**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to assess and monitor a resident after a fall and failed to follow their own Fall management and Neurological evaluation policies and procedures by obtaining neurological assessments for residents who had unwitnessed falls for 3 of 6 residents reviewed for falls. (Resident #9, #23, #71) The facilities Falls Management Policy last updated 2/2025 states under procedure; A fall incident report will be completed after a resident has had a fall, whether it is witnessed or not. Complete Post Fall Observation Tool, following a fall, to identify if the cause of the fall is related to mental status changes, physical limitations or environment factors. A neurological assessment tool will be initiated for falls where there is a known head bump. A neurological assessment will also be initiated for an unwitnessed fall in a resident who has a BIMS (Brief Interview for Mental Status) score of 12 or lower. The facilities Neurological Assessment Policy updated on 1/9/2025 states under procedure; Neurological assessment following resident head injury will be completed for all residents sustaining head trauma or suspected head trauma. In EMR (Electronic Medical Record): Neuro Checks will be conducted - every 15 min x4, every 30 min x4, every 1 hr. x4, every 4 hr. x2 and every 8 hr. x1. Frequency of neuro checks after 24 hours is determined by resident's observed signs and symptoms of neurological compromise. 1. Review of Resident #9’s quarterly Minimum Data Set (MDS) dated [DATE] revealed he/she had a Brief Interview for Mental Status (BIMS) of 5 of 15 indicating he/she was not cognitively intact. On 7/31/25 Resident #9 had an unwitnessed fall and was found lying on the floor. The nurses note dated 7/31/25 at 12:57 p.m., stated, “This writer was sitting at the nurses station when I heard housekeeping telling resident to hold on help was coming, this writer along with 2 CNAs (Certified Nursing Aids) looked around the corner and saw resident laying on the floor in front of [his/her] wheelchair near the visitor restroom. SLP (Speech therapists) states she saw resident attempting to reposition in wheelchair right before the fall. No observable injuries noted, no c/o pain. No indication resident hit head. Resident hoyered off the floor. VM (voice mail) left for POA (Power of Attorney), Copy of incident report in SBAR (Situation Background Assessment and Recommendations) book for provider.” Further review of the medical record lacked evidence of a post fall observation and the neurological assessments being completed after this fall. On 8/9/25 Resident #9 had another unwitnessed fall and was found lying on the floor. The nurses note dated 8/9/25 at 8:02 a.m., stated, “Unwitnessed fall, resident found in bathroom lying on [his/her] right side, Resident is alert and pleasantly confused. [He/she] said, I am in my bedroom, resident also said [he/she] hurt [his/her] forehead on floor. Resident was checked for injury, VSS (Vital signs stable), NVSS (neurological vital signs stable), rom (range of motion) x 4 to baseline. Safety checks throughout shift in place. Notified [resident representative]. Resident stated [he/she] was a little sore from fall. Tylenol given and taken for pain with good effect., will continue to monitor.” Further review of the “Neurological Check Flow Sheet” after this fall has only 5 of the 15 neurological assessments completed. On 8/25/25 at 2:31 p.m., during an interview, the Registered Nurse Manager of the July Unit confirmed the above stating the post fall observation and neurological assessments should be completed after an unwitnessed fall if the resident reports he/she hit their head and if the residents BIMS is below 12 then the neurological assessments should be completed regardless for any unwitnessed falls. 2. Review of Resident #23’s quarterly Minimum Data Set (MDS) dated [DATE] revealed he/she had a Brief Interview for Mental Status (BIMS) of 11 of 15 indicating he/she was moderately cognitively impaired. On 08/25/2025 at 10:53 a.m., in an interview with a surveyor, Resident #23 stated he/she had experienced “a bad fall,” but could not remember the details. A review of Resident #23’s clinical record revealed a progress note, dated 8/24/25, which stated “Writer entered room to find patient sitting on the floor. Writer asked patient what happened and he/she stated he/she was on his/her way from the bathroom and his/her feet got twisted up and he/she fell. Writer asked why his/her walker was over by the bathroom and patient stated he/she wasn't using it at the time. He/she states he/she does not remember hitting his/her head. Writer performed complete assessment of patient to find no injuries. (Pupils equal in roundness and reactive to light and accommodation) PERRLA intact, no signs or symptoms of trauma. Vital signs stable. Patient denies pain. Patient stated he/she did not need or want to go to the hospital. Writer called and left message with patient’s son. Notified provider.” A Neurological Check Flowsheet, dated 8/24/25, revealed only 3 of 15 neurological assessments had been completed. On 8/27/25 at 9:50 a.m., in a discussion with a surveyor, the Director of Nursing confirmed staff had not followed the facility’s policy after Resident #23’s fall on 8/24/25, as only 3 neurological assessments had been completed. 3. Review of Resident #71’s quarterly Minimum Data Set (MDS) dated [DATE], revealed he/she had a Brief Interview for Mental Status (BIMS) of 3 of 15 indicating severe cognitive impairment. On 9/16/24 at 10:15 a.m., there is documentation of an unwitnessed fall for Resident #71. There is an incident report stating that the Nurse Practitioner (NP) was in the facility at the time and evaluated the resident and had him/her sent to the Emergency Department (ED) for further evaluation and treatment. On 9/16/24 at 6:30 p.m., there is documentation of Resident #71 having an unwitnessed fall. The record lacks documentation of any further post fall evaluation or neurological assessments being done. On 9/16/24 at 7:30 p.m., there is documentation of another unwitnessed fall for Resident #71. Documentation of neurological assessments started at 7:30 p.m. and continued into the eighth hour after the fall. All other components of the neurological assessment were unremarkable. On 9/17/24 at 3:00 p.m., there is documentation of an unwitnessed fall for Resident #71. Due to extensive injuries, Resident #71 was sent to the local Emergency Department via Emergency Medical Services and then transferred to Maine Medical Center for further evaluation and treatment. On 8/26/25, in an interview with a surveyor, the Director of Nursing (DON) provided documentation for Resident #71's three falls on 9/16/24, and one fall on 9/17/24. The DON confirmed that there were no notes for monitoring Resident #71 with post fall documentation, and there were no neurological assessments documented for the second fall on 9/16/24. On 8/27/25 at approximately 9:00 a.m. in an interview with a surveyor, the July Unit Manager, reviewed the documentation for Resident #71 and confirmed that They should have done neuro checks after the second fall and did not. I was not here at the time, I had already left for the day.

Based on record review and interviews, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week on 5 of 62 days (December 2023 and January 2024) reviewed for RN coverage. Finding: On 1/24/2024, during a review of Daily Staffing Postings and nursing working schedules from 12/1/2023 - 1/24/2024, they indicated that on 12/16/23 (Wednesday), 12/17/23 (Thursday), 12/23/23 (Wednesday), 1/12/24 (Friday), and 1/13/24 (Saturday) the facility did not have a Registered Nurse (RN) on duty for at least 8 consecutive hours. On 1/24/2024, at 10:45a.m., in an interview with the Director of Nursing, the surveyor confirmed the lack of RN coverage for a least 8 consective hours a day, 7 days a week on the dates identified in December of 2023 and January of 2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 11/14/22 at 11:45 a.m., Resident #113 stated no one had met with him/her since admission to discuss care planning. Resident #113 stated he/she had not been provided a summary of the baseline care plan. A review of Resident #113's clinical record indicated he/she was admitted to the facility on [DATE]. The baseline care plan was initiated on 11/11/22. The clinical record lacked evidence that the resident, and/or resident representative, were provided a summary of Resident #113's baseline care plan. On 11/16/22 at 12:00 p.m., the Social Worker stated the facility does not provide copies of baseline care plans or conduct resident/family meetings to discuss care planning within 48-72 hours of admission. On 11/16/22 at 12:10 p.m., the findings were discussed with the Director of Nursing. Based on interview and record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare instructions necessary to properly care for the resident and failed to ensure that a resident, and/or resident representative, was provided a summary of the care plan for 2 of 3 residents sampled for new admissions (#44 & #113). Findings: 1. Resident #44 was admitted to the facility on [DATE] for rehabilitation. A clinical record review revealed that Resident #44 has a medical diagnosis of Atrial fibrillation and is prescribed an anticoagulant medication Eliquis 20 milligrams (mg) daily. Resident #44's baseline care plan or comprehensive care plan wasn't completed until 8/27/22, 12 days later.

Based on observations, record review and interviews, the facility failed to review and revise the care plan to reflect the current needs of 1 of 2 residents reviewed for respiratory. (#52) Finding: On 11/14/22 at 12:11. p.m., during an interview, Resident #52 stated, he/she only uses the oxygen during the night from 7p.m.-7a.m. At this time, the oxygen nasal cannula tubing was observed rolled up and stored under the handle of the oxygen concentrator. Resident #52's Significant Change Minimum Data Set (MDS) 3.0 comprehensive assessment, dated 6/28/22, reflected the use of oxygen therapy under section O0100 Special treatments. On review of Resident #52's current care plan, the surveyor could not locate a care plan to address oxygen therapy. On 11/16/22 at 10:36 a.m., the Director of Nursing confirmed the resident uses oxygen nightly and the care plan did not include the use of oxygen therapy.

Based on observation, record review and interview, the facility failed to follow their own policy on oxygen (O2) storage and failed to obtain physician orders for oxygen therapy for 1 of 2 residents reviewed for respiratory care. (#52) Findings: Facilities Oxygen Use and Storage policy, revised 7/22, states under Section 5. Respiratory Care: Oxygen tubing should be discarded and changed every week. A label indicating the date and the initials of the staff changing the tubing should be applied to the tubing and Staff changing the tubing should document on the Treatment Administration Record (TAR) when the tubing has been changed following this policy. Facilities Oxygen Safety Precautions policy, revised on 5/18/22, states O2 tubing is changed weekly for those residents on continuous oxygen and anyone on PRN oxygen. When not in use O2 tubing should be stored in close about plastic bag attached to the concentrator. This will be documented on the tar in PCC. On 11/14/22 at 12:11. p.m., during an interview, Resident #52 stated, he/she only uses the Oxygen during the night from 7p.m.-7a.m. At this time, the oxygen nasal cannula tubing was observed to be unlabeled, rolled up and stored under the handle of the oxygen concentrator. Additional observations were made on 11/15/22 at 12:45 p.m. and 11/16/22 at 10:36 a.m., of the nasal cannula tubing, unlabeled, rolled up and stored under the handle of the oxygen concentrator. A review of Resident #52's physician orders lacked evidence of an order for oxygen therapy and oxygen tubing changes. A review of the TAR lacked evidence of oxygen tubing changes weekly. A review of nursing notes dated 6/27/2022 states, Resident noted to have audible wheezes and rapid respirations today, using accessory muscles with breathing short of breath with talking. O2 sat (oxygen saturation in the blood) 82 to 84% on room air, oxygen applied at 2L (liters) with sats up to 99%. A quarterly meeting note dated 6/29/2022 states, [Resident] is currently using O2 intermittently. 96% on 2L. Additional review of the vitals for pulse oximetry (O2 saturations in the blood) reveals he/she frequently uses oxygen of 2-3 Liters per minute. On 11/16/22 at 10:36 a.m., Director of Nursing (DON) and surveyor observed the oxygen tubing unlabeled and stored under the handle of the concentrator. The DON confirmed the resident uses oxygen nightly. At this time, the surveyor discussed the lack of tubing changes, storage of the tubing and the absence of a physician's order for oxygen.

Based on record review and interview, the facility failed to ensure an as needed (prn) psychotropic medication order met the required 14-day time limit or provided the rationale to extend the time limit beyond the 14 days, with the indicated duration, for 1 of 2 residents reviewed for pain management (Resident #51). Finding: During a review of Resident #51's clinical record, a surveyor noted an order, dated 8/1/22, for a psychotropic medication, Lorazepam, to give 0.5 milligrams (mg), 1 to 2 tablets by mouth every 4 hours as needed for anxiety. The surveyor noted no 14-day limit on the PRN order. On 11/16/22 at 3:30 p.m., the MDS (Minimum Data Set) Coordinator stated physician orders are renewed every 60 days and the lorazepam order had last been renewed on 9/20/22. The MDS Coordinator confirmed that the order did not have a 14-day time limit or rationale for continuing the order beyond the 14-day limit, with a specified duration of the order.

Based on observation, interview and record review, the facility failed to be free of medication error rate of 5% or more. There were a total of 2 medication errors out of 33 opportunities. The medication error rate was 6.06% Findings: The facility Eye Drop Administration Policy and Procedure, effective 5/1/2018 instructs nursing to put on examination gloves, with a gloved finger, gently pull down lower eye lid to form pouch, while instructing resident to look up. Place other hand against the resident's forehead to steady. Hold inverted medication bottle between the thumb and index finger and press gently to instill prescribed number of drops into pouch near outer corner of eye, while the eye is closed, use one finger to compress the tear duct in the inner corner of the eye for 1-2 minutes, wipe off tears or excess solution with clean the gods, cotton ball, or tissue, If another drop of the same or different medication is prescribed for administration in the same eye at the same time, wait 10 minutes then repeat procedure above and If administering medications to both eyes, use a different gloved finger to apply pressure to the inner tear duct. On 11/15/22 at 8:36 a.m., two surveyors observed a RN on the July Unit prepare and administer medications to Resident #16 and Resident #18. The following occurred: - Resident #16's medication included Clonazepam 0.25 mg and Tamsulosin 0.4 mg capsule with instructions of: Do not open/ crush/ chew. The RN popped out a Clonazepam tablet, dropping it on the medication cart then picking it up with her ungloved hand and placing it in the medicine cup with the other medications. She then applied gloves and removed the already obtained Tamsulosin capsule from the medicine cup, opened it up releasing the contents into the cup with the other medications. She then put all the medications into a white envelope, crushed the medications and then put the mixture back into the medicine cup adding vanilla pudding. At this time, the surveyor intervened and reviewed the Tamsulosin instructions of Do not open/ crush/ chew with the RN. A surveyor asked the RN if opening up the capsules and crushing them is her normal practice she stated, I do, not acceptable, I won't be doing it anymore and then stated, I guess it's too late now and proceeded to administer the medications. -Resident #18's medications included Artificial Tears, 1 drop to both eyes, Olopatadine eye drops,1 drop to both eyes, Keppra 500 mg tablet, Memantine 10 mg tablet, Vescepa 1 gram capsule- give 2 capsules and Levemir Insulin 25 units subcutaneous daily. The RN without applying gloves, held the resident's eyes open and administered olopatadine eye drops, wiping both eyes immediately with the tissue. Next, without waiting the time in-between eye drops, she again, with ungloved hands, held the resident's eyes open and administered the artificial tear eye drops, wiping both eyes immediately with the same tissue. Upon leaving the residents room the RN discarded the insulin needle into the sharps container. At this time, the surveyor discussed the concerns observed during the medication pass with the RN. On 11/15/22 at approx. 9:30 a.m., during an interview with the Director of Nursing and the [NAME] President of Clinical the surveyor discussed the crushing non crushable meds and giving them after surveyor intervention, and not waiting the in-between time when administering eye drops.

Based on observations and interviews, the facility failed to ensure that medications were stored properly by having unattended medication cards on top of the cart allowing residents and unauthorized persons access to them on 1 of 3 days of survey. In addition, the facility failed to ensure expired medications were removed from the supply available for use in 2 of 2 medication rooms (July and August). Findings: 1. On 11/15/22 at 8:36 a.m., during the medication pass observations, the Registered Nurse (RN) locked the medication cart leaving 3 blister packs of medication on top of the cart while she walked away and entered the medication room. The medications were unsecured for approx. 2 minutes. Upon return to the cart, the RN immediately unlocked the cart and put the blister packs away stating, she never leaves them on the cart. On 11/15/22 at approx. 9:30 a.m., this finding was discussed with the Director of Nursing and the [NAME] President of Clinical. 2. On 11/15/22 at 9:49 a.m., observation of the August unit medication room with the Director of Nursing (DON). Refrigerator #2 contained one opened multi use vial of Tuberculin Purified Protein Derivative (TB) with manufacturer's directions of discard opened product after 30 days, further observation reveals the TB vial did not have an opened date nor a discard date. At this time, the DON discarded the TB vial. 3. On 11/15/22 at 1:42 p.m., observation of July unit Medication room with the DON. Refrigerator #1 contained one opened multi use vial of TB with manufacturer's directions of discard opened product after 30 days, further observation reveals the TB vial was labeled with open date of 7/29/22 and an expiration date of 8/28/22. In addition there was one opened vial of Lispro insulin with no residents name and labeled with the date of opening as 7/30/22. At this time, the DON discarded both the TB and the insulin stating the insulin expires 28 days after opening.

Based on observations, interviews and record review, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner and failed to ensure food was labeled and dated in the refrigerator for 2 of 3 days of survey. In addition, the facility failed to monitor refrigerator/freezer temperatures and sanitizer bucket part per million (ppm) daily. Findings: 1. On 11/14/22 at 9:20 a.m., during the initial tour of the kitchen with the Dietician and the Food Service Director (FSD), the following was observed: A moderate amount of debris all over the floor, a heavy amount of dirt and debris on the bottom shelf of the food prep stand, two ceiling vents coated with dust and two ceiling vents with dust hanging from the vents. At this time, the FSD stated the facility currently did not have a cleaning schedule for the Kitchen. The refrigerator contained ham, cheese and eggs which were unlabeled and undated. The FSD and the Dietician confirmed the above concerns during the initial tour. 2. Review of the kitchen temperature logs/sanitizer bucket logs revealed the following: Refrigerator log lacks temperature monitoring since 11/10/22 Reach in freezer log lacks temperature monitoring for 11/11/22 and 11/13/22 Walk in freezer log lacks temperature monitoring since 11/1/22 Walk-in fridge log lacks temperature monitoring for 11/12/22 and 11/13/22 Sanitizer bucket log lacks monitoring of temperature and PPM's for 11/6/22, 11/7/22, and 11/13/22 3. On 11/15/2022, at 8:48 a.m. during the second kitchen tour with the Dietitian, the surveyor observed in the reach-in refrigerator, 2 packages of unlabeled and undated shredded cheese. In addition, a Cleaning checklist for Dietary Aids was observed in the corner of the kitchen above eye level, the last day of documentation was 3/13/22. On 11/15/22 at 10:00a.m., the above findings were confirmed with the Dietitian.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to maintain an Infection Control Program designed to help prevent the development of infection related to oxygen tubing, bed pans and commodes for 3 of 3 days of survey and failed to prevent the possible transmissions of infections by handling medications and administering injection and eye drops with ungloved hands during medication administration for 2 of 2 medication pass observations. Findings: 1. On 11/14/22 at 11:51 a.m., 11/15/22 at 8:01 a.m., and 11/16/22 at 8:33 a.m., observations of room [ROOM NUMBER] to have Oxygen tubing and nasal cannula lying on the floor, a bed pan stored upside down on the toilet and a seat cushion stored between the toilet and the wall. 2. On 11/14/22 at 10:00 a.m., 11/15/22 at 8:15 a.m., and 11/16/22 at 8:41 a.m., observations of room [ROOM NUMBER] to have 2 commode buckets stored on the floor under the sink and a bed pan stored on the shower chair. 3. On 11/14/22 at 10:41 a.m., 11/15/22 at 11:36 a.m., and 11/16/22 at 8:43 a.m., observations of room [ROOM NUMBER]A bathroom to have a bed pan stored behind the toilet between the handrail and the wall, a commode bucket on the floor with a bariatric bed pan stored upside down on top of it, an emesis basin and a basin filled with boxes of denture cleaning tabs on floor under the sink. 4. On 11/14/22 at 10:44 a.m., 11/15/22 at 11:37 a.m., and 11/16/22 at 8:45 a.m., observations of room [ROOM NUMBER] bathroom to have a commode bucket on the floor with the lid on its side leaning against the wall. 5. On 11/14/22 at 10:46 a.m., 11/15/22 at 8:17 a.m., and 11/16/22 at 8:45 a.m., observation of room [ROOM NUMBER] bathroom to have a commode bucket stored on top of the toilet seat and another commode bucket stored on the shower chair. 6. On 11/14/22 at 11:20 a.m., 11/15/22 at 8:02 a.m., and 11/16/22 at 8:53 a.m., observation of room [ROOM NUMBER] bathroom to have a bed pan stored between the wall and the handrail. On 11/16/22 at 10:36 a.m., during an environmental tour with Director of Nursing (DON), the above findings were observed. 7. On 11/15/22 at 8:02 a.m., a surveyor observed a Registered Nurse (RN) on the August Unit prepare medication for Resident #39. During this observation, the RN had handled 2 separate medications with ungloved hands. At this time, in an interview with the RN, the surveyor confirmed the touching the pills and dropping the medication on the cart to be an infection control concern. 8. On 11/15/22 at 8:36 a.m., two surveyors observed a RN on the July unit prepare medications for both resident #16 and #13. During these observations, the RN handled 6 separate medications with ungloved hands and administered 2 separate eye drop medications without wearing gloves. In addition, the RN administered Insulin injection without wearing gloves, then engaged the safety slide on the needle and placed the used needle in her scrub pocket. Upon leaving the residents room the RN discarded the insulin needle into the sharps container. At this time, the surveyor discussed the infection control concerns with the RN. Facilities: Injectable Medication Administration Policy and Procedure, effective 5/1/2018 for subcutaneous injections, instructs nursing to put on gloves prior to administering the injection. Facilities: Eye Drop Administration Policy and Procedure, effective 5/1/2018 instructs nursing to put on examination gloves prior to administering the eye drops. On 11/15/22 at approx. 9:30 a.m., during an interview with the Director of Nursing and the [NAME] President of Clinical the surveyor discussed the multiple concerns during the medication pass observations.

Based on record reviews and interviews the facility failed to ensure as needed (PRN) psychotropic medications met the required 14-day limit for 1 of 6 residents reviewed for unnecessary medications (Resident #5). Finding: A review of physician's orders revealed Resident #5 with an order for an antipsychotic, dated 10/8/19, which indicated, Haldol 2 mg (milligrams)/ml (milliliters) solution. Give 0.5 mg po (by mouth) q 4 h (every four hours) as needed (PRN) for nausea/vomiting; re-evaluate in 1 week. On review of the resident's current physician's orders, dated 11/19/19, the surveyor noted the original PRN order was continued with no stop date. The medical record lacked evidence the medication order was stopped and there was no evidence the physician reviewed the order to provide rational to continue the (PRN) medication. On 12/10/19 at 2:51 PM in an interview with the Director of Nursing, the surveyor confirmed Resident #5 was prescribed a PRN antipsychotic since 10/8/19 with no stop date after 14 days and no re-evaluation of the order.

Based on record reviews and interviews the facility failed to ensure that 3 of 5 residents reviewed for immunizations received pneumococcal vaccinations (Residents #20, #38 and #41). Findings: 1. During a review of Resident #20's immunization record, the surveyor noted the Resident received the Pneumococcal Conjugate Vaccine (Prevnar 13) on 5/15/18. The surveyor could not locate evidence that the second vaccine, Pneumococcal Polysaccharide Vaccine (PPSV23), was provided to the resident. In an interview with the Infection Preventionist on 12/10/19 at 11:45 PM, the surveyor confirmed that Resident #20 did not receive the PPSV23. 2. During a review of Resident #38's immunization record, the surveyor noted the resident received the PPSV23 on 10/1/07. The surveyor could not locate evidence that the second vaccine, Prevnar 13, was provided to the resident. In an interview with the Infection Preventionist, on 12/10/19 at 11:45 PM, the surveyor confirmed that Resident #38 did not receive the second pneumococcal vaccination. 3. During a review of Resident #41's immunization record, the surveyor noted the resident received the PPSV23 on 5/18/15, but could not locate evidence that the second vaccine, Prevnar 13, was provided to the resident. In an interview with the Infection Preventionist on 12/10/19 at 11:45 PM, the surveyor confirmed that Resident #41 did not receive the Prevnar 13 vaccination.

Based on record reviews and interview, the facility failed to send a new Preadmission Screening and Resident Review (PASRR) Level I Screen due to a status change, indicating a change in condition, which must be submitted to KEPRO for review for 1 of 2 sampled residents with a mental disorder (#19). Findings: Instructions on the PASARR Level I Screen, Terminal Illness Waiver, states, Should the individual's status change, a new Level I Screen indicating a change in condition must be submitted to KEPRO for review. During review of Resident # 19's clinical record, the surveyor noted that Resident #19 has a diagnosis of mental illness, Schizoaffective disorder. The Level I PASARR dated 4/18/18 had a Terminal Illness Waiver which states, Should the individual's status change a new Level I Screen indicating a change in condition must be submitted to KEPRO for review. On 9/26/18 the Hospice Agency issued a discharge revocation of services. On 12/12/18 at 03:15PM in an interview with the Social Worker, the Surveyor confirmed with the Social Worker that currently there is no evidence that a new PASARR Level I was completed following the change in condition per Terminal illness Waiver instructions.

Based on interview and record review, the facility failed to develop a discharge summary that included a recapitulation of the resident's stay for 1 of 1 residents reviewed for a community discharge (Resident #66). Finding: On review of Resident #66's clinical record, a surveyor noted an admission date of 9/6/18 with a discharge back to the community on 9/17/18. The surveyor noted in the clinical record a Recapitulation of Resident Stay form in which the following sections were left blank: Nursing, Status on Discharge, Dietary and Activity Department. Social Services staff completed their component of the form. The surveyor reviewed the nursing notes and noted no summary of Resident #66's care and status while in the facility. During an interview with the Director of Nursing on 12/13/18 at approximately 11:00 a.m., the surveyor confirmed the medical record did not contain a complete recapitulation of Resident #66's stay in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that a resident requiring dialysis receive services consistent with the professional standards of practice for 1 of 1 resident receiving dialysis services (#41). Finding: On review of Resident #41, a surveyor noted the resident was admitted to the facility on [DATE] with a diagnosis of end-stage renal disease requiring dialysis treatments, accessed through an Arteriovenous (A-V) fistula. Resident #41 had a physician's order, originally dated 12/14/17 with a re-order dated 10/19/18, instructing staff to Check A-V Fistula site for thrill and bruit every shift for A-V fistula monitoring and maintenance. Also included in Resident #41's clinical record was the Care of the A-V Fistula or Graft that indicated, Check the access for the presence of a bruit and/or thrill several times a day. If the bruit or thrill is not detectable, notify the dialysis unit and nephrologist immediately. On review of Resident #41's Treatment Administration Record, the surveyor noted documentation supporting monitoring of the A-V fistula does not reflect consistent provision of care. The October 2018 Treatment Administration Record reflected 12 out of 93 shifts where provision of A-V fistula monitoring for thrill and bruit was not documented; The November 2018 Treatment Administration Record reflected 18 out 90 shifts where provision of A-V fistula monitoring for thrill and bruit was not documented; and December 1 through 11, 2018 Treatment Administration Record reflected 6 out 33 shifts where provision of A-V fistula monitoring for thrill and bruit was not documented. In an interview with the Registered Nurse - Nurse Coordinator on 12/13/18 at 5:54 a.m., the surveyor confirmed that documentation does not reflect Resident #41's A-V Fistula site was checked for thrill, bruit and site maintenance each shift.

Based on observations and interview, the facility failed to serve food in a sanitary manner on 1 of 3 survey days. Finding: On 12/13/18 at 9:04 a.m., two Certified Nursing Assistants (CNA) entered the 100 Unit kitchenette. CNA #1 removed bread from a bread bag with ungloved hands and placed the bread in a toaster. CNA #2 also removed bread from the bread bag with ungloved hands and awaited use of the toaster. With ungloved hands, CNA #1 removed the toast from the toaster and placed it on a plate. The surveyor intervened and discussed the practice of handling ready to eat foods with bare hands. The CNAs then obtained gloves to handle ready to eat foods. At 12/13/18 on 11:00 a.m. in an interview with the Manager of Food Services and Chef, the surveyor confirmed that staff cannot handle ready to eat foods with bare hands.

2. On 12/12/18 at 11:45 a.m., during an interview with Resident #47, the Surveyor determined that he/she smokes independently off the facility campus. On review of Resident #47's clinical record, the Surveyor noted a smoking assessment, dated 11/4/18. The assessment indicated, Yes to the question Plan of care is used to assure resident is safe while smoking? On 12/13/18 at 1:10 p.m., the surveyor confirmed in an interview with the Director of Nursing that a plan of care was not developed to address Resident #47's safety while smoking. Based on interviews and records review, the facility failed to develop a care plan to meet the safety needs of 2 of 2 residents reviewed for smoking (Resident #15 and #47). Findings: 1. On 12/11/18 at 10:23 a.m., during an interview with Resident #15, the surveyor determined the resident smokes cigarettes independently off the facility campus. On 12/12/18 at 9:53 a.m., the surveyor accompanied Resident #15 off campus and continued with the interview. The resident pointed to area that is off-limits to him as he flipped his wheel chair in the past. On review of Resident #15's clinical record, a surveyor noted a smoking reassessment, dated 12/8/18. The reassessment indicated, Yes to the question Plan of care is used to assure resident is safe while smoking? On review of the care plan, written 2/7/18 and most recently reviewed 10/11/18, the surveyor could find no care plan developed to address the smoking safety needs of Resident #15. On 12/12/18 at 11:17 a.m., the surveyor confirmed in an interview with the Director of Nursing that Resident #15's plan of care was not developed to address Resident #15's safety while smoking.

Based on interviews and record review, the facility failed to provide services to maintain and/or improve residents' highest level of range of motion (ROM) and/or mobility for 2 of 2 residents reviewed for limited range of motion (Resident #15 and #26). Findings: 1. On 12/11/18 at 10:33 a.m., in an interview with the surveyor, Resident #15 stated, they don't do any exercises of range of motion. On review of Resident #15's care plan, dated 2/7/18 with the most recent review of the care plan dated 10/11/8, the surveyor noted the resident has limited physical mobility with the approach to provide gentle range of motion as tolerated with daily care. On further review of Resident #15's clinical record, the surveyor noted documentation sheets, indicating PROM with instructions to initial and document the amount of time spent on the exercises. The documentation for November 2018 indicated the resident received PROM a total of five out of 60 shifts and from 12/1/8 through 12/12/18, the documentation indicated Resident #15 did not receive and PROM services. In an interview with Minimum Data Set Coordinators (MDS-C), Registered Nurses (RN) on 12/12/18 at 12:31 p.m., They stated that the PROM is done by the assigned Certified Nursing Assistants (CNA) with caregiving. On 12/12/18 at 1:42 p.m., a CNA stated in an interview with the surveyor that he/she does not perform PROM when giving care unless assigned to be the restorative aide for the shift. In a follow-up interview with the MDS-C on 12/12/18 at 2:30 p.m. the surveyor confirmed that PROM services are not being provided as care planned. 2. On 12/11/18 at 10:09 a.m., during an interview with the surveyor, Resident #26 stated that staff do not routinely exercise me. On review of Resident #26's clinical record, a surveyor noted a restorative program, dated 7/1/18, to: > maintain or improve [Resident #26's] ability to ambulate 15 to 100 feet with 2 staff assist for a minimum of 15 minutes daily, 6-7 days a week; > maintain or improve [Resident #26's] functional transfer ability with 1 staff assist for a minimum to moderate assist for a minimum of 15 minutes daily, 6-7 days a week; and > [Resident #26] will maintain or improve Assisted Active Range of Motion (AAROM) to right upper extremity for a minimum of 15 minutes daily, 6-7 days a week. A review of the clinical documentation in October 2018, the resident received or was offered restorative ambulation services 8 times; in November 2018 - 12 times; and through 12/1/18 - 12/12/2018 - 2 times. A review of clinical documentation in October 2018, the resident received or was offered restorative transfer services 11 times; in November 2018 - 8 times; and through 12/1/18 - 12/12/2018 - 8 times. A review of clinical documentation in October 2018, the resident received or was offered restorative range of motion services 8 times; in November 2018 - 12 times and through December 12, 2018 - none. A Rehab Screen Form, dated 8/10/18, indicated no change in the Resident's status. On 12/12/18 at 1:42 p.m., a CNA stated in an interview with the surveyor that he/she does not perform restorative services when giving care unless assigned to be the restorative aide for the shift. In a follow-up interview with the MDS-C on 12/12/18 at 2:30 p.m. the surveyor confirmed that restorative services are not being provided as care planned.