Based on interview, record review, and review of facility policy, the facility failed to ensure medication was administered according to professional standards of practice for one of 25 sampled residents, Resident (R) 81. This failure placed R81 at risk for inappropriate behavior, confusion, and disorientation. The findings include: Review of the facility's policy titled, Medication Administration Standard of Practice, dated 10/2020, revealed Medications will be administered in a safe and timely manner, and as prescribed .Medications must be administered in accordance with the orders, including any required time frame .The individual administering the medication must sign the resident's MAR/TAR [Medication Administration Record/ Treatment Administration Record] after giving each medication, along with any additional prior or follow up requested information. Review of R81's undated admission Record located in the resident's electronic medical record (EMR) under the Resident tab, revealed the facility admitted the resident on 01/26/2024 with diagnoses which included lung cancer under Hospice care. Review of R81's Telephone Physician's order, provided by the facility, revealed orders for Ativan Intensol [anti-anxiety medication] [two] 2 mg [milligram] per [one] 1 ml, [one] 1 ml [milliliter] by mouth every [six] 6 hours for anxiety and sleep. This telephone order was undated and untimed, had no physician's signature, and was not placed into the Electronic Medical Record (EMR) order system. Review of the Patient Controlled Substance Administration Record-Liquids form, revealed Registered Nurse (RN) 3 signed as receiving 30 ml of Ativan from pharmacy on 03/14/2024. A sticker from pharmacy was attached to the controlled substance record which revealed R81's name and Lorazepam 2 mg/ml, generic for Ativan. Give 0.5 ml (1MG) by mouth every [six] 6 hours as needed for up to 10 days. Kentucky Medication Aide (KMA)1 initialed the form to indicate a 1.0 ml dose of Ativan was administered to R81 on 03/14/2024 at 0000 [12:00 AM], leaving a balance of 29 ml. [Therefore, 2 mg was administered instead of the 1 mg that was to be administered according to the sticker on the controlled substance record.] Review of R81's Medication Administration Record (MAR), dated March 2024, located in the resident's EMR under the MAR/TAR [Treatment Administration Record] tab, revealed no record of the Ativan medication being administered. Review of R81's Progress Note, dated 03/14/2024 at 6:42 AM, located in the EMR under the Documentation tab and the Progress Note tab, revealed Resident received new order for PRN [as needed] Ativan Intensol with medication delivered from pharmacy last night. First dose administered as requested. Soon after administration, the resident became very confused and disoriented. Staff entered the room to find [R81] undressed and sitting on the edge of his bed. [R81] was making multiple sexually inappropriate comments toward all staff but could be verbally redirected. Resident soon calmed and rested the remainder of the shift. Spoke with pharmacy about the directions on the medication bottle. The physician wrote an order for [one] 1 ml every [six] 6 hours PRN; however, the bottle read 0.5 ml every [eight]8 hours PRN [as needed]. Clarification from physician this morning was to follow directions as filled on script for 0.5 ml every 8 hours PRN. Review of a second telephone order provided by the facility, revealed an order clarification dated 03/14/2024, at 7:15 AM, for Ativan Intensol [two] 2 mg/ml, 0.5 ml by mouth every [six] 6 hours as needed PRN. Registered Nurse (RN)3 signed the order. During an interview, on 07/26/2024 at 6:55 AM, RN3 stated, The KMA gave the medication to the resident. I called the physician to confirm the dosage and write the new order that the physician signed. The Surveyor attempted to interview KMA1 by phone; however, the KMA did not respond to the calls. During an interview, on 07/25/2024 at 3:30 PM, the Director of Nursing (DON) stated, The order lacks the date and time as it was written, who wrote the order, and if the order was a verbal order. This is an incomplete order, and the resident was given the wrong dose according to the pharmacy label on the narcotic count sheet. During an interview, on 07/25/2024 at 4:16 PM, the Medical Director stated, I do not write a paper medication order. All orders are in the EMR. I would never write an order for Ativan. During an interview, on 07/26/2024 at 3:34 PM, the Administrator stated, My expectation for the medication administration is that nursing follows the protocols for professional standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to administer a tube feeding as ordered by the physician for one (1) of two (2) residents reviewed for tube feeding out of a total sample of of 25 residents, Resident (R) 51. This failure had the potential for unplanned weight loss. The findings include: Review of R51's undated Face Sheet located under the Face Sheet tab of the electronic medical record (EMR), revealed R51 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included cerebral aneurysm, chronic obstructive pulmonary disease, respiratory failure with hypoxia, gastrostomy status, and tracheostomy status. Review of R51's Physician's Orders located under the Orders tab in the EMR, revealed an order, dated 06/05/2024, for Glucerna 1.5 calorie 1210 ml/day (milliliters per day) at 55 cc/hour (cubic centimeters per hour) by gastrostomy for 22 hours and to have a 50 cc/hour water flush for 20 hours per day. Review of R51's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/27/2024, revealed the facility assessed the resident as having short term and long-term memory loss; and as never/rarely making decisions. R51 was also assessed as having a gastrostomy feeding tube. Review of R51's care plan, dated 06/30/2024 and located under the Care Plan tab of the EMR, revealed .there will be no significant weight changes and tolerate enteral feedings/flushes . with an intervention of .Enteral feedings & [and] flushes per [by] order . During an observation, on 07/26/2024 at 12:22 PM, R51's tube feeding pump was noted to be infusing Glucerna 1.5 calorie at 50 cc/hour. During an interview, on 07/26/2024 at 1:02 PM, Licensed Practical Nurse (LPN) 1 stated, I always come into work and check to make sure the feeding is infusing. But to be very honest, I don't always check to make sure the rate is correct, but I should. When asked if she checked the infusion rate this morning, LPN1 stated, I don't remember if I did. During an interview, on 07/26/2024 at 1:30 PM, the Director of Nursing (DON) confirmed the nurse should always check to make sure the enteral feeding pump was set to infuse the rate of the feeding as ordered by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, the facility failed to ensure pain assessments were completed prior to and after the administration of PRN (as needed) narcotic pain medications for one (1) of two (2)sampled residents reviewed for pain management out of 25 sampled residents, Resident (R)19. R19 was ordered and administered pain medication; however, there was no documented evidence pre or post pain assessments were completed to measure if the medication was effective to ensure the resident's pain was being managed. This failure placed the resident at risk for a decreased quality of life related to uncontrolled pain. The findings include: Review of the facility's policy titled, Pain Management Standard of Practice, dated 07/2020, revealed The facility works to ensure compliance with the regulatory intent of F697, that pain management is provided to residents consistent with professional standards of practice, the comprehensive care plan, and the resident's goals and preferences .5. Monitoring for effectiveness and/or adverse consequences . Review of R19's undated admission Face Sheet, located in the resident's electronic medical record (EMR) under the Face Sheet tab, revealed the resident was readmitted to the facility on [DATE] with diagnoses which included chronic pain syndrome and polyneuropathy. Review of R19's Pain care plan, initiated 02/19/2020 and located in the resident's EMR under the Care Plan tab, revealed the resident's Care Plan identified the following problems: Patient has chronic pain in neck and shoulders; Dx [diagnosis] chronic pain syndrome; Dx Polyneuropathy; Resident returned to facility from pain clinic . [Pain Clinic Physician's Name] has now turned over pain management to [Resident's Attending Physician's Name] .[Resident's Attending Physician's Name] sent script at this time. Resident aware and verbalizes understanding; [R19's Name] has chronic pain r/t [related to] impaired mobility, contractures, and dx of OA [Osteoarthritis]. R19 Care Plan goal stated, Will not experience unrelieved pain through next review. R19's Care Plan included interventions of: .Administer medications as ordered and observe for effectiveness and side effects .Notify physician of any unrelieved s/s [signs/ symptoms] of pain . Review of R19's significant change in status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/20/2024 and located in the MDS tab of the electronic medical record (EMR), revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating intact cognition. The facility further assessed R19 as being on a scheduled pain management regimen, receiving PRN (as needed) pain medications, and frequently having pain during the assessment period. Review of R19's Physician orders located in the resident's EMR under the List tab, revealed an order, dated 05/20/2024, for Hydromorphone [narcotic pain medication] 2 mg [milligram] by mouth every [six] 6 hours as needed . Review of R19's Medication Administration Record (MAR), dated July 2024, revealed the resident was being administered the hydromorphone 2 mg tablet medication PRN (as needed). Continued review of R19's MAR revealed no documented evidence the resident's pain was being assessed prior to the administration of the pain medication, nor was the resident's pain being assessed post administration of the pain medication to measure the effectiveness of the pain medication, as of 07/24/2024. During an interview, on 07/24/2024 at 11:51 AM, R19 stated she felt like the facility could do better about controlling her pain. When asked to elaborate, the resident stated once her pain medications took effect, then her pain was better. The resident stated she just received her pain medication with her noon medications, about 30 minutes ago, and she would now rate her pain as a seven (7) out of 10 with 10 being the worse pain possible. During a subsequent interview, on 07/24/2024 at 4:00 PM, R19 stated the nurse came and explained to her she could have her pain medication every six (6) hours if she needed it. R19 further stated she thought her pain medication was scheduled and she did not know she could ask for it after six (6) hours of receiving a dose of pain medication. During record review and interview, on 07/24/2024 at 3:35 PM, Licensed Practical Nurse (LPN) 4 reviewed R19's MAR, dated July 2024, and confirmed there was no documented evidence the resident's pain was being assessed prior to the administration of the PRN pain medication of hydromorphone, nor post administration of the PRN pain medication. LPN4 stated the resident's MAR did not contain a pre or post pain level, but should have. The LPN stated normally when a resident was ordered a PRN pain medication, the MAR would automatically populate a pre and post section to document the assessments. LPN4 further stated it was important to complete a pre and post pain assessment to ensure the resident's pain was being managed appropriately. During an interview, on 07/26/2024 at 5:16 PM, the Director of Nursing (DON) stated it was her expectation R19's pain would have been assessed before and after the administration of her PRN pain medication. The DON further stated this was important to ensure the medication was effective. During an interview with the Administrator, on 07/26/2024 at 5:18 PM, he was questioned regarding the need for pain assessments before and after administration of pain medication. He stated he was not clinical and deferred to the DON.

Based on observation, interview, and record review, the facility failed to ensure residents were free from unnecessary medications for two (2) of six (6) residents reviewed for unnecessary medications out of a total of 25 sampled residents, Resident (R)79 and R11. This failure placed both residents at risk for side effects such as drowsiness and sedation. R79 was ordered Lorazepam (fast-acting antianxiety medication) with no stop date to reevaluate the medical necessity of the medication. Additionally, R11 was ordered and routinely administered Hydroxyzine HCI (an antihistamine medication) for itching; however, the medication was being used to control the resident's behavior. The findings include: 1. Review of R79's undated admission Face Sheet, located in the resident's electronic medical record (EMR) under the Face Sheet tab, revealed the facility admitted the resident on 05/31/2023 and most recently readmitted the resident on 02/12/2024, with diagnoses which included generalized anxiety disorder (GAD) and restless leg syndrome. Review of R79's Physician's orders located in the resident's EMR under the List tab, revealed an order, dated 03/22/2024, for Lorazepam (fast-acting antianxiety medication) Oral Concentrate two (2) MG/ML (milligram/milliliter), one (1) ml By Mouth Every four (4) hours as needed. The order did not have a stop date. Review of R79's Medication Regimen Review (MRR), dated 03/26/2024 and provided by the facility, revealed a pharmacy recommendation of Per CMS [Centers for Medicare and Medicaid Services], PRN psychotropic medications are limited to 14 days (no exceptions). If use is beyond 14 days, the rationale and an estimated duration of use must be documented. Please add an estimated duration of use to prn Lorazepam for CMS compliance. The Medical Director responded to the recommendation by marking Resident is comfort measures-90 day stop date. Review of R79's Physician's orders located in the resident's EMR under the List tab, revealed a current order dated 05/30/2024 for Lorazepam Oral Concentrate 2 MG/ML, 1.5 ml By Mouth Every four (4) hours as needed. The order did not have a stop date. This order also included for Comfort Measures Only . Review of R79's Medication Administration Record (MAR), dated July 2024 and located in the resident's EMR under the MAR/TAR [Treatment Administration Record] tab, revealed the resident was ordered and administered the PRN (as needed) Lorazepam for agitation. The MAR revealed the resident was administered the Lorazepam on 07/01/2024, 07/08/2024, and 07/09/2024. During an interview and record review, on 07/25/2024 at 3:16 PM, the Medical Director who was also R79's Attending Physician, reviewed the orders and confirmed there was no stop date on the PRN Lorazepam. The Medical Director stated R79 was on end-of-life comfort care, and she was not aware a stop date was needed for the medication since the resident was on comfort care. During an interview, on 07/26/2024 at 5:22 PM, the Director of Nursing (DON) stated it was her understanding that a stop date for a PRN antianxiety medication was needed for a resident on comfort care. 2. Review of R11's undated admission Face Sheet, located in the resident's EMR under the Face Sheet tab, revealed the facility admitted the resident on 11/03/2016 and most recently readmitted the resident on 11/22/2022, with diagnoses which included bipolar disorder, cerebral palsy, and generalized anxiety disorder. Review of R11's Physician orders located in the resident's EMR under the List tab, revealed a current order, originally dated 10/04/2023, for Hydroxyzine HCI [an antihistamine medication with anticholinergic side effects] Oral tablet 25 mg, [one] 1 tablet via G-Tube [Gastric Tube] TID [three times a day] .for itching. Review of R11's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/17/2024 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident was cognitively intact. The assessment also revealed the resident had not engaged in any behaviors during the assessment period. Review of R11's MARs, dated October 2023, November 2023, December 2023, January 2024, February 2024, March 2024, April 2024, May 2024, June 2024, and July 2024 and located in the resident's EMR under the MAR/TAR tab, revealed the hydroxyzine medication was initialed as administered three (3) times a day as ordered except for the following dates: 11/16/2023 (one dose), 12/05/2023 (one dose), 01/12/2024 (two doses), 01/19/2024 (one dose), 02/22/2024 (one dose) and 06/21/2024 (one dose). An observation and interview with R11 was conducted on 07/23/2024 at 2:52 PM, in the presence of Licensed Practical Nurse (LPN) 4. When R11 was questioned if he had ever had any problems with his body itching, he stated No. Due to the resident having expressive communication deficit, LPN4 confirmed R11's answer was, No. LPN4 stated R11 had never complained to her of any itching; however, the resident did engage in the behavior of scratching his legs. Further observation revealed R11 had dressings on both legs. During a subsequent interview, on 07/24/2024 at 9:19 AM, R11 was questioned if he had any itching episodes overnight, and the resident stated, No. R11 was observed to be lying in his bed watching tv. During an interview, on 07/24/2024 at 3:48 PM, Certified Nursing Assistant (CNA) 4 stated she was often assigned to R11 and was familiar with him. CNA4 stated R11 had never complained to her about itching, and she had never observed him scratching himself from body itching. CNA4 further stated R11 used to scratch his legs a lot; however, this was a behavior when his call light was not answered quick enough. The CNA stated the resident would also engage in behaviors of yelling or putting himself on the floor. During an interview, on 07/24/2024 at 3:51 PM, CNA5 stated R11 had never complained to her about itching and she had never observed him scratching his body. During an interview, on 07/25/2024 at 3:16 PM, the Medical Director stated hydroxyzine was normally ordered and administered for itching. However, the Medical Director stated she ordered the medication for R11 more for behaviors and less for itching. The Medical Director further stated when she put the electronic order in, the drop down only had two diagnoses for hydroxyzine, anxiety and itching. In continued interview the Medical Director further stated the resident had wounds to his legs from him scratching himself, which was a behavior, and this was during a bad period of acting out. She stated she should have only ordered the medication for 10 days and stopped it after that. During an interview, on 07/26/2024 at 5:27 PM, the Director of Nursing (DON) stated it was her expectation the Medical Director would have followed the regulatory requirement for the use of the hydroxyzine medication. During an interview, on 07/26/2024 at 5:53 PM, the Administrator stated it was his expectation the Medical Director would have followed the regulatory guidance when prescribing the hydroxyzine medication.

Based on observation, interview, record review, and review of facility policy, 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. The facility failed to follow infection control guidelines and facility policy during wound care dressing changes for three (3) of three (3) residents reviewed for wound care out of a total sample of 25 residents, Resident (R) 84, R19, and R81. The findings include: Review of the facility's policy titled, Skin Care Standard of Practice, dated 07/2020, revealed, .A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing . Review of the facility's undated Clean Wound Dressing Change competency for the nursing staff, revealed .Remove old dressing .Discard soiled dressing and gloves in plastic bag. Wash hands. [NAME] [put on] gloves .Pour sterile solution over gauze/cotton swabs using a basin or pouring over plastic bag. Cleanse wound using gauze/swabs from center outward in spiral motion with gentle pressure .Note on dressing: date, time dressing changed, and initials . 1. Review of R84's undated Face Sheet located in the resident's electronic medical record (EMR), under the Face Sheet tab, revealed the facility re-admitted the resident on 05/07/2024 with diagnoses of stage IV pressure ulcers to the right and left buttocks. Review of R84's Care Plan located under the Care Plan tab of the EMR, dated 03/21/2024, revealed a Goal stating .open areas will heal without worsening or complications . Interventions put into place included: Foley catheter to assist in wound healing; Mattress - pressure reduction; Provide gentle support when turning/positioning/transferring, and Provide pressure ulcer care as ordered. Review of R84's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/06/2024, revealed the facility assessed the resident as having two (2) stage IV pressure ulcers that were facility acquired. Review of the Physician Orders located in the resident's EMR under the List tab, revealed an order, dated 07/25/2024 to: .Cleanse area to Right Buttocks with wound cleanser and pat dry. Pack wound with Iodoform Packing Strip and cover with border gauze daily . Review of the Physician Orders located in the resident's EMR under the List tab revealed an order dated, 07/25/2024 to: .Cleanse area to the Left Buttock with wound cleanser and pat dry. Mix collagen powder with Medi honey and apply to wound. Cover with border gauze daily. During a wound care observation, on 07/26/2024 at 9:15 AM, with Licensed Practical Nurse (LPN) 2, the following failures were noted: 1) The scissors were cleaned with an alcohol prep pads prior to cutting the Iodoform packing strip gauze; 2) The over bed table was not cleaned prior to laying the barrier down on top of it; 3) LPN2 removed the resident's right buttock dressing, then while exposed the resident was turned to the other side. She then removed the left buttock dressing; 4) LPN2 removed her dirty gloves, then without performing hand hygiene, she applied clean gloves; 5) LPN2 cleaned the left buttock wound with a 4 x 4, then folded the 4 x 4 over and cleaned the wound again using the same 4 x 4; and 6) LPN2 sprayed the wound cleanser directly into the left buttock wound prior to cleaning the wound, and then applied Medi honey into the left buttock wound using a gloved finger. During an interview on 07/26/2024 at 5:55 PM, LPN2 stated, I only know to clean my scissors with the alcohol preps before using them on a dressing change. I realized I did not clean the over bed table with a bleach wipe when I laid the barrier down. When I was performing the wound care, I remembered that I needed to dress one wound then go to the other one, but that was after I started and had already removed the dressings on both areas. I did not realize that I had used my gloved finger to apply the ointment into the left buttock wound until we started talking about it just now. I should have used a Q-Tip, and I should have sprayed the wound cleanser to the 4 x 4 instead of spraying it directly into the wound. 2. Review of R19's undated Face Sheet located under the Face Sheet tab in the EMR revealed the facility re-admitted the resident on 05/17/2024 with diagnoses including an unstageable pressure ulcer to the right calf and a stage II pressure ulcer to the right heel. Review of R19's Care Plan located under the Care Plan tab of the EMR, dated 05/08/2024, revealed a Goal stating .skin impairments will show signs of healing . Interventions included: Assist with turning/positioning; Provide diet/fluids as ordered; Provide pressure redistribution cushion to chair; Pressure redistributing mattress to bed to promote skin integrity; and Provide treatments as ordered. Review of R19's significant change MDS with an ARD of 05/20/2024, revealed the facility assessed the resident as having an unstageable pressure ulcer to the right calf and a stage II pressure ulcer to the right heel which were present on admission to the facility. Review of the Physician Orders located in the EMR under the List tab, revealed an order, dated 07/25/2024, to .Cleanse area to right calf with wound cleanser and pat dry. Moisten collagen sheet with normal saline and cut to size of the wound bed. Apply collagen sheet to wound bed. Moisten calcium alginate sheet with normal saline and cut to size of wound bed. Apply calcium alginate to wound bed over collagen. Apply superabsorbent dressing and cover with ABD [abdominal gauze] pad. Wrap with Kerlix from just below the knee to ankle daily. Review of the Physician Orders located in the EMR under the List tab, revealed an order, dated 07/25/2024, to .cleanse wound to Right heel with wound cleanser and pat dry. Apply Medi honey and cover with border gauze daily. During a wound care observation, on 07/26/2024 at 9:45 AM, with Registered Nurse (RN) 1, the following failures were noted: 1) The over bed table was not cleaned prior to placing the barrier on the table; 2) The privacy curtain was touching the clean barrier on the over bed table where dressing supplies were located; 3) The bottle of wound cleanser was stored in the bedside table and was placed on the clean barrier without wiping it with a disinfectant wipe prior to wound care; 4) RN1 obtained Medi honey ointment from the original tube by using a Q-Tip and applied the ointment by spreading it to the outer edges of the wound first, then into the center of the wound on the right heel; 5) RN1 cleaned the wound to the right calf, then with the same soiled gloves, applied clean dressings as ordered with clean dressing supplies; 6) RN1 cleaned the wound to the right calf by wiping the 4 x 4 the length of the wound and did not use a circular motion; 7) RN1's dirty gloves touched the privacy curtain prior to removing them after the dressing change to the right calf; 8) The clean dressings were applied to the right heel and to the right calf with no dates documented on the dressings; and 9) RN1 took the dirty scissors back to the Medication Storage room in the rehab unit where clean supplies were kept. RN1 washed the scissors with soap and water, dried them, and placed the scissors back into the wound care cart. During an interview, on 07/26/2024 at 5:45 PM, RN1 stated, I know right off, I should have cleaned the over bed table with a wipe prior to starting. I sat the wound cleanser on the clean barrier, and I should not have. I realized when I was getting the Medi Honey out of the container that I should have placed it in a medicine cup and not brought the container into the resident's room, and I should have changed my gloves between cleaning and redressing the wound. I forgot to date the dressings that I had applied. When asked if RN1 should have taken the dirty scissors into the medication storage room where the clean dressing supplies were kept, RN1 replied, No. When asked if she should have used the disinfectant wipes to clean the scissors instead of using soap and water, RN1 replied, Yes I should have used the wipes. 3. Review of R81's undated Face Sheet located under the Face Sheet tab in the EMR revealed the facility admitted the resident on 01/26/2024 with diagnoses including an unstageable pressure ulcer of the right heel, diabetes, and peripheral vascular disease. Review of R81's quarterly MDS with an ARD of 05/03/2024, revealed the facility assessed the resident as having a stage IV pressure ulcer to the right heel which was facility acquired. Review of R81's Care Plan located under the Care Plan tab of the EMR, dated 03/04/2024, revealed a Goal stating .wounds will shoe [sic] improvement/heal . Interventions included: Float heels off mattress as resident will allow; Pressure reduction mattress; Treatment as ordered; and Provide gentle support when turning/positioning/transferring. During an observation, on 07/26/2024 at 11:15 AM with RN2, the following failures were noted: 1) The over bed table was not cleaned with a disinfectant wipe prior to placing the barrier down; 2) RN2 cleaned the wound, then used a 4 x 4 to wipe the wound twice without using a different area of the 4 x 4 for each time the wound was wiped. During an interview, on 07/26/2024 at 5:40 PM, RN2 stated, I didn't clean the over bed table with a wipe before I placed the barrier down and I should have. I should have used a clean 4 x 4 each time I wiped the wound or used a different area of the 4 x 4 each time. During an interview, on 07/26/2024 at 6:10 PM, the Director of Nursing (DON)stated, The over bed tables should have been cleaned with a disinfectant wipe prior to placing the barrier down. The nurses should change gloves after a wound is cleaned and before applying the clean dressings. The dressings should be timed and dated when the clean dressing is applied. Scissors should be cleaned with a disinfectant wipe and not soap and water before and after each dressing change. The nurse's dirty gloves should not touch the privacy curtain because you have contaminated the curtain when you do that. If the nurse is dressing two wounds, they should be treated as two different wounds. Each being dressed before the nurse moves on to the next wound. The wound cleanser should be sprayed on a 4 x 4 and not directly into the wound. When the nurse cleans a wound, they should start in the center cleaning in a circular motion and working their way out to the edges of the wound. The nurse can discard the 4 x 4 each time the wound is cleaned, or they can use a different area of the 4 x 4 to clean the wound. The wound cleanser bottle should not be placed on the clean barrier. Any type of ointment should be placed in a medicine cup and the tube or container should not be taken in the resident's room. This should be applied with a clean Q-Tip.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the Resident Council's right to have their group meeting without staff present was honored and promoted for seven (7) of seven (7) residents reviewed for Resident Council resident rights out of a total sample of 25 residents, Resident (R)6, R12, R21, R38, R54, R56, and R63. This failure violated the residents' right to autonomy and to be able to bring up concerns without staff present. The findings include: R6, R12, R21, R38, R54 (Resident Council President), R56, and R63 attended the Group Interview conducted by the Surveyor on 07/25/2024 at 10:00 AM, in the Main Dining Room. Observation on 07/25/2024 at 10:00 AM, revealed two (2) activity staff and a dietary staff member sitting in the dining room for the meeting. When the Surveyor explained to the facility staff, the Group Interview meeting was closed to staff members of the facility unless a resident requested their presence, the staff exited the meeting. During the Group Interview, on 07/25/2024 at 10:06 AM, the group was asked if they regularly attended the Resident Council meetings. R38 stated she used to; however, she did not regularly attend anymore because staff ran the council meeting and not the residents. In continued interview, R38 stated in November 2023 or December 2023, she approached the Activity Director (AD) who ran the group, and explained to her the residents were supposed to be the ones who ran the group and not her. However, the AD informed R38, she was the one who had to conduct the meeting. R38 stated it was not a safe space if they had a concern about staff, but could not fully express it in fear of staff not keeping it confidential. All residents agreed with R38's concern. 1. Review of R6's undated admission Face Sheet, located in the resident's Electronic Medical Record (EMR) under the Face Sheet tab, revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Review of R6's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/17/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated intact cognition. 2. Review of R12's undated admission Face Sheet, located in the resident's EMR under the Face Sheet tab, revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Review of R12's quarterly MDS with an ARD of 05/30/2024, revealed the facility assessed the resident to have a BIMS score of 13 out of 15 which indicated intact cognition. 3. Review of R21's undated admission Face Sheet, located in the resident's EMR under the Face Sheet tab, revealed the resident was admitted to the facility on [DATE]. Review of R21's quarterly MDS with an ARD of 05/07/2024, revealed the facility assessed the resident to have a BIMS score of 15 out of 15 which indicated intact cognition. 4. Review of R38's undated admission Face Sheet, located in the resident's EMR under the Face Sheet tab, revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Review of R38's quarterly MDS with an ARD of 05/10/2024, revealed the facility assessed the resident to have a BIMS score of 15 out of 15 which indicated intact cognition. 5. Review of R54's undated admission Face Sheet, located in the resident's EMR under the Face Sheet tab, revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Review of R54's quarterly MDS with an ARD of 05/17/2024, revealed the facility assessed the resident to have a BIMS score of 15 out of 15 which indicated intact cognition. 6. Review of R56's undated admission Face Sheet, located in the resident's EMR under the Face Sheet tab, revealed the resident was admitted to the facility on [DATE] and most recently readmitted on [DATE]. Review of R56's quarterly MDS with an ARD of 06/04/2024, revealed the facility assessed the resident to have a BIMS score of 15 out of 15 which indicated intact cognition. 7. Review of R63's undated admission Face Sheet, located in the resident's EMR under the Face Sheet tab, revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Review of R63's quarterly MDS with an ARD of 06/07/2024, revealed the facility assessed the resident to have a BIMS score of 15 out of 15 which indicated intact cognition. During an interview, on 07/25/2024 at 10:54 AM, the AD stated she had been in her position since December 2023. When asked if residents could have the Resident Council meeting without her or other staff present, the AD stated she had been told she was required to attend the Resident Council meetings. The AD did not remember who told her she was required to attend the meetings. The AD further stated she did remember R38 telling her the meetings were to be run by the residents and not the staff and the residents did not want staff to attend. However, the AD stated she was not aware residents could hold the meetings without staff present. During an interview, on 07/26/2024 at 5:34 PM, the Administrator stated it was his expectation the facility would follow the regulatory requirement to allow residents privacy during the resident council group.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy, the facility failed to issue the resident or their representative a written notification of transfer when the resident was transferred to the hospital for five (5) of five (5) sampled residents reviewed for emergency transfers out of a total sample of 25 residents, Resident (R)29, R36, R48, R73, and R199. The facility did not have a system in place for sending written notification of transfer to residents or their representatives. This created the potential for the resident and/or their representative to have incomplete information related to the reason for transfer, location of transfer and/or how to appeal the transfer, if desired. The findings include: Review of the facility's policy titled, Admission, Discharge, and Transfer Standard of Practice, dated 10/2020, revealed the purpose of the policy is to ensure the process of admission, discharge, and transfer meets regulatory requirements. Discharge/Transfer: . 2. Before the facility transfers or discharges a resident, the facility shall a) Notify the resident and resident representative to include the reason in a language and manner they understand .c) Notice of transfer or discharge will be made with at least 30 days notice for a safe transition; or as soon as practicable when .iii. An immediate transfer or discharge is required due to urgent medical needs. Further review of the policy, revealed it failed to address the requirement to provide written notice to the resident and the resident's representative(s) regarding transfer. 1. Review of R29's undated admission Face Sheet located in the resident's Electronic Medical Record (EMR) under the Face Sheet tab, revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). Review of R29's EMR Progress Notes, located under the Progress Notes tab, revealed the Nurse's Status Note, dated 06/12/2024, stated new orders were received to send the resident to the hospital emergency room (ER) to evaluate and treat. The Assistant Director of Nursing (ADON) and Power of Attorney (POA) were notified. Further review of R29's EMR, revealed there was no documented evidence of a written transfer notice sent to the resident/resident representative regarding the hospital transfer on 06/12/2024. 2. Review of R36's undated admission Face Sheet, located in the resident's EMR under the Face Sheet tab, revealed the resident was admitted to the facility on [DATE] and most recently readmitted to the facility on [DATE] with diagnoses which included bipolar disorder, COPD, and chronic respiratory failure. Review of R36's Nurse's Progress Note, dated 03/08/2024 and located in the resident's EMR under the Progress Notes tab, revealed, At 1500 [3:00 PM] Resident was found on floor left side of bed face down .resident had just been in bed she had been very restless and anxious unable to redirect .resident assessed no injury noted no c/o [complaints of] or s/s [signs/ symptoms] of pain. Resident assisted back into bed per staff resident refused to let nurse get vitals and obtain full set of neuros .resident taking off O2 [oxygen] wont [sic] leave it on ripping out her hair very anxious and restless .call placed to [Medical Director] gave orders to send out to ER for eval [evaluation]. Call placed to EMS [Emergency Medical Services]. EMS arrived and took the resident out of facility at 1530 [3:30 PM]. Further review of R36's EMR, revealed there was no documented evidence of a written transfer notice sent to the resident/resident representative regarding the hospital transfer on 03/08/2024. Review of R36's Nurse's Progress Note, dated 04/03/2024 and located in the resident's EMR under the Progress Notes tab, revealed, Resident arrived [readmitted ] at facility by stretcher per EMS and taken to her room . Review of R36's discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/25/2024 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. During an interview, on 07/24/2024 at 12:05 PM, R36 was questioned related to what kind of paperwork she received during her most recent transfer to the hospital. R36 stated she did not remember the facility giving her any written paperwork. 3. Review of R48's undated admission Face Sheet, located in the EMR under the Face Sheet tab, revealed the facility admitted the resident on 01/18/2024 and readmitted the resident on 06/03/2024, with diagnoses which included polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body) and chronic kidney disease. Review of R48's EMR Progress Notes, located under the Progress Notes tab, revealed the Nurse's Status Note, dated 05/30/2024, stated, Resident being transported non-emergent via EMS [Emergency Medical Service] to the hospital at this time; r/t [related to] x-ray report of likely fracture to femoral head. Resident left facility at 11:15 AM. Direct admit to [room number]. All parties aware . Further review of R48's EMR, revealed there was no documented evidence of a written transfer notice sent to the resident/resident representative regarding the hospital transfer on 05/30/2024. During an interview, on 07/23/2024 at 1:50 PM, Family member (F) 48 stated, I did not receive anything in writing from the facility about her transfer to the hospital. 4. Review of R73's undated admission Face Sheet, located in the resident's EMR under the Face Sheet tab, revealed the resident was admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included unspecified dementia and type II diabetes mellitus with hyperglycemia. Review of R73's Nurse's Progress Note, dated 06/14/2024, located in the resident's EMR under the Progress Notes tab, revealed, Resident noted with gradual decline so far this shift. Refuses to keep NC [nasal cannula] in place, O2 [oxygen] sat [saturation] declines to 75-84% [percent] on RA [room air]. Staff attempt to replace NC without success. Phoned [Medical Director] to make aware and received order for 40 mg [milligram] IM [intramuscular] Lasix [a diuretic medication]. BP [blood pressure] 100/48 so unable to administer Lasix safely. Attempted to notify [Medical Director] but on call hours had began [sic]. Phoned on call MD [medical doctor] .Order received to send resident to .ED [emergency department] for evaluation. EMS here at 12:10 [PM] to transport resident. Further review of 73's EMR, revealed there was no documented evidence of a written transfer notice sent to the resident/resident representative regarding the hospital transfer on 06/14/2024. Review of R73's readmission Nurse's Progress Note, dated 06/15/2024 and located in the resident's EMR under the Progress Notes tab, revealed Resident arrived to facility per EMS at 1500 [3:00 PM] transferred to bed per EMS and staff . During an interview, on 07/23/2024 at 12:41 PM, Family Member (F) 73 stated she had received bed hold notices and policies during R73's hospital transfers; however, she had never received anything in writing about the resident's transfer including appeal rights. 5. Review of R199's undated admission Face Sheet located in the EMR under the Face Sheet tab, revealed the facility admitted the resident on 07/10/2024 and readmitted the resident on 07/22/2024, with diagnoses which included femur fracture and Chronic Obstructive Pulmonary Disease (COPD). Review of R199's EMR Progress Notes located under the Progress Notes tab, revealed the Nurse's Status Note, dated 07/19/2024, stated Resident ambulating from room to hallway and fell. As she attempted to ambulate around her w/c [wheelchair] she tripped on the left w/c leg/pedal . ROM [Range of Motion] severely limited, length disproportionate. MD [Medical Doctor] notified with new orders to send to ER [Emergency Room] to eval [evaluate] and treat. Emergency contact- Husband [name] notified at this time . Further review of R199's EMR, revealed there was no documented evidence of a written transfer notice sent to the resident/resident representative regarding the hospital transfer on 07/19/2024. During an interview, on 07/25/2024 at 1:15 PM, the Administrator stated, We do not provide written notification of transfers to the resident or their representative.

Based on observation, interview, and review of facility policies, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. These failures had the potential to affect all 95 residents in the facility who consumed food from the kitchen. The findings include: Review of the facility's policy titled, Food Storage: Cold Foods, dated 02/2023, revealed All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA [Food and Drug Administration] Food Code .All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of the facility's policy titled, Environment, dated 09/2017, revealed All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition .The Dining Services Director will ensure that all employees are knowledgeable in the proper procedures for cleaning and sanitizing of all food service equipment and surfaces .All food contact surfaces will be cleaned and sanitized after each use. On 07/23/2024, the following observations in the kitchen were identified and verified by the Dietary Manager (DM) and the District Manager. 1. Observation at 8:43 AM, revealed the freezer contained one (1) bag of hamburgers, (1) bag of cookie dough and one (1) bag of dinner rolls that were not sealed. 2. Observation at 9:00 AM, revealed the sanitizer was not dispensing sanitizer from the Eco Lab dispenser; therefore, the sanitizing part of the three (3) pan sink, and red sanitizing buckets had no sanitizer in them. The Surveyor asked the Dietary Manager to test the sink and the red bucket for sanitizer. No sanitizer registered with the test strips. The DM then added the sanitizer to the sink by hand and mixed it with water and the sanitizer registered. 3. Observation at 11:00 AM, revealed 60 plastic drinking cups and coffee mugs to be used for lunch were not allowed to air dry and were wet on the inside. They were stored stacked in a plastic container beside the tray line to be used for lunch. During this observation, the Dietary Manager asked dietary staff to rewash the cups. 4. Observation at 11:00 AM, revealed there were five (5) plastic cups that had a dried milky like substance and what appeared to be dried food particles on the inside of the cups that were to be used for lunch. The plastic cups were stacked in the dish washing room. During this observation, the Dietary Manager asked dietary staff to rewash the cups. 5. Observation at 11:00 AM, revealed there were six (6) dirty plates with what appeared to be dried food particles in the plate warmer that were ready to be used for lunch. They were stacked in the plate warmer beside the tray line. During this observation, the Dietary Manager asked dietary staff to rewash the plates. 6. Observation at 11:00 AM, revealed the dirty dishes and dishwasher were in the same room with clean dishes. When the dirty dishes and trays came through a window, a dietary staff member sprayed them before sending the dishes through to the dishwasher. The dirty spray from the dirty dishes was contaminating the clean cups and dishes which were on a rack in the same room. 7. Observation at 11:00 AM, revealed the 32 kitchen trays the residents used to serve the residents their meals had plastic pieces missing from the corners and edges. Interview with the Dietary Manager during the observation revealed new trays had been ordered. During an interview on 07/26/2024 at 3:26 PM, the District Manager stated, It is my expectation for the kitchen to be fully functional, sanitary, and timely. During an interview on 07/26/2024 at 3:21 PM, the Administrator stated, It is my expectation for the kitchen to follow policies and standards.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, for two (2) of thirty-two (32) sampled residents (Residents #60 and #45). Observations on 03/05/19 revealed staff entered Resident #45's and #60's rooms without knocking on the door prior to entering. The findings include: Review of the facility's policy titled, Resident Rights Standard of Practice, last reviewed September 2017, revealed all residents have the right to be treated with respect and dignity. These rights will be promoted and protected by the facility. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to privacy and confidentiality. 1. Record review revealed the facility admitted Resident #45 on 01/14/19, with diagnoses which included Anxiety Disorder. Review of the admission Minimum Data Set (MDS) assessment, dated 01/21/19, revealed the facility assessed Resident #45's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fourteen (14) which indicated the resident was interviewable. Observation on 03/05/19 at 10:37 AM revealed Nurse Aide (NA) #1 entered Resident #45's room to retrieve his/her meal tray without knocking on the door and asking permission to enter. Interview with Resident #45 on 03/05/19 at 1:55 PM, revealed some staff enter his/her room without knocking. He/She stated, I guess they forget. 2. Record review revealed the facility readmitted Resident #60 on 01/25/19 with diagnoses which include Dementia. Review of the Quarterly MDS assessment, dated 02/01/19, revealed the facility assessed Resident 60's BIMS score as a seven (7) indicating the resident was not interviewable. Observation on 03/05/19 at 1:31 PM, revealed NA #1 entered Resident #60's room without knocking on the door and asking permission to enter. Interview with NA #1 on 03/05/19 at 3:31 PM, revealed she usually knocked on the residents' doors before entering, but she was in a hurry and may have forgotten do so. She stated she was taught during her orientation to knock before entering a resident's room because this was the resident's home. Interview with the Director of Nursing (DON) on 03/07/19 at 5:16 PM, revealed staff was taught during orientation to knock on the residents' doors prior to entering because this was the resident's home. She stated the facility did not have a policy worded to reflect knocking; however, the facility followed State and Federal regulations related to dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation of a G-tube (gastrointestinal) treatment, on 03/06/19 at 8:34 AM, in room [ROOM NUMBER] revealed the sink was not in use due to the sink being clogged and not draining. Licensed Practical Nurse (LPN) #2 stated she would go across the hall and wash her hands during the treatment. LPN #2 stated the sink had been clogged off and on for a few weeks. She revealed she had not put in a work order for Maintenance. 3. Observation on 03/06/19 at 9:28 AM during a skin assessment in room [ROOM NUMBER], revealed the sink in the room was holding water and draining extremely slow. LPN #2 stated the sink had been draining slowly for a few weeks. She stated she was not sure if the Maintenance Director had been contacted about the sinks. LPN #2 stated the process of getting the sink repaired was that she could call or page the Maintenance Director or fill out a work order and send to Maintenance. Interview with the Maintenance Director on 03/07/19 at 9:58 AM, revealed he had received a request for the sinks to be unclogged in rooms #227 and #230. The Maintenance Director presented a request to repair the sink that was dated 03/06/19. He stated LPN #2 had filled out the maintenance request and this was the only maintenance slip he had received about the sinks in rooms #227 and #230. Interview with the Maintenance Director on 03/25/19 at 3:57 PM revealed most of the time the toilets become clogged due to wipes being thrown into the commode instead of the trash. He stated when there is a lot of rain, the drains become sluggish; however, the sewer has never backed up into the facility. He stated when there has been six (6) to ten (10) inches of rain like now, the city sewer system will back up and then he has to have a plumber come out and unclog the lines at the street due to the increase flow from the rest of the area around the facility. Further interview revealed he and his assistant were in and out of the rooms and check on the drains. He stated, We usually go in on Mondays and Fridays to check the drains. He further stated his system to make sure maintenance issues were addressed was to keep two (2) trays at the maintenance door, one tray with blank work orders to be filled out by staff when maintenance issues were identified, and the second tray where the work order request should be placed. Interview with the Director of Nursing (DON) on 03/07/19 at 10:30 AM revealed she knew there had been some problems in some rooms with sinks not flowing properly due to all the recent rain. The DON stated she expected each room to have sinks in good repair with running water and unclogged sinks. Based on observation, interview, and review of facility's policy, it was determined the facility failed to provide maintenance services necessary to maintain an orderly, comfortable, and homelike interior in three (3) of sixty-four (64) residents' rooms. Observations, of room [ROOM NUMBER], on 03/05/19 revealed tiles in the bathroom that were uneven, cracked, and chipped, brown stained areas in the ceiling, and gouged and scraped wood trim along the walls. Further observation revealed large areas of peeling paint particles hanging from the wall. In addition, a storage cabinet in the room had multiple areas of chipping paint. Observation on 03/06/19, revealed a totally clogged sink in room [ROOM NUMBER]; and, room [ROOM NUMBER] had a slow running drain. The findings include: Review of the facility's policy, Position Description for Maintenance Director, not dated, revealed the duties are to direct, supervise, coordinate, and perform the activities of the maintenance department to ensure the center is maintained in good repair and all systems are in compliance with applicable safety and fire regulations and Federal, State, and local building codes to ensure a safe, comfortable environment. 1. Observation of room [ROOM NUMBER], on 03/05/19 at 10:29 AM revealed the tiles in the bathroom were uneven, cracked, and chipped. There were browned stained areas in the ceiling, gouged and scraped wood trim along the walls, and large areas of peeling paint particles hanging from the wall. In addition, a storage cabinet in the room had multiple areas of chipping paint. Interview with the Maintenance Director on 03/06/19 at 3:15 PM, revealed room [ROOM NUMBER] had a previous water leak and flooring had been ordered. He stated he could cut the gauged pieces of wood trim out and replace them with new. However, the room was next on his list to remodel. He further stated he expected the environment to be more homelike for the residents and he was doing his best to prioritize the repairs. Interview with the Administrator on 03/07/19 at 12:58 PM, revealed room [ROOM NUMBER] was next on the list to be remodeled and supplies had been ordered for the floor. He stated flooring was ordered for the bathroom because there was a water leak recently. The Administrator stated they were working on things and the residents did not want to move out of the room until they were ready to do the repairs. He stated he expected the facility to be a homelike environment for the residents and repairs were in the works.

**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 develop a comprehensive person-centered care plan for (2) of thirty-two (32) sampled residents (Resident #2, and #49). The facility failed to develop a Comprehensive Care Plan for oral/dental care for Residents #2 and #49. The findings include: Review of the facility's policy titled, Comprehensive Care Plans Standard of Practice, last revised 11/17, revealed it is the practice of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily live. 1. Record review revealed the facility readmitted Resident #2 on 01/16/17 with diagnoses which included Wernicke's Encephalopathy, Gastro-esophageal Reflux Disease, Dysphagia, Gastrostomy Status and Athrosclerotic Heart Disease with Angina. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], Section L for Dental revealed None of the above present, revealing no problems with teeth. Review of Resident #2's Comprehensive Care Plan revealed no documented evidence a Oral/Dental/Activities of Daily Living (ADL) Care Plan was developed. Review of a Quarterly MDS assessment, dated 02/26/19, revealed the facility assessed Resident #2's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable Observation of Resident #2 on 03/06/19 at 8:34 AM; and, on 03/06/19 at 1:45 PM revealed the resident had most teeth missing with only four (4) or five (5) teeth present in his/her mouth. The teeth present were dark, broken, and jagged; and appeared to have a film over the teeth. There was no odor noted. The resident stated he/she could not remember the last time he/she had his/her teeth brushed and he/she stated he/she would like to have his/her teeth brushed. Interview with Resident #2 on 03/06/19 at 1:45 PM revealed his/her teeth had been bad for a long time, approximately a year or more. Review of Resident #2's Hygiene Roster for dates 01/07/19 to 03/07/19 revealed there was no documented evidence the resident received oral/dental care on eleven days. Interview with Resident #2 on 03/07/19 at 8:46 AM, revealed the aide brushed his/her teeth yesterday afternoon and it felt really good. Observation at this time, revealed the resident's gums and teeth appeared cleaner than yesterday, without a film and build up. 2. Record review revealed the facility readmitted Resident #49 on 03/03/18 with diagnoses which included Athrosclerotic Heart Disease, Celebellar Stroke Syndrome, Chronic Obstructive Pulmonary Disease with exacerbation and Dysphagia. Review of Resident #49's Annual MDS assessment dated [DATE], revealed Section L was coded as None of the above were present which revealed the resident had no problems with oral/dental health. Due to the resident's contractures of his/her arms, the resident was unable to brush his/her own teeth. However, review of the Comprehensive Care Plan revealed there was no documented evidence an Oral/Dental/ADL Care Plan was developed to address Resident #49's need for assistance with oral care. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #49's cognition as moderately impaired with a BIMS score of ten (10) which indicated the resident was interviewable. Observation of Resident #49 on 03/06/19 at 9:28 AM revealed tooth fragments, and obvious broken and decayed natural teeth. Interview with Resident #49 on 03/06/19 at 9:50 AM, revealed his/her teeth have been broken/missing/decayed for a few years. The resident stated he/she had pain and a Canker sore in the mouth. He/She also stated he/she did not remember the last time he/she had his/her teeth brushed, but would love to have his/her teeth brushed every day. Review of Resident #49's Hygiene Roster from 01/07/19 to 03/07/19 revealed there was no documented evidence the facility provided oral/dental care on sixteen (16) days. Interview with Certified Nurse Aide (CNA) #2 on 03/06/19 at 3:45 PM, revealed she could not remember the last time she was able to complete Resident #49's oral care. She stated she made sure she had the big things done like baths and incontinent care; however, things get crazy and she was not always able to do oral care. Interview with the MDS Coordinator on 03/06/19 at 4:42 PM, revealed she evaluated Resident #2's and #49's mouths and found their teeth to be broken, rotten, and missing. She stated the MDS was coded improperly and should have been coded as broken, missing teeth. The MDS Coordinator stated if the MDS had been properly coded, a Comprehensive Care Plan would have been generated. Interview with Director of Nursing (DON) on 03/07/19 at 5:32 PM revealed she expected the MDS Coordinator to accurately assess residents' oral/dental status and to reflect her findings on the MDS assessment. The DON stated a Comprehensive Care Plan for oral/dental hygiene should have been generated. She also revealed she expected the Assistant Director of Nursing to make sure the Comprehensive Care Plans were written.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of Mosby's Textbook for Long Term Care Nursing Assistants, it was determined the facility failed to ensure a resident, who was unable to carry out activities of daily living (ADL's), received the necessary services to maintain oral hygiene for three (3) of thirty-two (32) sampled residents (Residents #2, #49 and #104). The facility failed to provide oral care daily for Residents #2, #49 and #104. The findings include: Interview with the Director of Nursing (DON) on 03/07/19 at 2:24 revealed she did not have a policy for oral care but used the Mosby's Textbook for Long-Term Care Nursing Assistants. Review of the Mosby's Textbook for Long-Term Care Nursing Assistants Seventh Edition, revealed staff were to assist with oral hygiene after sleep, after meals, and at bedtime. Many people practice oral hygiene before meals. Some persons need mouth care every two hours or more often. Always follow the care plan. Many people perform oral hygiene themselves. Others need help gathering and setting up equipment for oral hygiene. You may have to perform oral hygiene for persons who: are very weak, cannot move or use their arms, or are too confused to brush their teeth. 1. Record review revealed the facility readmitted Resident #2 on 01/16/17 with diagnoses which included Wernicke's Encephalopathy, Dysphagia, Gastrostomy Status and Athrosclerotic Heart Disease with Angina. Review of Resident #2's Quarterly Minimum Data Set (MDS) assessment, dated 02/26/19 revealed the facility assessed Resident #2's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. The facility also assessed the resident was unable to do his/her own oral care and required an assist of one caregiver. Observation of Resident #2 on 03/06/19 at 8:34 AM, revealed the resident had most teeth missing with only four (4) or five (5) teeth present in his/her mouth. The teeth present were dark, broken, jagged and there appeared to be a film over the teeth. Interview with the resident at this time revealed he/she could not remember the last time he/she had his/her teeth brushed. Resident #2 stated he/she would like to have his/her teeth brushed as it would make him/her feel much better. Review of the Annual MDS, Section L Dental, dated 06/05/18, revealed the MDS Coordinator coded None of the above present, revealing no problems with teeth was inaccurate and resulted in there being no care plan developed to address Oral/Dental Care. Review of Resident #2's Hygiene Roster for dates 01/07/19 to 03/07/19 revealed there were eleven days that there was no documented evidence the facility provided oral/dental care for the resident. Interview with Resident #2 on 03/07/19 at 8:46 AM revealed the aide brushed his/her teeth yesterday afternoon and it felt really good. Observations at this time revealed the resident's gums and teeth had no film buildup. 2. Record review revealed the facility readmitted Resident #49 on 03/03/18 with diagnoses which included Athrosclerotic Heart Disease, Celebellar Stroke Syndrome, Chronic Obstructive Pulmonary Disease with exacerbation and Dysphagia. Review of the Quarterly MDS assessment, dated 01/23/19 revealed the facility assessed Resident #49's cognition as mildly impaired with a BIMS score of ten (10) which indicated the resident was interviewable. Due to the resident's contractures of his/her arms, the resident was not able to brush own teeth. He/She required an assist of one care giver for oral hygiene. Review of Resident #49's Medical Record revealed a dental visit was provided on 02/08/17 with a notation the resident had several broken teeth. The visit included a Comprehensive Clinical Exam, Tooth Charting, Oral Cancer Exam and TMJ Exam. Further review of the record revealed a dental visit was provided on 06/11/18 and included a Comprehensive Clinical Exam, Tooth charting, Oral Cancer Exam and TMJ Exam. However, there was no mention of broken natural teeth on this visit. Observation of Resident #49's skin assessment on 03/06/19 at 9:28 AM revealed the resident had broken teeth that appeared blackened and multiple missing teeth. Interview with Resident #49 at this time revealed he/she did not remember the last time his/her teeth were brushed, but he/she would love to have his/her teeth brushed every day. The resident also stated he/she needed to see a dentist due to a canker sore that appeared on his/her lower mouth area the day before. The resident pulled his/her lower lip out and down and revealed a pea size raised dark red area. He/She stated he/she did not inform the staff of the canker sore or that she needed to see a dentist. Interview with LPN #2 on 03/06/29 at 9:28 AM, revealed the resident had not complained of any concerns until today and she would place the resident on dental list to see the Dentist. Review of Resident #49's Hygiene Roster from 01/07/19 to 03/07/19 revealed no documented evidence the facility provided oral/dental care on sixteen (16) days. Interview with Resident #49 on 03/07/19 at 8:54 AM revealed he/she had the Certified Nurse Aide (CNA) brush his/her teeth yesterday and showed the State Survey Agency Surveyor his/her teeth. 3. Record review revealed the facility admitted Resident #104 on 11/20/18 with diagnoses which included Type II Diabetes Mellitus, Morbid Obesity, and Major Depressive Disorder. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #104's cognition as severely impaired with a BIMS score of seven (7) which indicated the resident was not interviewable. The resident required set up and encouragement for assistance with oral hygiene. Review of the Comprehensive Care Plan for at risk for poor oral/dental health related to Resident #104 has natural teeth with some missing and in poor condition, dated 11/27/18, revealed interventions to encourage/assist with mouth care at least daily, independent for oral care, encourage to assist with oral care, set up items as will allow. Review of the Hygiene Roster for Resident #104 dated 01/07/19 to 03/07/19 revealed there was no documented evidence the facility provided oral/dental care on thirty-one (31) days. Observation on 03/07/19 at 9:35 AM revealed Resident #104 had natural teeth missing, broken, and mostly rotten. The teeth present appeared dirty with a build up of food particles in areas and appeared to need oral care. Interview with the Social Services Assistant on 03/26/19 at 2:48 PM revealed Resident #104's dental visits were scheduled every six (6) months with his/her personal dentist by the resident's sister. He revealed he spoke to the resident's sister last week and she stated the resident had an appointment in May 2019 with the dentist. The Social Services Assistant stated the sister calls and lets them know about the resident's appointments. Further review of the Social Service Dental Log revealed Resident #104 was admitted [DATE] and the sister revealed the resident had gone to the dentist prior to admission to the facility. Interview with Certified Nurse Aide (CNA) #2 on 03/06/19 at 3:45 PM revealed she had not completed the residents' oral care today and it was last week when she last did oral care. CNA #2 stated she made sure she completed the big things, but things get crazy and she did not always do oral care. She stated she did not chart when oral care was not done nor tell the Charge Nurse. Interview with CNA #1 on 03/07/19 at 1:27 PM revealed she would do oral care throughout the day as she completed daily morning care. CNA #1 stated there were times when she did not get oral care completed. She stated she would tell the resident she would do it the next day if there was something she did not get to do. She also revealed she passed the information to the next shift. CNA #1 stated she understood oral care should be done at least daily and if it was not charted it was not completed. Interview with NA (Nurse Aide) #2 on 03/07/19 at 1:44 PM revealed if she could not get oral care completed, she would tell her nurse and also tell the staff coming on during rounds. She stated she did not chart when oral care was not completed, but she would leave the box for oral care blank. She also stated oral care should be completed at least once daily and, as needed. Interview with Licensed Practical Nurse (LPN) #2, Charge Nurse for the 200 Hall on 03/07/19 at 11:00 AM revealed she expected the CNA's to complete oral care daily. She also revealed she expected all CNA's to inform her if any care was not completed. Interview with Assistant Director of Nursing on 03/26/19 at 1:45 PM revealed she monitored the residents by making rounds and speaking to the residents to make sure oral care had been completed per CNA care plans. She also stated she would check the Kiosk every two (2) hours to make sure ADL's were completed. Interview with Director of Nursing on 03/07/19 at 5:32 PM revealed she expected all Activities of Daily Living to be completed as written in the care plans. She stated she expected staff to make the Charge Nurse aware of any care that was not provided. The DON further stated she felt like the oral care was probably completed but not charted; however, she could not be sure.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure a resident, with an indwelling catheter, received the appropriate care and services to prevent urinary tract infections to the extent possible for one (1) of thirty-two (32) sampled residents (Resident #100). Three (3) observations revealed improper positioning of Resident #100's urinary catheter tubing and drainage bag placement. The findings include: Review of the facility's policy and procedure titled, Giving Catheter Care, not dated, revealed after providing catheter care, ensure the catheter is secured. Further review revealed the catheter tubing should be coiled and secured. Record review revealed the facility readmitted Resident #100 on 08/04/17, with diagnoses which included Retention of Urine, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, and Acute Kidney Failure. Review of the Annual Minimum Data Set (MDS) Assessment, dated 02/21/19, revealed the facility did not complete the Brief Interview of Mental Status (BIMS) examination, as the resident was assessed to be rarely/never understood, which indicated the resident was not interviewable. Further review of the MDS revealed the resident required total dependence with toilet use and personal hygiene and had a suprapubic catheter. Observations on 03/05/19 at 10:42 AM and 11:05 AM, and on 03/07/19 at 8:46 AM, revealed Resident #100 was lying in bed on his/her left side with the urinary catheter drainage bag anchored to his/her wheelchair not coiled and secured to the bed. Further observation revealed Resident #100 was lying on the catheter tubing. In addition, observations on 03/06/19 at 8:36 AM and 1:26 PM revealed Resident #100 was in his/her wheelchair with catheter tubing dragging the floor. Interview with Certified Nurse Aide (CNA) #8 on 03/07/19 at 1:47 PM, revealed Resident #100 sometimes self transferred from the wheelchair to the bed and staff were constantly trying to monitor the resident's tubing, because the resident did not know to move the drainage bag from the wheelchair to the bed. Interview with CNA #5, on 03/26/19 at 2:55 PM, revealed the catheter drainage tubing should be coiled and positioned under the resident's leg. CNA #5 stated, if the drainage tubing is positioned over the top of the resident's leg, the drain tube would create pressure to the top of the residents' leg. Further interview revealed the catheter drainage bag should be attached to the bed frame and covered in a privacy bag. CNA #5 revealed she had not received any education on how to position a urinary catheter tubing and drainage bag while employed at the facility. Interview with Licensed Practical Nurse (LPN) #2, on 03/26/19 at 10:25 AM, revealed she monitored care provided by the CNA when she made rounds. Further interview revealed the facility did not require licensed staff to make rounds in a designated time frame. However, she monitored the resident's care by answering call lights and assisting CNA's with resident care when requested. LPN #2 stated she also talked with the residents when providing care. Interview with the Assistant Director of Nursing (ADON) #1, on 03/06/19 at 2:10 PM, revealed the urinary catheter drainage bag should be anchored to the bed frame because it could create too much tension placed on the wheelchair. He stated the resident should not be lying on the catheter tubing because it could cause kinks and not allow the urine to drain properly. The ADON further revealed the CNA's should ensure the catheter bag and tubing were positioned properly during their rounds. In addition, he stated the CNA's were taught about catheter care skills, resident care plans, and to monitor during rounds on the floor during their orientation period. Interview with ADON #2, on 03/26/19 at 11:17 AM, revealed licensed staff monitor the CNA's by doing rounds to ensure resident care needs were met. Interview with the Director of Nursing (DON) on 03/07/19 at 5:16 PM, revealed she expected staff to monitor the position of the bedside drainage bag and the catheter tubing during their rounds on the floor. The DON stated if the catheter drainage bag was observed anchored on the wheelchair, it should be hung up on the bed frame to help the flow and prevent infection.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the nurse who gave pain medication to the resident assessed and evaluated a resident's pain characteristics such as intensity, pattern, location, frequency, and duration prior to administering pain medication according to professional standards of practice, for one (1) of thirty-two (32) sampled residents (Resident #83). In addition, the nurse failed to make the resident aware of what medication was being administered (Oxycodone). The findings include: Review of the facility's policy titled, Pain Management Process, last revised October 2015, revealed the facility recognizes that each resident has the right to treatment and services to maintain their quality of life. The facility also recognizes that each resident reacts to pain in different ways, and that narcotics carry significant risk with use including side effects and abuse. The facility will react to the resident's pain control needs based on the resident's goals for pain relief and the resident's goals functional ability. If pain is triggered, the facility will complete a comprehensive pain assessment/evaluation to include current presence of pain, type of scale to utilize, predisposing causes of the pain, location, quality, intensity and duration of the pain. Record review revealed the facility admitted Resident #83 on 03/04/16 with diagnoses which included Diabetes Type 2 with Diabetic Neuropathy Unspecified, Lymphedema, Cellulitis, Hypertension, Iron Deficiency Anemia, and Major Depressive Disorder. Review of the Annual Minimum Data Set (MDS) Assessment, dated 01/28/19, revealed the facility assessed Resident #83's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of twelve (12) which indicated the resident was interviewable. Review of Resident #83's Physician's Orders, dated 03/02/19, revealed an order for Oxycodone-Acetominophen (pain medication) 7.5-325 milligrams (mg) one (1) tablet by mouth every six (6) hours, as needed for pain. Review of Resident #83's Comprehensive Care Plan revealed, Experiences Alteration in Level of Comfort as exacerbated by Pain, dated 02/04/19, revealed an intervention to identify location and rate of pain prior to and after any interventions, medications as ordered. Observation of Resident #83's wound care, on 03/06/19 at 10:00 AM performed by the facility's Wound Care Nurse (WCN), revealed the resident complained of pain in the opposite leg the WCN was providing wound care The WCN assessed the resident's pain which was identified in the right lower extremity that the resident described as pinching, sharp, extending from the right thigh to the right buttock. Further observation revealed Resident #83 described the pain as eight (8) on pain scale of 0 - 10, with 10 being the worse. A staff member assisting the WCN went to inform the nurse covering the unit of Resident #83's complaint of pain. Observation on 03/06/19 at 10:05 AM revealed Registered Nurse (RN) #1 entered Resident #83's room and gave the resident a white tablet. However, RN #1 failed to evaluate and assess the resident's need for pain medication and failed to inform the resident the name of the medication. Interview with Resident #83, on 03/06/19 at 1:35 PM, revealed the throbbing pain to the right leg was better after he/she received pain medication. The resident stated the pain was at two (2) on a pain scale of 0-10, with 10 being the worse. Interview with RN #1, on 03/06/19 at 2:15 PM, revealed she was notified by a staff member that Resident #83 complained of pain. RN #1 stated she was informed by the staff member the resident's pain was in the left lower extremity and the pain score was six (6), instead of the right lower extremity and a pain score of eight (8), as reported by the resident during the State Survey Agency's observation. RN #1 revealed she failed to evaluate the resident's pain and identify characteristics of the pain herself. She stated she also failed to inform the resident what pain medication he/she was giving. Further interview revealed RN #1 assessed Resident #83's pain an hour later and the resident's pain was at two (2). Interview with the Director of Nursing (DON) on 03/07/19 at 5:20 PM, revealed she expected the nurse giving medication to identify medication to the resident. She stated she also expected the licensed staff to do a pain assessment on resident before giving pain medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to provide assistive devices for one (1) of thirty-two (32) sampled residents (Resident #65). Observations on 03/05/19 at 11:03 AM, on 03/06/19 at 8:36 AM, and on 03/07/19 at 8:32 AM, revealed Resident #65 did not receive his/her foam built up fork and spoon to enable the resident to feed self. The findings include: Record review revealed the facility readmitted Resident #65 on 06/29/17, with diagnoses to include Rheumatoid Arthritis, Feeding Difficulties, Dysphagia, and Gastro-esophageal Reflux Disease. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #65's cognition as intact with a Brief Interview of Mental Status (BIMS) score of thirteen (13) which indicated the resident was interviewable. Review of Resident #65's Comprehensive Care Plan, Risk for Alteration in Nutrition, dated 07/09/18, revealed an intervention for divided plate and foam built up spoon and fork utensils. Observation on 03/05/19 at 11:03 AM, revealed Resident #65 was sitting up in a wheelchair at the bedside feeding himself/herself breakfast. Observation of the resident's diet card revealed the resident required a foam built up spoon and fork, and a divided plate. However the foam built up spoon and fork were not available for the resident to use. Interview with Certified Nurse Aide (CNA) #3, on 03/05/19 at 11:25 AM, revealed she served Resident #65's breakfast tray. She stated the dining room staff was supposed to ensure assistive devices were on meal trays. CNA #3 stated she should have made sure the resident's assistive devices were on the meal tray to enable the resident to in feed himself/herself. Observations, on 03/06/19 at 8:36 AM and 03/07/19 at 8:32 AM, revealed Resident #65 feeding himself/herself breakfast. However, the foam built up spoon and fork were not on the meal tray. Interview with Resident #65, on 03/25/19 at 3:57 PM, revealed the divided plate, built up fork and spoon were used at each meal. Resident #65 stated, I have bad arthritis and can hold them better. Interview with CNA #4, on 03/07/19 08:32 AM, revealed she should have made sure Resident #65's assistive devices were on the meal tray. CNA #4, stated, It was dietary's, and staff who passed meal trays, responsibility to ensure the resident had the assistive devices listed on his/her diet card. She stated Dietary Staff should ensure the adaptive equipment was on the meal tray. She also revealed CNA's were to review meal cards when the residents' trays were served and if any adaptive utensils were not on the meal trays then the utensils should be obtained before serving trays. Interview with the Interim Dietary Manager, on 03/25/19 at 2:55 PM, revealed the adaptive devices/utensils for Resident #65 were available; however, dietary staff failed to add the utensils to the breakfast meal tray. Interview with the Interim Dietary Manager, on 03/07/19 at 2:35 PM, revealed she expected assistive devices to be added to the meal trays during tray line set up. She stated if staff identified an assistive device listed on a diet card was not on the meal tray during tray delivery, staff should make sure the assistive device was obtained before serving the tray. Interview with DON, on 03/06/19 at 8:48 AM, revealed if an assistive device was listed on the resident's diet card and care plan, the assistive device should be on the meal tray.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the RAI 3.0, effective October 2018, Section M: Skin Conditions, revealed to document the risk, presence, appearance, and change of pressure ulcers as well as other skin ulcers, wounds or lesions. Also includes treatment categories related to skin injury or avoiding injury. Record review revealed the facility readmitted Resident #42 on 06/22/18 with diagnoses which included Hypertension, Unspecified Kidney Failure, Pressure Ulcer of Sacral Region Stage 4, Neuromuscular Dysfunction of Bladder, and Benign Prostatic Hyperplasia. Review of the Skin Integrity Report (SIR), dated 01/14/19, revealed the facility identified Resident #42 to have a Stage 4 pressure ulcer on the right ishium. However, review of the Quarterly MDS assessment, dated 01/17/19, for Section M 0210: Skin Conditions revealed the facility failed to identify the resident had an unhealed pressure ulcer. 5. Record review revealed the facility admitted Resident #83 on 03/04/16 with diagnoses which included Diabetes Type 2 with Diabetic Neuropathy Unspecified, Lymphedema, Cellulitis, Hypertension, Iron Deficiency Anemia, and Major Depressive Disorder. Review of the SIR revealed the facility identified Resident #83 to have a diabetic ulcer to the left heel on 02/08/19 and observation, on 03/06/19 at 10:00 AM, revealed the resident still had a diabetic ulcer to the left heel. However, review of Resident #83's Quarterly MDS, dated [DATE], Section M 0150, revealed a coding of zero (0), which indicated the facility failed to assess the resident at risk for developing pressure ulcers/injuries and review of Section M0140 revealed the facility failed to identify the resident had a Diabetic Ulcer to the left heel. 6. Record review revealed the facility readmitted Resident #93 on 09/12/17 with diagnoses which included End Stage Renal Disease (ESRD), Diabetes Type ll with Chronic Kidney Disease, Alcohol Abuse with Unspecified Alcohol -Induced Disorder, Hypertension, Idiopathic Peripheral Autonomic Neuropathy, and Major Depressive Disorder, single episode, unspecified. Review of the SIR dated 02/11/19 and observation, on 03/06/19 at 10:50 AM, revealed the resident had an unhealed diabetic ulcer to his/her outer right ankle. However, review of the Quarterly MDS assessment, dated 02/14/19, for MDS Section M-0150: Skin Conditions, revealed the facility assessed the resident as not at risk for developing pressure ulcers/injuries. Review of Section M-1040 revealed the facility failed to identify Resident #93 as having any other ulcers, wounds, and skin conditions. Interview with the MDS Coordinator, on 03/07/19 at 5:05 PM, revealed she failed to code Resident #42's Quarterly MDS assessment, dated 01/17/19, to reflect an unhealed pressure ulcer. The MDS Coordinator stated, I should have coded the unhealed pressure ulcer on the MDS, I'm not sure why I didn't. Further interview revealed the MDS Coordinator also failed to identify Residents #83's and #93's Skin Conditions on their MDS assessment. Interview with the DON, on 03/07/19 at 5:16 PM, revealed she expected the resident assessments to be coded to reflect the services and status of each resident per the RAI manual. 2. Review of the RAI Version 3.0 Manual dated October 2018 revealed Section L Oral/Dental Status should have all oral or dental problems present on assessment recorded. Record review revealed the facility readmitted Resident #2 on 01/16/17 with diagnoses which included Wernicke's Encephalopathy, Gastro-esophageal Reflux Disease, Dysphagia, Gastrostomy Status and Athrosclerotic Heart Disease with Angina. Review of a Quarterly MDS assessment, dated 02/26/19 revealed the facility assessed Resident #2's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Observation of Resident #2 on 03/06/19 at 8:34 AM and on 03/06/19 at 1:45 PM revealed he/she had most teeth missing with only four (4) or five (5) teeth present in his/her mouth. The teeth present were dark, broken, and jagged. Interview with Resident #2 on 03/06/19 at 1:45 PM revealed that his/her teeth had been bad for a long time, approximately a year or more. However, further review of the Quarterly MDS assessment, dated 02/26/19 revealed no information was checked in the L boxes for Oral/Dental information to indicate the resident had missing teeth and the remaining teeth were broken and jagged. 3. Record review revealed the facility readmitted Resident #49 on 03/03/18 with diagnoses which included Athrosclerotic Heart Disease, Celebellar Stroke Syndrome, Chronic Obstructive Pulmonary Disease with exacerbation and Dysphagia. Observation of Resident #49 on 03/06/19 at 9:28 AM revealed the resident had missing natural teeth, and teeth that were broken, and decayed. However, review of the L section of Resident 49's most recent Comprehensive Assessment, an Annual MDS dated [DATE] revealed there were no dental concerns. Interview with the MDS Coordinator on 03/06/19 at 4:42 PM revealed it was her job to assess the residents' mouths to identify any oral/teeth concerns and code the MDS accordingly. Further interview with the MDS Coordinator on 03/07/19 at 1:18 PM revealed she had evaluated Resident #2's and #49's mouths and found their teeth to be broken, rotten, and missing. She also stated the MDS was coded improperly and should have been coded as broken, missing teeth. She stated these assessments were completed prior to her taking over. Interview with the Director of Nursing (DON) on 03/07/19 at 5:32 PM revealed she expected the MDS Coordinator to accurately assess residents' oral/dental and to reflect her findings on the MDS assessment. She stated she expected the MDS Coordinator to complete the assessments per the Resident Assessment Instrument [NAME]. Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Version 3.0 User Manual, it was determined the facility failed to ensure six (6) of thirty-two (32) sampled residents received an accurate assessment, reflective of the resident's status at the time of the assessment (Residents #2, #49, #93, #42, #83, and #50). The facility failed to code the Minimum Data Set (MDS) assessment accurately for Resident #50 related to receiving Hospice Services; Residents #2 and #49 related to Oral/Dental Status; and, Residents #42, #83 and #93 related to pressure ulcer or diabetic foot ulcers. The findings include: 1. Review of the RAI Version 3.0 User Manual, dated October 2018, for Coding instructions for Section O0100 Special Treatments, Procedures, and Programs, Column 2 instructs to check all treatments, procedures, and programs received or performed by the resident after admission/entry or reentry to the facility and within the 14 (fourteen)-day look-back period. Record review revealed the facility readmitted Resident #50 on 05/19/18, with diagnoses which included Heart Failure, Hypertension, and Aphasia. Review of Resident #50's Physician's Orders dated March 2019, revealed an order for hospice services as of 07/20/18. However, review of Resident #50's Quarterly MDS Assessment, dated 01/24/19, revealed the facility failed to check the Hospice Care O0100K box Column 2 Section O0100 Special Treatments, Procedures, and Programs, to indicate the resident received hospice services. Interview with the MDS Coordinator on 03/06/19 at 4:10 PM, revealed she was responsible for completing Section O for Resident #50. She stated she knew Resident #50 received hospice services; however, she overlooked it and failed to accurately code it on the Quarterly MDS.

**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 ensure Comprehensive Care Plans were revised for four (4) of thirty-two (32) sampled residents (Residents #9, # 17, #79, and # 81). The facility assessed Residents #9, #17, #79, and #81 to require the use of adaptive equipment for eating; however, review of the care plans revealed there was no documented evidence the care plans were updated to include the adaptive equipment. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, Standard of Practice, last revised November 2017, revealed the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive, significant change of condition and Quarterly Minimum Data Set (MDS) assessment. 1. Record review revealed the facility admitted Resident #9 on 01/05/18 with diagnoses which included Dementia. Review of an annual MDS dated [DATE] revealed the facility assessed Resident #9's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of eleven (11) which indicated the resident was interviewable. Further review of the MDS revealed the facility also assessed the resident required set up for eating. Review of a facility provided Residents Adaptive Equipment Report revealed that as of 03/25/19, Resident #9 required a Kennedy cup (special cup with lid) at all meals. However, review of a Comprehensive Care Plan initiated on 08/22/17 revealed there was no documented evidence a care plan was developed to address the resident's assessed need of a Kennedy cup. Interview with Resident #9 on 03/25/19 at 12:20 PM revealed he/she received a Kennedy cup at meals. 2. Record review revealed the facility admitted Resident #17 on 11/25/16 with diagnoses which included Parkinson's Disease. Review of the Quarterly MDS assessment, dated 12/17/18 revealed the facility assessed Resident #17's cognition as moderately impaired with a BIMS score of eight (8) which indicated the resident was interviewable. Further review of the MDS revealed the facility also assessed the resident required set up for eating. Review of a Resident Adaptive Equipment Report revealed as of 03/25/19, Resident #17 required a red foam fork. However, review of a Comprehensive Care Plan initiated on 12/27/18 revealed there was no documented evidence the resident was care planned for the use of a red foam spoon for meals. Observation on 03/26/19 at 12:27 PM revealed there was a red foam fork on Resident #17's tray. 3. Record review revealed the facility admitted Resident #79 on 11/03/18 with diagnoses which included Failure to Thrive and Cerobrovascular Accident. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #79's cognition was moderately impaired with a BIMS score of nine (9), which indicated the resident was not interviewable. Further review of the MDS revealed the facility also assessed the resident required tube feeding and was totally dependent on one staff person for eating, as resident received tube feedings and food by mouth. Review of a Resident Adaptive Equipment Report revealed that as of 03/25/19, Resident #79 required a divided plate with all meals. However, review of a Comprehensive Care Plan initiated on 10/31/18, revealed there was no documented evidence the resident required a divided plate with all meals. Observation at meal time on 03/24/19 at 12:22 PM revealed Resident #79 only wanted a sandwich and soup, so the resident was not observed with a divided plate. 4. Record review revealed the facility admitted Resident #81 on 04/07/18 with diagnoses which included Congestive Heart Failure, Weakness, and Dysphagia (difficulty in swallowing). Review of an annual MDS assessment dated [DATE], revealed the facility assessed Resident #81's cognition was intact with a BIMS score of 13, which indicated the resident was interviewable. Further review of the MDS assessment revealed the facility also assessed the resident required set up only for meals. Review of a Resident Adaptive Equipment Report revealed as of 03/25/19, Resident #81 required a Kennedy cup with all meals. However, review of a Comprehensive Care Plan initiated on 04/14/18, revealed no documented evidence the resident required the use of a Kennedy cup with all meals. Interview with Resident #81 on 03/26/19 at 11:54 AM revealed he/she received a special cup at meals and the cup was easier for him/her to use due to Arthritis. Observation of the resident eating on 03/24/19 at 11:54 AM, revealed the resident had a Kennedy cup. Interview with the Dietary Manager on 03/26/19 at 11:15 AM, revealed therapy was responsible for updating the care plans when a resident needed an assistive device for eating. She stated she has been going through all the residents' care plans to ensure the care plans were updated with assstive devices. She stated the reason Resident #17's, #79's, #81's and #9's care plans did not have the assistive/adaptive devices was because she had not got around to updating those yet. Interview with Director of Nursing (DON) on 03/26/19 at 11:00 AM revealed all nursing staff were responsible for updating the care plans.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide care in accordance with each resident's written plan of care for four (4) of thirty-two (32) sampled residents (Resident #104, #65, #83 and #100). The facility failed to implement the Comprehensive Care Plan for Resident #104 related to oral care. Resident #65 related to assistive devices for eating. Resident #83 related to pain assessment; and, Resident #100 related to catheter care. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, Standard of Practice, last revised November 2017 revealed; it is the practice of this facility to implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objective and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 1. Record review revealed the facility admitted Resident #104 on 11/20/18 with diagnoses which included Type II Diabetes Mellitus, and Major Depressive Disorder. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 02/26/19 revealed the facility assessed Resident #104's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of seven (7) which indicated the resident was not interviewable. Review of the Comprehensive Care Plan for at risk for poor oral/dental health dated 11/27/18, revealed interventions to encourage/assist with mouth care at least daily, independent for oral care, encourage to assist with oral care, and set up items as will allow. However, review of the Hygiene Roster for Resident #104 dated 01/07/19 to 03/07/19 revealed there was no documented evidence oral/dental care was provided to Resident #104 on thirty-one (31) days. Observation on 03/07/19 at 9:35 AM revealed Resident #104's natural teeth were missing and/or broken and appeared rotten. However, there was no odor detected. Further observation revealed food particles in his/her teeth. Interview with Certified Nurse Aide (CNA) #2 on 03/06/19 at 3:45 PM, revealed she did not complete Resident 104's oral care on 03/06/19 and could not remember the last time it was completed. She stated she made sure she had the big things done like baths and incontinent care; however, things get crazy and she did not always do oral care. CNA #2 stated she did not chart that when oral care was not completed, nor did she tell the charge nurse. She further stated the last time she provided the resident's oral care was last week. Interview with NA (Nurse Aide) #1, on 03/07/19 at 1:27 PM revealed she was responsible for Resident #104's oral care. She stated she tried to complete the resident's oral care throughout the day when she completed her every two (2) hour bed checks, She stated there were times when she did not get oral care completed. Further interview revealed she understood oral care should be done at least daily and if it was not charted, it was not completed. Interview with Licensed Practical Nurse (LPN) #2, Charge Nurse for the 200 Hall on 03/07/19 at 11:00 AM revealed she expected the CNA's to complete oral care daily and follow the care plans as written. She stated she made rounds to ensure care was provided and she expected the CNA's to inform her when care was not completed. Interview with Director of Nursing (DON) on 03/07/19 at 5:32 PM revealed she expected all Activities of Daily Living to be completed as written in the care plans. She stated she expected the Assistant Director of Nursing to make sure the Comprehensive Care Plans were carried out as written. Interview with Assistant Director of Nursing (ADON) on 03/26/19 at 1:45 PM revealed she monitored the residents by making rounds and speaking to the residents to make sure oral care was completed per CNA care plans and Comprehensive Care Plans. She stated she checked the Kiosk (CNA input of care station) every two (2) hours to make sure Activities of Daily Living (ADL's) were completed. 2. Record review revealed the facility readmitted Resident #65 on 06/29/17 with diagnoses which included Rheumatoid Arthritis, Feeding Difficulties, Dysphagia, and Gastro-esophageal Reflux Disease. Review of the Quarterly MDS assessment, dated 02/04/19, revealed the facility assessed Resident #65's cognition as intact with a BIMS score of thirteen (13) which indicated the resident was interviewable. Review of Resident #65's Comprehensive Care Plan, Risk for Alteration in Nutrition, dated 07/09/18, revealed an intervention for divided plate and foam built up spoon and fork utensils. In addition, review of Resident #65's Dietary Card revealed divided plate, foam built up spoon and fork utensils for meals. However, observations on 03/05/19 at 11:03 AM, on 03/06/19 at 8:36 AM, and on 03/07/19 at 8:32 AM, revealed Resident #65 was feeding himself/herself without foam the built up spoon and fork, as they were not available for the resident to use. Interview with CNA #3, on 03/05/19 at 11:25 AM and CNA #4, on 03/07/19 at 8:32 AM, revealed they should have ensured Resident #65's assistive devices were on the meal tray before serving it to the resident. Interview with the Interim Dietary Manager, on 03/07/19 at 2:35 PM, revealed she expected dietary staff to ensure assistive devices were on meal trays before leaving the kitchen. She stated if staff noticed assistive devices listed on a diet card were not on the meal tray, staff should have obtained the assistive devices before serving the tray. Interview with the DON, on 03/06/19 at 8:48 AM, revealed therapy determined Resident #65 needed adaptive eating utensils after an evaluation was completed. The DON stated, If an adaptive eating utensil was listed on the resident's care plan, the utensils should be on the resident's meal tray. 3. Record review revealed the facility admitted Resident #83 on 03/04/16 with diagnoses which included Diabetes Type 2 with Diabetic Neuropathy Unspecified, Lymphedema, Cellulitis, Hypertension, Iron Deficiency Anemia, and Major Depressive Disorder. Review of Resident #83's Comprehensive Care Plan, Experiences Alteration in Level of Comfort as exacerbated by Pain, dated 02/04/19, revealed an intervention to identify location and rate of pain prior to and after any interventions, medications as ordered. However, observation on 03/06/19 at 10:05 AM revealed Registered Nurse (RN) #1 entered Resident #83's room after being informed by another staff member that Resident #83 needed pain medication and gave the resident a white tablet without evaluating and assessing the resident's need for pain medication. Interview with Registered Nurse (RN) #1, on 03/06/19 at 2:15 PM, revealed a staff member notified her Resident #83 complained of pain to the left leg rated at six (6). RN #1 revealed she administered the pain medication to the resident and failed to assess the resident's pain herself prior to administering the pain medication. She stated, I did not identify the resident had pain, characteristics of the pain, or inform the resident what pain medication he/she was given. Interview with the DON, on 03/07/19 at 5:20 PM, revealed she expected the nurse giving medication to identify the medication to the resident. She stated she also expected the staff to do a pain assessment on Resident #83 before giving pain medication as indicated in the resident's care plan. 4. Record review revealed the facility readmitted Resident #100 on 08/04/17, with diagnoses which included Retention of Urine, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, and Acute Kidney Failure. Review of the Annual MDS Assessment, dated 02/21/19, revealed the facility did not complete a BIMS examination, as the resident was assessed to be rarely/never understood, which indicated the resident was not interviewable. Further review of the MDS revealed the resident had a suprapubic catheter. Review of Resident #100's Comprehensive Care Plan initiated on 12/18/17, revealed an intervention for staff to keep the resident's catheter tubing free of kinks. However, observations on 03/05/19 at 10:42 AM and 11:05 AM, and on 03/07/19 at 8:46 AM, revealed Resident #100 was lying in bed on his/her left side with the urinary catheter drainage bag anchored to his/her wheelchair not coiled and/or secured to the bed. Further observation revealed the resident was lying on the catheter tubing. In addition, observations on 03/06/19 at 8:36 AM and 1:26 PM, revealed Resident #100 was in his/her wheelchair with the catheter tubing dragging the floor. Interview with CNA #8, on 03/07/19 at 1:47 PM, revealed Resident #100 transferred self from the wheelchair to the bed at times. CNA #8 revealed staff constantly monitored Resident #100's catheter tubing, because the resident did not know to move the drainage bag from the wheelchair to the bed. Interview with CNA #5, on 03/26/19 at 2:55 PM, revealed the catheter drainage tubing should be coiled and positioned under the resident's leg. CNA #5 stated, if the drainage tubing is positioned over the top of the resident's leg, the drain tube could create pressure to the top of the residents' leg. Further interview revealed the catheter drainage bag should be attached to the bed frame and covered in a privacy bag. CNA #5 stated she did not receive education on how to position urinary catheter tubing and urine drainage bag while employed at the facility. Interview with LPN #2, on 03/26/19 at 10:25 AM, revealed she monitored care provided by the CNA's when she made rounds. LPN #2 stated the facility did not require licensed staff to make rounds in a designated time frame; however, she monitored the resident's care by answering call lights and assisting CNA's with resident care when requested. LPN #2 stated she also talked with the residents when providing care. Interview with ADON #1, on 03/06/19 at 2:10 PM, revealed the urinary catheter drainage bag should be anchored to the bed frame because it could create too much tension when placed on the wheelchair. He stated the resident should not be lying on the catheter tubing because it could cause kinks and not allow the urine to drain properly. The ADON further stated the CNA's should be aware of proper placement of the catheter bag and tubing during rounds. In addition, he stated the CNA's were taught about catheter care skills and resident care plans during their orientation period. Interview with ADON #2, on 03/26/19 at 11:17 AM, revealed licensed staff monitored the CNA's by doing rounds to ensure resident care needs were met. ADON #2 stated the licensed staff were not required to make rounds at scheduled times. Interview with the DON on 03/07/19 at 5:16 PM, revealed she expected staff to monitor the position of the bedside drainage bag and the catheter tubing during their rounds on the floor. The DON stated if the catheter drainage bag was observed anchored on the wheelchair, it should have been moved up on the bed frame to ensure proper urine flow and to prevent infection.