were the result of abuse, and investigate all allegations of abuse immediately. Investigations were to include interviews of all involved and assessments of involved residents. Review of Resident #73's clinical record revealed the facility admitted the resident on 08/05/17, with diagnoses of Insomnia, Anxiety, and Alzheimer's Dementia. The Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility was unable to conduct a Brief Interview for Mental Status (BIMS) due to his/her cognitive skills for daily decision-making were severely impaired and he/she was rarely/never understood. There were no physical behavior symptoms displayed toward others per the MDS. Review of Resident #73's Nursing Note, dated 03/11/18, revealed the resident exhibited behaviors of hitting, kicking, spitting, and swinging at staff. Review of Resident #73's Care plan, dated 03/08/18, revealed the resident continued to be combative with staff and staff was to offer diversional activities as needed. Interview with Certified Nursing Assistant (CNA) #2, on 04/26/18 at 1:49 PM, revealed while providing care for Resident #73 earlier in the day, he/she swung at her and tried to hit her and another CNA working with her. She stated the resident tried to hit CNAs daily, and struck the CNA in the stomach about two (2) weeks ago. She stated she reported the incident to a male nurse, who no longer worked at the facility, but nothing was done about it. During Group Interview, on 04/25/18 at 11:12 AM, Resident #10 stated Resident #73 hit him/her on the back with his/her fist earlier in the day (04/25/18). Resident #10 stated it hurt and his/her back felt sore. Resident #10 also stated he/she reported the incident to Licensed Practical Nurse (LPN) #1 after it occurred. Observation and continued interview with Resident #10, on 04/26/18 at 9:53 AM, revealed the resident was in bed with pillows under his/her back and continued to complain of pain in the upper back area. LPN #1 entered the room and Resident #10 requested pain medication for the back pain. Review of Resident #10's clinical record revealed the facility assessed the resident on 04/17/18, with a BIMS score of fifteen (15) out of fifteen (15) and determined the resident interviewable. Review of a Nursing Note, dated 04/26/18 at 10:30 AM, revealed LPN #1 documented the resident complained of pain in his/her back and right knee, and had a headache. Tylenol was administered. Interview with LPN #1, on 04/26/18 at 4:02 PM, revealed earlier in the day (on 04/25/18), Resident #10 told her Resident #73 had hit her/him on the back and she reported the allegation to the Director of Nursing (DON). She stated the facility abuse policy required staff to do a thorough investigation into all allegations of abuse. She stated she had not witnessed Resident #73 hit other residents; however, she saw him/her roll in his/her wheelchair up and down halls and go into other residents' rooms. Interview with Restorative Aide #1, on 04/26/18 at 2:10 PM, revealed on 04/25/18 about 7:15 AM, she was getting ready to walk Resident #10 and the resident told her Resident #73 hit him/her on the back earlier that morning. The Aide stated she immediately reported the incident to the DON. Interview with the DON, on 04/26/18 at 5:24 PM, revealed she was aware Resident #10 was hit by Resident #73. She stated the facility policy directed staff to protect residents from abuse, and thoroughly investigate allegations as soon as they were received. The DON stated she did not identify the incident as abuse and did not initiate a thorough investigation after learning Resident #73 hit Resident #10. Interview with the Administrator, on 04/25/18 at 12:15 PM, revealed he was not aware of any resident-to-resident abuse incidents that included Resident #73. The Administrator stated when staff was made aware of any allegation of abuse; the facility must thoroughly investigate the allegation. Continued interview on 04/26/18 at 6:10 PM, revealed the facility did not identify the incident as abuse. Interview with Resident #14, on 04/25/18 at 4:55 PM, revealed on 04/20/18, Resident #73 entered his/her room and made a fist and hit Resident #14's wrist down on the table. Resident #14 stated it hurt and left a bruise and made him/her very mad. Resident #14 stated later in the day she reported the incident to a CNA, name unknown, and LPN #1. Resident #14 stated on 04/25/18, Social Services came to see him/her and he/she told Social Services about Resident #73 having hit him/her but she acted as if she did not believe the incident occurred. Review of Resident #14's clinical record revealed the facility assessed the resident on 08/23/17, with a BIMS score of fifteen (15) out of fifteen (15) and determined the resident interviewable. Interview with the Social Services Director, on 04/26/18 at 4:25 PM, revealed she knew Resident #73 was combative with staff; however, she did not recognize his/her hitting another resident as abuse, and did not assure the incidents were thoroughly investigated. She stated she was responsible for training all new staff on the prohibition of abuse including investigating allegations of abuse. Interview with the DON, on 04/26/18 at 5:24 PM, revealed Resident #14 had reported to staff Resident #73 hit him/her on the arm days ago; however, the facility did not thoroughly investigate the allegation. Interview with the Administrator, on 04/26/18 at 6:10 PM, revealed staff made him aware of allegations related to Resident #73 hitting other residents on 04/25/18. He stated he would need to reeducate staff on the abuse policy and procedure intervention related to confused residents hitting other residents.