Based on interview, record review, and review of facility policy, the facility failed to ensure allegations of abuse were immediately reported to the State Survey Agency and other officials (Department for Community Based Services) in accordance with state law for three (Resident (R) 35, R17 and R 32) of 17 sampled residents. Specifically, the facility failed to report allegations of abuse to the State Survey Agency and the Department for Community Based Services (DCBS) when R31 hit and squeezed R32's ankle, when R65 smacked R17 with a flyswatter and when R65 hit R35 on the head. The findings include: Review of the facility's undated policy titled, Abuse, Neglect, & Exploitation, revealed Any alleged incidence of abuse, neglect or exploitation must be reported immediately to the Administrator of the facility. The Administrator or their designee will then immediately notify the Department of Community Based Services, the Office of the Inspector General (OIG) and other appropriate state/local agencies as required by law. Further review of the policy revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Defined under Physical Abuse included hitting, slapping, pinching, or kicking. As well as controlling behavior through corporal punishment. Continued review of the policy revealed, If a resident-to-resident altercation occurs, the resident's safety will first be assured. The residents shall be separated from each other, and the family and physician shall be notified. An investigation will be performed to determine if abuse has occurred as defined on page one. If it is determined that abuse has occurred, an evaluation of the abusing resident shall be completed to determine if there is a problem that would require medical intervention. The incident will be viewed as a reportable incident with proper protocol followed with notification to the Department of Community Based Services, to the OIG and other state/local agencies as required. Review of the medical records of R17, R31, R32, R35 and R65 revealed the following resident-to-resident altercations: 1. Review of R35's medical record which included progress notes dated 10/03/2024 at 4:30 PM revealed R35 was in an activity when R35 touched R65's walker and R65 hit R35 in the head with a closed fist. Per the progress notes, no injury was observed to R35, but the resident was placed on Alert Documentation for 72 hours to monitor for latent injury or pain with no changes in condition observed. Review of R65's medical record which included progress notes dated 10/03/2024 at 4:30 PM revealed R65 was sitting in the activity room when R35 touched her walker. R65 told R35 don't do that and then punched R35 in the head with a closed fist. Further review of the progress notes revealed that when R65 was asked if she had hit R35, she raised her closed fist and stated, I'll do it again. During an interview on 10/10/2024 at 8:29 PM, Activity Aide (AA) 12 stated that she witnessed the altercation on 10/03/2024 and wrote a statement regarding the event. She stated R35 was walking around and then went to R65's walker. Per the Activity Aide, R35 was touching R65's walker and R65 said to stop. She stated R35 did not stop and R65 hit R35 in the side of her head. An interview with State Registered Nursing Assistant (SRNA) 10, revealed R65 was sitting at the table with her walker to her side. R35 was bending over like she does to grab imaginary things. Per the SRNA, R65 said 'stay away from my buggy.' and R65 held her fit up to hit R35. SRNA10 stated R35 bent over and R65 hit her in the side of the head near her ear with a closed fist. During an interview on 10/11/2024 at 8:45 AM, the Director of Nursing (DON) stated the incident where R65 hit R35 was not reported to the State Survey Agency or to the Department of Community Based Services (DCBS). 2. Review of R17's medical record which included nursing progress notes dated 07/26/2024 at 2:40 PM revealed R17 was participating in an activity called balloon bat when another resident began to smack him on the left arm with a fly swatter. Review of R17's Quarterly MDS assessment with an Assessment Reference Date (ARD) of 09/17/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Review of the nursing progress notes for R65 on 07/26/2024 at 1:50 PM revealed R65 began to hit another resident with a fly swatter. The residents were separated, and the fly swatter was removed. The physician and Power of Attorney (POA) were notified of the event. Interview with R17 on 10/10/2024 at 3:30 PM regarding the incident on 07/26/2024 at 2:42 PM, revealed he was in activities playing hit the balloon with a fly swatter. He sat down beside her (R65), and she hit him on the arm three times. R17 stated he told her not to do that again and she (R65) hit him three more times on the arm. He states she did not hurt him, but he got up and moved to a different part of the table. Per R17, the staff that was in the activity made sure he was fine. R17 stated he guessed staff reported it to the higher ups, because someone came and made sure he had no injuries. He could not remember who came and checked on him. He stated he still passes the lady (R65) from time to time during the day. Per R17, he speaks to her but does not know if she would remember the incident. During an interview on 10/11/2024 at 8:45 AM, the DON stated the allegation where R65 hit R17 was not reported to the State Survey Agency or to the Department of Community Based Services. 3. Review of R32's medical record which included nursing progress notes dated 06/25/2024 at 5:14 PM, revealed R31 walked underneath my stop sign and stood at the foot of my bed and hit my left lower leg then squeezed it. No indentation no redness no hand print noted to left lower leg. Resident stated she will close her door but did not lock it. Review of R31's medical record which included nursing progress notes for 06/25/2024 at 3:21 PM revealed Reported this resident went into another resident's room, walked underneath the stop sign and stood at the foot of the bed and hit and squeezed the left ankle of another resident. Removed resident and placed her on 15-minute checks x 2 weeks. Further review of the nursing progress notes revealed the resident was placed on Alert Documentation for 72 hours following the event. Review of R32's most recent Quarterly MDS with an ARD of 09/13/2024, revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. In an interview on 10/09/2024 at 3:44 PM with R32 revealed there was an incident earlier this year where R31, entered her room uninvited. R32 stated R31 hit her on the ankle and squeezed it. R32 stated that she probably told R31 to get out of her room and that probably made her mad. R32 stated she put her call light on to summons staff but before the staff could come to the room, the resident wandered out. R32 stated the nurse examined her leg and did not find an injury; however, she did report it hurt when the resident squeezed her leg. During an interview on 10/09/2024 at 3:15 PM, Licensed Practical Nurse 1 (LPN1) stated that she thought staff made her aware of the incident and she went to R32's room. LPN1 stated she checked the resident for signs of injury and there was no injury found. LPN1 stated she documented the incident in the nurse's notes. LPN1 stated the process she followed if an incident occurred was to notify the DON, a family member, and the physician. LPN1 stated she did not know if there was an investigation of the incident completed. LPN1 stated residents were to be initially separated and kept safe then both residents would be placed on alert charting for 72 hours for monitoring related to the incident. LPN1 stated the perpetrator in this resident-to-resident altercation was placed on 15-minute checks for two weeks. In a phone interview on 10/10/2024 at 2:42 PM, the Administrator, he stated he was aware of the resident-to-resident altercations were not reported to the Office of Inspector General (OIG - State Survey Agency). He further stated that historically the facility had looked at intent with resident-to-resident altercations involving residents with dementia. He stated if there was no intent to harm and the incident involved residents with dementia, the facility did not deem the altercation as abuse. Per the Administrator, he had recently attended a training presented by OIG and will now have to take a different look at the resident-to-resident altercations. He stated the recent training redefined what we thought with Alzheimer's and dementia patient and altercations can still be considered abuse. During an interview on 10/11/2024 at 8:45 AM, DON stated the allegation where R31 hit R32's ankle was not reported to the State Survey Agency or to the Department of Community Based Services. In an interview with the Medical Director, he stated on 10/11/2024 at 9:30 AM, They [the facility] call me right away with everything. He stated he was unaware the facility was not reporting resident-to-resident altercation events.

Based on observation, interview, record review, and facility Resident Rights review, it was determined the facility failed to protect and promote the rights of one (1) of twelve (12) sampled residents (Resident #38). Observation on 12/10/19, revealed staff failed to knock on door prior to entering the spa room where Resident #38 was located. The findings include: Review of facility policy for Resident Rights, not dated, revealed when a resident enters the facility they must be treated with respect, dignity and consideration. Record review revealed the facility admitted Resident #38 on 02/04/19 with diagnoses which included Alzheimer's Disease, and Cognitive Communication Deficit. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 11/08/19 revealed the facility assessed Resident #38's cognation as severely impaired with a Brief Interview of Mental Status score of two (2) which indicated the resident was not interviewable. Observation of Resident #38 on 12/10/19 at 10:18 AM revealed the resident walked around nursing corner hall and entered the bathroom/spa room, then opened the spa room door to come out of bathroom but then went back into bathroom by self. Further observation revealed at 10:21 AM, Certified Nurse Aide (CNA) #2 came around corner and went into bathroom without knocking prior to entering. Interview with CNA #2 at 12/10/19 on 10:24 AM revealed staff should knock before entering spa room (bathroom) and she did not knock. CNA #2 stated when she entered Resident #38 was toileting. Interview with Registered Nurse (RN) #1 at 12/11/19 at 10:17 AM revealed staff should knock on bathroom door before entering. Interview with the Director of Nursing (DON) on 12/10/19 at 10:27 AM revealed staff should knock on doors before entering.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility Laboratory Protocol, it was determined the facility failed provide or obtain laboratory services to meet the needs of one (1) of twelve (12) sampled residents (Resident #33). Resident #33 had an order to have a Basic Metabolic Profile (BMP) drawn every three (3) days on 05/16/19; however, the lab was not drawn every 3 days as ordered. The findings include: Review of facility Laboratory Protocol, not dated, revealed Laboratory results are available to the facility within (24) twenty-four to (48) forty-eight hours by fax. The charge nurse will assure the laboratory reports are called to the attending physician as soon as possible upon receipt. The charge nurse will assure that the missing lab reports are followed by a call to the lab, and will check on lab reports daily to assure reports are received and acted upon. Record review revealed the facility admitted Resident #33 on 07/27/18 with diagnoses which included Congestive Heart Failure, other specific Disorders of Kidney and Ureter, and Cardiomegaly. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #33's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Review of a Laboratory Result Report, dated 05/16/19 revealed an order to obtain a BMP every three (3) days. Review of Laboratory Result Reports, revealed Resident #33 had a BMP conducted on 05/17/19, 05/20/19, and 05/23/19 However, another BMP was not drawn until 05/28/19 (five days later). Further review revealed results dated 05/31/19 and 06/03/19; however, there were no results again until 06/12/19, then not again until 09/18/19. Further review of the Lab Reports and Physician Orders revealed there was no further order changing the timeframe on drawing the BMP's Interview with Registered Nurse (RN) #2 on 12/11/19 at 9:13 AM revealed the charge nurse should ensure labs are completed for residents and if resident refuses it should be charted. Interview with RN #2 on 12/11/19 at 1:44 PM revealed she looked into the BMP for Resident #33 and had found the order to obtain every three (3) days. She stated she did not see a lab completed on 05/26/19 and the last lab she found was completed 06/03/19, then Resident #33 started getting them monthly. She revealed she could not find an order that changed them to monthly, so she obtained the order today. She stated there should be an order in the chart to change to monthly. She revealed she was the one that puts the order in the computer for the lab to come draw; however, she could not find the order or the requisition. Interview with Dietician and MDS Coordinator on 12/11/19 at 9:25 AM revealed the lab (BMP) was on the lab slip to be completed every three days and they could find no further documented evidence they were being done. Interview with the Director of Nursing (DON) on 12/11/19 at 10:03 AM revealed the lab was not drawn on 05/26/19 but was drawn again on 05/31/19. The DON stated she could not find an order that changed the lab to be drawn less often than every three days. Further interview with the DON on 12/11/19 at 10:08 AM revealed she expected there to be a lab order change for Resident #33.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure gloving procedures were followed related to a medication pass. Observation on 12/11/19, revealed licensed staff handled a resident's medication with her bare hands. The findings include: Review of the facility policy titled, Specific Medication Administration Procedures, not dated, revealed staff should cleanse hands before handling medication and before contact with resident. Interview with the Director of Nursing (DON) on 12/11/19 at 2:35 PM, revealed the facility policy does not address touching medications with bare hands; however, the facility follows state and federal regulations when administering medications. Observation of a medication administration pass on 12/11/19 at 8:23 AM, revealed Certified Medication Aide (CMA) #1, removed two (2) medications from blister packs with her bare finger prior to placing the medications in the medication cup. Interview with CMA #1 on 12/11/19 at 8:35 AM, revealed she should not have used her bare fingers to remove medications from the blister pack because it is an infection control issue and unsanitary. Interview with the Director of Nursing (DON) on 12/11/19 at 2:35 PM, revealed she does monthly audits of medication passes to ensure proper hand hygiene practices are carried out. The DON stated she would expect staff to wear gloves if they need to remove a medication from the blister pack and not use their bare hand.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored, in accordance with professional standards for food service safety. Observation of the kitchen, on 12/09/19, revealed food stored in the freezer was opened and not dated. Review of the facility Census and Condition, dated 12/09/19, revealed forty-two (42) of forty-two (42) residents received their meals from the kitchen. The findings include: Review of the facility policy titled, Frozen Storage, not dated, revealed all frozen food will be properly wrapped, dated, and labeled. Observation of the freezer on 12/09/19 at 10:18 AM, revealed one bag of chicken breasts not dated and one bag of unsealed garlic toast not dated. Interview with the Dietary Manager on 12/09/19 at 10:23 AM, revealed she expected all food items stored in the refrigerator and freezer to be dated when prepared or opened.

Based on interview and review of the Skilled Nursing Facility Beneficiary Protections Notifications, it was determined the facility failed to issue the appropriate and required Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) to resident/beneficiaries when Medicare covered services were ending for three (3) of three (3) Medicare Discharges reviewed (Resident's #3, #6, #40) Review of Resident #3's, #6's, and #40's Medicare Discharge, revealed the facility did not issue a SNFABN CMS Form-10055. The findings include: Review of the Skilled Nursing Facility Beneficiary Protection Notification Review completed by the facility revealed the facility discharged Resident #3 from Medicare Part A services with the last covered day being 03/22/18; Resident #6 on 04/20/18; and Resident #40 on 07/03/18; however, the residents still had benefit days that were not exhausted. Further review of the Skilled Nursing Facility Beneficiary Protection Notification Review, revealed the facility did not provide a SNFABN form CMS-10055 to these residents. Interview with the facility Administrator on 09/12/18 at 3:38 PM revealed a policy had not been developed for the SNFABN and the Advanced Beneficiary Notice, Form CMS-10055, had not been implemented. The Administrator stated it got missed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to ensure interventions of the comprehensive care plan were followed for one (1) of fifteen (15) sampled residents, (Resident #42). Resident #42 was care planned to float heels in bed; however, observations on 09/12/18 revealed the resident lying in bed with feet elevated on pillow but the heels were directly on pillow and not extended beyond pillow to float heels. The findings include: Review of the facility's policy and procedures titled, Development of a Care Plan, not dated, revealed care plans are to be created by the interdisciplinary care plan team within seven (7) days of the completion of the comprehensive Minimum Data Set (MDS) Assessment. Each discipline is to contribute to the entire care plan as appropriate and indicated. Don't forget to make sure CNA care plan record matches the care plan exactly, have care plans ready for immediate implementation after making them resident specific (infections, wounds, falls, etc.). Record review revealed the facility admitted Resident #42 on 08/09/18 with diagnoses which included Alzheimer's Disease, Unspecified Dementia, Diabetes, Acute Kidney Failure, and History of Malignant Neoplasm of Prostate. Review of the Initial Minimum Data Set (MDS) assessment, dated 08/16/18, revealed the facility assessed Resident #42's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score pf zero (0) which indicated the resident was rarely/never understood and not interviewable. Further review of the MDS: Section G- Functional Status, related to bed mobility, revealed the facility assessed Resident #42 at a score of three (3:3) which indicated the resident required extensive assistance of two (2) or more persons to physically assist. Further review of the MDS: Section M -Skin Conditions; revealed Resident #42 did not have any pressure ulcers. Review of Resident #42's Weekly Wound Observation Tool, dated 09/01/18, revealed the resident had a blistered area to (R) heel and was assessed to be an unstageable pressure ulcer. Review of the Resident #42's Comprehensive Care Plan for Actual Pressure Ulcer Development, dated 09/05/18, and Resident #42's Visual/Bedside [NAME] Report, Skin Management, not dated, revealed an intervention to float heels in bed. However, observations of Resident #42 on 09/12/18 at 8:20 AM and at 3:36 PM revealed the resident was lying in bed on back with both feet elevated on pillow but the heels were directly on the pillow and did not extend beyond pillow to float heels. Interview with Certified Nursing Assistant (CNA) #8, on 09/12/18 at 4:00 PM, revealed she did not know Resident #42 was to float heels while in bed. CNA #8 stated, I would have to check with nurse related to floating the resident heels. I know his/her feet are to be up on the pillow while in bed because of the blister on his/her foot but, I'm not sure if the feet are to be up on the pillow or elevated over the pillow. Interview with Licensed Practical Nurse (LPN) #1 on 09/12/18 at 5:45 PM revealed Resident #42's heels should be floated while in bed to relieve pressure. LPN #1 stated the CNA's should follow the care plan interventions for each resident while providing care. LPN #1 revealed resident care is monitored during rounds to ensure necessary care is provided. Further interview revealed LPN #1 would expect for staff to float Resident #42's heels while in bed. Interview with the Director of Nursing (DON), on 09/13/18 at 3:25 PM, revealed she expected Resident #42's heels to be floated while in bed per care plan intervention. The DON stated she expected Resident #42's feet to extend over the pillow and not be on the pillow if he/she had an order to float heels.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to follow physician's diet order for one (1) of fifteen (15) sampled residents (Resident #40). The findings include: Interview on 09/13/18 at 3:30 PM with the facility Corporate Nurse revealed the facility does not have a policy for physician orders and and the facility follow the regulations. Record review revealed the facility admitted Resident #40 on 05/10/18 with diagnoses which included Unspecified Dementia without Behavioral Disturbance, Anxiety Disorder, Chronic Obstructive Pulmonary Disease, and Sepsis. Review of a Telephone Physician's Order, dated 06/04/18, revealed to change diet to mechanical soft consistency and review of the July 2018 through September 2018 Physician Order Sheets revealed Resident #40 was ordered to have regular diet/regular texture, lactose free milk, and prune juice at breakfast. Review of Resident #40's breakfast meal ticket dated 09/12/18 revealed the resident was to receive a mechanical soft diet but did not specify to serve prune juice or lactose free milk. Observation on 09/12/18 at at approximately 8:50 AM in the dining room revealed Resident #40 eating a mechanical soft diet with no prune juice with meal. Observation and interview on 09/12/18 at 9:22 AM with Director of Nursing (DON) revealed Resident #40's breakfast tray contained water, arginaid extra, and coffee; but did not have prune juice per POS. Interview with Licensed Practical Nurse (LPN) #1 and Assistant Director of Nursing (ADON) on 09/12/18 at 9:44 AM and 10:00 AM revealed Resident # 40's prune juice should be on dietary slip and provided for breakfast. Interview on 09/12/18 at 04:02 PM with Dietary Manager revealed it was the responsibility of the DON to ensure that the dietary slip was received, and was notified today (09/12/18) to add prune juice to Resident #40's breakfast and the dietary ticket.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, to promote healing and prevent new ulcers from developing for one (1) of fifteen (15) sampled residents (Resident #42). Resident #42 was assessed by the facility to have an unstageable Pressure Ulcer to right heel on 09/01/18 and an intervention was put in place to float heels when in bed to promote heeling and prevent further ulcers from developing. However, observations on 09/12/18 revealed the resident's heels were not floated and were resting directly on the pillow causing pressure. The findings include: Review of the facility's policy titled, Skin Care Management, last revised March 2012, revealed the purpose of the policy is to strive to prevent the development of avoidable pressure ulcers. It is the policy of this facility that protocols will be in place for the prevention and treatment of pressure ulcers. Frequency of turning and repositioning will be individualized in accordance to each resident's skin assessment findings. If a resident has a pressure ulcer, avoid positioning on the area if possible, relieve pressure on heels by using devices such as pillows or facility approved boots. Record review revealed the facility admitted Resident #42 on 08/09/18 with diagnoses which included Alzheimer's Disease, Unspecified Dementia, Diabetes, Acute Kidney Failure, and History of Malignant Neoplasm of Prostate. Review of the Initial Minimum Data Set (MDS), dated 08//16/18, revealed the facility assessed Resident #42's cognition as severely impaired with a Brief Inventory of Mental Status (BIMS) score zero (0) which indicated the resident was rarely/never understood and not interviewable. Further review of the MDS: Section G- Functional Status, related to bed mobility, revealed the facility assessed Resident #42 at a score of three (3:3) which indicated the resident required extensive assistance of two (2) or more persons to physically assist. Further review of the MDS: Section M -Skin Conditions; revealed Resident #42 did not have any pressure ulcers. Review of Resident #42's Progress Note, dated 09/01/18 at 7:00 AM, revealed staff was getting the resident out of bed and noticed a fluid filled blister to right (R) heel was draining. The blistered area to (R) heel measured six (6) centimeters (cm) length by five (5) cm width. Review of Resident #42's Weekly Wound Observation Tool, dated 09/01/18, revealed the facility assessed blistered area to (R) heel as an unstageable pressure ulcer. Review of the Resident #42's Comprehensive Care Plan, Actual Pressure Ulcer Development, dated 09/05/18, revealed an intervention to float heels in bed. Review of Resident #42's Visual/Bedside [NAME] Report, Skin Management, revealed to float heels in bed. Observations of Resident #42 on 09/12/18 at 8:20 AM and at 3:36 PM revealed the resident was lying in bed on back, with both feet elevated on pillow; however, the resident's heels were resting directly on the pillow and did not extend beyond pillow to float heels. Observation of wound care to Resident #42's (R) heel, on 09/12/18 at 11:35 AM, performed by Licensed Practical Nurse (LPN) #1 revealed a circular flat area, pale yellow in color, non blanchable, measuring five (5) cm length by 5 cm width. Interview with Certified Nursing Assistant (CNA) #8, on 09/12/18 at 4:00 PM, revealed she did not know Resident #42 was to float heels while in bed. CNA #8 stated, I would have to check with nurse related to floating the resident heels. I know his/her feet are to be up on the pillow while in bed because of the blister on his/her foot but, I'm not sure if the feet are to be up on the pillow or elevated over the pillow. Interview with Licensed Practical Nurse (LPN) #1 on 09/12/18 at 11:35 AM revealed Resident #42's pressure ulcer to (R) heel was facility acquired and identified on 09/01/18. LPN #1 stated the (R) heal was initially assessed as a unstageable pressure ulcer due to the blister being intact when identified. Further interview with LPN #1 on 09/12/18 at 5:45 PM revealed Resident #42's heels are to float while in bed to relieve pressure. LPN #1 stated resident care is monitored during rounds to ensure necessary care is provided. LPN #1 further stated she expected the staff to float Resident #42's heels while in bed. Interview with the Director of Nursing (DON), on 09/13/18 at 3:25 PM, revealed Resident #42's wound was initially assessed as an unstageable pressure ulcer because the blister was still intact even though it had been draining. The DON stated the pressure ulcer was identified as facility acquired and the resident's clinical condition did not indicate the pressure ulcer was unavoidable. The DON stated, I would expect for his/her (Resident #42) feet to extend over the pillow and not be on the pillow if he/she had an order to float heels.

Based on observation, interview, and review of the facility policy, it was determined the facility failed to ensure drugs and biological's used in the facility must be labeled in accordance with currently accepted professional principles, and include the expiration date when applicable for three (3) medications for three (3) of fifteen (15) sampled residents (Residents #15, #23, and #1). and two (2) medications for two (2) residents not in the sample (Residents #29 and #21). Unsampled Resident #15, #29's and 21's Milk of Magnesium (MOM) were expired; Resident #23's Novolog (Insulin) was not dated when opened; and Resident #1's Robitussin (cough medication) was expired. The findings include: Review of the facility policy titled, Consultant Pharmacist Services Provider Requirements, not dated, revealed regular and reliable consultant pharmacist services are provided to residents. Specific activities that the consultant pharmacist performs includes: checking the medication storage areas at least monthly for proper storage and labeling of medications, cleanliness, and removal of expired medications. Observation of three (3) of five (5) medication carts on 09/12/18 at 10:07 AM revealed Unsampled Resident #29's MOM expired 07/31/18; Unsampled Resident #21's MOM expired 06/01/18; Resident #15's MOM expired 06/23/18; and Resident #1's Robitussin expired January, 2018. Further observation revealed Resident #23's Novolog was not dated when opened. Interview with Certified Medication Technician (CMT) on 09/12/18 at 10:26 AM revealed the CMT's check the medication stock for expiration every couple weeks and the corporate pharmacist checks the stock monthly. Interview with the Director of Nursing (DON) on 09/12/18 at 10:32 AM revealed the Insulin should have been labeled with the date it was opened and the expiration date. She stated she expected the CMT to check the medication stock for expired drugs weekly and the pharmacist consultant to check monthly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and facility policy review, it was determined the facility failed to ensure each resident's written plan of care includes both the most recent hospice plan of care; and, failed to designate a person to obtain the most recent hospice plan of care specific to each patient, and Hospice physician and attending physician (if any) orders for two of fifteen (15) sampled residents (Resident #38 and #40). In addition, the facility failed to ensure there was a signed Physician certification and recertification of the terminal illness. The findings include: Review of Hospice Contract titled, Nursing Facility & Hospice Services Agreement, dated 01/01/14, revealed the following information shall be provided by hospice to facility: plan of care, hospice election form, physician certification and recertification names, and physician medication information specific to each resident. Responsibility of Facility: facility shall designate a member of Interdisciplinary Team (IDT) who is responsible for working with hospice to coordinate care provided by the facility and hospice staff to any resident under hospice care. Facility is to ensure that each resident's plan of care includes both the most recent hospice plan of care and a description of services provided by the facility. Communication protocol: Hospice and Facility shall work together to develop a written communication protocol governing how they will communicate all information needed for the resident's care (such as physician orders, and medication information), including how such communications will be documented to be ensure the needs of residents are met (24) twenty-four hours a day and clearly outlines the chain of communication between the parties that will address changes to the hospice plan of care. It must also address how hospice physician orders will be communicated to facility staff. Record review revealed the facility admitted Resident #38 on 11/03/15 with diagnoses which included Altered Mental Status, Coronary Artery Disease, Peripheral Vascular Disease, Cerebral Ventriculomegaly, Stroke and Dementia without Behaviors. Review of facility telephone order dated 04/07/18 revealed Resident #38 was admitted to hospice. Further record review revealed there was no Hospice Care plan or Hospice Physician Orders per Hospice contract 2. Record review revealed the facility admitted Resident #40 on 05/10/18 with diagnoses which included Unspecified Dementia without Behavioral Disturbance, Anxiety Disorder, Chronic Obstructive Pulmonary Disease, and Sepsis. Further review revealed the facility was admitted to hospice on 09/05/18. Further record review revealed there was no Hospice Physician Orders or Hospice Care Plan per Hospice contract. Interview with LPN #1 on 09/11/18 at 12:24 PM revealed Resident #40 is on hospice and the Hospice Certificate of Terminal Illness was not signed by the medical director of hospice and physician of Resident #40. Interview with the DON on 09/13/18 at 8:45 AM revealed she did not have a copy of Resident #40's unsigned sheet (Hospice Certification of Terminal Illness) but will bring a copy and had talked with hospice RN #2 and the forms are electronically signed. Additionally, DON stated it was not their form and not sure if signed one is on the chart and it is hospice decision. Interview with Supervisor of Hospice ([NAME]) on 09/13/18 at 9:15 AM revealed Hospice Certification of Terminal Illness should be signed on resident's chart. Interview with Director of Nursing (DON) on 09/12/18 at 5:35 PM revealed the Hospice Certification of Terminal Illness should be in chart by now but that medical records may have it and she would check. Upon return from medical records, the DON stated that the form had not been signed by the medical director or the attending physician related to the brief narrative statement/attestation and Hospice Certification of Terminal Illness per contract. Interview with Hospice Staff (Hospice Supervisor, Hospice Social Service Director (SSD), and Hospice Registered Nurse (RN) #2) on 09/13/18 at 9:00 AM revealed they speak with the facility nurse assigned to the resident on day of hospice visit to coordinate care. The Hospice staff further revealed they were not aware of a designated person on the IDT team to talk with, but they met quarterly for the care plan meeting with facility staff. The Hospice staff stated they print off care plans and compare them with the facility care plans once a month, look at them on the first visit and discuss with nurse/physician at quarterly care plan conference. Interview on 09/13/18 at 9:15 AM with Supervisor of Hospice ([NAME]) revealed there should be medication orders on the chart, a list of what orders to call hospice on and what orders not to call hospice on, and the long term care (LTC) facility nurse would have to be aware of the orders in order to call hospice about them, and it is the responsibility of the hospice nurse to ensure they are in the chart. Additionally, [NAME] stated the orders would have to be faxed to the facility for residents. Interview with Minimum Data Set (MDS) Supervisor, on 09/13/18 at 9:54 AM revealed she would talk with hospice at the care plan meeting and meet with family and they sign the information when they come. The MDS Supervisor stated she could not provide documentation of when she had met with hospice; but she may meet with them weekly, and there is no set time for hospice to come and she never looks under the hospice tab. The MDS Supervisor looked at the hospice tab and revealed there was no orders for Resident #40. Interview with Assistant Director of Nursing (ADON) on 09/12/18 at 9:47 AM revealed she was not sure how the facility ensured the continuity of care between the facility and hospice regarding communication about plan of care, agreement of services and physician orders. Interview with the Director of Nursing (DON) on 09/13/18 at 10:15 AM revealed she was not aware the facility needed to have the Physician Orders in the chart. She stated the night nurse does the change over and hospice comes in, writes phone orders and the facility transcribes the orders from their phone orders. When asked who coordinates the care between the facility and hospice, the DON stated it was done by whatever nurse is working that day.

Based on observation, interview and facility policy review, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections during medication pass. Observation on 09/12/18 revealed the Certified Medication Technician (CMT) administered medication without sanitizing hands from one resident to the next. The findings include: Review of the facility policy titled, Specific Medication Administration Procedures, not dated, revealed to administer medications in a safe and effective manner. Cleanse hands before handling medications and before contact with resident. Observation on 09/12/18 at 9:03 AM, revealed the CMT administered medications to a resident and touched him/her on the shoulder. The CMT then returned to the medication cart, prepared medications for another resident and administered those medications to the next resident. The CMT did not, at any time, sanitizer her hands from one resident to the next. Interview with the CMT on 09/12/18 at 9: 07 AM, revealed she did not sanitize her hand between residents because she was taught she did not have to sanitize her hands between each resident, but with every third resident. Interview with the Director of Nursing (DON) on 09/12/18 at 10:32 AM, revealed she expected CMTs to wash or sanitize their hands before and after every resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to ensure five (5) of fifteen (15) sampled residents was not administered a Psychotropic medication without an appropriate diagnosis (Resident #12, #15, #17, #19. and #40). The findings include: Review of the facility policy titled, Behavioral Interventions that Reduce the Use of Anti-psychotic, Psychopharmacological, and Hypnotic Drugs, last revised April 2007, revealed residents are assessed according to established protocols prior to implementation of behavioral management or anti-psychotic, psychopharmacological, or hypnotic drug use. A protocol when resident is on medication is to assess for appropriate diagnosis/justifying indications for the medication. Review of the Nursing Drug Handbook by Lipponcott, dated 2014, revealed Risperidone was used for the following: Schizophrenia, Aggression, Irritability, Temper Tantrums, Self-injury associated with Autism, and Turettes Syndrome., Review of the Black Box Warning revealed fatal Cardiovascular or Infectious adverse events may occur in elderly patients with dementia and is not safe or effective in these patients. Review of the PDR Nursing Drug Handbook, 2012 edition, revealed Zyprexa is used for treatment of Schizophrenia, Acute Treatment of manic or mixed episodes associated with Bi-Polar 1 Disorder. Review of the Black Box Warning revealed elderly patients with dementia-related psychosis treated with anti-psychotic drugs are at an increased risk of death, most are cardiovascular or infectious in nature. Zyprexa is not approved for the treatment of patients with dementia-related psychosis. 1. Record review revealed the facility admitted Resident #12 on 03/07/12 with diagnoses which included Unspecified Dementia without Behavioral Disturbance; Unspecified Anxiety Disorder; and Parkinson's Disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no behaviors, delusions, or hallucinations during the look back period. Further review of the Quarterly MDS assessment revealed the facility assessed Resident #12's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of five (5) indicating the resident was not interviewable. Review of the Resident #12's Comprehensive Care Plan for Potential for side effects due to use of psychotropic medications, last revised 03/14/18 revealed interventions to administer medications as ordered and monitor/document for side effects and effectiveness; monitor/record and report to the medical doctor side effects and adverse reactions of psychoactive medications; monitor/record occurrence of target behavior symptoms of pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others; and discuss with medical doctor, family regarding ongoing need for use of medication. Review of Resident #12's September 2018 Physicians Orders revealed ordered for Olanzapine (Zyprexa) 2.5 milligrams (mg), take one (1) tablet by mouth every morning, dated 10/20/16. Review of Resident #12's Psychotropic Medication Side Effect Monitoring sheets for July 2018, August and September 2018 revealed no side effects. There was no documented evidence of monitoring for behaviors. Interview with Resident #12's Physician on 09/13/18 at 11:41 AM revealed the resident has Parkinson's Disease with Psychosis but was not aware that Psychosis was not included on the resident's diagnoses list. The Physician further stated the resident has a long list of diagnoses and the psychosis diagnosis not being documented on the resident's chart was over looked. 2. Record review revealed the facility admitted Resident #19 on 08/23/13 with diagnoses which included Unspecified Dementia without Behavioral Disturbance; Alzheimer's Disease, Unspecified. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no behaviors, delusions, or hallucinations during the look back period. Further review of the Quarterly MDS assessment revealed the facility assessed Resident's #19's cognition as severely impaired with a BIMS score of ninety-nine (99) indicating the resident was not interviewable. Review of Resident #19's Comprehensive Care Plan for Potential for side effects to use of psychotropic medications, last revised 06/04/18, revealed interventions to administer medications as ordered, monitor/document for side effects and effectiveness; monitor/record and report to the medical doctor side effects and adverse reactions of psychoactive medications; monitor/record occurrence of target behavior symptoms of pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others; Discuss with medical doctor, family regarding ongoing need for use of medication. Review of Resident #19's September 2018 Physician's Order revealed Risperidone 0.25 mg, take one (1) tablet by mouth every night at bedtime, dated 03/09/16. Review of Resident #19's Psychotropic Medication Side Effect Monitoring sheets for July, August, and September 2018 revealed no side effects. There was no documented evidence of monitoring for behaviors. Interview with Resident #19's Physician on 09/13/18 at 10:57 AM revealed the medication, Risperdone, was ordered for Dementia with agitation. The Physician was not aware there was not an appropriate diagnosis on the chart. She stated the pharmacy reviews the medications and diagnoses and notifies the physicians of any irregularities. She further stated not having an appropriate diagnosis on the resident's chart was an oversight. 3. Record review revealed Resident #15 was admitted by the facility on 06/23/18 with diagnoses which included Depression, Mild Dementia, Anxiety and Major Depressive Disorder. Review of the September 2018 Physician Orders revealed the resident was currently taking Risperdal 0.5 mg twice daily. A call was placed to the physician regarding the order for an anti-psychotic medication without an appropriate diagnosis, but the call was not returned. 4. Record review revealed the facility admitted Resident #17 on 02/02/17 with diagnoses which included Senile Dementia and Alzheimer's Disease. Review of the September 2018 Physician Orders revealed the resident was currently taking Seroquel 100 mg by mouth at bedtime and 50 mg by mouth every morning. Interview with Resident #17's Physician, on 09/13/18 at 11:31 AM, revealed he was aware of the black box warning but the resident experienced behaviors when he tried to do a gradual dose reduction on this resident. He stated he was aware the resident does not have a diagnosis to support the anti-psychotic medication. 5. Record review revealed the facility admitted Resident #40 on 05/10/18 with diagnoses which included Unspecified Dementia without Behavioral Disturbance, and Anxiety Disorder. Review of the September 2018 Physician Order revealed the resident was currently taking Aipiprazole (Abilify) 5 mg take one tablet by mouth once daily, Interview with Resident #40's Physician 09/13/18 at 02:49 PM revealed he expected to be notified of resident being administered anti-psychotic without an appropriate diagnosis. Interview with the Director of Nursing (DON) on 09/13/18 at 9:30 AM revealed the Pharmacist reviews the resident's medications and diagnoses on a monthly basis and if there was a new medication ordered without a diagnosis, the Pharmacist makes the recommendation to implement a diagnosis. The DON further stated she reviews the Pharmacist's recommendations and follows up on those. Additionally, the DON state she thinks the Dementia/Alzheimer's with behavioral disturbance is an appropriate diagnosis for administration of anti-psychotic medications. Interview with the Pharmacist Consultant on 09/13/18 at 11:52 AM revealed she reviews the medication regimes and diagnoses lists monthly. She stated if there are irregularities, a letter is sent to the physician with the black box warning information and recommendations for the specific medication. She further stated the recommendations are also given to the DON at the facility.

Based on observation and interview, it was determined the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Observations of the kitchen revealed dirty kitchen equipment and expired or not dated food/drink in the refrigerators. Review of the facility Census and Condition, dated 09/11/18, revealed forty-three (43) of forty-three (43) residents received their meals from the kitchen. In addition, observations on 09/11/18 revealed Certified Nurse Aides (CNA's) failed to sanitize hands in between passing and setting ups trays for each resident. The findings include: Review of the facility policy titled, Refrigerated Storage, not dated, revealed it is the policy of the facility to store, prepare, and serve foods in accordance with federal, state, and local sanitary codes. All foods will be properly stored in sealed containers and dated and labeled. Food will be discarded within appropriate shelf life. 1. Observation of the walk-in refrigerator on 09/11/18 at 10:54 AM, revealed a pitcher of lemonade was dated 09/07/18 and expired 09/09/18; a pitcher of apple juice had no visible date; and a container of cole slaw had expired on 08/31/18. Interview with the Dietary Manager on 09/11/18 at 11:00 AM, revealed she expected expired items to be disposed of on the expiration dates. 2. A policy for cleaning kitchen equipment was requested but not provided by the facility. Observation on 09/11/18 at 11:10 AM, revealed plate covers were stored on a rack with the dome side down with white particles or crumbs collected in the concave side of the covers. Interview with the Dietitian on 09/11/18 at 11:17, revealed she expected the lids to be stored dome side up to keep the concave side clean. 3. Observation on 09/11/18 at 11:21 AM, revealed the manual can opener had a black sticky substance on the opening edge. Interview with the Dietary Manager on 09/11/18 at 11:26 AM, revealed she expected the can opener to be cleaned nightly. 4. Review of facility policy titled, Handwashing, not dated, revealed handwashing and hand antisepsis shall be regarded by this facility as the single most important means of preventing the spread of infections. All personnel shall follow the established handwashing and hand antisepsis procedures to prevent the spread of infection and disease to other personnel, residents, and visitors. Wash hands if visibly soiled with either a non antimicrobial soap and water or antimicrobial soap and water. If not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations to include after contact with inanimate objects in the immediate vicinity of the resident. Observation in the dining room on 09/11/18 at 12:37 PM revealed four (4) Certified Nurse Aides (CNA's) passing trays. Further observation revealed two of the CNA's (CNA #3 and CNA #5) did not sanitized hands between the serving of each tray and two CNA's (CNA #9 and CNA #2) and would sanitize their hands intermittently. Interview with CNA #3 on 09/13/18 at 9:45 AM revealed staff usually sanitize their hands before they pass trays, and wash them afterwards. CNA #3 stated she did sanitize every time she passed trays. Interview with CNA #5 on 09/13/18 at 9:51 AM revealed she had worked on 09/11/18 and staff should sanitize hands after they give each resident their tray. She stated she sanitized her hands on on 09/11/18. She stated they sanitize their hands for sanitary reasons. Interviews on 09/13/18 with CNA #1 at 9:43 AM and CNA #4 at 9:49 revealed staff are to sanitize hands between every tray. Interview with Registered Nurse (RN) #1 on 09/13/18 at 8:41 AM revealed staff should sanitize hands after every tray and wash if there is something on their hands. Interview with Director of Nursing (DON) on 09/13/18 at 8:43 AM revealed staff should sanitize hands between every resident because they touch every tray and tables.