Based on record review and interview, it was determined that facility staff failed to follow a physician's order. This was evident for 1 (#111) of 2 residents reviewed for pain management.The findings include:A medical record review for Resident #111 on 9/9/25 at 9:43 AM revealed a medication administration record (MAR) for May of 2025, which noted the resident was ordered an opioid 10 mg as needed every 4 hours for a pain level of 7-10. However, on the following dates and times facility staff failed to follow the physicians orders and gave the medications for a pain level less than 7; 5/7 at 9:00 PM for pain level of 6, 5/9 at 1:22 PM for a pain level of 0, 5/13 at 12:09 AM for a pain level of 0, 5/14 at 6:30 PM for a pain level of 6, 5/17 at 1:18 PM for a pain level of 0, 5/27 at 9:44 PM for a pain level of 6, 5/28 at 6:00 PM for a pain level of 0, 5/28 at 11:59 PM of a pain level of 6, 5/29 at 2:15 PM for a pain level of 0, 5/30 at 8:41 PM for a pain level of 6, and 5/31 at 10:10 AM for a pain level of 4. The following dates were for June 2025; 6/2 at 2:17 PM for a pain level of 0 and 6/5 at 5:08 PM for a pain level of 0. An interview with Licensed Practical Nurse (LPN) #34 on 9/10/25 12:21 PM revealed that she was aware that the medication was to be given based on the physician's parameters of a pain level of a 7-10. She reported Resident #111 was demanding when s/he requested their pain medication and would not give a pain score at times. Reviewed the MAR with LPN #34 when she documented a pain score of 0 on 6/5/25 and administered the pain medication. She reported she could not recall if the resident did not give a pain score or if it was a typographical error. When asked if she had documented a pain assessment in the progress notes she reported she had not. During an interview with the Director of Nursing (DON) on 9/10/25 at 1:49 PM she reported staff were expected to provide and level of pain for the resident and then give the medication according to the parameters. The DON acknowledge the concern.

Based on surveyor observation, review of the medical records, and interview with facility staff, it was determined the facility failed to provide quality care to residents by 1) not following physician orders for oxygen therapy and 2) not reporting a change in condition. This was found to be evident for 2 residents (Residents #45 and #47) out of 4 residents observed on oxygen therapy and 1 resident (Resident #115) of 2 residents reviewed for pressure ulcer complaints during the facility's recertification survey.The findings include:1) Oxygen (O2) therapy is a treatment that provides you with extra oxygen to breathe in. It is also called supplemental oxygen. It is only available through a prescription from the health care provider. Oxygen saturation or SpO2, is a medical measurement that indicates the percentage of oxygen-carrying hemoglobin in the blood compared to the total amount of hemoglobin. It is a key indicator of how well oxygen is being distributed from the lungs to the rest of the body. An oxygen flow rate is the volume of oxygen delivered to a patient per minute, usually measured in liters per minute (LPM). On 09/04/2025 at 8:08 AM, during the initial tour of the facility, Resident #45 was observed in bed with a nasal cannula in place and oxygen flowing at 3.5 liters per minute (LPM). On 09/04/2025 at 8:21 AM, in an interview with Registered Nurse (RN#3), when asked how many liters of oxygen was prescribed for Resident #45, she stated it was 3 LPM. When called to verify the oxygen flow rate, she confirmed it was set to 3.5 LPM and stated she would readjust it since the surveyor had noticed the discrepancy. When asked how often oxygen flow rate was checked, she stated that it was checked every other day and that it was also checked during the tubing changes. When asked when it was last checked, she stated that she did not know. On 09/04/2025 8:23 AM, Registered Nurse (RN#3) informed the surveyor that after checking the physician's order for Resident #45, he/she was to receive oxygen at 2 LPM. She immediately adjusted the flow meter to 2 LPM. On 09/04/2025 at 8:43 AM, during the continued tour of the facility, Resident #47 was observed in bed with oxygen running at 2.5 LPM via a nasal cannula. On 09/04/2025 at 8:45 AM, in an interview with Licensed Practical Nurse (LPN#4) when asked how many liters of oxygen was prescribed for Resident #47, she stated that he/she was prescribed 2 liters of oxygen and when asked for dual observation of the oxygen flow rate, she confirmed it was set to 2.5 LPM and readjusted it to 2 LPM. On 09/04/2025 at 12:02 PM, review of Resident #45's order on 09/05/2024 showed “Oxygen Inhalation (via nasal cannula at 2 LPM) to keep oxygen saturation greater than 90% related to Chronic Obstructive Pulmonary Disease (COPD) every shift for shortness of breath”. On 09/04/2025 at 12:13 PM, reviewed of Resident #47's order on 10/06/2024 showed “oxygen at 2L/min via nasal cannula continuously every shift”. On 09/04/2025 at 1:48 PM, in an interview with the Director of Nursing (DON) while the Nursing Home Administrator (NHA) was present, when she was asked how often the oxygen flow meters were checked, she stated that the nurses checked it weekly when changing the tubing. When she was asked how the nurses would know the amount of oxygen the residents were getting every shift, if it was checked weekly, she stated “There was no how the nurses would have known.” When she was informed about the concerns with oxygen flow rate for the residents and staff not following the order for the amount of oxygen level every shift, She acknowledged the error and stated that she would provide in-service education on following physician's order and to ensure flow meters were checked every shift going forward so as to prevent future occurrences of increased or decreased oxygen rate. 2) On 9/4/25 at 10:53 AM a review of a complaint received regarding Resident #115 revealed that the resident was sent to the hospital from the facility 4 days after admission in 2023. The complainant reported that the resident had low blood sugar and was septic from his/her wounds. The complainant reported that when the facility nurse called to report the resident was being sent to the hospital but was unable to provide any details as to what was going on with the resident. A medical record review for Resident #115 on 9/8/25 at 5:03 PM revealed a discharge summary from the acute care hospital dated 6/8/23. It was documented that the resident came to the hospital due to low blood pressure and anemia. The summary read that the resident had an extended stay in the hospital between April and May of 2023 and was bedbound at home which caused a sacral pressure ulcer. A review of the history and physical conducted by the attending physician on 6/9/23, revealed the resident was being treated for the following conditions; end stage renal disease and required peritoneal dialysis, type 2 diabetes, hypothyroidism, gastrointestinal bleeding, leukocytosis, sacral ulcer, and delirium related to high doses of steroid treatment during hospitalization. Review of the admission minimum data set (MDS) with the assessment reference date of 6/12/23 revealed that the resident had no cognitive impairment. Review of the progress notes revealed that on 6/12/23 at 9:59 AM it was noted the resident was refusing to eat breakfast. Then at 1:34 PM Registered Nurse (RN) #23 wrote that the resident reported s/he had vomited 4 times in the morning but there was no evidence of emesis and no staff reported vomiting so the nurse will continue to monitor. There was no change in condition found or a progress note documenting that the nurse conducted an assessment of the resident for this change in condition or notification to a practitioner. Further review of the progress notes revealed at 4:44 PM the same nurse wrote the resident was found to be lethargic and she obtained an order to send the resident to the hospital. RN #23 started a change in condition evaluation and upon review of the document it was revealed the nurse failed to obtain vital signs at the time of the change, she failed to obtain a blood sugar level, and failed to complete a thorough assessment of the resident prior to sending them to the hospital. On 9/9/25 at 9:45 AM a review of the emergency department (ED) report dated 6/12/23 for Resident #115 revealed that EMS (emergency medical system) reported that the resident's blood sugar was 37 (normal blood sugar levels are between 70 – 110) and they administered a glucose (sugar) past and IV (intravenous) fluids prior to arrival to the ED. The ED physician documented that the resident was able to report that s/he was feeling ok but was having pain in the sacrum. On 9/9/25 at 8:56 AM and 9:39 AM contact information for RN #23 was requested, but facility staff failed to provide the information. Therefore, the nurse was unavailable for an interview. An interview with Licensed Practical Nurse (LPN) #6 on 9/9/25 at 8:56 AM revealed that as the Unit Manager she remembered Resident #115 as a pleasant person who was cognitively intact. She would have expected the nurse to complete a change in condition (an assessment form) for a resident who was complaining of vomiting and to notify the practitioner. She stated that when the nurse found the resident lethargic, she would have expected her to obtain a set of vital signs and check the resident's blood sugar since she was diabetic and reported vomiting earlier in the day. Furthermore, she stated that the change in condition form should have been fully completed prompting the nurse to do a thorough assessment. She stated that the nurse was an agency nurse and was not currently working at the facility. Requested the last known contact for the nurse. On 9/9/25 at 9:39 AM the concerns were reviewed with the Director of Nursing (DON) and she acknowledged the concerns.

Based on observation, record review, and staff interviews, it was determined that the facility 1) failed to provide services for pressure ulcer for a new admission and 2) to document and provide ordered treatment to promote healing of pressure injuries. This was found to be evident for 2 (Resident #115 and Resident #113) of 4 residents reviewed for pressure injuries during the survey. The findings include:1) On 9/4/25 at 10:53 AM a review of a complaint received regarding Resident #115 revealed that the resident was sent to the hospital from the facility 4 days after admission in 2023. The complainant reported that the resident's wounds had worsened, and s/he was diagnosed with sepsis because the wounds were infected. A medical record review for Resident #115 on 9/8/25 at 5:03 PM revealed a discharge summary from the acute care hospital dated 6/8/23. It was documented that the resident came to the hospital after being bedbound at home with a sacral pressure ulcer. The wound care was ordered as follows; clean daily with normal saline, pat dry, and apply medihoney (a wound treatment ointment or gel) and cover with bordered foam. A review of the Admit/Readmit Screener completed on 6/8/23 for Resident #115 revealed the nurse documented that the resident had a sacral wound. A review of the physician orders revealed an order dated 6/8/23, read “clean with normal saline, pat dry apply Midihoney [medihoney] on the sacral wound and cover with bordered foam. One time a day for wound care”. However, review of the treatment administration record (TAR) revealed staff failed to provide treatment to the wound until 6/10/23, 2 days after the resident was admitted . Further review revealed the resident was seen by the wound specialist on 6/12/23, and it was recommended that the resident had blood drawn and an x-ray of the sacral region to rule out an infection, however, this was not done because the resident was sent to the hospital that day for lethargy. An interview with the Director of Nursing (DON) on 9/9/25 at 9:39 AM revealed her expectation was that staff would remove the sacral wound dressing while conducting the admission assessment (admit/readmit screener) and then provide the wound treatment as ordered by the physician. She stated that it was unacceptable to wait 2 days after the admission to provide wound treatment for the resident. 2) On 9/11/25 at 10:53 AM, Complaint #344422 was reviewed. The complaint alleged Resident #113 was not receiving proper care and treatment to prevent pressure wounds. On 9/11/25 at 11:15 AM, a review of Resident #113's records was conducted. The resident has an order for wound care to be completed daily and as needed and an order for the resident to be turned and repositioned. In the Treatment administration record, the facility did not document wound care on 6/10/24 and 6/17/24. In the task documentation survey report, the facility did not document Resident #113 being turned and repositioned for 6/4/24 Night, 6/8/24 Day and Night, 6/10/24 Night, 6/12/24 Night, 6/13/24 Evening and Night, 6/14/24 Day, 6/15/24 Night, 6/16/24 Night, 6/17/24 Day and Evening. The facility documented the resident was not being turned and repositioned on 6/5/24 and 6/15/24. On 9/11/25 at 11:45 AM, an interview was conducted with the Director of Nursing (DON). When asked what is expected from nurses when documenting wound care, The DON stated that the nurses completing the wound care are expected to document the treatment and description of the wound. When asked who is responsible for documenting the wound care is expected to document the treatment in the TAR, the Person completing wound care for resident should be documenting the wound care completed in the TAR. This surveyor told the DON of missing documentation for wound care and turning and repositioning for Resident #113. The DON was made aware of concerns with documentation and resident not being turned as evidenced by task documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint, observations, staff interview, and record review, it was determined that the facility failed to maintain a safe, clean, comfortable, and homelike environment for when individual room air conditioning systems failed to cool resident rooms. Residents were exposed to ambient temperatures above 81 degrees Fahrenheit. This was evident for 4 (Residents #1, #2, #3, #4) of 4 residents reviewed during a complaint survey. The findings include: Review of complaint MD00196573 on 09/06/23 at 12:30 PM that revealed an allegation from emergency services and local law enforcement that on 09/05/23 at 10:30 PM, the residents in the facility did not have a functioning air condition system and that one resident room, room [ROOM NUMBER], was subject to temperatures of up 92.4 degrees Fahrenheit. During an observational tour of the facility with the director of maintenance on 09/06/23 at 12:58 PM, observation of room [ROOM NUMBER] revealed that Resident #1 and #2 had been transferred to a different room in the facility on 09/05/23 at 10:30 PM. Observations of the individual air conditioning unit in room [ROOM NUMBER] revealed a thermostat setting of 81 degrees Fahrenheit. The manual temperature of the air conditioning unit was obtained and confirmed that the air coming out of the unit was 81 degrees. The ambient temperature in room [ROOM NUMBER] was 83 degrees Fahrenheit. As the observational tour of the facility continued, the temperature obtained in room [ROOM NUMBER] indicated a temperature of 83 degrees Fahrenheit. Residents #3 and #4 were not residing in room [ROOM NUMBER] at the time of the observation tour. In an interview with the facility administrator on 09/06/23 at 2:45 PM, the administrator stated that Residents #1 and #2 had placed a grievance with the facility on 08/30/23 at approximately 10 AM alleging that their air conditioning unit does not work well at night. The facility administrator stated that Residents #1 and #2 were offered room changes on 08/30/23 and 09/05/23 but both residents had refused a room change. During the exit conference on 09/06/23 at 4:50 PM, the administrator presented the surveyor with a purchase order for 4 new air conditioning units dated 06/14/23. The administrator stated the 4 new single air conditioning units were never delivered to the facility. The administrator stated there was a discussion with the company afterwards, but the units were never delivered.

Based on observation and staff interview, it was determined that the facility failed to ensure that resident room hand sanitizing dispensers were functioning properly. This was evident for 8 of 56 rooms reviewed during a complaint survey. The findings include: During a tour of the facility on 09/06/2023 at 12:58 PM with the Director of Maintenance, the nurse surveyor observed and tested the facility rooms for functioning hand sanitizer receptacles. Each resident room has a hand sanitizer receptacle at the doorway to each room. The purpose of these alcohol-based hand sanitizer is to help prevent the spread of germs. 8 (rooms 5, 10, 28, 34, 48, 50, 55, and 57) of 56 rooms failed to have functioning hand sanitizer receptacles. In an interview with staff member #6 on 09/06/23 at 5 PM, staff member #6 stated that the hand sanitizer receptacles were functioning but the gel in the receptacles may be old and can become sticky. Staff member #6 stated the staff just need to clean the tip of the dispenser and the hand sanitizer will function.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility staff failed to provide showers per a resident's request (Resident #223). This was evident for 1 of 43 residents reviewed during an annual survey. The findings include: During interview with Resident #223 on 5/30/23 at 10:34 AM, Resident #223 was asked if he/she chooses how many times a week he/she gets a shower. Resident #223 stated no, he/she would like to receive more showers and has only had one shower since admission to the facility. Review of Resident #223's medical record on 6/5/23 revealed the Resident was admitted to the facility on [DATE] and has only one documented shower on 5/5/23. Interview with the Regional Director of Nursing on 6/5/23 at 2:10 PM confirmed Resident #223 has only one documented shower from 5/2/23 until 6/5/23.

Based on record review and interview, it was determined that the facility staff failed to thoroughly investigate an allegation of physical abuse. This was evident for 1 (Resident #31) out of 3 residents who were reviewed for abuse. The findings include: Review on 06/02/23 at 09:31 AM of Facility Reported Incident MD00187003 dated 12/22/2022 alleged Resident #31's head was banged against the side rail of his/her bed while being changed by GNA #21. Review of Resident's #31's electronic record on 6/2/2023 at 9:31 AM revealed the resident had a history of dementia with behavior problems including combativeness and refusing care. On 6/6/23 at 9:16 AM, review of the Facility Reported Incident (FRI) investigation file review revealed agency GNA #21 was not interviewed by the facility and her self-report statement was illegible and not dated. She was placed on administrative leave on 12/22/2022. The facility did not interview all on-duty staff that shift or all other residents whom GNA #21 cared for. During an interview on 6/7/2023 at 12:55 PM with Regional Nurse #7, the Regional Nurse stated the facility did not have an interviewer to interview GNA #21 (who was on administrative leave and then did not return back to the facility). She did acknowledge that no other interviews were conducted. On 6/7/23 at 2:00 PM Regional Nurse #7 presented a copy of all other residents' interview sheets dated 12/23/2022. None had an interviewer's name or signature. The copies were provided by the Administrator who stated it was in another file.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and staff interview it was determined that the facility staff failed to accurately code the resident's status on the Minimum Data Set (MDS) assessment (Resident #19). This was evident for 1 of 43 residents reviewed during an annual survey. The MDS is a federally-mandated assessment tool that helps nursing home staff gathers information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. The findings include: During interview with Resident #19 on 5/31/23 at 8:34 AM, Resident #19 stated he could not find his/her dentures and was actively looking in his/her dresser drawers for them. Observation of the Resident at that time revealed the Resident to be edentulous and not wearing dentures. Review of Resident #19's medical record on 6/2/23 revealed the Resident was admitted to the facility on [DATE]. Further review of the Resident's medical record revealed the facility staff completed an admission MDS assessment on 9/18/22 for Section L0200 Dental. The facility staff failed to indicate the Resident was edentulous. Interview with the Regional Director of Nursing on 6/6/23 at 10:50 AM confirmed the facility staff inaccurately coded the Resident's Dental Status in L0200 for 9/18/22 and should have indicated the Resident was edentulous.

Based on record review and interview, it was determined that the facility staff failed to implement a resident's care plan as written. This was evident for 1 (Resident #31) out of 43 residents reviewed for the care plan. The findings include: Review on 06/02/23 at 09:31 AM of the Facility Report Incident MD00187003 dated 12/22/2022 alleged that Resident #31's head was banged against the side rail of his/her bed while being changed by GNA #21. Review of Resident #31's electronic record on 6/2/2023 at 9:31 AM revealed the resident had a history of dementia with behavior problems including combativeness and refusing care. On 6/6/2023 at 9:39 AM the facility's investigation file was reviewed and revealed there was only one staff (GNA #21) who was changing this resident on the day of the allegation. However, review of Resident #31's care plans revealed on 11/3/2022 a focus area related to the resident resisting care, and one of the interventions was documented as two staff to assist with care at all times. During an interview on 6/7/2023 at 10:03 AM with Regional Nurse #7, she stated that she was unaware Resident #31 had an intervention of two staff to assist with care at all times. After this Surveyor presented the care plan to her, she acknowledged that the staff did fail to follow this resident's care plan and to have two staff members for providing care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility staff failed to hold a care plan meeting to include the interdisciplinary team, resident and resident's representative quarterly (Resident #45). This was evident for 1 out of 43 residents reviewed during an annual survey. The findings include: Once the facility staff completes an in-depth assessment (MDS) of the resident, the interdisciplinary team meet and develop care plans. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions and assure the resident's needs are attended to. The care plan is to be reviewed and revised at each assessment time of the resident to ensure the interventions on the care plan is accurate and appropriate for the resident. Care plan meetings are held each quarter and as needed. During interview with Resident #45's Representative on 5/30/23 at 3:37 PM the Representative stated the facility has not had a quarterly care plan meeting for the Resident in the last 2 years. Review of Resident #45's medical record on 6/1/23 revealed the Resident was admitted to the facility on [DATE]. Further review of the Resident's medical record revealed the last documented care plan meeting was on 6/24/21. Interview with Regional Director of Nursing on 6/2/23 at 10:30 AM confirmed the facility staff failed to conduct quarterly care plan meetings for Resident #45.

Based on observations, clinical record review, and staff interview, it was determined that the facility staff failed to ensure that dependent residents were provided with the necessary services to maintain clean and trimmed fingernails. This was evident for 1 (#14) of 6 residents reviewed for activities of daily living (ADL). ADLs are tasks of everyday life. Examples of ADLs include dressing, bathing, grooming, and toileting. Nail care would fall under this category. The findings include: On 05/31/23 at 09:43 AM, resident #14 was observed to have long fingernails. Several fingernails had a dark substance under the nails. Resident #14 stated that he/she would like their fingernails to be trimmed. On 06/01/2023 at 2:30 PM, resident #14 was observed to still have long fingernails with a dark substance beneath several of the nails. A subsequent review of the resident ' s care plan revealed that the resident required assistance with ADLs. On 06/02/2023 at 8:50 AM, an interview with Geriatric Nursing Assistant (GNA) #14. The GNA stated that residents ' nails should be trimmed twice a week and that the GNAs are responsible for identifying and documenting nail care in their notes. On 06/02/2023 at 9:08 AM, resident #14 ' s nails were once again observed to have long fingernails with a dark substance beneath several of the nails. This finding was corroborated by GNA #14. The GNA assured the resident that his/her fingernails would be trimmed that day. An observation confirmed they had been cleaned and trimmed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility staff failed to obtain ophthalmology services for a resident (Resident #45). This was evident for 1 of 43 residents reviewed during the annual survey. The findings include: During interview with Resident #45's Emergency Contact on 5/30/23 at 3:37 PM, the Emergency Contact stated the Resident was in need of eye glasses. Review of Resident #45's medical record revealed the Resident was admitted to the facility on [DATE]. Review of Resident's care plans revealed a care plan entitled impaired visual function related to disease process initiated on 6/23/22 with 2 interventions: 1. arrange consultation with eye care practitioner as required 2. able to wear glasses and see large print. Review of Resident #45's Annual MDS (Minimum Data Set) assessment on 11/13/21 Section B1200 Corrective Lenses revealed the facility staff coded Yes. Review of Resident #45's Annual MDS assessment on 2/20/23 Section B1200 Corrective Lenses revealed the facility staff coded the Resident as No. Further review of Resident #45's medical record revealed the Resident has not seen an ophthalmologist since admission to the facility. Interview with Regional Director of Nursing on 6/2/23 on 10:30 AM confirmed the facility staff failed to obtain ophthalmology services for Resident #45.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The findings included: 3. Resident #324 was admitted from the hospital on 1/7/2021 with a stage 2 pressure ulcers. Review of Resident #324's medical record revealed a BRADEN scale assessment for predicting pressure sore risk. The Braden Scale is an evidenced-based tool, that predicts the risk for developing a hospital or facility acquired pressure ulcer/injury. The Braden Scale uses a scores from less than or equal to 9 to as high as 23. The lower the number, the higher the risk for developing an acquired ulcer/injury. Resident #324 on admission scored 13 on the BRADEN scale which is at moderate risk for developing a pressure sore. On 1/21/202 the BRADEN scale was re-evaluated and Resident #324 scored 15 which placed him/her at mild risk. The standard of practice for the care of pressure ulcers is for the facility staff to conduct weekly assessments and document findings that include the location, measurement, stage and characteristics of a pressure ulcer. This information provides facility staff with information to determine whether the pressure ulcer is healing or worsening at future assessments and to evaluate which treatment plan would be most effective to heal the ulcer. Further review of resident's #324 medical record revealed no initial wound evaluation by facility staff for the stage 2 sacral ulcer. On 1/9/2021, the Physician ordered: Clean sacral area with NSS, apply calcium alginate, cover with dry dressing daily. two times a day for Skin break down. This was 2 days after Resident #324 was admitted to the facility and no orders was enter in the Electronic Medical Record (EMAR) to monitor, to conduct weekly assessments and document findings that include the location, measurement. The resident's treatment record revealed that the full body assessment was not done. On 6/13/23 at 11:30 AM the Regional Nursing confirmed the facility failed to conduct weekly skin assessments for Resident #324. Based on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers (Resident #15, #45 and #324). This is evident for 3 of 5 residents reviewed for pressure ulcers during an annual survey. The findings included: A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and / or eschar in the wound bed). A deep tissue injury (DTI) is a unique form of pressure ulcer. The National Pressure Ulcer Advisory Panel defines a deep tissue injury as A pressure-related injury to subcutaneous tissues under intact skin. Initially, these lesions have the appearance of a deep bruise. 1. Review of Resident #15's medical record on 6/1/23 revealed the Resident was admitted to the facility on [DATE]. Further review of the Resident's medical record revealed the Resident was seen weekly by the Wound Care Specialist (WCS). Review of the Wound Care Specialist progress note on 4/17/23 revealed the WCS assessed the Resident to have a Stage III pressure ulcer and recommended a Santyl dressing. Santyl is a medication that removes dead tissue from wounds so they can start to heal. The WCS continued to see the Resident on 4/24/23, 5/1/23 and 5/8/23 and continued to recommend a Santyl dressing for the Resident's sacral pressure ulcer. Review of Resident #15's Treatment Administration Records for April and May 2023 revealed the facility staff failed to change the sacral pressure ulcer dressing treatment to a Santyl dressing until 5/9/23. Interview with the Regional Director of Nursing on 6/2/23 at 11:45 AM confirmed the facility staff failed to provide treatment as recommended by the Wound Care Specialist timely for Resident #15's sacral pressure ulcer. 2. Review of Resident #45's medical record on 6/1/23 revealed the Resident was admitted to the facility on [DATE]. Further review of the Resident's medical record revealed the Resident was seen weekly by the Wound Care Specialist (WCS) to assess and recommend treatment for the Resident's 3 pressure ulcers. Review of the WCS progress note on 3/6/23 revealed the Resident has a Stage IV sacral pressure ulcer, a Stage IV right ankle pressure ulcer and a Stage III right thigh pressure ulcer. Review of the Resident's March, April and May 2023 Treatment Administration Records revealed the facility staff failed to provide treatment to the Resident's pressure ulcers on the following dates: A. Sacral-3/1, 3/15 and 4/7/23 B. Right ankle-3/1, 3/7, 3/12, 3/15, 3/16, 3/23 and 4/7/23 C. Right thigh-3/1, 3/7, 3/12, 3/15, 3/16, 3/23 and 4/7/23 Interview with the Regional Director of Nursing on 6/2/23 at 10:30 AM confirmed the facility staff failed to administer treatments for Resident #45's pressure ulcers as ordered by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility staff failed to provide supervision to prevent an accident (Resident #224). This was evident for 1 of 43 residents reviewed during an annual survey. The findings include: Review of Resident #224's medical record revealed the Resident was admitted to the facility on [DATE] from the hospital for rehabilitation. Further review of the medical record revealed on 10/7/21 the Resident was assessed by facility staff to be a low risk for elopement. The facility reported to OHCQ (Office of Health Care Quality) on 10/31/21 the Resident was found outside the facility stating he/she was going to go trick or treating. The Resident was assessed at that time and found to have no injuries. During interview of Receptionist #1 on 6/8/23 at 11:47 AM, Receptionist #1 stated she was working on 10/31/21 and she was assisting visitors sign in at the desk. Receptionist #1 stated at the same time she opened the front door and let out other visitors. Receptionist #1 stated her complete view of the front door was blocked by the visitors at the desk and a few minutes later she opened up the front door for another visitor. At that time the new visitor stated he/she saw a resident walking down the drive of the facility. Receptionist #1 stated she immediately called the nurse who went out and located Resident #224 and returned him/her to the facility. The surveyor reviewed education provided to staff on 10/31/21 to ensure staff are aware of their assigned residents' location at all times. During interview with the Regional Director of Nursing (RDON) on 6/5/23 at 11:30 AM, the RDON confirmed the facility staff failed to provide supervision for Resident #224.

Based on clinical record review and staff interview, it was determined that the facility staff failed to ensure that a dietary consult was obtained after a significant weight loss. This was evident for 1 (#10) of 8 residents reviewed for nutritional status. The findings include: On 06/05/2023 at 9:35 AM, a clinical record review revealed that resident #10 had dysphagia, a condition that makes it difficult to swallow. From 12/07/2022 to 01/03/2023, resident #10 lost 12% of his/her body weight. On 01/05/2023, both a dietary and speech consult had been ordered by physician. Resident #10 was seen by speech therapy however, he/she was not seen by a dietician as per order. A dietician is a health professional who has special training in diet and nutrition. For a resident with significant weight loss, having a dietary consult would have been important as the dietician would have recommended additional interventions and would have provided an individualized nutrition plan of care for the resident. On 01/10/2023 resident #10 was examined by staff #15, a nurse practitioner (NP). The notes indicated that the NP recognized and addressed the weight loss. In the exam notes the NP wrote Communicated plan with facility staff Face-to-Face and Discussed status and [plan of care] with nursing status including unit manager. On 06/02/2023 at 1:10 PM, interviews were conducted with staff #15, NP and the Regional Director of Nursing (RDON). Per the NP, she had evaluated the resident for weight loss and had written several orders, including a dietary consult. The NP and the RDON both verified that the dietary consult never occurred. When asked why staff did not follow up on the order, the RDON stated, I can ' t account for it fully.

Based on clinical record review, observations, and staff interview, it was determined that the facility staff failed to ensure that a tube feeding container was labeled. This was evident for 1 (#2) of 3 residents reviewed for tube feedings. The findings include: A feeding tube is a device to administer nutrition to a person who cannot safely take food by mouth. On 06/01/2023 at 8:58 AM, a clinical record review revealed that resident #2 had a feeding tube for nutritional support due to having difficulty swallowing. The orders for the resident included receiving nothing by mouth and administering Jevity 1.5 tube feeding, which is calorically dense liquid food, via a pump over 16 hours. On 06/02/2023 at 8:12 AM, an observation of resident #2 revealed that he/she was in the process of receiving his/her tube feeding. It was noted that the tube feeding container with attached tubing was not labeled with information such as the resident's name, the date, or start time. There was a manufacturer's label on the tube feeding container where this information could have been written. On 06/02/2023 at 8:36 AM an interview was conducted with staff #5, an RN familiar with the resident. Staff #5 verified that the tube feeding container had not been labeled. Staff #5 stated it should have been dated. Per staff #5, the tube feedings are started during the night shift. Labeling tube feeding containers ensures that the right resident receives the ordered product and that those providing care know what date and time the tube feeding was hung. The date and time are important pieces of information because hanging a tube feeding longer than the manufacturer's recommendations can lead to contamination which could potentially adversely affect the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview it was determined that the facility staff failed to provide dialysis care consistent with professional standards of practice and ordered by the physician (Resident #231). This was evident of 1 of 3 residents reviewed for dialysis during the annual survey. The findings include: Review of Resident #231's medical record on 6/9/23 revealed the Resident was admitted to the facility on [DATE] from the hospital with a diagnosis to include end stage renal disease. The Resident was discharged from the facility on 1/21/22. Review of the Resident's orders for peritoneal dialysis revealed the Resident was ordered for pre and post weights, pre and post blood pressure, was receiving two 2.5% green bags. Review of Resident #231's Dialysis record and electronic medical record the facility from 1/12 until 1/20/22 revealed the facility failed to do pre and post dialysis weights, there is only one weight documented daily on the dialysis record. The facility staff failed to do pre and post blood pressure readings, there is only one blood pressure documented daily on the dialysis record. Further review of the Resident's Dialysis record revealed the staff were documenting the Resident was receiving two 2.5% bags and one 4.25% bag, for a total of three bags instead of two as ordered. On 1/16 and 1/19/22 the facility staff documented 11,400 volume pulled off which can not be an accurate amount based on the Resident's other volumes and history. On 1/19/22 the facility staff documented the Resident's weight as 205 pounds which is a more than 5 pound weight gain with no evidence the physician was notified to determine if treatment needed to be changed. The facility staff failed to administer Heparin as ordered on 1/14 and 1/15/23. Heparin is a medicine that prevents clots and it is used to prevent fibrin formation associated with peritoneal dialysis. Interview with the Regional Director of Nursing on 6/9/23 at 11:30 AM confirmed the facility staff failed to obtain pre/post blood pressures and weights, document accurate bags administered for each treatment, administer Heparin as ordered, notify the physician for an increase in weight and document an accurate volume pulled off in dialysis.

Based on interview and record review, it was determined that the Physician failed to provide timely visit notes to the electronic record system following each visit. This was evident for 1 (Resident #40) out of 5 residents reviewed for urinary catheter care. The findings include: Review on 6/01/23 at 8:12 AM of Resident #40's medical record revealed he/her last physician visit by the attending physician (Staff #23) was on 4/25/2023. However, the note's upload date was on 5/25/2023. Further review of Physician #23's visit notes were delayed as followings: 2/20/2023 visit Uploaded on 5/1/2023 4/4/2023 visit Uploaded on 5/25/2023 During an interview on 6/7/23 at 10:03 AM with Regional Nurse #7, she stated that she was to follow up on Physician #23's late uploading of his visiting notes. She thought the Physician gave his notes over to the unit secretary to upload. During an interview on 6/08/23 at 10:50 AM with Regional Nurse #7, she indicated that the Physician was responsible for uploading his regular visit notes and she acknowledged that physician #23 failed to upload his visit notes timely.

Based on observation, interview, and record review, it was determined that the facility staff failed to ensure Resident # 16's preferences were honored and to provide appropriate foods to meet his/hers needs. This was evident for 1 (Resident #16) out of 2 resident reviewed for food preferences and serving proper food. The findings include: On 6/8/2023 at 10:20 AM, a medical record review for Resident #16 was conducted. The resident's diagnosis included acid reflux disease and Gastroparesis (Gastroparesis is a condition in which the stomach muscles do not work properly). The resident's care plan interventions were to; avoid foods or beverages that irritate the esophageal (food pipe) lining such as alcohol, chocolate, caffeine, acidic or spicy foods, and fried or fatty foods. An observation of the Resident's food tray on 6/09/23 at 12:29 PM revealed the fried fish on their plate and the ticket indicated no fish. Further review of the lunch ticket on the tray indicated that the resident should have had chicken tenders per their request. Surveyors showed Resident's #16 lunch meal ticket to the Kitchen Supervisor (KS) # 20, during an interview on 06/09/23 at 1:18 PM. KS #20 stated the food served on the lunch tray was an error, she remade the plate and served it to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview it was determined the facility staff failed to maintain the medical record in the most complete and accurate form for Resident (#324). This was evident for 1 of 43 residents selected for review during the survey process. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. On 6/12/23 at 9am a review of resident #324's medical record revealed that the Resident was admitted to the facility on [DATE] with a diagnosis of Alzheimer's dementia. Alzheimer's is a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment. BIMS (Brief Interview for Mental Status) is a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility. On 1/26/21 a BIMS was conducted with Resident #324. Resident #324 had a score of 99 which means that the resident was unable to complete one or more questions of the interview. Resident #324 will be considered to have a severe impairment. Further, review of the medical record revealed that a Discharge Plan Documentation Section A was filled out that the resident had no cognitive impairment, was being discharge home alone and was responsible for self and make own decisions. On 6/13/23 at10:55 AM in an interview with the Regional Nursing confirmed the facility staff failed to maintain the medical record in the most complete form for Resident #324.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. The facility failed to ensure Resident #16 received insulin treatment timely. During an interview on 5/30/23 at 8:20 AM, Resident #16 revealed that he/she had type-one Diabetes Mellitus (DM) and was prescribed before-meal insulin (a hormone that regulates the amount of glucose in the blood) coverage. However, Resident #16 stated that the nursing staff were always late to check blood sugar and then would provide insulin coverage after the resident already ate. A medical record review of the nursing progress note on 5/30/23 at 9:12 AM revealed diagnoses of type one DM and obesity. The nursing staff documented on 5/22/2023 at 10:45 AM that Resident #16 had been eating less than 25% of his/her meal in the last 3 days. Resident #16 was prescribed insulin Humalog KwikPen Subcutaneously coverage before each meal with the sliding scale: if 0 - 150 = 0 units Call (Doctor of Medicine) MD for (fingerstick) FS <70; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 united; 351 - 400 = 10 units Call MD for FS >400, In a medical record review on 6/08/23 at 1:33 PM, the resident's care plan was focused on nutritional risk related to morbid obesity and noncompliance with their DM diet. The goal was to consume greater than 50 percent of at least 2 meals per day with the following interventions: education on carbohydrates/DM 2 diet and encouraging proper weight loss efforts. During an interview with Resident #16 on 6/09/23 at 9:09 AM, he/she stated that, on 6/2/2023, there were no before-meal blood sugar checks. Therefore, he/she did not get Humalog insulin coverage on that day. On 6/09/23 at 11:17 AM, a record review of blood sugar monitoring data revealed that, between 6/1/2023 and 6/4/2023, there were 2 delays on 6/1 at dinner and 6/3 at lunch with checking blood sugar before meals and 3 times blood sugar checks were missed on 6/2 and 6/3 which indicated the prescribed order for before meal insulin coverage was not being followed. 6/1/2023 9:52PM 315.0 mg/dL (delay) 6/2/2023 6:47AM 316.0 mg/dL 6/2/2023 11:30AM Missed 6/2/2023 6:30PM Missed 6/3/2023 7:00AM Missed 6/3/2023 1:53PM 192.0 mg/dL (delay) 6/3/2023 4:38PM 202.0 mg/dL 6/4/2023 7:05AM 305.0 mg/dL 6/4/2023 11:55AM 113.0 mg/dL 6/4/2023 4:25PM 104.0 mg/dL The findings include: 6. Medical record review on 05/30/23 11:15 AM for Resident #57 revealed on 4/21/2023 the physician ordered: D/C Labs, Weights, Vitals and Admit to Hospice Care. Hospice care is a special kind of care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness. Vital signs measure the basic functions of your body. They include your body temperature, blood pressure, pulse and respiratory (breathing) and pulse oxygen rate. Further record review revealed that the facility staff continue to obtain and recorded the blood pressures, pulse, respiratory (breathing), body temperature and pulse oxygen rate for Resident #57 on 4/23, 4/29, 4/30, 5/2, 5/8, 5/9, 5/13, 5/14. 5/15, 5/16, 5/19, 5/21. And 6/3, 2023. On 6/3/23 at 10 AM an interview with the Regional Nurse confirmed the facility staff failed to follow the physician orders. Based on observations, resident interview, staff interview, family interview and clinical record reviews, it was determined that the facility staff failed to ensure that wound care was provided to a resident (#274) as ordered, that a resident (#2) received the size catheter that was ordered, that a resident (#225) was provided transportation for an appointment, that a resident (#227) was administered medications on time, that consultant recommendations were followed for a resident (#45), that a resident (#16) received insulin on time as per physician order, and that vital signs were discontinued as ordered for a hospice resident (#57). These deficient practices were evident for 7 (#274, #2, #225, #227, #45, #16, #57) of 43 residents reviewed during the recertification process. The findings include: 1. A wound vac is a type of therapy to help heal wounds. During the treatment, a device decreases air pressure on the wound which can help the wound heal faster. On 06/09/2023, a clinical record review was conducted for resident #274. The record review revealed that the resident was discharged from the hospital and admitted to the facility on [DATE] for wound management. Hospital discharge instructions stated that a wound vac was to be placed upon admission to the facility. On the day of admission, the facility physician wrote orders for a negative pressure therapy/wound vac to be applied to the left calf. There was an additional order for a dressing which involved applying a wound care solution and wrapping the left leg. The dressing order did not specify when or how often to perform the dressing change. In a nursing progress note dated 01/17/2021 the nurse wrote that at 9:45 AM resident had complaints of not having yet received wound vacuum device for wounds on [his/her] [left lower extremity], [he/she] said [he/she] was told by previous nurses the device was ordered and on the way, this nurse advised [him/her] that she would follow up about the device when she got the chance, and she should report back to resident with more information when it became available to her. Clinical records from admission on [DATE] to discharge on [DATE] did not provide evidence that a wound vac was placed or had been ordered. There was no evidence of any wound care, either placement of a wound vac or a dressing change. Review of the Treatment Administration Record (TAR) did reveal that no wound care was performed during resident #274's stay. On 06/09/2023 at 10:30 AM, an interview was conducted with the Regional Director of Nursing (RDON) regarding resident #274's wound-vac. The RDON acknowledged that the resident had an order for a wound-vac however, there was no wound-vac in place during the resident's stay. Additionally, she confirmed no wound care was signed off on the TAR. She confirmed that the dressing order should have stated how often to change the dressing and that it should have been ordered as needed. She stated that it usually takes 24-48 hours to get a wound-vac once ordered. The facility could not provide documentation that the wound vac had been ordered. 2. Neurogenic bladder refers to several urinary conditions in people who lack bladder control due to a brain, spinal cord, or nerve problem. An indwelling urinary catheter (Foley) is a tube that drains urine from the bladder into a bag outside the body. They are held in place in the bladder by a balloon. Foley catheters are sized according to the diameter using the French (FR) scale. On 05/30/2023 at 1:02 PM, a clinical record review revealed that resident #2 had an indwelling urinary catheter due to having a neurogenic bladder. Physician orders for the indwelling catheter were the following: a. Foley catheter 18 FR with 30cc balloon to bedside straight drainage for neuromuscular dysfunction of the bladder. This order was made active on 05/23/2023. b. Change Foley Catheter (18, 20FR) when occluded or leaking as needed. This order was made active on 10/04/2022. A review of the nursing progress notes from 03/01/2023 to 05/31/2023 revealed that when inserting new Foleys, nurses inserted a size 18 FR one time, a size 16 FR nine times, and a size 24 FR one time. On 06/01/2023 at 10:10 AM, an interview was conducted with staff #5, an RN familiar with resident #2. The RN stated that the resident's Foley catheter falls out so often causing him/her to require insertion of a new Foley catheter. He stated, I replaced the catheter yesterday. When asked what size he used he responded, 16 FR, [he/she] is ordered for 16 FR. The RN was asked to look at the order and he verified that the order was for 18 FR, not 16 FR. On 06/01/2023 at 10:20 AM, the 2nd floor supplies storage room was examined with staff #5 present. There were no 18 FR catheters available. When asked what he does when he is missing or low on supplies, he explained that he must borrow from other units and then he must tell staff #6, who oversees ordering supplies. On 06/01/2023 at 10:25 AM, an observation of the 1st floor supplies storage room revealed that there were no 18 FR catheters available on that other unit either. On 06/01/2023 at 11:06 AM, an interview was conducted with staff #6. Staff #6 indicated that she relies on the nursing staff to let her know when the unit is short on supplies. She said that she also likes to go down on both floors to look to see what we're running low on. Regarding Foley catheters, she stated, I like to keep 18, 16, 14. I check my storeroom every day. On 06/01/2023 at 11:46 AM the findings were brought to the attention of the RDON. The RDON verified that multiple catheter sizes had been inserted during the lookback period. 3. The facility staff failed to follow the recommendations of a consultant for Resident #45. Review of Resident #45's medical record on 6/1/23 revealed the Resident was admitted to the facility on [DATE] with a diagnosis to include diabetes. Further review of the Resident's medical record revealed the Resident regularly is seen by an endocrinologist. An endocrinologist is a doctor who specializes in the diagnosis and treatment of hormone-related diseases and conditions such as diabetes. Review of the Endocrinology follow up notes for Resident #45 on 2/6/23 and 4/27/23 revealed the Endocrinologist documented for the Resident to begin Lispor Insulin 4 units prior to breakfast, lunch and dinner. Review of Resident #45's physician orders revealed the Lispor Insulin has not been ordered. Review of Resident #45's March, April and May 2023 Medication Administration Records reveal the Resident has not received Lispor Insulin as recommended by the Endocrinologist. Interview of the Regional Director of Nursing on 6/2/23 at 10:30 AM confirmed the facility staff failed to follow the recommendations of the Endocrinologist. 4. The facility staff failed to arrange transportation for Resident #225 to go to a scheduled medical appointment. Review of Resident #225's medical record on 6/9/23 for the Resident's concern he/she missed a medical appointment due the facility failing to arrange transportation revealed the Resident was admitted to the facility on [DATE] from the hospital for rehabilitation. Further review of Resident #225's medical record revealed on 12/12/22 Employee #22 (Nurse Practitioner) documented the Resident had a right shoulder rotator cuff manipulation appointment on 12/16/22. On 12/19/22 Employee #22 documented, Patient was scheduled for procedure on her right shoulder manipulation of rotator cuff on Friday 12/16/22 however due to staffing challenges for escort services patient procedure was cancelled and staff are working with surgery center to have it rescheduled for a later date and time for a closer facility. Interview with the Regional Director of Nursing on 5/9/23 at 11:00 AM confirmed the facility staff failed to provide transportation for Resident #225's appointment on 12/16/22. 5. The facility staff failed to administer medications timely for Resident #227. Review of Resident #227's medical record on 6/7/23 for the Resident's concern he/she was not receiving medications timely revealed the Resident was admitted to the facility on [DATE] from the hospital for rehabilitation and discharged on 2/24/23. Further review of the Resident's medical record revealed on 6/8/23 with the Regional Nurse revealed the following medications were administered 2 hours or more past the time they were ordered to be given: A. Baclofen 10 mg 2/4/23 ordered at 9:00 PM and administered at 11:48 PM, 2/5/23 ordered at 9:00 AM and administered at 2:57 PM, 2/6/23 ordered at 9:00 AM and administered at 3:37 PM, 2/23/23 ordered at 10:00 PM and administered 2/24/23 at 12:13 AM B. Oxycontin 40 mg 2/4/23 ordered at 9:00 PM and administered at 11:48 PM, 2/5/23 ordered at 9:00 AM and administered at 3:11 PM, 2/6/23 ordered at 9:00 AM and administered at 3:37 PM, 2/7/23 ordered at 9:00 AM and administered at 11:49 AM, 2/12/23 ordered at 9:00 AM and administered at 11:09 AM, 2/14/23 ordered at 9:00 AM and administered at 1:09 PM, 2/17/23 ordered at 9:00 AM and administered at 11:49 AM, 2/20/23 ordered at 9:00 AM and administered at 2:32 PM, 2/22/23 ordered at 9:00 AM and administered at 11:54 AM, 2/23/23 ordered at 9:00 PM and administered 2/24/23 at 12:13 AM C. Sennosides 8.6 mg 2/4/23 ordered at 9:00 PM and administered at 11:48 PM, 2/5/23 ordered at 9:00 AM and administered at 3:17 PM, 2/6/23 ordered at 9:00 AM and administered at 3:38 PM, 2/7/23 ordered at 9:00 AM and administered at 11:43 AM, 2/12/23 ordered at 9:00 AM and administered at 11:09 AM, 2/14/23 ordered at 9:00 AM and administered at 12:52 PM, 2/17/23 ordered at 9:00 AM and administered at 11:48 AM, 2/20/23 ordered at 9:00 AM and administered at 11:33 AM, 2/22/23 ordered at 9:00 AM and administered at 12:02 PM, 2/23/23 ordered at 9:00 PM and administered 2/24/23 at 12:13 AM D. Pregabalin 200 mg 2/4/23 ordered at 9:00 PM and administered at 11:48 PM, 2/5/23 ordered at 9:00 AM and administered at 3:38 PM, 2/7/23 ordered at 9:00 AM and administered at 11:54 AM, 2/8/23 ordered at 9:00 PM and administered at 11:33 PM, 2/9/23 ordered at 9:00 AM and administered at 12:40 PM, 2/12/23 ordered at 9:00 AM and administered at 11:09 AM, 2/14/23 ordered at 9:00 AM and administered at 12:52 PM, 2/17/23 ordered at 9:00 AM and administered at 11:49 AM, 2/20/23 ordered at 9:00 AM and administered at 11:33 AM, 2/22/23 ordered at 9:00 AM and administered at 11:54 AM, 2/23/23 ordered at 9:00 PM and administered 2/24/23 at 12:13 AM E. Hydrochlorothiazide 25 mg 2/5/23 ordered at 10:00 AM and administered 2/5/23 at 3:01 PM, 2/6/23 ordered at 10:00 AM and administered at 3:37 PM, 2/14/23 ordered at 10:00 AM and administered at 12:52 PM, 2/22/23 ordered at 10:00 AM and administered at 12:02 PM F. Diltiazem 360 mg 2/5/23 ordered at 10:00 AM and administered at 3:01 PM, 2/6/23 ordered at 10:00 AM and administered at 3:37 PM, 2/14/23 ordered at 10:00 AM and administered at 12:52 PM, ordered at 10:00 AM and administered at 12:02 PM G. Aspirin 81 mg 2/5/23 ordered at 10:00 AM and administered at 3:12 PM, 2/6/23 ordered at 10:00 AM and administered at 3:37 PM, 2/14/23 ordered at 10:00 AM and administered at 1:09 PM, 2/22/23 ordered at 10:00 AM and administered at 12:02 PM H. Lidocaine Patch 2/5/23 ordered at 10:00 AM and administered at 3:33 PM, 2/6/23 ordered at 10:00 AM and administered at 3:38 PM, 2/9/23 ordered at 10:00 AM and administered at 12:40 PM I. Spironolactone 25 mg 2/5/23 ordered at 12:00 PM and administered at 3:16 PM, 2/6/23 ordered at 12:00 PM and administered at 3:38 PM, 2/9/23 ordered at 12:00 PM and administered at 3:14 PM, 2/10/23 ordered at 12:00 PM and administered at 3:25 PM, 2/15/23 ordered at 12:00 PM and administered at 2:29 PM, 2/18/23 ordered at 12:00 PM and administered at 2:17 PM J. Buspirone 5 mg 2/17/23 ordered at 9:00 AM and administered at 11:48 AM, 2/20/23 ordered at 9:00 AM and administered at 11:33 AM, 2/22/23 ordered at 9:00 AM and administered at 11:54 AM, 2/23/23 ordered at 9:00 PM and administered 2/24/23 at 12:13 AM K. Atorvastatin 40 mg 2/4/23 ordered at 5:00 PM and administered at 11:47 PM, 2/6/23 ordered at 5:00 PM and administered at 10:23 PM, 2/10/23 ordered at 5:00 PM and administered at 8:23 PM, 2/11/23 ordered at 5:00 PM and administered at 8:04 PM, 2/13/23 ordered at 5:00 PM and administered at 8:31 PM, 2/20/23 ordered at 5:00 PM and administered at 8:16 PM, 2/21/23 ordered at 5:00 PM and administered at 8:08 PM, 2/24/23 ordered at 5:00 PM and administered at 10:34 PM L. Losartan 100 mg 2/4/23 ordered at 5:00 PM and administered at 11:47 PM, 2/6/23 ordered at 5:00 PM and administered at 10:23 PM, 2/7/23 ordered at 5:00 PM and administered at 9:58 PM, 2/8/23 ordered at 5:00 PM and administered at 9:22 PM, 2/10/23 ordered at 5:00 PM and administered at 8:24 PM, 2/11/23 ordered at 5:00 PM and administered at 8:04 PM, 2/20/23 ordered at 5:00 PM and administered at 8:16 PM, 2/21/23 ordered at 5:00 PM and administered at 8:08 PM, 2/24/23 ordered at 5:00 PM and administered at 10:34 PM M. Escitalopram 20 mg 2/4/23 ordered at 5:00 PM and administered at 11:48 PM, 2/6/23 at 8:00 PM and administered at 10:23 PM, 2/22/23 ordered at 8:00 PM and administered at 10:05 PM, 2/23/23 ordered at 8:00 PM and administered 2/24/23 at 12:13 AM, 2/24/23 ordered at 8:00 PM and administered at 10:34 PM N. Tamsulosin 0.4 mg 2/4/23 ordered at 8:00 PM and administered at 11:48 PM, 2/6/23 ordered at 8:00 PM and administered at 10:23 PM, 2/22/23 ordered at 8:00 PM and administered at 10:06 PM, 2/23/23 ordered at 8:00 PM and administered 2/24/23 at 12:13 AM O. Doxazosin 1 mg 2/4/23 ordered at 8:00 PM and administered at 11:47 PM, 2/6/23 ordered at 8:00 PM and administered at 10:23 PM, 2/8/23 ordered at 8:00 PM and administered at 11:35 PM, 2/13/23 ordered at 8:00 PM and administered at 11:31 PM, 2/22/23 ordered at 8:00 PM and administered at 10:05 PM, 2/23/23 ordered at 8:00 PM and administered 2/24/23 at 12:13 AM, 2/24/23 ordered at 8:00 PM and administered at 10:34 PM P. Melatonin 5 mg 2/13/23 ordered at 8:00 PM and administered at 11:11 PM, 2/22/23 ordered at 8:00 PM and administered at 10:04 PM, 2/23/23 ordered at 8:00 PM and administered at 12:13 AM, 2/24/23 ordered at 8:00 PM and administered at 10:34 PM Interview with the Regional Director of Nursing on 6/8/23 at 10:30 AM confirmed the facility staff failed to administered medications timely to Resident #227.

Based on resident and staff interview and review of the medical record, it was determined that the facility failed to ensure that the resident/resident representative were given the opportunity to participate in his/her care planning process. This was evident for 1 (#86) of 4 residents reviewed for care plan. The findings include: On 1/2/19 at 12:20 PM, an interview was conducted with Resident #86 and the resident was asked if he/she attended his/her care plan meeting. Resident #86 stated, I have not been, and I do not know if anyone goes for me. The resident was alert and oriented and had a BIMS (Brief Interview of Mental Status) score of 14 which indicated the resident was cognitively intact. On 1/4/19 at 9:20 AM, Staff #5 stated that the resident was invited to care plan meetings but had a guardian that came in his/her place. Review of the medical record on 1/4/19 revealed documentation that the last care plan meeting was held on 9/19/18. There was no documentation of a care plan meeting in December 2018. The Director of Social Work (Staff #34) was interviewed on 1/4/19 at 12:23 PM and stated they did not have a care plan meeting for Resident #86 in December 2018. Further review of the care plan list that Staff #34 was looking at revealed the resident's name did not appear on the list for December 2018 or January 2018. Staff #34 confirmed that the meeting was missed. The Nursing Home Administrator and the Corporate Nurse were advised on 1/10/19 at 9:21 AM.

Based on observation, resident and staff interview, and medical record review,, it was determined that the facility staff failed to ensure access to the nurse call bell, the over the bed tray table, and an ordered snack for a resident who was totally dependent on nursing staff for daily care due to impaired mobility. In addition, the facility failed to provide enough geriatric chairs to ensure that all residents that wanted to get up and out of bed could do this daily. This was evident for 2 (#63, #72) of 35 residents reviewed during the annual survey. The findings include: 1) Observation was made, on 1/2/19 at 12:03 PM, of Resident #63 reclining in a geriatric (geri) next to the resident's bed. The resident's graham cracker snack, which was labeled 1/2, was sitting across from the resident on the bureau next to the television. The resident was unable to walk or get out of the geri chair independently. The chair was approximately 8 to 10 feet away from the bureau. Also observed was the call light cord which was draped around the side rail, which was out of reach for the resident, as the position of the side rail was behind the geri chair. The resident was asked how he/she would call for the nurse and the resident yelled, nurse. In addition, observation was made of a water cup with no ice and very little water siting on the over the bed tray table with a box of cookies and an empty medication cup. The over the bed tray table was sitting at the end of the bed and was not accessible to the resident. On 1/3/19 at 3:03 PM, Staff #34 was in the resident's room evaluating if the resident was able to use the call bell. Resident #63 was able to demonstrate use. Staff #34 pushed the resident's over the bed tray table closer to the bed. The unopened graham crackers continued to sit unopened on the bureau. Review of Resident #63's care plan, at risk for falls had the intervention use call bell for assistance. Review of the care plan, while in the facility, it is important that resident has the opportunity to engage in daily routines that are meaningful relative to preferences had the intervention I like to snack between meals and prefer cookies. A third care plan, is at nutritional risk r/t increased nutrient needs r/t wound healing had the intervention offer snacks. The care plans were not followed. On 1/4/19 at 9:49 AM, discussed with Staff #5 and at 1:32 PM discussed with the Director of Nursing. 2) On Wednesday 1/2/19 at 11:50 AM, the surveyor went in and spoke with Resident #72 who stated he/she wanted to get up and out of bed. Staff #3 came into the resident's room and the surveyor asked why the resident was still in bed. Staff #3 stated, we alternate between Resident #72 and another resident getting up and out of bed due to the geri chairs. If Resident #72 stayed in bed yesterday then another resident would get up. If the other resident stayed in bed then Resident #72 would be gotten up. The surveyor asked if there were enough geri-chairs for all the residents and the response was, I have to go downstairs to see if I can find one for him/her. Resident #72 was observed again on 1/2/19 at 2:50 PM and the resident was still in bed. Resident #72's medical record was reviewed on 1/3/19 and a Hospice recommendation that was written on 9/12/18 stated, assist pt. to geri-chair and place in hallway on Monday, Wednesday and Friday. This order was not followed as on Wednesday, 1/2/19, the resident did not get out of bed as there was no geri chair available. In addition, the nurse signed off on 1/2/19 that the resident was assisted to the gerichair and placed in the hallway in the morning on Wednesday. The unit manager confirmed that the resident did not get out of bed on 1/2/19 because there was no geri chair. On 1/3/19 at 12:29 PM, the surveyor asked the unit manager, Staff #5 about the order. Staff #5 stated, I became aware of the order yesterday. The surveyor asked if there were enough geri chairs for all residents that wanted to get out of bed and the answer was no. 3) On 1/2/19 at 12:31 PM, an interview was conducted with Resident #86. During the interview, the resident stated there was no cord for the resident to turn the light on and off over his/her bed. The resident stated, they stated they were supposed to fix it. It has been like that for about 3weeks. Discussed with the Director of Maintenance on 1/10/19 at 10:34 AM. The Director of Maintenance stated that he/she was never made aware of the missing cord.

2) A blood pressure is a measurement of the pressure that the blood places on the arteries as it is moving through them. The top number is the systolic pressure, which is a measurement of the pressure when the heart pumps out the blood into the arteries. The bottom number is the diastolic pressure which is a measurement of the pressure when the heart is between beats (resting). Review of the medical record on 1/8/19, revealed that Resident #78 had End Stage Renal Disease (kidneys are failing), high blood pressure, and orthostatic blood pressure (blood pressure decreases when the person is standing). He/she was on three medications to lower the blood pressure and one medication to increase the blood pressure. However, further review of the medical record revealed that from 12/1/18 -12/31/18, the resident's blood pressure was below 100 for the top number and below 60 for the bottom number for 7 days during the month. There was no documentation that the physician was notified of these blood pressures in accordance with professional standards of practice. Based on observation, interview with facility staff, and record review, it was determined that facility staff failed to notify a resident's physician of a change in a residents' conditions. This was evident for 1 (#24) of 5 residents reviewed for respiratory status and 1 (#78) of 5 residents reviewed for unnecessary medications. The findings include: 1) A tracheostomy tube is a device that enables residents with compromised oral airways to bypass the upper airway and ventilate through a hole made in the front of the neck. Residents with tracheostomy tubes have a variety of special needs and challenges, including a greater risk of infectious organisms reaching the lungs. Resident #24 was observed in his/her bed on 1/8/19 at 12:45 PM. During the observation, it was noted that the resident had a significant amount of pink tinged frothy material dribbling out of his/her tracheostomy tube. While some amount of sputum production and expectoration is normal, the amount of sputum that was noted would be abnormal, and the pink tinge would always be considered abnormal. Registered Nurse (RN) #29 was notified of surveyor findings at 12:50 PM, and was asked to come in to observe the resident and identify if this was a new finding. RN #29 stated that this was his/her first day working in this facility and that s/he was not familiar with this resident. However, RN #29 also stated that s/he had been working with Resident #24 all morning and had not seen anything similar to what the surveyor described. RN #29 came in with the surveyor to see Resident #24 at 12:55 PM and confirmed that the fluid dribbling out of the resident's tracheostomy tube appeared to be sputum, appeared frothy and pink tinged, and was new since this morning. When asked what RN #29's next steps would be with this information, RN #29 stated that the Resident would be further evaluated and the Resident's physician would be notified of this change in condition. During the conversation, Resident #24 coughed noisily and more of the fluid came out of the tracheostomy tube. RN #29 denied having performed any suction on the resident so far during the day (RN #29's shift began at 7:00 AM). Resident #24's medical record was reviewed at 1:05 PM. The resident had been hospitalized within the previous 2 months for healthcare-acquired pneumonia and had recently been admitted to hospice care. The nurse practitioner caring for the resident (NP #36) was interviewed that afternoon at 3:15 PM. During the interview, NP #36 stated that s/he had not received any notification of a change in Resident #29's condition. This was supported by a review of nursing notes and assessments. Documentation could not be found that indicated NP #36 had been notified of the change in condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) During an interview with Resident #189 on 1/2/19 at 11:31 AM, the resident reported that he/she was sent to the hospital and staff did not explain to him what was going on. During a medical record review on 1/4/19, it was revealed that Resident #189 was transferred to the hospital on [DATE] and 12/21/18. Further review of the medical record revealed no documentation was found to indicate that staff fully prepared the resident for the transfers to ensure safety of the resident. Administrator and DON were informed of the deficient practice at time of exit conference on 1/10/19. Based on medical record review and staff interview, it was determined the facility failed to document what preparation and orientation was given to residents to ensure an orderly transfer to an acute care facility. This was evident but not limited to for 2 (#29, #189) of 7 residents reviewed for hospitalization. The findings include: 1) Review of the medical record for Resident #29 on 1/9/19 revealed documentation that Resident #29 had an unplanned transfer to an acute care facility on 11/21/18. Review of a nursing progress note, dated 11/21/18, did not include any documentation related to preparation and/or orientation to the resident before transferring the resident to an acute care facility. The progress note indicated that Resident #29 had an unplanned transfer and a name and telephone number of the resident's contact person that was notified of the transfer. An interview was conducted with the Director of Nursing on 1/9/19 at 8:42 AM and revealed that he/she was unaware of the regulator requirement of sufficient preparation and orientation for a resident prior to a facility-initiated transfer to an acute care facility.

Based on medical record review and staff interview, it was determined the facility staff failed to complete, within 14 days, a significant Minimum Data Set (MDS) comprehensive assessment. This was evident for 1 (#29) of 7 residents reviewed for hospitalization. The findings include: The MDS is part of the Resident Assessment Instrument (RAI) that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. Review of Resident #29's medical record on 1/9/19 revealed that the resident had returned from an acute care facility on 12/14/19. At 2:29 PM on 1/9/19, record review revealed that the facility had initiated a significant change assessment with an Assessment Reference Date (ARD) of 12/21/19 however, the assessment was incomplete and should have been completed and submitted by 1/4/19. Interview of two Resident Assessment Coordinators (RAC) (staff #7, staff #11) at 3:30 PM revealed that the significant change assessment with an ARD of 12/21/19 had just been submitted. The RACs acknowledged that interdisciplinary team members are notified daily of the incomplete sections of MDS assessments that are pending. Review of Resident #29's medical record on 1/10/19 at 9:17 AM revealed the significant change MDS assessment with an ARD of 12/21/2018 was locked and accepted on 1/9/19.

Based on medication administration observation, medical record review and staff interview, it was determined the facility staff failed to meet professional standards of quality by 1) failing to check placement and residual for residents who received medications and nutrition through a feeding tube, 2) failing to administer all physician ordered medications, 3) failing to accurately document which medications were given or not available, 4) failing to follow physician's orders for the ordered amount of tube feeding flushes and 5) failing to administer medications and a scheduled tube feeding on time. This was evident for 2 (#45, #47) out of 5 residents observed during medication administration by 1 (Staff #2) of 2 registered nurses and 2 certified medicine aides observed. The findings include: 1) The surveyor approached Staff #2 on 1/8/19 at 9:48 AM. Staff #2 was preparing to give medications to Resident #45. Staff #2 poured the medications (1) Metoprolol 50 mg. and (1) Metoprolol 25 mg., (1) Daily Vite and (2) Senna 8.6mg. All medications were crushed and separated into 30 cc. medication cups. The surveyor confirmed with Staff #2 that there were 5 pills in the medication cup prior to Staff #2 crushing the medications. The surveyor and Staff #2 walked into Resident #45's room. Resident #45 was lying in bed and was non-verbal. Staff #2 proceeded to pull on the resident's hospital gown while searching for the end of the tube feeding tube. Once Staff #2 found the end of the tube, Staff #2 removed the cap. Staff #2 then poured water from a large Styrofoam cup into a small 120 cc. plastic cup, filling the cup up with approximately 100 cc. Staff #2 mixed 15 cc. of water with each crushed medicine. Staff #2 then poured half of the water in the feeding tube as a flush prior to giving the medications, which was approximately 50 cc. Staff #2 poured the first medication in the tube and then flushed with 30 cc. of water. The second medication was poured followed by a 30 cc. water flush. The third medication was poured followed by a 30 cc water flush and then Staff #2 poured in a 230 cc. water flush. Staff #2 failed to check tube placement prior to administering the medications and failed to check to see if there was a residual. After watching medication administration, the surveyor reviewed the January 2019 physician's orders in the medical record to verify that the correct medications were given. The physician's orders stated that Hydralazine 37.5 mg, Protein liquid 1 oz., Ascorbic Acid 500 mg., Psyllium Powder 49% 1 TBSP, Lansoprazole 30 mg., Polysaccharide Iron Complex 150 mg., and Hyoscyamine 0.125mg. should have been given during the morning medication administration in addition to the medications that the surveyor observed being given. Review of the January 2019 Medication Administration Record (MAR) was void of Staff #2's initials which would have indicated that the medications were given. In addition, the Metoprolol and Senna were ordered to be given at 8:00 AM and 8:00 PM every day, and the Daily Vite every morning at 8:00 AM. The medications were not given until after 10:00 AM, which was 2 hours late. Furthermore, the physician's orders stated, enteral feed: flush tube with 15 ml. (cc) of water before each medication pass and flush tube with at least 15 ml. of water between each medication and flush tube with at least 15 ml of water after final medication. Staff #2 failed to give (7) medications and failed to flush the tube with the proper amount of water before, during and after the medication administration and failed to give the medications at the ordered time. 2) The surveyor accompanied Staff #2 to Resident #47's room to observe medication administration on 1/8/19 at 10:16 AM. Staff #2 poured the medications (1) Sodium Chloride 1 gm., (1) Ranitidine 150 mg., (1) Citalopram 10 mg., Valproic Acid 250 mg/5 ml. in which Staff #2 poured 15 ml. and (1) Clonazepam 0.5mg. There was a total of 4 pills and 1 liquid that was dispensed into individualized medication cups which the surveyor verified with Staff #2 prior to Staff #2 crushing the medications. Staff #2 proceeded to pour 10 to 15 ml. in with each crushed medication to mix. Staff #2 then proceeded to flush the feeding tube with 50 cc. of water, gave the first medication and then the second medication, flushed with 30 cc. of water, gave another flush, gave the third medication, a 30 cc water flush, the fourth medication, a 25 cc. water flush, the fifth medication, a 30 cc. water flush and then a 180 cc. water flush. In addition, Staff #2 failed to check for tube placement and residual prior to medication administration. After the medication administration on 1/8/19, the surveyor reviewed Resident #47's January 2019 physician's orders. It was noted that the resident should have also received Hydralazine 10 mg., Lactulose 30 ml. and Multivitamin 10 ml. Review of Resident #47's January 2019 MAR revealed that Staff #2 signed the 3 medications as if they were given. In addition, the physician's orders stated, flush tube with at least 15 ml. of water after final medication and flush tube with at least 15 ml. of water between each medication. Staff #2 gave an additional 270 ml. of water flushes beyond what was ordered by the physician. Furthermore, the medication Clonazepam was ordered to be given 3 times per day at 8:00 AM, 12:00 noon and 8:00 PM. The resident did not receive the medication until 10:25 AM which was 2 hours and 25 minutes late and the next dose was due at noon. The Sodium Chloride was ordered for twice per day, at 9:00 AM and 9:00 PM. The medication was given late. The Valproic Acid Solution was ordered at 9:00 AM and 9:00 PM and was given late. The Citalopram and Ranitidine were ordered for 8:00 AM and both medications were given 2 hrs. and 25 minutes late. In addition, Resident #47 was ordered, enteral feed order 5 times a day TwoCal NH 237 ml. bolus at 6:00 AM, 10:00 AM, 2:00 PM, 6:00 PM and 10:00 PM. As of 11:45 AM, the 10:00 AM feeding had not been signed off. Resident #47 did not receive a tube feed bolus during medication administration at 10:25 AM. The surveyor went back to Staff #2 on 1/8/19 at 11:45 AM and noted that some of Resident #47's medications were missed, but signed off as given. Staff #2 stated, I signed them off in error. There were not given because the meds were not available. It was not documented anywhere that the medications were not given. The surveyor brought up about the medications for Resident #45 being missed and Staff #2 stated, Oh they were. The surveyor also asked Staff #2 why the tube feeding was not given at 10:00 AM. Staff #2 stated, I just gave the feeding at 11:30 AM. The surveyor advised it was not signed off as given. Staff #2 just stared at the surveyor. The surveyor also asked Staff #2 why the medications were being passed late. Staff #2 stated, I worked my other job from 3:00 PM yesterday and did not get off until 4:00 AM this morning. I only got a couple of hours sleep and then came in after 9:00 AM. I was running late. At 11:47 AM, the Corporate Nurse was advised of the 3 omitted medications that were signed off as given, the 7 medications that were missed being given, the inaccurate water flushes, the failure to check residual and tube placement on both residents, the lateness of the medication pass and the failure of Staff #2 to give an ordered tube feeding at 10:00 AM to Resident #47. The Corporate Nurse and Nursing Home Administrator advised the survey team on 1/8/19 at 12:15 PM that Staff #2 was immediately removed from duty and that the physician was being notified.

2) Resident #341 was observed on 1/2/19 at approximately 9:30 AM, lying in bed, the room was quiet. At 1:30 PM, the resident was sitting reclined in a Geri-chair in the hallway across from the nurse's station watching others. During an interview at 1:45 PM, the resident's caregiver indicated that he/she had been to the facility almost every day since Resident #341's admission. He/She thought Resident #341 attended 1 church service, but was not aware of anyone inviting and/or assisting the resident to any other activities. Resident #341's medical record was reviewed on 1/8/19 at 9:26 AM. A Recreation Comprehensive Assessment was completed with the resident's family member and caregiver on 12/15/18 at 14:15, a few days after the resident's admission to the facility. The assessment identified interests and activities very important for the resident to participate in which included, but were not limited to, spending time by himself/herself listening to music including his/her favorite musician, all sports including favorite teams, walking, going outside, playing cards and specific religious services. The assessment identified that it was somewhat important for the resident to keep up with the news via TV, to do things with groups of people and in the past he/she enjoyed playing cards. The assessment identified that Resident #341 would benefit from accommodations due to cognitive limitations and needed reminders. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. Resident #341's plan of care included the resident's preferences and limitations as identified by the comprehensive assessment. However, the care plan interventions did not identify the services that the facility would provide to meet the residents activity needs. During an interview on 1/8/19 at 11:20 AM, Staff #40 was asked what Resident #341's activity goal was. He/She indicated watching TV and/or movies. He/She added that the facility staff wanted Resident #341 to attend his/her preferred activities; when asked how many activities, Staff #39 stated no number, we like him/her to attend what he/she wants to. Staff #39 was asked what activities were provided to accommodate Resident #341's identified music interests. He/She indicated that the resident was provided with a radio but then confirmed that he/she was never given a radio. The resident's activity participation records from 12/12/18 thru 1/8/19 were reviewed and reflected that Resident #341 had 5 individual staff visits, attended 1 church service and watched/listened to TV/Movies 2 times during the 27 day period reviewed. The record failed to reflect that the resident refused any activities offered. Staff #39 confirmed that the resident had not refused any activities. The facility failed to develop and implement a resident centered activity plan based on the residents identified needs, interests and preferences. Based on observation, medical record review and staff interview, it was determined that the facility staff 1) failed to provide an activities program to meet the needs and preferences of all residents and 2) failed to revise the care plan when a resident's health and ability to participate in activities declined. This was evident for 2 (#63, #341) of 2 residents reviewed for activities. The findings include: 1) Observation was made, on 1/2/19 at 12:11 PM, of Resident #63 sitting in a reclining geriatric (geri) chair in the resident's room next to the resident's bed. The television, which was sitting directly across from the resident, was off. The room was quiet and there was no radio on. The resident was observed again on 1/2/19 at 2:40 PM, and the resident was sitting in the same position with no radio or television on. Several observations were made of Resident #63 throughout the day on 1/3/19. The resident stayed in bed all day and there was no television or radio playing. Review of Resident #63's Annual MDS assessment with an assessment reference date (ARD) of 6/5/18 documented in section F0400, how important is it to you to have snacks available between meals? and the response was very important. How important is it to have books, newspapers and magazines to read and the response was very important.? How important is it to you to listen to music you like and the response was very important.? How important is it to you to keep up with the news and the response was very important.? How important is it to you to participate in religious services or practices and the response was very important.? Review of the activity care plan, while in the facility, resident states that it is important that he/she has the opportunity to engage in daily routines that are meaningful relative to their preferences with the interventions provide 1:1 unstructured check-in visits to monitor for any changes in his/her leisure routine/preferences; it is important for me to choose what clothing to wear; own clothing; it is important to me to tend to my personal belongings; I like to snack between meals and prefer cookies; it is important for me to have reading materials such as magazines, bible; I enjoy listening to music and prefer soft; I keep up with the news by reading, watching tv; I like to participate in groups with others; I like to lay down/rest, read, watch tv/movies, by myself in my bedroom. The 12/4/18 and 9/4/18 care plan evaluation documented no change in status. The care plan was not updated to reflect the resident's declining health over the past 9 months. The care plan was not followed as the television was not on, the radio was not on, and the resident did not have any reading material at the bedside. On 1/4/19 at 10:00 AM, Resident #63's Participation Record for Activities was reviewed. The log for October 2018 documented 7 visits from family and 1 time listening to music. There was no further documentation of any activities that the resident was involved in, which included reading, listening to music, keeping up with the news, watching television, or any special events that the facility offered. The November 2018 participation log documented 3 times the resident listened to music and 1 day out of the month had a visit from family. The remainder of the log was blank. The December 2018 participation log documented 3 times listening to music up until 12/12/18, 1 time being around children on 12/15/18, and 4 family visits. The remainder of the log was blank. As of 1/4/19, the January 2019 participation log only had documentation for 2 visits from family and 1 day of listening to music on 1/2/19 at 2 PM. The Activities Director was interviewed on 1/4/19 at 10:01 AM and stated, there is room for improvement. Reviewed the care plan with the Activities Director and he/she agreed it had not been updated.

Based on resident and staff interview and medical record review, it was determined the facility failed to follow up with the resident to ensure the resident received the services necessary to maintain adequate hearing. This was evident for 1 (#86) resident reviewed for communication/sensory. The findings include: On 1/2/19 at 12:21 PM, an interview was conducted with Resident #86. The resident was asked if he/she had any problems with hearing and the resident stated, I am hard of hearing and I do not wear hearing aids and I would like to know why I can't hear out of the left ear and see what can be done about it. It was noted that the resident told the surveyor to sit to the right of the bed, so he/she could hear. On 1/4/19 at 9:21 AM, the unit manager (Staff #5) was asked about the resident's hearing and Staff #5 stated his/her hearing was fine. Staff #5 proceeded to ask the Physical Therapy Manager who was at the nurse's station if he/she knew anything about the resident's hearing. On 1/4/19 at 9:25 AM the Physical Therapy Manager read an occupation therapy note which stated the resident was hard of hearing. Review of physician's progress notes dated 8/30/18, 11/26/18 and 12/13/18 documented hearing impaired. Review of the MDS assessments, with an assessment reference date (ARD) of 6/16/18, Section B0200, Hearing, coded that the resident had minimal difficulty with hearing. The MDS assessments with an ARD of 9/16/18 and 12/17/18, Section B0200, Hearing, coded 0 which indicated the hearing was adequate. On 1/4/19 at 1:07 PM, discussed with the MDS coordinator, and the MDS coordinator stated he/she goes by the nursing assessment when coding the MDS assessment. Review of the care plan while in the facility resident states that it is important that he/she has the opportunity to engage in daily routines that are meaningful relative to his/her preference with interventions I would benefit from accommodation for hearing loss by having other speak deeper and louder, decreased environmental noises. There was no goal on the care plan. There was no further documentation about hearing loss in the medical record and there were no provisions made for a professional evaluation. Discussed with the Director of Nursing on 1/4/19 at 1:32 PM.

Based on observation, medical record review and staff interviews, it was determined that the facility staff failed to provide appropriate care for a resident that required total assistance with positioning and was assessed to have a pressure ulcer and continued to be at risk for development of pressure ulcers. This was evident for 1 (#63) of 4 residents reviewed for pressure ulcers. The findings include: Observation was made, on 1/2/19 at 12:05 PM, of Resident #63 sitting in a geriatric (geri) reclining chair with knees towards the window, pillow behind the head and nothing between the resident's knees. The resident was sitting on a Hoyer lift quilted pad. On 1/2/19 at 2:05 PM, the resident was in the same position and on 1/2/19 at 2:41 PM, the resident remained in the same position. A second surveyor observed the positioning of the resident. Observation was made, on 1/3/19 at 7:40 AM, of Resident #63 lying on his/her back with his/her head to the left towards the curtain with 2 pillows around the head. The feet were positioned on a pillow. On 1/3/19 at 11:46 AM, the surveyor observed Staff #3 and Staff #4 place a pain patch on the resident. The resident was placed in the same position as observed on 7:40 AM. Subsequent observations were made on 1/3/19 at 12:46 PM, 1:35 PM and 3:03 PM. The resident remained in the same position. Observation was made on 1/4/19 at 7:35 AM of Resident #63 lying in bed with his/her head on 2 pillows which leaned to the left. The knees were facing the window with a pillow in between the knees. On 1/4/19 at 9:17 AM, Resident #63 was in bed in the same position with the head of bed elevated 45 degrees with the over the bed tray table in front of the resident. The resident's body alignment was the same as the 7:35 AM observation. Review of the care plan Resident has actual skin breakdown r/t limited mobility with interventions: assist resident in turning & reposition every 2 hours and prn. Encourage resident to consume all fluids during meals, pressure reducing cushion to chair while out of bed, waffle cushion behind back when out of bed in wheelchair. The care plan was not followed as the resident was not turned and repositioned every 2 hours and the pressure reducing cushion was not in the geri chair when the resident was out of bed on 1/2/19. Further review of the medical record documented that the resident obtained a stage 4 facility acquired pressure ulcer on the right hip on 3/19/18 that continued to be treated. The resident also had a history of a pressure ulcer on the left hip. Discussed with Staff #5 on 1/4/19 at 9:49 AM and with the DON on 1/4/19 at 1:32 PM. The staff did not change the resident's position per the care plan and physician orders for this resident with a stage 4 pressure ulcer. Further review of the wound care physician's progress notes, that were done weekly, documented that the pressure ulcer would be nearly healed, stall or decline. The last wound care note, dated 1/3/19, documented that the wound was currently stable.

Based on observation, medical record review and staff interview, it was determined the facility staff failed to ensure that residents with a limited range of motion received the appropriate treatment and services to prevent further decline in range of motion. This was evident for 1 (#74) of 4 residents reviewed for mobility. The findings include: On 1/2/19 at 2:19 PM, observation of Resident #74 revealed the resident's right hand with fingers bent and there was no splint or device in place. On 1/4/19, during an interview, Staff #1 confirmed the resident had a contracture. A contracture is a condition of shortening and hardening of muscles, tendons or other tissue which often leads to deformity and rigidity of joints. On 1/8/18, review of the medical record revealed on 8/7/18, in a progress note, the physician documented that the resident had a right-hand contracture. Resident #74's 12/13/18 quarterly assessment documented that Resident #74 had no functional limitation in range of motion, which was inaccurate. On 1/8/18 at 11:53, AM, during an interview, Staff #32 stated that Resident #74 received Occupational Therapy (OT) to work on splinting of the right hand from 9/2017 to 11/2017. OT therapist stated that, when the resident was discharged from OT services, he/she was wearing a right resting hand splint for 6 hours a day. On 11/21/17, in an OT Discharge Summary, the Occupational Therapist documented discharge recommendations that included a right resting hand splint. Continued review of Resident #74's medical record failed to reveal a physician order for a right resting hand splint and failed to reveal evidence that Resident #74 was receiving services to prevent further decline in the resident's ROM. Review of Resident #74's care plans failed to reveal a plan of care had been developed to address Resident #74's right hand contracture and limited range of motion (ROM). Staff #5 and Staff #9 were made aware of these findings on 1/10/19 at 9:31 AM. Based on review of the medical record and interview with the resident and staff, it was determined the facility staff failed to provide services to increase or prevent decline in the resident's range of motion (ROM). This was evident for 1 (#70) of 4 residents reviewed for Position/Mobility. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. Review of Resident #70's medical record on 1/9/19 at 10:09 AM revealed a list of diagnoses which included, but was not limited to, monoplegia (paralysis of one limb) of upper limb. Review of the resident's Quarterly MDS with the reference date 12/10/18 Section G Functional limitation on Range of Motion indicated A. Upper extremity = 0. No impairment, B. Lower extremity 2. Impairment on both sides. Section I Diagnoses - did not include monoplegia of upper limb. During an interview and observation of the resident on 1/10/19 at 10:06 AM, the resident's left elbow was observed to be bent approximately 90 degrees and the fingers of his/her left hand were in a cupped position indicating possible contractures (fixed resistance to passive stretch of a muscle). The resident indicated that he/she was unable to extend his/her fingers or straighten his/her arm on his/her own. During an interview on 1/10/19 at 11:18 AM, Staff #32 indicated that Resident #70 was in the process of being fitted for a left-hand splint but was not receiving Physical or Occupational therapy. He/She added that Resident #70 received Occupational therapy from 9/6/18 - 10/10 18 to increase left upper extremity ROM to decrease worsening contracture. On 1/10/19 at 11:38 AM, Staff #17 indicated when asked that Resident #70 had very limited ROM in his/her left shoulder and that his/her left elbow is pretty fixed. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. The surveyor failed to find that a plan of care had been developed to address Resident #70's care needs related to his/her limited ROM/contractures. Cross reference F 641 and F 656.

Based on observation, medical record review and staff interview, it was determined facility staff failed to provide the appropriate treatment and services to prevent complications of enteral feedings by not giving proper tube flushes and by not providing a tube feeding when ordered. This was evident for 2 (#45, #47) of 2 residents observed with tube feedings during medication pass observation. The findings include: 1) Observation was made on 1/8/19 at 9:48 AM of Staff #2 administering medications to Resident #45. Resident #45 was lying in bed and was non-verbal. Staff #2 proceeded to pull on the resident's hospital gown while searching for the end of the tube feeding tube. (A feeding tube is a device that's inserted into the stomach through the abdomen. It is used to supply nutrition for someone that has trouble eating). Once Staff #2 found the end of the tube, Staff #2 removed the cap. Staff #2 then poured water from a large Styrofoam cup into a small 120 cc. plastic cup, filling the cup up with approximately 100 cc. Staff #2 then poured half of the water in the feeding tube as a flush prior to giving the medications which was approximately 50 cc. of water. Staff #2 poured the first medication in the tube and then flushed with 30 cc. of water. The second medication was poured followed by a 30 cc. water flush. The third medication was poured followed by a 30 cc water flush and then Staff #2 poured in a 230 cc. water flush. Staff #2 failed to check tube placement prior to administering the medications and failed to check to see if there was a residual. After watching medication administration, the surveyor reviewed the January 2019 physician's orders in the medical record. The physician's orders stated, enteral feed: flush tube with 15 ml. (cc) of water before each medication pass and flush tube with at least 15 ml. of water between each medication and flush tube with at least 15 ml of water after final medication. Staff #2 failed to flush the tube with the proper amount of water before, during and after the medication administration. Review of Resident #45's care plan resident has an enteral feeding tube to meet nutritional needs r/t dysphagia, increased nutrient needs r/t wound healing, abnormal labs, concern for hydration status and weight loss trends had the intervention free H2O (water) as ordered. The care plan was not followed as the amount of milliliters before, during and after medication pass exceeded the ordered amount. 2) The surveyor accompanied Staff #2 to Resident #47's room to observe medication administration on 1/8/19 at 10:16 AM. Staff #2 prepared the medications. Staff #2 then proceeded to remove the tube feeding cap and flush the feeding tube with 50 cc. of water, gave the first medication and then the second medication, flushed with 30 cc. of water, gave another flush, gave the third medication, a 30 cc water flush, the fourth medication, a 25 cc. water flush, the fifth medication, a 30 cc. water flush and then a 180 cc. water flush. Staff #2 failed to check for tube placement and residual prior to medication administration. After the medication administration on 1/8/19, the surveyor reviewed Resident #47's January 2019 physician's orders. The physician's orders stated, flush tube with at least 15 ml. of water after final medication and flush tube with at least 15 ml. of water between each medication. Staff #2 gave an additional 270 ml. of water flushes beyond what was ordered by the physician. In addition, Resident #47 was ordered, enteral feed order 5 times a day TwoCal NH 237 ml. bolus at 6:00 AM, 10:00 AM, 2:00 PM, 6:00 PM and 10:00 PM. As of 11:45 AM, the 10:00 AM feeding had not been signed off. Resident #47 did not receive a tube feed bolus during medication administration at 10:25 AM. The surveyor went back to Staff #2 on 1/8/19 at 11:45 AM, and inquired about Resident #47 missing the 10:00 AM feeding. Staff #2 stated, I just gave the feeding at 11:30 AM. The surveyor asked why it was late and Staff #2 stated again, I just gave it. The feeding was not signed off as given. Review of Resident #47's care plan, Resident has an enteral feeding tube to meet nutritional needs, CVA, dysphagia had the interventions feeding (2 cal HN) at room temperature as ordered and NSS (water) flushes as ordered. The care plan was not followed. On 1/8/19 at 11:47 AM, the Corporate Nurse was advised of the concerns related to both residents not receiving the proper water flushes and tube feeding. The Corporate Nurse and Nursing Home Administrator advised the survey team on 1/8/19 at 12:15 PM that Staff #2 was immediately removed from duty.

2) A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. On 1/8/19, Resident #33's medical record was reviewed. Resident #33's most recent MDS assessment with a reference date of 11/8/18 documented that the resident had a BIMS (Brief Interview of Mental Status) of 4. A BIMS coded between 0 and 7 indicated severe cognitive impairment, scores between 8 and 12 indicated moderate impairment, while scores above 13 showed little to no impairment. The evaluation is used to detect cognitive impairment at that time. The assessment documented that Resident #33's required extensive assistance for ADLs (activities of daily living), was totally dependent for bathing and had an active diagnosis of Alzheimer's. On 12/12/19 in a behavioral health note, the CRNP (certified registered nurse practitioner) documented that Resident #33 had dementia with behavioral disturbance. A. Review of Resident #33's care plans revealed a care plan, the resident has impaired/decline in cognitive function or impaired thought processes related to a condition other than delirium: Alzheimer's disease, with the goals will be able to make simple decisions by responding yes or no on most days during the review period, will maintain a pattern of sleep sufficient to promote health and well-being throughout review period and had the interventions 1. Monitor for decline in function. Refer to rehabilitation therapy if decline in ADLs is noted; 2. Allow resident/patient to make daily decisions. Use verbal cues, gestures and demonstration to assist in decision making, if needed and 3. Provide consistent, trusted caregiver and structured daily routine, when possible. The plan of care did not identify what the resident's current level of cognitive function was or the measurable objectives that the staff were to use when determining the resident's progress or lack of progress toward reaching his/her goal. Review of the medical record failed to reveal that the resident's progress toward his/her goal was evaluated. B. Review of Resident #33's Activity interview for daily and activity preferences, completed on 10/24/18, after admission to the facility, documented that the resident thought it was very important to listen to music, keep with the news and to do things with groups of people and it was somewhat important to do favorite activities and somewhat important to go outside to get fresh air when the weather is good. Review of Resident #33's October 2018 activity participation record documented that the resident had 4 family visits in 14 days with no other activity documented. The November 2018 participation record documented that the resident listened to music on 3 of 31 days, watched TV on 5 of 31 days, visited with family on 3 of 31 days and attended 1 special event. There was no documentation found that other activities were offered or that a structured plan was created every day as some of the activities took place on the same day. C. Continue review of Resident #33's care plans revealed a care plan, while in the facility, (the resident's name) states that it is important that she has the opportunity to in engage in daily routines that are meaningful relative to her preferences had the goal, will verbalize herself during 1:1 unstructured check-in visits and out of room group programs till next review had the interventions, 1. Encourage activity preferences, 2. I enjoy listening to music and prefer R & B, 3. I like to listen to music, lay down/rest, pray, watch TV/movies by myself in my bedroom, 4) I enjoy watching/listening TV, 5) It is important for me to vote, 5) I would benefit from accommodation for cognitive limitations by verbal prompts, single step tasks and reminders. The plan of care's goal was not resident centered with measurable objectives to reflect the resident's progress or lack of progress toward achieving his/her goals. The care plan evaluation note dated 11/11/18 indicated that there were no changes in the resident's leisure routine since admission, documented that the resident had moved to another floor in the facility and appeared to be content and comfortable, that the resident needs staff assistance with ADL care and mobility, the resident's family visits and are involved his/her care and recreation will continue with the plan of care until next review. D. Further review of Resident #33's care plans failed to reveal that a resident centered, comprehensive care plan was developed for the resident's specific behavioral problems related to the resident's dementia with behavioral disturbance and use of psychotropic medication. On 1/8/19 at 2:13 PM, Staff #10 was made aware of these findings. Based on observation, family and staff interview and medical record review, it was determined the facility failed to provide coordinated interdisciplinary services for a resident to maintain his or her highest practicable physical, mental and psychosocial well-being. This was evident for 2 (#58, #33) of 2 residents reviewed for dementia care. The findings include: 1) Observation was made on 1/2/19 at 9:19 AM of Resident #58 laying on a visibly, urine stained bedspread. It was also noted the fabric chair in the resident's room was urine stained. On 1/2/19 at 9:44 AM Resident #58's POA (Power of Attorney) was interviewed and stated that he/she didn't feel the staff was properly trained to deal with his/her spouse's dementia. The resident's spouse stated he/she refuses care and will not let anyone change him/her, shower him/her, etc. except for the spouse. The spouse said he/she felt as though he/she should not have to come in to do it. Staff #37 stated on 1/9/19 at 11:31 AM, we try, and we leave and retry to reapproach. He/she will throw a cup of water at us and kick us. He/she cusses at us, hits and kicks, tells us to get out of his/her room. We take clean clothes out of the closet and place on the bed and he/she will throw them back in the closet. He/she has been like this since he/she has been here. It is frustrating. I used to work in mental health and I have never seen anyone with his/her behaviors. When asked how the staff cares for the resident Staff #37 stated, we wait for the spouse to come in. When the spouse comes in and talks to the resident we can change the sheets on the bed. When asked how often the spouse comes in Staff #37 stated, at least 2 times a week. When asked what staff does when the resident is wet and is combative the response was, we just leave him/her alone. Staff #4 stated on 1/9/19 at 11:40 AM, he/she will hit you in the back. When he/she gets out of bed and walks in the hallway the aide will go in and change his/her bed. We try to re-approach, but he/she is very combative. The resident was observed on 1/2/19 at 9:41 AM in the resident's room. Resident #58 was in bed with the television on. During the survey, the resident was not observed out of the room until 1/9/19, when the resident ambulated down the hall looking for a snack. On 1/9/19 at 11:45 AM, the psychiatric nurse practitioner (NP) was interviewed about what was being done for the resident. The NP stated, I tried to send him/her out and the POA was resistant to sending him/her out. There aren't many facilities that care for this type of behavior. I tried to send to a specialty hospital, however, he/she does not have a qualifying diagnosis besides a psychiatric (psych) diagnosis and they won't take just a psych diagnosis. If we send to the emergency room they just send him/her back. The surveyor asked if a psychiatrist had seen the resident yet and the response was not yet. During the conversation, 2 staff members went into the resident's room because the resident was wet. The resident started yelling explicatives and threw water on the staff. Review of a physician's progress note, dated 11/21/18, documented that the resident was being followed for a diagnosis of dementia w/behavioral disturbances and was aggressive at times. A physician's note of 10/3/18 documented the resident's mood was irritable, insight poor and judgement impaired. Behavioral goal was to keep mood neutral. Staff to provide structured socialization and ADL care. On 1/9/19 at 1:15 PM, the activity logs were reviewed for Resident #58 for September, October, November, December 2018 and January 2019. The logs lacked documentation of any activities/interventions tried for the resident. The December 2018 activity log revealed the last documentation of any type of activity was on 12/15/18. For November 2018, the only documentation was listening to music on 11/18/18 and visiting family on 11/27/18. The October 2018 activity log revealed the last documentation was on 10/9/18 and the September 2018 activity log had documented a visit by family on 9/9/18, 9/18/18 and 9/25/18. Staff #39 confirmed that the care plan was not updated and there was no coordinated effort between nursing and activities.

Based on observation, staff interview and medical record review, it was determined that the facility failed to provide residents' medications in a timely manner. This was evident for 2 (#18, #47) of 5 residents observed during medication administration. The findings include: 1) Observation was made, on 1/18/19 at 8:34 AM, of Staff #3 preparing medications for Resident #18. Staff #3 dispensed 8 pills in a medication cup. There were 2 medications that were not in the medication cart; Linzess 72 mcg. and Aldactone 50 mg. Staff #3 proceeded to go to the medication dispensing machine and the medications were not available. Staff #3 stated he/she would have to re-order them from the pharmacy. The Linzess was started on 11/8/17 and the Aldactone was started on 5/14/17. Staff #3 was asked why the medications were not available and the response was someone didn't order them. I will order them and give them when they come in later today. The medications were ordered to be given every day. Resident #18's Medication Administration Record (MAR) was reviewed the next day, on 1/19/19, and the resident did not receive the medications on 1/18/19. 2) The surveyor accompanied Staff #2 to Resident #47's room to observe medication administration on 1/8/19 at 10:16 AM. Staff #2 poured the medications (1) Sodium Chloride 1 gm., (1) Ranitidine 150 mg., (1) Citalopram 10 mg., Valproic Acid 250 mg/5 ml. in which Staff #2 poured 15 ml. and (1) Clonazepam 0.5mg. There was a total of 4 pills and 1 liquid that was dispensed into individualized medication cups which the surveyor verified with Staff #2 prior to Staff #2 crushing the medications. After the medication administration on 1/8/19, the surveyor reviewed Resident #47's January 2019 physician's orders. It was noted that the resident should have also received Hydralazine 10 mg., Lactulose 30 ml. and Multivitamin 10 ml. Review of Resident #47's January 2019 MAR revealed Staff #2 signed the 3 medications as if they were given. The surveyor went back to Staff #2 on 1/8/19 at 11:45 AM and inquired about Resident #47's medications that were missed, but signed off as given and Staff #2 stated, I signed them off in error. There were not given because the meds were not available. At 11:47 AM, the Corporate Nurse was advised of the 3 omitted medications that were signed off as given and at that time, Staff #2 told the Corporate Nurse that the medications were not available. The Corporate Nurse proceeded to call the pharmacy to inquire about the medications. On 1/8/19 at 3:30 PM, Staff #6 was asked if there were any issues with medications being available. Staff #6 stated, we have to call a lot. I order when there are 15 pills left just to be safe. If under 5 pills, I will either call, order through the computer or pull the labels. Sometimes the medicine isn't here, and we have to recalculate. Sometimes we have to call a couple of times.

Based on medical record review and staff interview, it was determined that the facility failed to have a process in place to ensure that pharmacy recommendations were reviewed and acted upon as necessary. This was evident for 1 (#78, #70) out of 6 reviewed for unnecessary medications. The findings include: Resident #78's medical record was reviewed on 1/9/19 and revealed no evidence that a monthly pharmacy review was done. During an interview with the corporate nurse (Staff #10) on 1/09/19 at 2:22 PM, s/he confirmed that the pharmacy reviews were not kept in the medical record. Staff #10 reported that the pharmacy reviews were sent via the computer as a compiled list of residents which stated, No issues. The list was not placed in resident medical records due to other resident's names being included. When the pharmacy had a recommendation, they are sent for individual residents. An interview with the Director of Nursing (DON) on 1/9/19 at 3:06 PM, revealed an expectation that the pharmacy recommendations were kept in the medical record under the consultation tab. However, he/she reported he/she had to print the recommendations for Resident #78 because they were not present in the medical record. A pharmacy recommendation, dated 11/20/18, stated, To avoid the need for documented re-evaluation and prochlorperazine order renewal every 14 days or every quarter for routine use, please consider discontinuing prochlorperazine (Compazine). If treatment is still needed, please consider promethazine (Phenergan) 12.5 mg for nausea or vomiting. The physician's response field was blank and there were no signatures present to indicate a review had occurred. However, according to the December 2018 MAR, Resident #78 continued to have an order for Compazine tablet 5 mg Give 5 mg by mouth every 8 hours as needed for nausea and vomiting. On 1/10/19 at 12:14 PM, an interview with physician staff #12 revealed that there was no process in place for pharmacy recommendations to be given to him/her for review. The Administrator was made aware of findings at time of exit conference on 1/10/19. 2) Resident #70's medical record was reviewed on 1/9/19 at 10:09 AM. The resident had a physician's order written on 11/9/18 for Valproate Sodium Solution give 5 milliliters by mouth at bedtime for seizures. Valproate Sodium is an anti-seizure medication which is also used for mood stabilization. Prior physician's orders for the same medication indicated it was prescribed for mood disorder. Further review of the resident's record failed to reveal a diagnosis of seizures but did include major depressive disorder. A clinical Pharmacist review on 12/17/18 failed to identify and refer to the physician that the Valproate Sodium was ordered for seizures for a resident without a seizure diagnosis. The Director of Nursing and Corporate Nurse were made aware of these findings on 1/10/19 at 10:22 AM. Cross reference F 842.

Based on medication administration observation, medical record review and staff interview, it was determined the facility staff failed to ensure a medication error rate of less than 5 percent for 2 (#45, #47) of 5 residents observed with 18 errors out of 37 medication administration opportunities which resulted in an error rate of 48.65% by 1 (Staff #2) of 2 registered nurses and 2 certified medicine aides observed. The findings include: 1) The surveyor approached Staff #2 on 1/8/19 at 9:48 AM. Staff #2 was preparing to give medications to Resident #45. Staff #2 poured the medications (1) Metoprolol 50 mg. and (1) Metoprolol 25 mg., (1) Daily Vite and (2) Senna 8.6mg. All medications were crushed and separated into 30 cc. medication cups. The surveyor confirmed with Staff #2 that there were 5 pills in the medication cup prior to Staff #2 crushing the medications. The surveyor and Staff #2 walked into Resident #45's room. Resident #45 was lying in bed and was non-verbal. Staff #2 proceeded to pull on the resident's hospital gown while searching for the end of the tube feeding tube. Once Staff #2 found the end of the tube Staff #2 removed the cap. Staff #2 then poured water from a large Styrofoam cup into a small 120 cc. plastic cup, filling the cup up with approximately 100 cc. Staff #2 mixed 15 cc. of water with each crushed medicine. Staff #2 then poured half of the water in the feeding tube as a flush prior to giving the medications which was approximately 50 cc. Staff #2 poured the first medication in the tube and then flushed with 30 cc. of water. The second medication was poured followed by a 30 cc. water flush. The third medication was poured followed by a 30 cc water flush and then Staff #2 poured in a 230 cc. water flush. Staff #2 failed to check tube placement prior to administering the medications and failed to check to see if there was a residual. After watching medication administration, the surveyor reviewed the January 2019 physician's orders in the medical record to verify that the correct medications were given. The physician's orders stated that Hydralazine 37.5 mg, Protein liquid 1 oz., Ascorbic Acid 500 mg., Psyllium Powder 49% 1 TBSP, Lansoprazole 30 mg., Polysaccharide Iron Complex 150 mg., and Hyoscyamine 0.125mg. should have been given during the morning medication administration in addition to the medications that the surveyor observed being given. Review of the January 2019 Medication Administration Record (MAR) was void of Staff #2's initials which would have indicated that the medications were given. In addition, the Metoprolol and Senna were ordered to be given at 8:00 AM and 8:00 PM every day and the Daily Vite every morning at 8:00 AM. The medications were not given until after 10:00 AM which was 2 hours late. Furthermore, the physician's orders stated, enteral feed: flush tube with 15 ml. (cc) of water before each medication pass and flush tube with at least 15 ml. of water between each medication and flush tube with at least 15 ml of water after final medication. Staff #2 failed to give (7) medications and failed to flush the tube with the proper amount of water before, during and after the medication administration and failed to give the medications at the ordered time. 2) The surveyor accompanied Staff #2 to Resident #47's room to observe medication administration on 1/8/19 at 10:16 AM. Staff #2 poured the medications (1) Sodium Chloride 1 gm., (1) Ranitidine 150 mg., (1) Citalopram 10 mg., Valproic Acid 250 mg/5 ml. in which Staff #2 poured 15 ml. and (1) Clonazepam 0.5mg. There was a total of 4 pills and 1 liquid that was dispensed into individualized medication cups which the surveyor verified with Staff #2 prior to Staff #2 crushing the medications. Staff #2 proceeded to pour 10 to 15 ml. of water in with each crushed medication to mix. Staff #2 then proceeded to flush the feeding tube with 50 cc. of water, gave the first medication and then the second medication, flushed with 30 cc. of water, gave another flush, gave the third medication, a 30 cc water flush, the fourth medication, a 25 cc. water flush, the fifth medication, a 30 cc. water flush and then a 180 cc. water flush. In addition, Staff #2 failed to check for tube placement and residual prior to medication administration. After the medication administration on 1/8/19, the surveyor reviewed Resident #47's January 2019 physician's orders. It was noted that the resident should have also received Hydralazine 10 mg., Lactulose 30 ml. and Multivitamin 10 ml. Review of Resident #47's January 2019 MAR revealed that Staff #2 signed the 3 medications as if they were given. In addition, the physician's orders stated, flush tube with at least 15 ml. of water after final medication and flush tube with at least 15 ml. of water between each medication. Staff #2 gave an additional 270 ml. of water flushes beyond what was ordered by the physician. Furthermore, the medication Clonazepam was ordered to be given 3 times per day at 8:00 AM, 12:00 noon and 8:00 PM. The resident did not receive the medication until 10:25 AM, which was 2 hours and 25 minutes late and the next dose was due at noon. The Sodium Chloride was ordered for twice per day, at 9:00 AM and 9:00 PM. The medication was given late. The Valproic Acid Solution was ordered at 9:00 AM and 9:00 PM and was given late. The Citalopram and Ranitidine were ordered for 8:00 AM and both medications were given 2 hrs. and 25 minutes late. The surveyor went back to Staff #2 on 1/8/19 at 11:45 AM and inquired about Resident #47's medications that were missed, but signed off as given and Staff #2 stated, I signed them off in error. There were not given because the meds were not available. It was not documented anywhere that the medications were not given. The surveyor brought up about the medications for Resident #45 being missed and Staff #2 stated, Oh they were. The surveyor also asked Staff #2 why the medications were being passed late. Staff #2 stated, I worked my other job from 3:00 PM yesterday and did not get off until 4:00 AM this morning. I only got a couple of hours sleep and then came in after 9:00 AM. I was running late. At 11:47 AM, the Corporate Nurse was advised of the 3 omitted medications that were signed off as given, the 7 medications that were missed being given, the inaccurate water flushes, the failure to check residual and tube placement on both residents and the lateness of the medication pass. The Corporate Nurse and Nursing Home Administrator advised the survey team on 1/8/19 at 12:15 PM that Staff #2 was immediately removed from duty and that the physician was being notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, it was determined that the facility failed to have quality laboratory supplies for resident diagnostic testing in 1 of 4 medication carts observed. The findings include: Observation was made on [DATE] at 11:02 AM, in the tube feed medication cart on the second- floor nursing unit, of 2 expired blood collection vials in the top drawer of the cart. There was (1) gray top tube lot #5295961 and (1) yellow/red top tube lot #5295961 with an expiration date of [DATE]. Staff #4 was with the surveyor at the time of observation. Staff #4 stated, I didn't know that. To assure accurate test reliability, specimen containers must be used by the expiration date.

5) On 1/10/19 at 10:05 AM, observation was made of Resident #89 pushing him/herself down the hallway backwards in a geriatric chair on wheels. S/he ran into a medication cart. Staff #14, stated no several times to the resident and then stated, This is not happening. Staff #14 grabbed the chair and pulled Resident #89 backwards around the nurse's station and then turned him/her around. Staff #14 continued down the hallway towards the front door with no further conversation with the resident. Based on observation and interview with staff, it was determined that 1) the facility failed to ensure that dependent residents were provided with feeding assistance in a manner that preserved resident dignity and 2) the facility staff failed to treat residents with respect and dignity by pushing their chair down the hallway instead of pulling the residents backwards. This was evident for 1 of 2 dining observations that took place in the dining room on the second floor, 1 random observation of mealtime in 1 of 2 nursing hallways and 2 random observations during the survey. The findings include: 1) Lunch service was observed in the second floor dining room on 1/2/19. Food was delivered to all of the seated residents between 11:54 AM and 11:57 AM. After food had been delivered to all of the residents who were present, it was found that five residents were completely dependent on staff for assistance - Residents #33, #35, #38, #11, and #40. It was also noted that Resident #50 required frequent cueing from staff. Between 11:57 AM and 12:38 PM, only Geriatric Nursing Assistant (GNA) #27 was available to help residents with dining. The Director of Nursing (DON) was notified at 12:36 PM that GNA #27 was the only staff member assisting with dining and two additional staff came to assist at 12:38 PM. During the meal observation, Resident #11 called out five times requesting assistance with eating. Residents #33 and #38 stated that their food was getting cold, and other residents spoke up that Resident #35 needed more assistance that s/he was getting. GNA #27 walked among four different tables to provide assistance to all the residents who required it and did not sit down with any resident who was being fed. GNA #27 was interviewed after the meal was completed, at 12:54 PM, and stated that s/he had made multiple requests to management that more staff be made available during lunch to provide assistance to dependent residents, but that more staff had never been assigned to this dining area. GNA #27 stated, it is always like this. 2) Observation was made on 1/8/19 at 2:00 PM of Staff #3 standing to feed Resident #34 in the resident's room. Resident #34 was lying in bed and Staff #3 was standing to the right side of the bed feeding the resident lunch. 3) Observation was made on 1/8/19 at 4:00 PM of Resident #72 sitting in a geriatric chair on the second floor nursing unit. Staff #1 was observed pulling Resident #72 down the first hallway backwards, turned the corner around the nurse's station and then continued pulling Resident #72 down the next hallway backwards until Staff #1 got to the resident's room. 4) Observation was made on 1/10/18 at 10:06 AM of Staff #14 pulling Resident #17 down the hallway backwards. Resident #17 was sitting in a geriatric chair and Staff #14 was taking the resident outside to smoke. On 1/10/19 at 9:21AM, the Nursing Home Administrator and the Corporate Nurse were advised of the observations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an observation of dining that took place at noon on 1/2/19, an evaluation of resident dining table tops was performed. Of the 14 dining tables, 7 of them had some damage to the laminate top and plastic siding. Many of the table tops had large gashes in them, the longest of which was about 22 in length. The Director of Maintenance was notified of the concern prior to exit. Based on surveyor observation, it was determined the facility staff failed to provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable and homelike environment. This was evident throughout the survey on 2 of 2 nursing units. The findings include: 1) On 1/2/19 at 10:55 AM, observation of room [ROOM NUMBER]'s shared bathroom revealed that the side rail between the toilet and the sink was loose where it was attached to the wall and the floor. 2) On 1/2/18 at 11:03 AM, observation of room [ROOM NUMBER] (next to the B bed) revealed a suction machine on a bedside table. The bed side table and the base of the suction machine was very dusty. The heating/air conditioner (ac) unit was dusty and the unit's vent grills had a build up of dust. Oxygen supplies, and a nebulizer machine were on top of the heating/ac unit. Observation of room [ROOM NUMBER]'s window revealed a window shade that was soiled and discolored, and the window had a curtain rod that did not have curtains. 3) On 1/2/19 at 11:46 AM, observation of room [ROOM NUMBER]'s shared bathroom revealed that the hand rail located between the toilet and the sink was loose. 4) On 1/2/19 at 2:15 PM, observation of Resident #74's Geri-chair revealed that the chair's left arm rest was loose. On 1/10/19 at 3:43 PM, Staff #31 accompanied the surveyor to see the above findings. Observation was made of several ceiling tiles on the first floor nursing unit that had brown stains on the tiles. Between room [ROOM NUMBER] and 18 in the center of the hallway, a brown stain covered 1/2 of 1 tile and 1/4 of the second tile. A ceiling tile in the center by room [ROOM NUMBER] had a brown stain as well. In room [ROOM NUMBER], there was a ceiling tile with a brown stain above A bed. In room [ROOM NUMBER], the second ceiling tile from the wall by the window had a brown stain. In room [ROOM NUMBER], the ceiling tile in the corner had 2 stains along with 1 other tile. In room [ROOM NUMBER] by the window, 1/2 of the tile was stained. The ceiling tiles in the 2nd floor activity area had brown stains. One ceiling tile had a brown stain which covered 3/4 of the tile and 1 ceiling tile with a brown stain that covered 1/2 of the tile and 1 tile was noted with a small 1/2 moon circle stain. The vinyl on the left armrest of the wheelchair in room [ROOM NUMBER] was torn. The wheelchair that Resident #26 sat in was missing an armrest on the left side. Resident #69 was sitting in a wheelchair. The vinyl on the left wheelchair armrest was torn along the sides along with the vinyl on the back cushion of the wheelchair. In the bathroom in room [ROOM NUMBER], there was a 1 1/2 inch by 1 inch hole in the ceramic tile next to the faucet. There was wood between the shower entrance and the floor. There were urine stains on the chair, and the bedspread and the pillowcase on the bed was stained brown on corners, approximately 5 inches by 2 inches. The bottom fitted sheet on the bed had a a tear in the top left corner, approximately 5 inches by 6 inches. The plastic covering on the over the bed light was broken and missing 4 inches by 2 inches of the plastic covering. In room [ROOM NUMBER], there were 3 beds in the room. There was one foot between the middle bed and the bed by the door. There were 3 soiled plastic gloves and a paper towel lying on the floor next to the bed by the window. In the shared bathroom, the toilet paper holder was hanging off the wall, unsecured. In room [ROOM NUMBER], there was no cord for Resident #86 to turn on and off the over the bed light. The resident stated, they were supposed to fix it. It has been like that for about 3 weeks. Also observed was a pillow on the floor behind the bedside nightstand, sanded spackle dust on the frame of the bed, areas of rough spackling on the wall behind bed and a gap of about 4 inches in the baseboard behind bed. The bathroom fan made a loud rattling noise and there was spackle on the wall at both ends of handrail in the bathroom. In room [ROOM NUMBER], the oxygen concentrator was running at 2L and the nasal cannula was lying on the floor under bed while the resident was sitting up in a geriatric chair. There were holes in the bottom fitted sheet on the bed. There was a straw and a straw in a styrofam lid lying on the floor. An opened 100 ml bottle of sterile 0.8% normal saline was sitting on the bureau, next to the television (which was not dated when opened lot #1803121). There was a used Lidocaine 5% patch, dated 12/29, which was lying on top of a pillow, sitting on top of a gel cushion, stacked on top of a brown cardboard box by the wall. This was observed on 1/2/19 at 12:05 PM. On 1/3/19 at 7:40 AM, the patch was still sitting in the same location. The surveyor showed the unit manager the patch on 1/4/19 at 9:20 AM. An interview was conducted with the DIrector of Maintenance (Staff #31) on 1/10/19 at 10:34 AM. Staff #31was asked if repairs are reported. Staff #31 stated, I started in December with getting work orders in PCC (the electronic system. There was a book on the nursing stations and we were relying on staff to report the issues to maintenance. Staff #31 was advised of all areas of concern. An interview was conducted with the Director of Housekeeping (Staff #16) on 1/10/19 at 10:41 AM. Staff #16 stated most of the time we are short of staff. Staff #16 was advised of the housekeeping concerns and the conditions of linens and pillows. Random observations of second floor on 1/10/19 at 3:06 PM revealed a buildup of caked on dust, grime, and/or rust discolorations alone the bottom vent grates of the heating/AC units (where the units contact the floor) in the following rooms; 45, 49, 50, 51, 53, 55, and 56. The heating/AC unit in room [ROOM NUMBER] was noted to have the buildup of dust, and grime on the top vent grates, in addition to the bottom vent grates.

7) Resident #24's medical record was reviewed on 1/2/19 at 10:18 AM. During the review, it was found that the significant change MDS assessment with an ARD of 11/2/18 had item G0110 A1 (Bed Mobility) coded as Extensive Assist which stated that the resident was involved in the activity. However, the resident was also coded in item B0100 as being in a persistent vegetative state / no discernible consciousness. Physician notes that were written in November and December of 2018 confirm that the resident was in a persistive vegetative state. The resident was observed on 1/2/19 at 1:30 AM and was noted to display no meaningful response to surveyor presence in the room, or when the resident was addressed by his/her name. The resident was unable to respond to commands. 8) On 1/4/19, review of Resident #74's medical record revealed that Resident #74's quarterly MDS with an ARD of 12/13/18 was inaccurate. Section G, G0400. Functional Limitation in Range of Motion, A. Upper extremity was coded 0, no impairment and B. Lower extremity was coded 0, no impairment. The MDS failed to capture the resident's upper extremity limitation in ROM related to the resident's right hand contracture. Section O. O0250.Influenza Vaccine, A. Did the resident receive the influenza vaccine in this facility for this year's influenza season? was coded no. The electronic medical record documented that Resident #74 received the influenza vaccine on 10/12/18. Staff #11 confirmed the MDS inaccuracies on 1/4/19 at 2:56 PM. 9) On 1/8/19, review of Resident #76's medical record revealed that Resident #76's quarterly MDS, with an ARD of 12/19/18, was inaccurate. Section I. Active Diagnosis, failed to capture the resident's insomnia diagnosis and failed to capture Resident #76's GERD (gastro-esophageal reflux disease) diagnosis. Resident #76's December 2018 MAR revealed documentation that the resident received Trazodone (antidepressant) by mouth every day at bedtime for insomnia since 12/6/18, and that the resident received Melatonin (a hormone that promotes sleep) every day at bedtime since 12/18/18 for insomnia. In addition, the MAR documented that the resident received Ranitidine (Zantac) 2 times a day for GERD every day since 12/3/18. On 1/8/18 at 11:52, Staff #11 confirmed the MDs inaccuracies. 10) On 1/8/19, review of Resident #33's medical record revealed that Resident #33's quarterly MDS with an ARD of 11/8/18 was inaccurate. Section I, 1300. Hyperlipidemia was left blank. Resident #33's November 2018 MAR documented that Resident #33 received Pravastatin (Pravachol) (lowers cholesterol) 20 mg by mouth every day for hyperlipidemia. 11) On 1/9/18, review of Resident #52's medical record revealed Resident #52's quarterly MDS with an ARD of 11/23/18, Section I, Active Diagnosis failed to capture the resident's diagnosis of heart failure, diabetes mellitus (DM), hyperlipidemia, asthma, GERD and arthritis. Review of Resident #52s November 2018 MAR revealed thatthe resident received Lasix (Furosemide) every day for CHF (congestive heart failure), Insulin Glargine (Lantus) Solution sq (subcutaneously) every day at bedtime for DM, Insulin Lispro (Humalog) Solution sq every day with meals for DM, Humalog solution per sliding scale (prescribed dose according to blood glucose result) sq 4 times a day for DM; Atorvastatin (Lipitor) by mouth every day at bedtime for cholesterol, Advair (Fluticasone-salmeterol) 1 inhalation 2 times a day for asthma, Celebrex (Celecoxib) by mouth twice a day for arthritis; Prednisone by mouth every day for arthritis and Ranitidine (Zantac) (used to treat GERD) by mouth 2 times a day. On 11/3/18, in a progress note, the physician documented that the resident had CHF, DM, interstitial lung disease with a history of Asthma and for the resident to continue Zantac for GERD. Staff #5 was advised of these findings on 1/10/19 at 9:30 AM. 6) Review of Resident #70's medical record on 1/9/19 at 10:09 AM, revealed a list of diagnoses which included but was not limited to, monoplegia (paralysis of one limb) of upper limb. Review of the resident's quarterly MDS with the ARD of 12/10/18 Section G Functional limitation on Range of Motion indicated A. Upper extremity = 0. No impairment. Section I Diagnoses - did not include monoplegia of upper limb. During an interview and observation of the resident on 1/10/19 at 10:06 AM, the resident's left elbow was observed to be bent approximately 90 degrees and the fingers of his/her left hand were in a cupped position indicating possible contractures (fixed resistance to passive stretch of a muscle). The resident indicated that he/she was unable to extend his/her fingers or straighten his/her arm on his/her own. Staff #7 the MDS coordinator was interviewed on 1/10/19 at 11:30 AM. He/She was asked how the information for Section G of the MDS was obtained. Staff #7 indicated that he/she did not complete a physical assessment of the resident for the MDS, that Staff #24, a nurse on the unit, assessed the resident and indicated that Resident #70 did not have an impairment. When asked who signed section Z of the MDS verifying accuracy of the assessment, Staff #7 indicated that he/she or another MDS nurse sign that is completed, but the other disciplines signed off for their own sections. When asked if the MDS nurse would be responsible for signing off for the nursing assessment, Staff #7 indicated yes. During an interview on 1/10/19 at 11:38 AM, Staff #17 indicated that Resident #70 had very limited ROM in his/her left shoulder and that his/her left elbow is pretty fixed. Resident #70's MDS was not accurately coded to reflect his/her limited ROM nor that he/she had a diagnosis (monoplegia) related to his/her limitation. Cross reference F 656 and F 688. Based on medical record review and staff interview, it was determined the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 11 (#35, #58, #72, #86, #41, #70, #24, #74, #76, #33, #52) of 35 residents reviewed. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. The findings include: 1) Review of Resident #35's medical record, on 1/9/19 at 2:34 PM, revealed an order to ensure that the resident's dentures were placed in the mouth in the morning prior to all meals and removed at bedtime. Review of the annual MDS with an Assessment Reference Date (ARD) of 8/25/18, Section K, Oral Status did not capture that the resident was edentulous (without teeth). 2) Review of Resident #58's medical record on 1/3/19 revealed physician's progress notes, dated 10/9/18 and 11/13/18. The plan documented dementia/depression with mood disturbances and that the order for Risperdal was to continue. The diagnosis CAD (coronary artery disease) was documented, along with an order to continue Aspirin. Review of November 2018 physician's orders documented the medications Aspirin every day for CAD, Escitalopram every day for depression and Mirtazapine every evening for depression. Review of Resident #58's annual MDS with an ARD of 11/19/18, Section I, Active Diagnoses, failed to capture Depression and Coronary Artery Disease. Further review of Section I revealed the diagnosis of dermatitis. Review of skin checks in the medical record, dated 11/7/18 and 11/14/18, indicated that there were no skin issues. 3) Review of the medical record for Resident #72 on 1/3/19 revealed documentation that the resident was admitted to Hospice services on 12/17/17. Interview of Staff #5 on 1/3/19 at 12:02 PM confirmed, the resident has been on Hospice since admission and has never been taken off of Hospice. Review of quarterly MDS assessments with ARDs of 3/9/18, 6/9/18 and the annual MDS with an ARD of 12/8/18, Section O0100K, Hospice Care, failed to capture that the resident received Hospice services. Further review of the medical record revealed physician's progress notes, dated 10/10/18 and 11/28/18, which revealed documentation of the assessment neuropathy - continue Neurontin 3 times per day, failure to thrive and hypertension. Review of the annual MDS with an ARD of 12/8/18, Section I, Active Diagnoses, failed to capture neuropathy, failure to thrive and hypertension. On 1/4/19 at 1:20 PM, the errors were discussed with the MDS Coordinator who confirmed the errors. 4) On 1/2/19 at 12:21 PM, an interview was conducted with Resident #86. The resident was asked if he/she had any problems with hearing and the resident stated, I am heard of hearing and I do not wear hearing aids and I would like to know why I can't hear out of the left ear and see what can be done about it. On 1/4/19 at 9:25 AM. the Physical Therapy Manager read an occupational therapy note which stated that the resident was hard of hearing. Review of physician's progress notes, dated 8/30/18, 11/26/18 and 12/13/18 documented hearing impaired. Further review of the physician's progress note, dated 11/26/18, revealed the assessment/diagnosis Schizophrenia - continue Risperdal. Review of MDS assessments with an ARD of 9/16/18 and 12/17/18, Section B0200, Hearing, coded 0 which indicated the hearing was adequate. Further review of the MDS assessment with an ARD of 12/17/18, Section I, Diagnoses, failed to capture the diagnosis Schizophrenia I6100. On 1/4/19 at 1:07 PM, the MDS coordinator confirmed the errors. Discussed with the Director of Nursing on 1/4/19 at 1:32 PM. 5) Review of Resident #41's medical record on 1/9/19 revealed that the facility failed to code/assess that the resident had a urinary tract infection (UTI) on 2 separate MDS assessments. Documentation in Resident #41's chart revealed that the resident was diagnosed to with a urinary tract infection on 10/2/18. Review of the quarterly MDS assessment, with an ARD of 10/29/18, revealed that there was not any coding/assessment in Section I - Active Diagnosis for Urinary tract Infection at I2300. The resident was diagnosed again with a UTI on 11/2/18 and the resident was prescribed antibiotics for the UTI on 11/2/18. Review of an MDS assessment, with an ARD of 11/16/18, did not capture the 30 day look back for a diagnosis of UTI at section I2300. Interview of the Resident assessment coordinator (Staff #11) on 1/9/19 at 3:30 PM confirmed the missed coding/assessment of UTI on both MDSs with ARDs of 10/29/18 and 11/16/18.

4) A dining observation took place in the upstairs dining area on 1/2/19 between 11:50 AM and 12:45 PM. During the dining observation, it was noted that Residents #'s 33, 35, 38, 11, and 40 were completely dependent on Staff to receive nutrition. Resident #50 was noted to require significant cueing to adequately consume the meal served to him/her. Residents began receiving their trays at 11:55 AM. Between 11:57 AM and 12:38 PM, Geriatric Nursing Assistant (GNA) #27 was the only staff member present in the upstairs dining area who was assisting residents with eating. The six residents listed above had all received their trays by 12:09 AM. At that time, GNA #27 was providing a few bites to each of the five residents who were dependent on staff to eat and then going on to the next. Resident #11 called out several times that s/he required assistance with eating and the other resident at the same table also spoke up that Resident #11 needed help with eating. Resident #38 complained that his/her food was getting cold and eventually refused to eat any more because the food had gotten too cold. After not being assisted with his/her meal for 15 minutes, Resident #33 attempted to feed him/herself with bare hands. Not all of the food reached the resident's mouth and instead fell onto the resident's lap. The Director of Nursing was notified of these findings at 12:36 PM. At 12:38 PM, two more staff members arrived to assist residents with eating. GNA #27 was interviewed at 12:50 PM and stated that s/he had asked nursing administration to provide more staff at lunchtime many times before. GNA #27 stated that this dining observation was representative of what s/he was used to. A second dining observation that took place on 1/8/2019 at noon revealed that more staff were present to help residents with their dining needs. Cross reference F725 3) On 1/2/19 at 2:10 PM, observation of Resident #74 revealed a thick, white coating on the resident's tongue. On 1/2/19, at 2:30 PM, Staff #5 was made aware of this finding. Continued observation of Resident #74's revealed the resident had long, dirty finger nails. On 1/3/19 at 2:00 PM, Staff #5 confirmed the finding. Review of Resident #74's most recent assessment with a reference date of 12/13/18, documented that the resident required extensive assistance to meet personal hygiene ADLs (activities of daily living). Review of Resident #74's care plans revealed a care plan Resident is dependent for ADL care in specify: bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting) related to: with the goal Residents/Patients ADL care needs will be anticipated and met throughout the next review period had the interventions: 1. Provide resident/patient with total assist of one staff person for bed mobility, 2. Provide resident/patient with total assist of two staff person for transfers using a total lift. The care plan was not resident centered with measurable goals and individualized approaches to address Resident #74's ADL needs. Staff #9 and Staff #10 were made aware of these findings on 1/10/19 at 9:30 AM. Based on family and staff interview, observation and medical record review, it was determined the facility failed to provide the appropriate care for activities of daily living to residents who were totally dependent on staff for all aspects of care. This was evident for 2 (#35, #63, #74) of 7 residents reviewed for activities of daily living and for 1 of 2 dining observations. The findings include: 1) On 1/9/19 at 12:39 PM, an interview was conducted with the family member of Resident #35. The family member expressed concern that the resident's dentures were not being placed in the resident's mouth in the morning before meals. The family member stated, yesterday I took off from work and I washed her clothes up. She was in the dining room and I walked in her room and her dentures were in her cup. She missed breakfast and lunch because she can't eat without her dentures. She does not have the mental capacity to put her dentures in. My other concern is did she get breakfast and lunch. She can't chew her food without her dentures. She is also not capable of taking out the dentures. On 1/9/19, the January 2019 Treatment Administration Record (TAR) was reviewed and it was noted that the nurse signed off that monitor use of dentures with meals, remove and clean at bedtime, before meals and at bedtime for ADL was performed for 7:30 and 11:30 AM on 1/8/19. Staff #1 was asked about the resident's dentures on 1/8/19, and Staff #1 stated, she did not have her dentures in yesterday until after 3:00 PM when the 3:00 to 11:00 PM shift came on. Discussed with the Director of Nursing on 1/9/19 at 3:07 PM. 2) Observation was made, on 1/2/19 at 12:05 PM, of Resident #63 sitting in a geriatric (geri) reclining chair with knees towards the window, pillow behind the head and nothing between the resident's knees. The resident was sitting on a Hoyer lift quilted pad and the resident was wearing a hospital gown and slippers. The chair was next to the bed. The resident's unopened graham cracker snack, which was labeled 1/2, was sitting across from the resident on the bureau next to the television. The resident was unable to walk or get out of the geri chair independently. The chair was approximately 8 to 10 feet away for the bureau. Also observed was the call light cord, which was draped around the side rail, and was out of reach for the resident as the position of the side rail was behind the geri chair. In addition, observation was made of a water cup with no ice and very little water siting on the over the bed tray table with a box of cookies and an empty medication cup. The over the bed tray table was sitting at the end of the bed and not accessible to the resident. On 1/2/19 at 2:05 PM, the resident was in the same position and on 1/2/19 at 2:41 PM, the resident remained in the same position. The resident remained in the hospital gown with slippers. A second surveyor observed the positioning of the resident. The unopened graham cracker remained on the bureau. Observation was made on 1/3/19 at 7:40 AM of Resident #63 lying on his/her back with his/her head to the left towards the curtain with 2 pillows around the head. The feet were positioned on a pillow and the resident was wearing a hospital gown with slippers. On 1/3/19 at 11:46 AM, the surveyor observed Staff #3 and Staff #4 place a pain patch on the resident. The resident was placed in the same position as observed on 7:40 AM. Subsequent observations were made on 1/3/19 at 12:46 PM, 1:35 PM and 3:03 PM. The resident remained in the same position. The unopened graham cracker snack from 1/2/19 was still sitting on the bureau next to the television, which was across the room from where the resident was lying in bed. Observation was made, on 1/4/19 at 7:35 AM, of Resident #63 lying in bed with his/her head on 2 pillows which leaned to the left. The knees were facing the window with a pillow in between the knees. On 1/4/19 at 9:17 AM, Resident #63 was in bed in the same position with the head of bed elevated 45 degrees, with the over the bed tray table in front of the resident. The resident's body alignment was the same as the 7:35 AM observation. Review of the care plan Resident has actual skin breakdown r/t limited mobility with interventions: assist resident in turning & reposition every 2 hours and prn. Encourage resident to consume all fluids during meals, pressure reducing cushion to chair while out of bed, waffle cushion behind back when out of bed in wheelchair. The care plan was not followed as the resident was not turned and repositioned every 2 hours and the pressure reducing cushion was not in the geri chair when the resident was out of bed on 1/2/19. Review of Resident #63's care plan, at risk for falls had the intervention use call bell for assistance. Review of the care plan, while in the facility, it is important that resident has the opportunity to engage in daily routines that are meaningful relative to preferences had the intervention I like to snack between meals and prefer cookies. A third care plan, is at nutritional risk r/t increased nutrient needs r/t wound healing had the intervention offer snacks. The care plans were not followed. On 1/4/19 at 9:49 AM, discussed with Staff #5 and at 1:32 PM, discussed with the Director of Nursing.

3) Resident #78 was interviewed on 1/2/19 at 2:06 PM and reported that on 11/17/18, while being transported to be weighed, blacked out and fell out of the wheelchair. Review of the medical record on 1/8/19, revealed that staff completed a SBAR (Situation, Background, Assessment, and Recommendation) dated 11/17/18, however, staff #19 documented vital signs that were pulled from 11/16/18 at 8:59 PM. There was no vital signs found in the medical record for the time of the incident. Further review of the medical record revealed that Resident #78 had fainting episodes on 12/24/18. A progress note written by the physician, dated 12/24/18 at 10:41 AM, revealed, PT reported syncopal episodes x2 this AM. A nurses' note, dated 12/24/18 at 1:36 PM, stated Therapy reported episodes of syncope. Pt was assisted back to bed. Vital signs monitored, lab work drawn (blood drawn for labs), and PIV (peripheral intravenous line which means it was placed in a vein in the arms or legs) per MD order. There was no evidence found in the medical record that a blood pressure was evaluated at the time of the incident. Review of Resident #78's care plan revealed Resident is at risk for falls: limited mobility. With an intervention stating, Monitor vital signs including orthostatic blood pressure as needed and report to MD as indicated. A second intervention stated, Obtain and evaluate orthostatic blood pressure. Facility staff failed to update the care plan after the incidents as there were no updates upon review. The Director of Nursing (DON) was informed of these findings on 1/10/19 at 1:49 PM, and confirmed that no investigations into the syncopal episodes was done. 4) Review of Resident #78's December 2018 physician's orders revealed that Resident #78 had been prescribed (3) antihypertensive (blood pressure lowering) medications. Review of the Medication Administration Record (MAR) for December 2018 revealed that one or two of these medications were administered when the systolic pressure (the top number) was below 100 and diastolic pressure (the bottom number) was below 60 three days during the review period of 12/1/18 - 12/31/18. Furthermore, there was no documentation that the physician had been notified. In addition, to the dates listed above, the blood pressure lowering medications were held on four days in the review period of 12/1/18 - 12/31/18, and there was no documentation that the physician was notified that the medications were held or of the low blood pressures. Staff #36 (Nurse Practitioner) confirmed the finding on 1/8/19 at 2:30 PM. 3. An observation of Resident #189 on 1/2/19 at 11:35 AM, revealed resident was receiving 3 liters of oxygen through a nasal cannula. However, review of the medical record on 1/3/19 at 1:54 PM, revealed that Resident #189 did not have a physician's order to receive oxygen. The DON was made aware and confirmed the findings on 1/4/19 at 11:39 AM. 4. On 1/2/19 at 11:31 AM, Resident #189 stated that s/he needs peritoneal dialysis and does not feel that the staff know how to provide the service because s/he has to tell them what to do. The November 2018, MAR was reviewed on 1/10/19 along with the list of trained staff that was given to the surveyor by the Corporate Nurse staff #10. Staff #21 and Staff #22 had signed off they had administered peritoneal dialysis, however, they were not on the list of trained staff. An interview with the Administrator (NHA) on 1/4/19 at 11:54 AM revealed that he/she was coordinating the Peritoneal Dialysis trainings since the Nurse Practice Educator (NPE), who was the person maintaining these education records, had left in November 2018. The NHA reported that the trainings were offered monthly and he/she was unable to provide proof of the trainings. Based on observation of the resident, medical record review and staff interview, it was determined that the facility staff failed to ensure that each resident received treatment and care in accordance with professional stands of practice by failing to ensure a resident who was dependent on oxygen had accurate physician orders; failing to ensure a resident's respiratory care supplies were stored in a clean and sanitary manner; failing to ensure a resident's oxygen was administered as ordered, failing to ensure emergency respiratory equipment was maintained at a resident's bedside, failing to ensure a prescribed biological was properly stored, failing to ensure Activities of Daily Living care was provided for a dependent resident and failing to ensure that residents with a limited range of motion received the appropriate treatment and services to prevent further decline in range of motion. This was evident for 1 (#74) of 2 residents reviewed for respiratory care. In addition, the staff failed to 1) fully assess a resident for a change in condition, 2) administer blood pressure medications within acceptable parameters, 3) obtain an order to administer oxygen to a resident, and 4) ensure staff performing peritoneal dialysis had proper training. This was evident for 2 (#78, #189) out of 3 residents reviewed for dialysis. The findings include: 1) On 1/2/19 at 11:04 AM, an observation was made of Resident #74 lying in bed. Resident #74 was observed to have a tracheostomy (trach) (surgical opening in the neck into the trachea (windpipe) with a tracheostomy tube (tube inserted through the opening that allows a person to breathe). The resident had a trach oxygen mask over his/her trach attached to corrugated tubing that had a yellow adjustable adapter set at 5 L which was connected to a humidification water bottle which was attached to a humidification compressor. Oxygen was connected to the water bottle via tubing connected to an oxygen (02) concentrator that was set at 2 liters/minute. Observation of the resident's room revealed trach supplies, oxygen supplies, and a dirty nebulizer were on top of the heater/air conditioner unit. On the bedside table, there was a humidification compressor and a suction machine that were covered in a layer of dust. On 1/2/19, a review of Resident #74's January 2019 TAR (treatment administration record) revealed an order for oxygen concentrator set to 2 liters/min (l/m) every shift. The medical record failed to reveal a physician's order for the use/setting of the humidification compressor and failed to reveal an order to indicate the setting of the adjustable adapter that connected to corrugated oxygen tubing to the water humidification bottle. Review of Resident #74's January 2019 TAR revealed an 8/1/18 order for #4 Shiley (brand and size of replacement trach tube or disposable inner cannula (inner trach tube)) and Ambu bag (mechanical ventilation bag used to deliver breaths when a person is unable to breath on their own) and there was an 8/1/18 order for #6 Shiley and Ambu bag at bedside. Both orders were documented as being done every shift. The resident's TAR also had an 8/1/18 order to change the inner cannula every day and evening shift, an 8/2/18 order to change the inner cannula as needed. The orders did not indicate what size inner cannula should be used. There was an 8/1/18 order to change the Trach tube monthly and was documented as being done every shift. The order did not indicate the size of the replacement trach tube. On 1/2/19 at 2:10 PM, observation of the resident's surroundings failed to reveal an Ambu bag at the resident's bedside. On 1/2/19 at 2:10 PM, observation was made of Resident #74 in his/her room, sitting in a Geri-chair. To the left of the resident, was an over-bed table. Following an introduction of the surveyor to the resident, the resident, who was non-verbal, stuck his tongue out towards the surveyor, revealing a thick, white coating on the resident's tongue. The resident reached his/her hand to the over-bed table and grabbed an unopened box containing Biotene (an oral product used for dry mouth), showed the product to the surveyor, and indicated he/she wanted it on their tongue, then placed the box back on the table. The Biotene box was labeled from the pharmacy with Resident #74's name and instructions for use. Biotene is a prescribed biological product, should not be left at a resident's bedside without a physician's order. The resident put on his/her call bell, a nurse entered the room, picked up the box, stated he/she would be back shortly and left the resident's room. On 1/2/19, at 2:30 PM, Staff #5 was made aware of this findings. On 1/3/19 at 2:00 PM, an observation of Resident #74 revealed the resident was wearing a trach oxygen mask with tubing connected to a humidification compressor and an oxygen concentrator that was set at 0 l/m. Staff #5 was made aware of the finding, accompanied the surveyor to the resident's room and confirmed the resident's concentrator set to 0. At that time, Staff #5 was made aware of the dust on the humidifier compressor and suction machine located on the bedside table and confirmed the finding. Staff #5 was advised of the previous surveyor observation of the resident's trach and oxygen supplies being stored on top of the heater/ac unit. The supplies were now observed to be on a bedside table. Staff #5 was made aware that an Ambu bag had not been observed at the resident's bedside. During an interview, when asked what the humidifier compressor settings were and what the settings were for the plastic adaptor that connected the corrugated tubing to the humidifier bottle, Staff #5 confirmed Resident #74 did not have an order for the humidifier compressor and did not have an order for the adjustable, plastic adaptor that was attached to the water bottle that was attached to the humidifier compressor. On 1/3/19 at 2:10 PM, an observation of Resident #74 revealed the resident's fingers on the right hands were bent inward toward the resident's palm, and there was no splint or device in the resident's hand. Observation of Resident #74's hands revealed the resident had long, dirty fingernails. On 1/4/19 at 1:45 PM, observation of Resident #74 revealed the resident's oxygen concentrator was set between 2.5 and 3 liters/minute. On 1/4/19, at 1:53 PM, Staff #5 accompanied the surveyor to the resident's room, observed the oxygen setting and confirmed the setting should have been set at 2 l/m. On 1/4/19, at 2:00 PM during an interview, Staff #1 confirmed that the resident had a right-hand contracture. At that time, during an interview, when asked if he/she was assigned to provide care for Resident #74 that day, Staff #1 stated no, then looked at the staffing board and stated that he/she did not know that he/she had been assigned the resident. When asked if the resident had received care that day, Staff #1 stated no, but he/she would go take care of the resident right away. On 1/4/19 at 2:10 AM, Staff #5 was made aware of the above findings and that the resident had a delay in the resident care. On 1/4/19, review of Resident #74's medical record revealed Resident #74's quarterly MDS with an ARD of 12/13/18 was inaccurate. Section G, G0400. Functional Limitation in Range of Motion, A. Upper extremity was coded 0, no impairment and B. Lower extremity was coded 0, no impairment. The MDS failed to capture the resident's upper extremity limitation in ROM related to the resident's right-hand contracture. Section O. O0250.Influenza Vaccine, A. Did the resident receive the influenza vaccine in this facility for this year's influenza season? was coded no. The electronic medical record documented that Resident #74 received the influenza vaccine on 10/12/18. Staff #11 confirmed the MDS inaccuracies on 1/4/19 at 2:56 PM. On 1/8/18, review of the medical record revealed on 8/7/18, in a progress note, the physician documented that the resident had a right-hand contracture. Resident #74's 12/13/18 quarterly assessment documented that Resident #74 had no functional limitation in range of motion, which was inaccurate. On 1/8/18 at 11:53, AM, during an interview, Staff #32 stated that Resident #74 received Occupational Therapy (OT) to work on splinting of the right hand from 9/2017 to 11/2017. The OT staff stated that when the resident was discharged from OT services, he/she was wearing a right resting hand splint for 6 hours a day. On 11/21/17, in an OT Discharge Summary, the Occupational Therapist documented discharge recommendations that included a right resting hand splint. Continued review of Resident #74's medical record failed to reveal a physician order for a right resting hand splint and failed to reveal evidence that Resident #74 was receiving services to prevent further decline in the resident's ROM. Review of Resident #74's care plans failed to reveal a plan of care had been developed to address Resident #74's right hand contracture and limited range of motion. Staff #5 and Staff #9 were made aware of these findings on 1/10/19 at 9:31 AM.

Based on medical record review and interview with facility staff, it was determined that the facility failed to ensure that residents remained free from accident hazards and received adequate supervision. This was evidenced by the failure to ensure a resident at risk for elopement received adequate supervision. This was evident for 1 (#10) of 4 residents reviewed for accidents. The findings includes: 1) A facility reported incident involving Resident #10 was reviewed on 1/9/19 at 10:45 AM. The incident involved two elopements that occurred with Resident #10, one in early November and the second in early December, 2018. Both times, the resident had been allowed to pass time outside the facility at a curb about 60 feet away from the front door. And both times, the resident had traveled further than the curb and left the premises without notifying staff. Resident #10 had a Brief Interview of Mental Status (BIMS) score of 15/15 on the most recent Minimum Data Set Assessment, which indicated that the resident had no significant mental impairment. The resident was also his/her own responsible party and had capacity to make decisions. The resident was hospitalized at the time of the survey and could not be reached for questions. It was determined through observation and interview with Receptionist #40 on 1/9/19 at 11:00 AM, that there was no visibility from the front desk to the curb, nor closed circuit camera that had visibility of the curb. Receptionist #40 stated that the resident continues to spend time at the curb and that the receptionist checks on the resident periodically while the resident is out there. The resident had not been asked to sign in or out at the front desk during any of these self-governed outings. Through interview with the Administrator that took place on 1/9/19 at 11:30 AM, it was discovered that the facility continued to allow the resident to spend time at the curb outside the facility. The Administrator stated that s/he was willing to make shopping trips on behalf of the resident, and that two such trips had been made so far. The resident was admitted to the facility in mid 2018. At the time, the resident was unable to propel himself/herself in a wheelchair. An elopement assessment was completed at that time, but only the first question was answered as a result of this limitation. The remaining history and assessment was not captured in that assessment. It was unclear from the record precisely when the resident became mobile in a wheelchair, but it happened either in the Summer or Fall of 2018. The facility was asked to provide evidence that a second elopement risk assessment was completed following the resident's improvement mobility. None was provided prior to survey exit.

5) During initial interview with Resident #189 on 1/2/19 at 11:35 AM, surveyor observed that resident was on 3L of continuous oxygen via nasal cannula. The tubing and nasal cannula was not initialed or dated. In addition, there was a sterile water disposable humidifier connected that was dated 11/18/18. On 1/3/19 at 1:03 PM, surveyor observed Resident #189 on 3 liters of oxygen, no date or initials on the tubing and nasal cannula and the humidifier was dated 11/18/18. On 1/3/19, a review of the medical record revealed that Resident #189 did not have an order for oxygen therapy. An interview with the Director of Nursing (DON) on 1/3/19 at 1:11 PM, revealed that the date written on the humidifier was the date it was opened, and when asked how often a sterile water humidifier should be changed, the DON stated when the container is empty or by the expiration date on the container. The DON was not sure if the tubing and nasal cannula should be dated. However, review of the Oxygen: Nasal Cannula policy, revised 12/1/18, revealed number 3.2 Nasal cannula labeled with date of initial set-up . and # 17 If using a non-disposable humidifier, change bottle every seven days or when bottle is empty and change sterile water every 24 hours to prevent bacterial contamination. Subsequent observation of the resident on 1/4/19 at 11:05 AM revealed s/he was on 3 liters of oxygen. During this observation, the Attending Physician came in the resident's room. He/She was informed that the resident did not have an order for oxygen and acknowledged surveyor's concerns. On 1/4/19 at 11:39, the DON was shown the sterile water humidifier and informed resident did not have an order to be on oxygen. The DON acknowledged the surveyor's concerns. (Cross Reference 880). Based on observations, medical record review, and interviews with facility staff, it was determined that the facility failed to provide residents with respiratory care consistent with professional standards. This was evident for 5 (#24, #63,#74, #52, #189) of 5 residents reviewed for respiratory care during the investigation phase of the survey. The findings include: 1) Resident #24 had a tracheostomy tube, a device that is tunneled directly into a resident's trachea to provide an airway that bypasses the natural airway. Air that is inspired through the tracheostomy tube does not benefit from the humidifying organs in the mouth and nose. In an effort to compensate for this effect, devices that add humidity to air are sometimes used to deliver more humidified air to the resident's tracheostomy tube. Resident #24 was observed in his/her room on 1/2/19 at 10:18 AM. During the observation, a device labeled as an air compressor was noted to be attached to a humidifier bottle that was administering humidified air through corrugated tubing to a cuff placed on top of Resident #24's tracheostomy tube. The device, called the Precision Medical Easy Air Compressor, had a gauge that was then reading 10 l/min. There was also an adjustable red valve on the connection between the air compressor and the air bubble humidifier that read, 28% / 5 L. Registered Nurse (RN) #29 was asked about the function of the device on 1/8/19 at 1:30 PM. RN #29 was unable to state what the purpose of the device was or to verbalize what the correct settings for the air compressor and the adjustable red valve were. The Director of Nursing (DON) was interviewed on 1/8/19 at 1:42 PM and also was unable to state what the correct settings were for the device. A current list of medications and treatments was reviewed for Resident #24 on 1/8/19 at 12:40 PM and no order for the humidification equipment or the air compressor could be found. The care plan was concurrently reviewed and did not specify settings for any of these devices. 3) On 1/2/19 at 11:04 AM, an observation was made of Resident #74 lying in bed. Resident #74 was observed to have a tracheostomy (trach) (surgical opening in the neck into the trachea (windpipe) with a tracheostomy tube. The resident had a trach oxygen mask over his/her trach attached to corrugated tubing. The corrugated tubing had a yellow adjustable adapter that was set at 5 L which was connected to a humidification water bottle which was attached to a humidification compressor. Oxygen was connected to the water bottle via tubing connected to an oxygen (02) concentrator that was set at 2 liters/minute. Near the top of the corrugated tubing, the date 12/26/18 was written and the date 12/19/18 was written on the two lower areas of the tubing. Observation of the resident's room revealed trach supplies, oxygen supplies, and a dirty nebulizer were on top of the heater/air conditioner unit. Next to the resident's bed, on the bedside table, was a humidification compressor and a suction machine that were covered in dust. On 1/2/19, a review of Resident #74's January 2019 TAR (treatment administration record) revealed an order for 02 (oxygen) concentrator set to 2 liters/min every shift and an order for a Ambu bag (mechanical ventilation bag used to deliver breaths when a persons is unable to breath on his/her own) at the bedside. Review of the medical record failed to reveal a physician's order for the use of the humidification compressor, the setting of the compressor and failed to reveal an order to indicate the setting of the adjustable adapter attached the corrugated oxygen tubing. On 1/3/19 at 2:00 PM, an observation was made of Resident #74 sitting in a Geri-chair in his/her room. The resident was wearing a trach oxygen mask with tubing connected to a humidification compressor and an oxygen concentrator that was set at 0. Staff #5 was made aware of the finding, accompanied the surveyor to the resident's room and observed the resident's concentrator set to 0, observed the dust on the humidifier and suction machine and confirmed the finding. Staff #5 was advised of the surveyor observations of trach and oxygen supplies being stored on top of the heater/ac unit, which were now held on a bedside table, made aware of the resident's corrugated tubing which had been labeled with 2 dates and made aware that surveyor observations of the resident's surroundings failed to reveal an Ambu bag at the bedside. At that time, during an interview, Staff #5 confirmed Resident #74 did not have an order for the settings and use of the humification compressor, and did not have an order for the settings for the adaptor that was attached to the water bottle that was attached to the humidification compressor. 4) On 1/2/19 at 9:40 AM, Resident #52 was observed wearing nasal cannula oxygen tubing connected to an oxygen concentrator set at 2 l/m (liters/minute). On 1/9/19 at 2:45 PM, Resident #52 was again observed wearing a nasal cannula connected to an oxygen concentrator set at 3 l/m. At that time, during an interview, Resident #52 stated he/she used oxygen continuously at 3 l/m. Review of Resident #52's medical record revealed on 12/6/18, in a progress note, the physician documented that the Resident #52 had interstitial lung disease, pulmonary fibrosis, a history of asthma and documented the resident's current plan of care included continuous oxygen therapy. Review of Resident #52's medical record failed to reveal a physician order for the resident's use of oxygen. Staff #5 confirmed the findings on 1/10/19 at 11:35 AM. 2) Observation was made, on 1/2/19 at 12:09 PM, of Resident #63 sitting in a reclining geriatric (geri) chair next to the bed. There was an oxygen concentrator sitting behind the chair that was turned on and dispensing 2L (liters) of oxygen. The resident was not wearing the nasal cannula that was hooked to the concentrator. The tubing and cannula were on the floor under the resident's bed. The tubing was not dated as to when it was connected to the oxygen concentrator. On 1/3/19 at 7:40 AM, the resident was observed lying in bed with the nasal cannula on the resident's face but not in the nares. The cannula was on the resident's chin. Review of Resident #63's medical record on 1/4/19 revealed December 2018 and January 2019 physician's orders which stated, oxygen at 2L/min. via nasal cannula, as needed post tx: evaluate heart rate, respiratory rate, pulse oximetry, skin color, and breath sounds. Review of the December 2018 and January 2019 Medication Administration Record (MAR) revealed blank spaces which indicated the oxygen was not administered. A review of nursing notes for January 2019 failed to indicate if the resident was wearing oxygen. There were no nursing notes related to assessment of respiratory status, breath sounds, heart rate and respiratory rate. Review of the care plan section of the medical record for Resident #63 failed to produce a respiratory care plan related to the use of oxygen. Discussed with Staff #5 on 1/4/19 at 9:33 AM who confirmed the findings.

2) Peritoneal dialysis is a process used to clean the blood when a person's kidneys do not work properly. Nurses are required to have specialized training to perform peritoneal dialysis. On 1/2/19 at 11:31 AM, Resident #189 stated that s/he needs peritoneal dialysis and does not feel that the staff know how to provide the service because s/he has to tell them what to do. MD The November 2018, MAR was reviewed on 1/10/19 along with the list of trained staff that was given to the surveyor by the Corporate Nurse; Staff #10, Staff #21 and Staff #22 had signed off they had administered peritoneal dialysis, however, they were not on the list of trained staff. An interview with the Administrator (NHA) on 1/4/19 at 11:54 AM, revealed that he was coordinating the Peritoneal Dialysis trainings since the Nurse Practice Educator (NPE), who was the person maintaining these education records, had left in November 2018. The NHA reported that the trainings were offered monthly and he/she was unable to provide proof of the trainings. (Cross reference F726 and F684). Based on review of training records and interview with facility staff, it was determined that the facility failed to ensure a system was in place to track the training that staff nurses received regarding peritoneal dialysis. This had the potential to affect all residents receiving peritoneal dialysis. The findings include: 1) The facility's resident matrix was reviewed on 1/2/19 at 10:00 AM and it showed that there were five residents (Residents #'s 64, 43, 77, 78, and 189) who were receiving peritoneal dialysis at the time of survey initiation. An interview was performed with the Administrator on 1/4/19 at 11:56 AM. During the interview, the Administrator stated that s/he had been coordinating with the two dialysis services that the facility has contracts with. The coordinating involved having dialysis nurses come to the facility at least monthly to perform dialysis training for facility nursing staff. However, the Administrator stated that no records were kept in the facility of who had received annual dialysis training and who had not. The Staff Scheduler was interviewed on 1/4/19 at 12:05 PM. During the interview, the staff scheduler state that s/he was responsible for making sure nurses with dialysis training are assigned care of dialysis patients. However, s/he further confirmed that nobody was maintaining a list of which staff had received dialysis training and who had not, as well as when renewal annual training was due for nurses who perform dialysis. S/he also provided the anecdote that Licensed Practical Nurse (LPN) #41 was assigned a dialysis resident on a night shift within the previous few months. The Staff Scheduler stated that on the night of the shift, LPN #41 informed the Staff Scheduler that LPN #41 did not know how to do peritoneal dialysis and that a replacement would have to be found. The Staff Scheduler stated to the surveyor that s/he relies on staff to inform him/her if the staff member has not been properly trained.

Based on observation and interview with facility staff, it was determined that the facility failed to maintain sufficient staff to provide care to residents to maintain the highest practical physical, mental, and psychosocial well-being of each resident as evidenced by residents failing to receive sufficient help during dining. This was evident for 1 of 2 dining observations. The findings include: A dining observation took place in the upstairs dining area on 1/2/19 between 11:50 AM and 12:45 PM. During the dining observation, it was noted that Residents #33, #35, #38, #11 and #40 were completely dependent on staff to receive nutrition. Resident #50 was noted to require significant cueing to adequately consume the meal served to him/her. Residents began receiving their trays at 11:55 AM. Between 11:57 AM and 12:38 PM, Geriatric Nursing Assistant (GNA) #27 was the only staff member present in the upstairs dining area who was assisting residents with eating. The six residents listed above had all received their trays by 12:09 AM. At that time, GNA #27 was providing a few bites to each of the five residents who were dependent on staff to eat and then going on to the next. Resident #11 called out several times that s/he required assistance with eating and the other resident at the same table also spoke up that Resident #11 needed help with eating. Resident #38 complained that his/her food was getting cold and eventually refused to eat any more because the food had gotten too cold. After not being assisted with his/her meal for 15 minutes, Resident #33 attempted to feed him/herself with bare hands. Not all of the food reached the resident's mouth and instead fell onto the resident's lap. The Director of Nursing was notified of these findings at 12:36 PM. At 12:38 PM, two more staff members arrived to assist residents with eating. GNA #27 was interviewed at 12:50 PM and stated that s/he had asked nursing administration to provide more staff at lunchtime many times before. GNA #27 stated that this dining observation was representative of what s/he was used to. A second dining observation that took place on 1/8/2019 at noon demonstrated more staff present to help residents with their dining needs. Cross reference F677

Based on record review and staff interview, it was determined that the facility failed to ensure that staff was properly trained to administer peritoneal dialysis. This had the potential to affect all residents on peritoneal dialysis. The findings include: Review of medical records on 1/10/19, for residents receiving peritoneal dialysis revealed that one RN and 1 LPN were administering peritoneal dialysis without proper training. An interview with the Administrator (NHA), on 1/4/19 at 11:54 AM revealed that he/she was coordinating the Peritoneal Dialysis trainings since the Nurse Practice Educator (NPE), who was the person maintaining these education records, had left in November 2018. The NHA reported that the trainings were offered monthly and he/she was unable to provide proof of the trainings. (Cross reference F698 and F684). NHA and Director of Nursing made aware of deficient practice at the time of exit conference on 1/10/19.

Based on record review and staff interview, it was determined that the facility staff failed to ensure that residents were administered medications that were not necessary by 1) not clarifying physician's orders when a resident had been ordered antihypertensive and anti-hypotensive medications, 2) not clarifying physician's orders when a resident was ordered two medications for pain management, 3) not questioning a medication that was given in excessive doses, and 4) not monitoring behaviors related to antipsychotic medications. This was evident with 3 (#78, #52, #72) of 6 residents reviewed for unnecessary medications. The findings include: 1) A blood pressure is a measurement of the pressure that the blood places on the arteries as it is moving through them. The top number is the systolic pressure, which is a measurement of the pressure when the heart pumps out the blood into the arteries. The bottom number is the diastolic pressure which is a measurement of the pressure when the heart is between beats (resting). Review of the medical record on 1/8/19, revealed on the medication administration record (MAR) that Resident #78 received an anti-hypotensive (medication to increase blood pressure) on 12/4/18 at 9:00 AM, 1:00 PM, and 9:00 PM when the blood pressure was outside the parameters per the physician's order. Order dated 12/4/18 stated, Midodrine HCI tablet 10 mg. Give 1 tablet by mouth three times a day for hypotension (low blood pressure) hold for SBP (systolic blood pressure) is > (greater than) 130, however,the blood pressure was 134/78 on 12/4/18. Furthermore, review of Resident #78's December 2018 physician's orders revealed that Resident #78 had been prescribed (3) antihypertensive (blood pressure lowering) medications. Review of the MAR for December 2018 revealed that one or two of these medications were administered when the systolic pressure (the top number) was below 100 and diastolic pressure (the bottom number) was below 60 three days during the review period of 12/1/18 - 12/31/18. Furthermore, on the same days these medications were administered, the resident also received a medication to increase the blood pressure. In addition, Resident# 78 was ordered an analgesic and narcotic for pain management. The orders did not state when to give the analgesic versus the narcotic. The MAR revealed that resident was given the analgesic for a pain level 7-9 (a pain scale from 1 to 10 used to determine the amount of pain a person is having. 1 being the lowest amount and 10 being the highest amount.) on December 14th, 26th, 27th, 2018,a n effectiveness is noted. However, the resident was given the narcotic for the same pain levels of 7-9 on December 5th - 11th, 13th, 15th, 18th, 19th, 21st, 24th, 26th, and 30th even though the analgesic was effectively taking care of pain. An interview on 1/7/19 at 10:08 AM as held with RN#34on and off regarding how to determine which pain medication to be given when no parameters are given by the physician. He/She stated that he uses the pain scale to determine which medication to give based on how high the resident rates their pain. During an interview with RN (staff #13) revealed he/she uses the pain scale to determine whether to give the analgesic or the narcotic. The Administrator and Director of Nursing(DON) were made aware of these findings at the time of the exit interview on 1/10/19. 2) On 1/9/18, Resident #52's medical record was reviewed. Review of Resident #52's January 2019 MAR revealed 2 orders for Ranitidine (Zantac) (antacid & antihistamine medication) 150 mg (milligrams) by mouth two times a day. The MAR documented that Resident #52 received Ranitidine 150 mg every day at 8:00 AM and 8:00 PM and the MAR documented that the resident received Ranitidine 150 mg every day at 9:00 AM and 5:00 PM. Review of the medical record failed to reveal documentation that Resident #52 was to receive Ranitidine 4 times a day. Continued review of Resident #52's January 2019 MAR revealed an order for Acetaminophen 650 mg by mouth every 8 hours as needed for pain and an order for Oxycodone 5 mg by mouth every 6 hours as needed for pain. There was no clear indication in the physician orders as to which medication to give first for pain. On 1/10/19 at 11:35 AM, Staff #5 confirmed the above finding. Cross Reference F 760. 3) Review of Resident #72's medical record on 1/3/19 revealed the resident was prescribed the medications Lorazepam for anxiety, Trazodone for insomnia/anxiety, Mirtazapine for depression and Seroquel (an antipsychotic) for depression. Further review of the electronic and paper medical record failed to produced behavior monitoring flowsheets. Staff #5 confirmed on 1/8/19 at 12:20 PM that the behavioral flowsheets were not being completed.

6) Record review conducted on 1/8/19, revealed that Resident #78 had been prescribed an antidepressant for depression and an anti-anxiety medication to be taken as needed for anxiety. However, there was no evidence in the medical record that Resident #78 was being monitored for behaviors. Director of Nursing and corporate nurse Staff #10 were informed of surveyor findings on 1/9/19 at 2:22 PM. Based on medical record review and staff interview, it was determined that the facility staff failed to ensure that resident medication regimens were free from unnecessary psychotropic medications by failing to adequately monitor residents for behaviors related to psychotropic medication use. This was evident for 1 (#74) of 5 residents reviewed for respiratory care, 4 (#33, #52 #58, #78) of 6 residents reviewed for unnecessary medications and 1 (#76) of 4 residents reviewed for care plans. The findings include: 1) On 1/8/18, Resident #74's medical record was reviewed. Resident #74's December 2018 MAR (medication administration record) documented the resident received Fluoxetine (Prozac) (antidepressant) by mouth every day for depression and the resident received Trazodone (antidepressant) by mouth every day at bed time for insomnia. Resident #74's January 2018 MAR documented Resident #74 received Fluoxetine by mouth every day for depression and Trazodone by mouth every day at bedtime for insomnia. Review of the medical record failed to reveal evidence the facility staff monitored Resident #74 for changes in behavior that necessitated the use of psychotropic medications, Fluoxetine and Trazodone. This was confirmed by Staff #35 on 1/8/19 at 12:20 PM. 2) On 1/8/19, a review of Resident #33's January 2019 MAR revealed the resident received Fluoxetine by mouth every day for behavioral disturbance and Haloperidol (Haldol) (antipsychotic) by mouth two times a day for agitation. Review of Resident #33's medical record revealed, on 12/12/18, in a behavioral health progress note, the CRNP indicated that the resident received Haldol for dementia with behavioral disturbance. Review of Resident #33's care plans failed to reveal a resident centered plan of care with measurable goals and individualized approaches had been developed that addressed Resident #33's dementia with behavioral disturbance, the resident's use of psychotropic medication and the behavior that necessitated the use of antidepressant and antipsychotic medication. Continued review of the medical record failed to reveal evidence the facility staff monitored Resident #33 for changes in behavior that necessitated the use of the psychotropic medications, Fluoxetine and Haloperidol. Staff #10 was made aware of this finding on 1/10/19 at 9:30 AM. 3) On 1/8/19, review of Resident #52's January MAR revealed the resident received Effexor XR (Venlafaxine HCL ER) by mouth every day for depression and Mirtazapine (Remeron) every day at bedtime for depression. Review of the medical record failed to reveal evidence the facility staff monitored Resident #52 for changes in behavior that necessitated the use of the psychotropic medications, Effexor and Mirtazapine. Staff #10 was made aware of these findings on 1/10/19 at 9:30 AM. 4) On 1/8/2019, a review of Resident #76's January 2019 MAR revealed the resident received Xanax (Alprazolam) (anxiolytic) by mouth three times a day for anxiety since 11/30/18, Trazodone (antidepressant) by mouth every day at bedtime for insomnia since 12/12/18. Review of Resident #76's care plans failed to reveal a comprehensive care plan with measurable goals and individualized approaches to address the resident's anxiety and failed to reveal a care plan to address the resident's use of Trazodone for insomnia. Continued review of Resident #76's medical record failed to reveal evidence the facility staff monitored Resident #76 for changes in behavior that necessitated the use of the psychotropic medications, Xanax and Trazodone. 5) Review of Resident #58's medical record on 1/3/19 revealed the resident received Risperdal 0.5 mg (antipsychotic medication) at bedtime and Risperdal 0.25 mg in the morning for dementia with behavioral disturbance. The resident also received Mirtazapine (antidepressant) for mood, Escitalopram (antidepressant) for depression and Trileptal (anti-seizure medication) for mood stabilization. Review of a physician's progress note, dated 11/21/18, documented that the resident was being followed for a diagnosis of dementia with behavioral disturbances and was aggressive at times. A psychiatric nurse practitioner's note of 10/3/18 documented the resident's mood was irritable, insight poor and judgement impaired. Behavioral goal was to keep mood neutral. Staff to provide structured socialization and ADL care. Further review of the medical record revealed there were no behavior monitoring notes or flowsheets and there was no documentation that side effects of the medications were being monitored. An interview was conducted with Staff #35 on 1/8/19 at 12:20 PM who confirmed that behavioral monitoring was not being done. Staff #5, the unit manager, stated on 1/9/19 at 11:08 AM, we fell off doing behavioral monitoring.

4) A blood pressure is a measurement of the pressure that the blood places on the arteries as it is moving through them. The top number is the systolic pressure, which is a measurement of the pressure when the heart pumps out the blood into the arteries. The bottom number is the diastolic pressure which is a measurement of the pressure when the heart is between beats (resting). Review of medical record on 1/8/19, revealed on the medication administration record (MAR) that Resident #78 received an anti-hypotensive (medication to increase blood pressure) on 12/4/18 at 9:00 AM, 1:00 PM, and 9:00 PM when the blood pressure was outside the parameters per the physician's order. Order dated 12/4/18 stated, Midodrine HCI tablet 10 mg. Give 1 tablet by mouth three times a day for hypotension (low blood pressure) hold for SBP (systolic blood pressure) is > (greater than) 130. However the blood pressure was 134/78 on 12/4/18. Furthermore, review of Resident #78's December 2018 physician's orders revealed that Resident #78 had been prescribed (3) antihypertensive (blood pressure lowering) medications. Review of the MAR for December 2018 revealed that one or two of these medications were administered when the systolic pressure (the top number) was below 100 and diastolic pressure (the bottom number) was below 60 three days during the review period of 12/1/18 - 12/31/18. In addition, on the same days these medications were administered the resident also received a medication to increase the blood pressure. Director of Nursing and corporate nurse staff #10 were made aware on 1/9/19 at 2:22 PM. 3) On 1/9/18, Resident #52's medical record was reviewed. Review of Resident #52's January 2018 MAR (medication administration record) revealed 2 orders for Rantidine (Zantac) (antacid & antihistamine medication) 150 mg (milligrams) by mouth two times a day. The MAR documented that Resident #52 received Ranitidine 150 mg every day at 8:00 AM and 8:00 PM and the MAR documented that the resident received Ranitidine 150 mg every day at 9:00 AM and 5:00 PM. Continued review of the medical record failed to reveal documentation that Resident #52 was to receive Ranitidine 4 times a day. On 1/10/19 at 11:35 AM, Staff #5 was made aware of the above finding and confirmed the medication error. Based on observation, medical record review and staff interview, it was determined the facility failed to keep residents free from significant medication errors as evidenced by 1) failing to give ordered medications, 2) failing to give medications within 1 hour of the ordered time, 3) failing to recognize a resident was receiving too many doses of a medication and 4) failing to follow physician's orders to administer blood pressure medications within parameters. This was evident for 2 (#45, #47) of 5 residents observed during medication administration and 2 (#52, #78) of 6 residents reviewed for unnecessary medications.The findings include: 1) The surveyor approached Staff #2 on 1/8/19 at 9:48 AM to watch medication administration for Resident #45. Staff #2 poured the medications (1) Metoprolol 50 mg. and (1) Metoprolol 25 mg., (1) Daily Vite and (2) Senna 8.6mg. All medications were crushed and separated into 30 cc. medication cups. The surveyor confirmed with Staff #2 that there were 5 pills in the medication cup prior to Staff #2 crushing the medications. After watching medication administration, the surveyor reviewed the January 2018 physician's orders on 1/8/19 at 11:05 AM in the medical record to verify that the correct medications were given. The physician's orders stated that Hydralazine 37.5 mg. (an anti-hypertensive) was to be given 3 times per day at midnight, 8:00 AM and 4:00 PM. Review of the January 2018 Medication Administration Record (MAR) was void of Staff #2's initials which would have indicated that the medication was given. 2) The surveyor accompanied Staff #2 to Resident #47's room to observe medication administration on 1/8/19 at 10:16 AM. Staff #2 poured the medications (1) Sodium Chloride 1 gm., (1) Ranitidine 150 mg., (1) Citalopram 10 mg., Valproic Acid 250 mg/5 ml. in which Staff #2 poured 15 ml. and (1) Clonazepam 0.5mg. There was a total of 4 pills and 1 liquid that was dispensed into individualized medication cups which the surveyor verified with Staff #2 prior to Staff #2 crushing the medications. After the medication administration on 1/8/19 at 11:05 AM, the surveyor reviewed Resident #47's January 2018 physician's orders. It was noted that the resident should have also received Hydralazine 10 mg. Review of Resident #47's January MAR revealed Staff #2 signed the medication off as if it was given. In addition, the medication Clonazepam (anti-anxiety) was ordered to be given 3 times per day at 8:00 AM, 12:00 noon and 8:00 PM. The resident did not receive the medication until 10:25 AM, which was 2 hours and 25 minutes late and the next dose was due at noon. The Valproic Acid Solution (anti-convulsant) was ordered at 9:00 AM and 9:00 PM and was given late. The medication was given 2 hrs. and 25 minutes late. The surveyor went back to Staff #2 on 1/8/19 at 11:45 AM, and brought up about Resident #47's medication that was missed, but signed off as given and Staff #2 stated, I signed them off in error. They were not given because the meds were not available. It was not documented anywhere that the medications were not given. The surveyor brought up about the medications for Resident #45 being missed and Staff #2 stated, Oh they were. The surveyor also asked Staff #2 why the medications were being passed late. Staff #2 stated, I worked my other job from 3:00 PM yesterday and did not get off until 4:00 AM this morning. I only got a couple of hours sleep and then came in after 9:00 AM. I was running late. At 11:47 AM, the Corporate Nurse was advised of the omitted medications. The Corporate Nurse and Nursing Home Administrator advised the survey team on 1/8/19 at 12:15 PM that Staff #2 was immediately removed from duty.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6) On [DATE] at 2:10 PM, observation was made of Resident #74 sitting in a Geri-chair in his/her room. At that time, the resident, who was non-verbal, reached his/her hand to the over-bed table and grabbed an unopened box containing Biotene (an oral product used for dry mouth) and showed it to the surveyor, then placed the box back on the table. The box was labeled from the pharmacy with Resident #74's name and instructions for use. The resident pushed his/her call bell. When the nurse entered the room, the resident motioned to the Biotene. the nurse picked up the box and removed it from the resident's room. Biotene, a biological product, was prescribed by the physician and should not be left at the resident's bedside. Based on observation, staff interview and facility documentation review, it was determined the facility staff failed to 1) label medications when opened, 2) discard medications when expired 3) lock and secure an unattended medication cart and 4) ensure that medications were not left at the bedside. This was evident for 1 of 2 medication rooms observed, 4 of 8 medication carts observed, 2 random resident room observations and 1 random observation on 1 of 2 nursing units. The findings include: Observation was made on [DATE] at 10:50 AM of the following medications that were observed in the refrigerator in the medication room on the second-floor nursing unit: 1) Resident #52's opened Lantus insulin 100units/ml vial with a fill date of [DATE]. There was no date when opened. Resident #13's opened Humalog insulin 100unit/ml with a fill date of [DATE] with no date when opened. Resident #45's opened Lantus insulin with a fill date of [DATE] with no date opened. Resident #41's opened Humulin R insulin with a fill date of [DATE] and no date opened. Resident #5's opened Humulin R with a fill date of [DATE] and no date opened. Resident #62's opened Humalog insulin with a fill date of [DATE] and no date opened. Resident #45's opened Levemir insulin with a date filled of [DATE] and no date opened. Resident #62's opened Lantus insulin with a fill date of [DATE] with no date opened. Resident #52's opened Lantus insulin with a fill date of [DATE] with no date opened. An opened vial of Levemir insulin with a date opened of [DATE]. There was no resident name on the vial and the vial had expired as Levemir insulin is only good for 42 days after being opened. The expiration date was [DATE]. Resident #30's opened Victoza injection pen with a fill date of [DATE] and no date opened. Staff #4 was with the surveyor at the time of the observation on [DATE] at 10:55 AM. 2) Observation was made in the tube feeding medication cart on [DATE] at 11:01 AM of Resident #30's opened vial of NovoLog with a fill date of [DATE] and no date opened. Resident #52's opened vial of Humalog insulin had a date opened of [DATE]. Humalog insulin is only good for 28 days after being opened. 3) Observation was made in the second medication cart on the second floor of Resident #23's opened Prednisolone acetate 1% eye drops with a date opened of [DATE]. Prednisolone acetate eye drops should be discarded after 28 days as the preservative can only ensure the drops are safe for the eye for a period of 28 days. Resident #62's opened Lantus insulin had a fill date of [DATE] and no date opened. Resident #73's opened Timolol maleate eye drops were filled on [DATE] and not dated when opened and (1) bottle was filled on [DATE] with no date when opened. Resident #55's opened Advair diskus 250-50mcg which was dispensed on [DATE] was not dated when opened. There was also a bottle of Ampicillin 500 mg from another drug store which was in the drawer, however the resident had been discharged from the facility. Staff #4 was advised on [DATE] at 11:10 AM. 4) Observation was made of a third medication cart on second floor nursing unit on [DATE] 11:12 AM. Resident #20's opened Advair diskus 100-50mcg disk was dispensed [DATE] and was not dated when opened. Resident #75's opened Olopatadine hcl 0.1% (Patanol) were not dated when opened. The drops contain a preservative which helps prevent germs from growing in the solution for the first 4 weeks after opening the bottle, therefore should be discarded after 4 weeks. Resident #35's opened Dorzolamide hcl 2% eye drops (2) bottles had an opened date of [DATE] and [DATE]. The drops should be discarded after 4 weeks of being opened. Resident #7's opened Latanoprost 0.005% eye drops were opened on [DATE]. According to the manufacturer's website the drops are only good for 6 weeks once opened. Staff #5 was with the surveyor at the time of observation. Observation was made a fourth medication cart on the second-floor nursing unit on [DATE] at 11:19 AM. Resident #41's opened Basaglar kwick pen was dispensed on [DATE] and not dated when opened. Also observed a 20 ml (milliliter) bottle of sterile water for injection, lot #640054P, which was opened and one-half empty. There was no date opened on the bottle. The sterile water should be discarded 24 hours after being opened. 5) Observation was made on [DATE] at 9:36 AM of an unlocked and unattended medication in the hallway outside of room [ROOM NUMBER] on the second-floor nursing unit. Staff #5 was with the surveyor at the time of observation. Staff #4 and the surveyor stood in the hallway until 9:40 AM when at that time the nurse walked up to the medication cart. Staff #4 informed the staff member of the unlocked and unattended cart. The Nursing Home Administrator and the Corporate Nurse were advised on [DATE] at 9:21 AM.

12) Resident #24 was observed in his/her room on 1/2/19 at 10:30 AM. During the observation, it was determined that the resident was comatose and unable to give any meaningful response to surveyor action or presence. This was confirmed during a review of the resident's most recent Minimum Data Set Assessment in which the resident was documented as being in a persistent vegetative state. Resident #24's medical record was reviewed on 1/8/19 at 10:00 AM. During the review, it was found that the resident had an order for an oral antigingival agent with the instructions to swish and spit. Resident 24's physician was briefly interviewed on 1/8/19 at 10:20 AM and confirmed that the resident was unable to swish or spit meaningfully. Furthermore, the resident had an order for Nothing By Mouth due to having an impaired swallow. The physician stated that the medication should be administered by a nurse using an oral sponge. 9) On 1/2/19 at 11:10 AM, an observation was made of Resident #74 lying in bed. At that time, it was observed that the resident's bed did not have bed rails. On 1/3/19, review of Resident #74's TAR (treatment administration record) revealed an order for bed rails ¼ as an enabler for turning and repositioning in bed every shift and inaccurately documented the bed rails as in use, on 6 of 8 shifts. Observation of Resident #74 revealed the resident had a tracheostomy (trach) (surgical opening in the neck into the windpipe) with a tracheostomy tube (tube inserted through the opening that allows a person to breath). Observation of Resident #74's surroundings failed to reveal an Ambu bag (mechanical ventilation bag used to deliver breaths when a persons is unable to breath on his/her own) at the resident's bedside. On 1/2/19 at 2:10 PM, an observation was made of Resident #74 sitting in a Geri-chair located next to his/her bed in the resident's room. At that time, observation of the resident's room failed to reveal an Ambu bag at the resident's bedside. On 1/3/19 at 2:00 PM, accompanied by Staff #4, observation of Resident #74 lying in bed in his/her room failed to reveal an Ambu bag at the resident's bedside. On 1/4/19, review of Resident #74's January TAR revealed an order for a #6 Shiley ((brand of replacement trach tube or disposable inner cannula) and Ambu bag at bedside was documented as present on 8 of 9 shifts and an order for #4 Shiley and Ambu bag at bedside was documented as present on 8 of 9 shift. 10) On 1/8/19, a review of Resident #33's medical record was conducted and documented the resident was admitted to the facility in the middle of October 2018. Review of progress notes revealed on 10/19/18, 10/22/18, 10/24/18, 10/29/18 and 10/31/18, in a progress note, the physician documented that Resident #33 was to continue Seroquel (quetiapine) (antipsychotic medication) 25 mg (milligrams) two times a day. On 10/18/18, 10/26/18, 11/2/18, 11/13/18, 11/16/18, 11/28/18, 12/10/18 and 12/11/18, in a progress note, the CRNP (certified registered nurse practitioner) documented that Resident #33 was to continue Seroquel 25 mg two times a day. Further review of the medical record failed to reveal documentation that Seroquel had been prescribed for the resident and failed to reveal documentation that Resident #33 had ever received Seroquel since his/her admission to the facility. Review of Resident #33's January 2019 MAR revealed a 10/18/18 order for Fluoxetine (Prozac) (antidepressant) 20 mg by mouth in the morning for behavioral disturbance. The indication for use of the Fluoxetine was inaccurate. Review of Resident #33's medical record revealed on 10/19/18, in a progress note, the physician documented for the resident's depression to continue Prozac. Continued review of Resident #33's January 2019 MAR revealed an order for Haloperidol Lactate (Haldol) (antipsychotic) 0.5 mg by mouth two times a day for agitation. The indication for use of the Haloperidol was inaccurate. Review of Resident #33's medical record revealed on 12/12/18, in a behavioral health progress note, the CRNP indicated that Haldol was indicated for the resident's dementia with behavioral disturbance. Staff #10 was made aware of these findings on 1/10/19 at 9:30 AM. 11) On 1/10/19, Resident #52's medical record was reviewed. Resident #52's January 2019 MAR documented that the resident received Clopidogrel Bisulfate (Plavix) (blood thinner) 75 mg by mouth once a day for hematological agents. The indication for use of the Clopidogrel was inaccurate. Hematological agent describes a category of medication, not an indicator for use. On 11/5/18, in a progress note, the physician documented that following stent (small tubes placed in the arteries that supply blood to the heart, to keep the arteries open) placement, the resident was placed on Plavix and to continue Plavix for CAD (coronary artery disease). Staff #5 confirmed the findings on 1/10/19 at 11:35 AM. 7) Resident #80's medical record was reviewed on 1/4/19 at 12:14 PM and revealed a Post admission Patient/Family Conference note, dated 12/5/18 09:30, which indicated the resident/representative did not receive a copy of the resident's baseline plan of care. A Progress note dated the same date and time indicated that the plan of care was reviewed with and a copy was given to the resident/representative as required. Both notes were signed by Staff #39. Resident #341's medical record was reviewed on 1/8/19 at 9:26 AM, and revealed a Post admission Patient/Family Conference note, dated 12/14/18 09:45, which indicated the resident/representative did not receive a copy of the resident's baseline plan of care. A Progress note, dated the same date and time, indicated that the plan of care was reviewed with and a copy was given to the resident/representative as required. Both notes were signed by Staff #39. Staff #39 was interviewed on 1/8/19 at 12:28 PM and confirmed that the progress notes for both resident #80 and #341 were incorrect, neither resident nor their representatives were provided with a copy of the resident's plan of care. 8) Resident #70's medical record was reviewed on 1/9/19 at 10:09 AM. The resident had a physician's order written on 11/9/18 for Valproate Sodium Solution, give 5 milliliters by mouth at bedtime for seizures. Valproate Sodium is an anti-seizure medication which is also used for mood stabilization. Prior physician's orders for the Valproate Sodium indicated it was prescribed for mood disorder. Further review of the record failed to reveal a diagnosis of seizures, but did include major depressive disorder. During an interview Staff #12 (a physician), confirmed that Resident #70 was prescribed the Valproate Sodium Solution for mood disorder and the indication of seizures was in error. Cross reference F 756. The Director of Nursing and Corporate Nurse were made aware of these findings on 1/10/19 at 10:22 AM. Based on observation, medical record review and staff interview, it was determined the facility failed to have accurate medical record documentation. This was evident for 12 (#35, #45, #47, #63, #72, #86, #80, #70, #74, #33, #52, #24) of 35 residents reviewed. The findings include: 1) On 1/9/19 at 12:39 PM, an interview was conducted with the family member of Resident #35. The family member expressed concern that the resident's dentures were not being placed in the resident's mouth in the morning before meals. The family member stated, yesterday I took off from work and I washed her clothes up. She was in the dining room and I walked in her room and her dentures were in her cup. She missed breakfast and lunch because she can't eat without her dentures. She does not have the mental capacity to put her dentures in. My other concern is did she get breakfast and lunch. She can't chew her food without her dentures. She is also not capable of taking out the dentures. Staff #1 was asked about the resident's dentures on 1/8/19 and Staff #1 stated, she did not have her dentures in yesterday until after 3:00 PM when the 3:00 to 11:00 PM shift came on. On 1/9/19, the January 2019 Treatment Administration Record (TAR) was reviewed and it was noted that the nurse signed off that monitor use of dentures with meals, remove and clean at bedtime, before meals and at bedtime for ADL was performed for 7:30 and 11:30 AM on 1/8/19. The medical record was inaccurate as staff signed off that an intervention was done when it was not done. Discussed with the Director of Nursing on 1/9/19 at 3:07 PM. 2) The surveyor approached Staff #2 on 1/8/19 at 9:48 AM. Staff #2 was preparing to give medications to Resident #45. Staff #2 poured the medications (1) Metoprolol 50 mg. and (1) Metoprolol 25 mg., (1) Daily Vite and (2) Senna 8.6mg. The surveyor confirmed with Staff #2 that there were 5 pills in the medication cup prior to Staff #2 crushing the medications. After watching medication administration, the surveyor reviewed the January 2018 physician's orders in the medical record to verify that the correct medications were given. The physician's orders stated that Hydralazine 37.5 mg, Protein liquid 1 oz., Ascorbic Acid 500 mg., Psyllium Powder 49% 1 TBSP, Lansoprazole 30 mg., Polysaccharide Iron Complex 150 mg., and Hyoscyamine 0.125mg. should have been given during the morning medication administration in addition to the medications that the surveyor observed being given. Review of the January 2018 Medication Administration Record (MAR) was void of Staff #2's initials which would have indicated that the medications were given. Furthermore, the physician's orders stated, enteral feed: flush tube with 15 ml. (cc) of water before each medication pass and flush tube with at least 15 ml. of water between each medication and flush tube with at least 15 ml of water after final medication. Staff #2 failed to sign on the MAR when the flushes were done. The MAR was printed and given to the surveyor on 1/9/18 at 11:24 AM. It was unknown if Resident #45 ever received the medications. The MAR was incomplete. Cross Reference F759 3) The surveyor accompanied Staff #2 to Resident #47's room to observe medication administration on 1/8/19 at 10:16 AM. Staff #2 poured the medications (1) Sodium Chloride 1 gm., (1) Ranitidine 150 mg., (1) Citalopram 10 mg., Valproic Acid 250 mg/5 ml. in which Staff #2 poured 15 ml. and (1) Clonazepam 0.5mg. There was a total of 4 pills and 1 liquid that was dispensed into individualized medication cups which the surveyor verified with Staff #2 prior to Staff #2 crushing the medications. After the medication administration on 1/8/19, the surveyor reviewed Resident #47's January 2018 physician's orders. It was noted that the resident should have also received Hydralazine 10 mg., Lactulose 30 ml. and Multivitamin 10 ml. Review of Resident #47's January MAR revealed Staff #2 signed the 3 medications as if they were given. The surveyor went back to Staff #2 on 1/8/19 at 11:45 AM and inquired about Resident #47's medications that were missed but signed off as given and Staff #2 stated, I signed them off in error. There were not given because the meds were not available. It was not documented anywhere that the medications were not given. 4) Observation was made on 1/2/19 at 12:05 PM of Resident #63 sitting in a geriatric (geri) reclining chair with knees towards the window, pillow behind the head and nothing between the resident's knees. The resident was sitting on a Hoyer lift quilted pad. On 1/2/19 at 2:05 PM the resident was in the same position and on 1/2/19 at 2:41 PM the resident remained in the same position. A second surveyor observed the positioning of the resident. Observation was made on 1/3/19 at 7:40 AM of Resident #63 lying on his/her back with his/her head to the left towards the curtain with 2 pillows around the head. The feet were positioned on a pillow. On 1/3/19 at 11:46 AM the surveyor observed Staff #3 and Staff #4 place a pain patch on the resident. The resident was placed in the same position as observed on 7:40 AM. Subsequent observations were made on 1/3/19 at 12:46 PM, 1:35 PM and 3:03 PM. The resident remained in the same position. Review of the January 2019 TAR on 1/4/19 documented nurse's initials which indicated on 1/2/19 that the pressure-redistribution cushion to chair while out of bed was in place and that on 1/2/19 and 1/3/19 the resident was turned and repositioned every 2 hours. The nurses documented that a treatment was in place when it was observed not in place. Discussed with Staff #5 on 1/4/19 at 9:49 AM and with the DON on 1/4/19 at 1:32 PM. 5) On Wednesday, 1/2/19 at 11:50 AM the surveyor went in and spoke with Resident #72 who stated he/she wanted to get up and out of bed. Staff #3 came into the resident's room and the surveyor asked why the resident was still in bed. Staff #3 stated, we alternate between Resident #72 and another resident getting up and out of bed due to the geri chairs. If Resident #72 stayed in bed yesterday then another resident would get up. If the other resident stayed in bed then Resident #72 would be gotten up. The surveyor asked if there were enough geri-chairs for all the residents and the response was, I have to go downstairs to see if I can find one for him/her. Resident #72 was observed again on 1/2/19 at 2:50 PM and the resident was still in bed. Resident #72's medical record was reviewed on 1/3/19 and a Hospice recommendation that was written on 9/12/18 stated, assist pt. to geri-chair and place in hallway on Monday, Wednesday and Friday. The nurse signed off on 1/2/19 that the resident was assisted to the gerichair and placed in the hallway in the morning on Wednesday. The unit manager confirmed that the resident did not get out of bed on 1/2/19 because there was no geri chair and that the documentation of the resident getting out of bed was not accurate. In addition, Resident #72 had an order to receive a House Supplement 3 times per day for underweight status. The December 2018 and January 2019 TAR was reviewed and the nurses signed off that the resident received the supplement but failed to document the percentage of the supplement consumed. 6) Review of Resident #86's medical record on 1/4/19 revealed a December 2018 MAR which documented a House Supplement three times a day for underweight status. The nurses signed off that the resident received the supplement but failed to document the percentage of the supplement consumed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the facility staff failed to follow infection control practices and guidelines while performing duties and caring for residents and not verifying evidence of immunity when an employee stated that they never had or been vaccinated for measles, mumps, rubella or was ever tested for evidence of immunity. This deficient practice had the potential to affect all residents, staff, and visitors in the facility. The findings include: 1) During initial interview with Resident #189 on 1/2/19 at 11:35 AM, the surveyor observed that the resident was on oxygen by way of nasal cannula. Further observation revealed the oxygen tubing and nasal cannula was not initialed or dated. In addition, there was a sterile water disposable humidifier connected that was dated 11/18/18. An additional observation made on the following day, revealed the resident receiving oxygen. The tubing and nasal cannula remained undated and un-initialed and humidifier had the same date. During an interview with the Director of Nursing (DON) on 1/3/19 at 1:11 PM, he/she revealed that the date on the humidifier was the date it was opened. He/She added that sterile water humidifier bottles should be changed when the container was empty or by the expiration date on the container. He/She was unable to state when tubing and nasal cannula should be dated. However, a review of the 12/1/18, Oxygen: Nasal Cannula policy indicated that the disposable set (oxygen tubing and nasal cannula) were to be labeled and changed every 7 days, and the sterile water should be changed every 24 hours to prevent bacterial contamination. Discussed with the DON on 1/4/19 at 11:39 AM. 2) During an observation of Unit 1, on 1/10/19 at 10:00 AM, surveyor observed GNA (Staff #25) pick up a tray of resident snacks and take the tray in and out of resident's rooms handing out their snacks. At one point, Staff #25 handed a resident two snacks from the tray and the resident took one and touched the other snack which was taken to the next resident's room. It was noted that Staff #25 did not wash his/her hands between resident contact. Further observation on the unit on 1/10/19 at 10:08 AM, laundry aide (staff #15) was observed putting laundry on laundry cart outside of room [ROOM NUMBER]. Staff #15 did not re-cover the laundry cart, leaving two sides exposed. 3) Observation of the 2nd floor unit at 10:25 AM was conducted. Observation was made of a linen closet at the elevators with the doors wide open with the laundry cart exposed. In addition, observation of the lounge room at 10:31 AM revealed two laundry carts that were not covered. Observation of the laundry department was conducted on 1/10/19 at 9:30 AM. The laundry area failed to have a physical separation between dirty and clean clothing. Further observation revealed Laundry Aide (staff #15) wheeled an uncovered bin of clean laundry through the dirty clothing area. Observation of the clean laundry folding area revealed 2 containers of clothing under a table with some of their contents on the floor. A pile of curtains was on the floor below a shelf. The curtains were later identified as trash during an interview with the Environmental Manager (EVM) (Staff #16) on 01/10/19 at 9:37 AM. A record review and interview with EVM on 1/10/19 at 9:37 AM, revealed that the clothes washer detergent dispenser was not monitored (Cross Reference F684) 4) A review of 6 employee files conducted on 1/10/19, revealed that 3 employees were unsure of their immunization status. However, further review failed to document that immunizations were verified. During the interview with the DON on 1/10/19 at 1:26 PM, he/she was made aware of the infection control findings. 7) Resident #70 was observed receiving his/her afternoon medications from Registered Nurse (RN) #29 in the hallway outside the resident's room on 1/10/19 at 1:14 PM. During the observation, it was noted that the resident's nasal cannula was lying on the floor, with the nasal flanges in direct contact with the tile. After the resident received his/her nasal spray, RN #29 was seen placing the nasal cannula back into Resident #70's nares without taking any steps to sanitize the flanges. 8) On 1/2/19, observation of Resident #74's room revealed tracheostomy supplies, oxygen supplies and a dirty nebulizer machine were on top of the heater/air conditioner unit, located under the window next to the resident's bed. On the top of the resident's bedside table was a humidification compressor and a suction machine that were covered in dust. 5) Observation was made on 1/2/19 at 12:09 PM of Resident #63 sitting in a reclining geriatric (geri) chair next to the bed. There was an oxygen concentrator sitting behind the chair that was turned on and dispensing 2L (liters) of oxygen. The resident was not wearing the nasal cannula that was hooked to the concentrator. The tubing and cannula were on the floor under the resident's bed. The tubing was not dated as to when it was connected to the oxygen concentrator. 6) Observation was made on 1/8/19 at 9:48 AM of Staff #2 dispensing medications into a medication cup for Resident #45. Staff #2 took the pills from the medication cards with his/her bare hands and placed them into a medication cup. Staff #2 proceeded to go into Resident #45's room, place gloves on his/her hands and then proceed to touch the resident's gown to search for the tube feeding tube. Staff #2 removed the plug from the end of the tube and then poured medications into the tube. Staff #2 then performed mouth care on the resident and then removed the gloves and returned to the medication cart and signed off medications via the computer. Staff #2 then proceeded to prepare medications for Resident #47. Staff #2 did not sanitize his/her hands after providing care to Resident #45. On 1/10/19 at 9:21AM the Nursing Home Administrator and the Corporate Nurse were advised of the observations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident medical records, it was found that the facility failed to prepare baseline care plans for residents within 48 hours of a resident's admission. This was evident for 7 (#24, #38, #341, #80, #76, #33, #52) of 7 recently admitted residents. This practice had the potential to affect all newly admitted or readmitted residents. A baseline care plan must be completed within 48 hours of a resident's admission to the facility and must include the initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. A summary of the baseline care plan as well as a list of the resident's current medications must be given to each resident. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. The findings include: 1) Resident #24's medical record was reviewed on 1/2/19 at 10:19 AM. The resident was hospitalized on ce in September and once in October, returning to the facility both times. For each of these two hospitalizations, the resident was reviewed for completion of a baseline careplan within 48 hours of admission, as well as evidence that the baseline care plan was shared with the resident. The first care plan that could be found for the hospitalization in September was initiated 5 days after the resident's admission. There was no evidence in the medical record that the resident received a summary of either care plan nor a list of his/her medications. 2) Resident #38's medical record was reviewed on 1/3/19 at 9:07 AM. The resident was hospitalized in October, 2018. The initiation date for the resident's first care plan was 4 days after the resident was admitted to the facility. There was no evidence in the medical record that the resident received a list of his/her medications at the time of admission or by the first care plan meeting. 5) On 1/8/19, review of Resident #74's medical record revealed documentation that the resident was admitted to the facility at the end of November 2018 for rehabilitation following a fall. On 11/30/18, the physician documented in a history and physical progress note that the resident's diagnosis included anxiety, chronic pain, bipolar disorder and a left below knee amputation. Continued review of the medical record failed to reveal evidence that a resident centered baseline care plan had been developed along with a summary of medications, and given to the resident or resident's representative. On 1/8/19, at 10:15 AM, during an interview, the Director of Nurses stated that within 24 hours of the resident's admission, the facility staff would try to implement one care plan and confirmed that the facility did not have a process in place for the development of baseline care plans within 48 hours of a resident's admission to the facility. 6) On 1/8/19, review of Resident #33's medical record documented that Resident #33 was admitted to the facility in the middle of October 2018 following hospitalization for depression and confusion. On 10/18/18, in a progress note, the physician documented that the resident's diagnosis included CHF (congestive heart failure), Alzheimer's disease, hypertension. Continued review of the medical record failed to reveal that a baseline care plan had been developed, and along with a summary of medications, given to the resident or resident's representative. 7) On 1/9/19, review of Resident #52's medical record documented that the resident was admitted to the facility in the middle of August 2018 following hospitalization for high blood sugar due to uncontrolled diabetes. The resident's admission assessment with a reference date of 8/23/18 documented the resident's diagnosis included hypertension, seizure disorder, depression, muscle weakness and difficulty walking. Continued review of the medical record failed to reveal that a baseline care plan had been developed, and along with a summary of medications, given to the resident or resident's representative. 3) Resident #341's medical record was reviewed on 1/8/19 at 9:26 AM. The resident was admitted on [DATE]. A comprehensive care plan was present in the electronic medical record however, no separate interim baseline plan of care was found. During an interview on 1/8/19 at 10:09 AM, Staff #8 indicated that a separate baseline care plan was not normally implemented, but a comprehensive plan was developed in the electronic medical record and implemented on admission. The plan of care for nutrition was dated 12/19/18, and was not developed within 48 hours of the residents admission as required. No plan of care for discharge was found. The care plan goals did not include measurable objectives to determine if the resident was meeting his/her care plan goals. A Post admission Patient-Family Conference V-3 form, dated 12/14/18, was found in Resident #341's record which indicated that the resident was present at the meeting, but his/her representative was not. The form also indicated that the resident/representative was not provided with a summary of the baseline care plan however, A Post admission Pt/Family Conference progress note, dated 12/14/18 09:45, included additional comments: This baseline, Person-Centered Care Plan is developed within 48 hours and is reviewed at the Post admission Patient/Family Conference and given to the resident and/or resident representative. Both the form and Progress note were electronically signed by Staff #39. 4) Resident #80's medical record was reviewed on 1/4/18 at 12:14 PM. The resident was admitted on [DATE]. The surveyor observed that the resident's nutrition plan of care was not initiated until 12/11/18, more than 48 hours after admission. The resident's Post admission Patient-Family Conference -V3 form indicated that the resident/representative was not provided with a copy of the care plan, but the Post admission Pt/Family Conference progress note, dated 12/5/18 09:30, included additional comments: This baseline, Person-Centered Care Plan is developed within 48 hours and is reviewed at the Post admission Patient/Family Conference and given to the resident and/or resident representative. Both the form and progress note were electronically signed by Staff #39. During an interview on 1/8/19 at 12:28 PM, Staff #40 was asked to clarify the conflicting documentation regarding the resident/representative receiving the copies. He/She indicated that copies of the care plans and medications were not provided to Resident #341 nor Resident #80 or their representatives. Staff #8 confirmed that the resident and/or representative were not provided with a copy of the plan or list of medications. Staff #10 was made aware of these findings on 1/8/19 at 4:09 PM. The Director of Nursing and Corporate Nurse were made aware of these findings on 1/10/19 at 10:22 AM.

12A) Review of Resident #78's medical record on 1/8/19, revealed that resident was prescribed an analgesic and a narcotic for pain. However, review of the care plan revealed there was not one for pain for this resident. (Cross Reference F757). 12B) Review of Resident #78's care plan on 1/8/19, revealed an intervention: to obtain and monitor blood pressures, to include an orthostatic blood pressure and report to physician as indicated. (An orthostatic blood pressure is a procedure to measure a person's blood pressure to determine if it is lower when they are standing) However, further review of Resident #78's blood pressures taken from October 1, 2018 - December 31, 2018, revealed no documentation that orthostatic blood pressures measurements were conducted. Furthermore, there was no documentation that the physician had been notified when blood pressures were abnormal. (Cross Reference F684 and F757) 13) During an interview with Resident #189 on 1/2/19 at 11:35 AM, the surveyor noted that the resident was receiving supplemental oxygen therapy by way of a nasal tube. However, review of the care plan failed to indicate a care plan to address the resident's oxygen therapy. (Cross Reference F684 and F880). Director of Nursing was made aware of these finding on 1/4/19 at 11:39 AM. 11) Resident #24's medical record and care plan were reviewed on 1/2/19 at 10:05 AM. The resident's care plan contained the focus: Resident requires assistance for ADL [Activities of Daily Living] care in (specify: bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting) related to limited mobility. The only intervention that specified the level of assistance that the resident needed was Provide patient with total assist of 2 for bed mobility. The care plan did not address the level of assistance that the resident required with any other ADL. Furthermore, the care plan included the intervention, Monitor for decline in ADL function. Refer to rehabilitation therapy if decline in ADLs is noted. However, the resident was comatose and completely dependent on staff for all ADL care, which was confirmed by surveyor observation made of the resident in his/her room on 1/2/19 at 11:15 AM. 14) On 1/2/19 at 2:10 PM, observation of Resident #74 revealed the resident's right hand with fingers bent and without a splint or or other device in place. On 1/4/19, during an interview, Staff #1 confirmed the resident had a contracture. A contracture is a condition of shortening and hardening of muscles, tendons or other tissue which often leads to deformity and rigidity of joints. On 1/8/18, review of the medical record revealed that, on 8/7/18 in a progress note, the physician documented that the resident had a right-hand contracture. Review of Resident #74's care plans failed to reveal that a plan of care had been developed to address Resident #74's contracture and limited range of motion. Staff #5 was made aware of these findings on 1/10/19 at 9:31 AM. On 1/2/19 at 2:10 PM, observation of Resident #74 revealed his/her finger nails were long and dirty and the resident's tongue was covered by a very thick, white coating. Review of Resident #74's most recent assessment with a reference date of 12/13/18, documented that the resident required extensive assistance to meet personal hygiene ADLs (activities of daily living). Review of Resident #74's care plans revealed a care plan Resident is dependent for ADL care in specify: bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting) related to: with the goal Residents/Patients ADL care needs will be anticipated and met throughout the next review period had the interventions: 1. Provide resident/patient with total assist of one staff person for bed mobility, 2. Provide resident/patient with total assist of two staff person for transfers using a total lift. The care plan was not resident centered with measurable goals and individualized approaches to address Resident #74's ADL needs. Staff #9 and Staff #10 were made aware of these findings on 1/10/19 at 9:30 AM. 15) On 1/8/2019, Resident #76's medical record was reviewed. Review of Resident #76's January 2019 MAR revealed that the resident received Xanax (Alprazolam) (anxiolytic) by mouth three times a day for anxiety since 11/30/18, Trazodone (antidepressant) by mouth every day at bedtime for insomnia since 12/12/18 and Melatonin (hormone that aids sleep) every night at bedtime for insomnia since 12/18/18. Review of Resident #76's care plans failed to reveal a comprehensive care plan with measurable goals and individualized approaches to address the resident's anxiety and failed to reveal a care plan to address Resident #76's insomnia. Continued review of Resident #76's care plans revealed a care plan focus, the resident/patient requires assistance for ADL care in bathing, dressing, transfer, locomotion, toileting and had the goal residents/patients ADL care needs will be anticipated and met throughout the next review period. The care plan's focus was not resident specific and did not indicate the reason why the resident required assistance in ADL care. The ADL care plan goals was not measurable and did not reflect the resident's goals and desired outcomes. On 1/8/18 at 10:15 AM, the Director of Nurses was made aware of the findings. 16) On 1/8/19, a review of Resident #33's January 2019 MAR revealed that the resident received the psychotropic medications, Fluoxetine (Prozac) (antidepressant) 20 mg (milligrams) by mouth every day for behavioral disturbance and Haloperidol (Haldol) (antipsychotic) 0.5 mg by mouth two times a day for agitation. Review of Resident #33's medical record revealed, on 12/12/18, in a behavioral health progress note, the CRNP indicated that the resident received Haldol for dementia with behavioral disturbance. Review of Resident #33's care plans failed to reveal that a resident centered plan of care with measurable goals and individualized approaches had been developed that addressed Resident #33's dementia with behavioral disturbance, the resident's use of psychotropic medication and the behavior that necessitated the use of antidepressant and antipsychotic medication. On 1/8/19 at 2:13 PM, Staff #10 was made aware of these findings. 17) On 1/2/19 at 9:40 AM, during an interview, Resident #52 stated he/she was receiving hospice services (specialized type of care for those facing a life-limiting illness). Review of Resident #52's medical record revealed that the resident was admitted to a hospice program in late December 2018. Review of Resident #52's care plans failed to reveal a comprehensive care plan with measurable goals and individual approaches to care to address Resident #52's end of life care. On 1/2/19 at 9:40 AM, Resident #52 was observed wearing nasal cannula oxygen tubing connected to an oxygen concentrator set at 2 l/m (liters/minute). On 1/9/19 at 2:45 PM, during an interview, Resident #52 stated he/she used oxygen continuously and the resident was observed wearing nasal cannula tubing connected to an oxygen concentrator set at 3 l/m. Review of Resident #52's medical record revealed that, on 12/6/18 in a progress note, the physician documented the resident's current plan of care included continuous oxygen. Review of Resident #52's medical record failed to reveal a physician order for the resident's use of oxygen. Review of Resident #52's care plans failed to reveal that a care plan had been developed to address the resident's use of oxygen. Resident #52 had a care plan focus Resident exhibits or is at risk for cardiovascular symptoms related to diagnosis of CHF (congestive heart failure) with interventions that included Monitor weight as ordered. Review of Resident #52's physician orders revealed a 9/10/18 order Weight three days a week, Mon., Wed. and Fri. for cardiomyopathy (disease of the heart muscle)/CHF. Review of Resident #52's weight summary in the EMR (electronic medical record) documented the resident's last recorded weight on 12/5/18 and failed to reveal documentation that Resident #52 was weighed 3 times a week. The facility staff failed to follow Resident #52's care plan by failing to weigh the resident as ordered. Continued review of Resident #52's care plans revealed a care plan focus Resident requires assistance for ADL care in (specify: bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting) related to: limited mobility with the goal Residents/Patients ADL care needs will be anticipated and met throughout the next review period had the interventions: 1. Monitor conditions that may contribute to ADL decline, 2. Monitor for decline in ADL function. Refer to rehabilitation therapy if decline in ADLs is noted and 3. Monitor for pain. Attempt non-pharmacologic interventions to alleviate pain and document effectiveness. Administer pain medication as ordered and document effectiveness/side effects. The care plan's focus was not resident specific, the goal was not measurable, and not resident centered, and the care plan did not have resident centered interventions to enable the resident to meet his/her ADL objectives. Staff #9 and Staff #10 were made aware of these findings on 1/10/19 at 9:30 AM. 8) Resident #341's medical record was reviewed on 1/8/19 at 9:26 AM. The facility developed a plan of care with the focus: the resident's caregiver and family stated it was important that the resident had the opportunity to engage in daily routines that were meaningful relative to his/her preferences. The focus did not identify the resident's individual activity needs. The care plan goal was: the resident will accept invites and choose to engage in preferred activities till next review. It did not identify Resident #341's preferred activities nor did it include the objectives to be measured when evaluating the residents progress toward meeting his/her care plan goal. The intervention: Encourage and assist with his/her activity preferences did not indicate how staff should assist. Several entries in the intervention section of the care plan identified what was important to the resident and his/her preferences and likes, but did not identify the services that the facility would provide to assist the resident in meeting his/her stated goal. During an interview on 1/8/19 at 11:20 AM, Staff #39 was asked what Resident #341's activity goal was. He/She indicated watching TV and/or movies and added that the facility staff wanted Resident #341 to attend his/her preferred activities; when asked how many activities, Staff #39 stated no number, we like him/her to attend what he/she wants to. Staff #39 did not indicate what Resident #341's preferred activities were. Cross reference F 679. 9) Resident #64's medical record was reviewed on 1/8/19 at 1:18 PM. The resident's care plan goals for Activities of Daily Living (ADL's) Daily routines, Mood, Chronic Pain and Psychotropic drugs did not include measurable objectives. A care plan for: exhibits or is at risk for cardiovascular symptoms or complications related to the diagnosis of hypertension intervention Monitor apical heart rate did not indicate when the resident's apical heart rate should be monitored. The resident's discharge care plan goal was Resident #64 will have an ongoing discharge plan that provides for safe and effective discharge. The interventions were instructions on developing a discharge care plan including Initiate Discharge Transition Plan per [corporate name] policy. They did not include Resident #64's specific discharge plans nor the individualized interventions to assist the resident in reaching his/her discharge goals. 10) Review of Resident #70's medical record on 1/9/19 at 10:09 AM revealed a list of diagnoses which included, but were not limited to monoplegia (paralysis of one limb) of upper limb. During an interview and observation of the resident on 1/10/19 at 10:06 AM, the resident's left elbow was observed to be bent approximately 90 degrees and the fingers of his/her left hand were in a cupped position indicating possible contractures (fixed resistance to passive stretch of a muscle). The resident indicated that he/she was unable to extend his/her fingers or straighten his/her arm on his/her own. On 1/10/19 at 11:38 AM, Staff #17 indicated when asked that Resident #70 had very limited ROM in his/her left shoulder and that his/her left elbow is pretty fixed. No plan of care was found in the record identifying Resident #70's limited range of motion and the services to be provided to increase or to prevent further decline in the resident's range of motion. Cross reference F 641 and F 688 Based on resident and staff interview, observation and medical record review, it was determined that the facility failed to develop and implement comprehensive person-centered care plans with measurable goals. This was evident for 17 (#86, #35, #63, #72, #45, #47, #58, #341, #64, #70, #24, #78, #189, #74, #76, #33, #52) of 35 residents reviewed. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1) On 1/2/19 at 12:21 PM, an interview was conducted with Resident #86. The resident was asked if he/she had any problems with hearing and the resident stated, I am hard of hearing and I do not wear hearing aids and I would like to know why I can't hear out of the left ear and see what can be done about it. It was noted that the resident told the surveyor to sit to the right of the bed, so he/she could hear. On 1/4/19 at 9:21 AM, the unit manager (Staff #5) was asked about the resident's hearing and Staff #5 stated his/her hearing was fine. Staff #5 proceeded to ask the Physical Therapy Manager who was at the nurse's station if he/she knew anything about the resident's hearing. On 1/4/19 at 9:25 AM the Physical Therapy Manager read an occupation therapy note which stated the resident was hard of hearing. Review of physician's progress notes, dated 8/30/18, 11/26/18 and 12/13/18, documented hearing impaired. Review of the care plan while in the facility resident states that it is important that he/she has the opportunity to engage in daily routines that are meaningful relative to his/her preference with interventions I would benefit from accommodation for hearing loss by having other speak deeper and louder, decreased environmental noises. There was no goal on the care plan. Further review of Resident #86's care plans failed to produce a care plan specific for hearing loss and accommodations that would be made to compensate for the loss. 2) On 1/9/19 at 12:39 PM, an interview was conducted with the family member of Resident #35. The family member expressed concern that the resident's dentures were not being placed in the resident's mouth in the morning before meals. The family member stated, yesterday I took off from work and I washed his/her clothes up. He/She was in the dining room and I walked in his/her room and his/her dentures were in his/her cup. He/She missed breakfast and lunch because he/she can't eat without his/her dentures. He/She does not have the mental capacity to put his/her dentures in. My other concern is did he/she get breakfast and lunch. He/She can't chew his/her food without his/her dentures. He/She is also not capable of taking out the dentures. Observation was made on 1/9/19 1:00 PM of the resident in the dining room being fed lunch. Resident #35 opened his/her mouth and showed the surveyor his/her dentures. Staff #1 was asked about the resident's dentures on 1/8/19 and Staff #1 stated, he/she did not have his/her dentures in yesterday until after 3:00 PM when the 3:00 to 11:00 PM shift came on. Review of the care plan resident is dependent for ADL care due to cognitive loss/dementia and had the intervention requires total assistance with eating. The goal was resident's ADL care needs will be anticipated and met in order to maintain the highest practicable level of functioning and physical well being x 90 days. The goal was not measurable. The care plan failed to mention the dentures and the care needed for the dentures. A second care plan resident exhibits or is at risk for oral health or dental care problems with a goal the resident will not have any discomfort or chewing problems r/t broke, loose or carious teeth in the next 90 days was not resident centered as the resident had dentures. The interventions of monitor for discomfort in mouth, broken or loose teeth was not pertinent to this resident, as the resident had dentures, not broken or loose teeth. Discussed with the DIrector of Nursing on 1/9/19 at 3:07 PM. 3A) Observation was made of Resident #63 on 1/2/19. Resident #63 was wearing a hospital gown with slipper socks. The resident was observed again on 1/3/19 at 11:46 AM and the resident was wearing a hospital gown and slipper socks. Continued observations made on 1/3/19 at 12:46 PM, 1:35 PM and 3:03 PM confirmed that Resident #63 was wearing a hospital gown and slipper socks. On 1/4/19 at 7:35 AM and 9:17 AM, the resident was wearing a hospital gown and slipper socks. Review of the care plan while in the facility resident states that it is important that he/she has the opportunity to engage in daily routines that are meaningful relative to their preference had the goal resident will plan and choose to engage in preferred activities till next review. The goal was not measurable. The intervention it is important for me to choose what clothing to wear: own clothing was not followed as there was no documentation that the resident refused to get up and get dressed in his/her own clothing. Review of the care plan resident requires assistance for ADL care in bathing, grooming, personal hygiene, dressing, bed mobility, transfer, locomotion, toileting related to limited mobility had the goal resident's ADL care needs will be anticipated and met throughout the next review period. The goal was not measurable and was not related to the resident's preferences. The interventions on the ADL care plan were not specific to the resident. The intervention monitor conditions that may contribute to ADL decline, including: metabolic causes (e.g., delirium, diabetes, thyroid disorder, liver disease, renal failure, electrolyte imbalance) respiratory problems, CVA, delusions, hallucinations, psychiatric disorder, poor nutrition, hearing or vision impairment, new/acute health problem, exacerbation of a chronic condition (e.g., CHF, diabetes), constipation, infection, head injury, pain, fever, dehydration or alcohol withdrawal was not the resident's focus for care. The care plan was initiated on 8/12/17. It did not pertain to the resident's current status. 3B) Observation was made of Resident #63 on 1/2/19 at 12:04 PM. The resident was sitting in a reclining geriatric (geri) chair next to the right side of the bed. A water cup with no ice and little water was sitting on the over the bed tray table with a box of cookies and an empty medication cup. The over the bed tray table was not accessible to resident, as it was placed at the end of the bed. The resident was sitting next to the bed. Also observed were the resident's unopened graham crackers that were labeled 1/2 (morning snack) which were sitting across from the resident on the bureau next to the television. The resident was unable to reach, as the resident's chair was approximately 8 to 10 feet away from the bureau. On 1/3/19 at 3:03 PM, observation was made of the unopened graham crackers still sitting on the top of the bureau. The date of the graham crackers was 1/2. On 1/4/19 observation was made at 7:20 AM of the 1/2/19 graham cracker snack sitting next to the television unopened. Review of the annual MDS with assessment reference date (ARD) of 6/5/18 documented in Section F0400, How important is it to you to have snacks available between meals? documented the resident's response as very important. Review of the care Plan: Resident is at nutritional risk r/t increased nutrient needs r/t wound healing had the interventions offer snacks. The care plan was not implemented. 3C) Observation was made on 1/2/19 at 12:05 PM of the Resident #63 sitting in a geri chair with knees towards the window, pillow behind the head and nothing between the resident's knees. The resident was sitting on a hoyer lift quilted pad. On 1/2/19 at 2:05 PM the resident was in the same position and on 1/2/19 at 2:41 PM the resident remained in the same position. A second surveyor observed the positioning of the resident. Observation was made, on 1/3/19 at 7:40 AM, of Resident #63 lying on his/her back with his/her head to the left towards the curtain with 2 pillows around the head. The feet were positioned on a pillow. On 1/3/19 at 11:46 AM, the surveyor observed Staff #3 and Staff #4 place a pain patch on the resident. The resident was placed in the same position as observed on 7:40 AM. Subsequent observations were made on 1/3/19 at 12:46 PM, 1:35 PM and 3:03 PM. Observation was made on 1/4/19 at 7:35 AM, of Resident #63 lying in bed with his/her head on 2 pillows which leaned to the left. The knees were facing the window with a pillow in between the knees. On 1/4/19 at 9:17 AM, Resident #63 was in bed in the same position, with the head of bed elevated 45 degrees with the over the bed tray table in front of the resident. The resident's body alignment was the same as the 7:35 AM observation. Review of the care plan Resident has actual skin breakdown r/t limited mobility with interventions: assist resident in turning & reposition every 2 hours and prn. Encourage resident to consume all fluids during meals, pressure reducing cushion to chair while out of bed, waffle cushion behind back when out of bed in wheelchair. The care plan was not followed as the resident was not turned and repositioned every 2 hours and the pressure reducing cushion was not in the geri chair. Discussed with Staff #5 on 1/4/19 at 9:49 AM, and with the DON on 1/4/19 at 1:32 PM. 3D) Review of Resident's care plan resident is at risk for falls; impaired mobility, compression fracture of fifth lumbar vertebra had the interventions floor mat to right side of bed, call bell for assistance, place call light within reach while in bed or close proximity to the bed; when resident is in bed, place all necessary personal items within reach. These interventions were not done as there was no floor mat next to the bed during the entire observation period, the call bell was not accessible to the resident, and personal items were not within reach- Cross Reference F558. 3E) Observation was made, on 1/2/19 at 12:09 PM, of Resident #63 sitting in a reclining geriatric (geri) chair next to the bed. There was an oxygen concentrator sitting behind the chair that was turned on and dispensing 2L (liters) of oxygen. The resident was not wearing the nasal cannula that was hooked to the concentrator. The tubing and cannula were on the floor under the resident's bed. Review of Resident #63's medical record on 1/4/19 revealed December 2018 and January 2019 physician's orders which stated, oxygen at 2L/min. via nasal cannula, as needed post tx: evaluate heart rate, respiratory rate, pulse oximetry, skin color, and breath sounds. Review of the care plan section of the medical record for Resident #63 failed to produce a respiratory care plan related to the use of oxygen. Discussed with Staff #5, on 1/4/19 at 9:33 AM, who confirmed the findings. 4A) Review of Resident #72's medical record on 1/3/19 documented the resident was totally dependent on staff for all ADL needs. On 1/3/19, a review of the care plan Resident is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting r/t failure to thrive and cognitive deficit with the goal Resident's ADL Care needs will be anticipated and met throughout the next review period was not measurable. 4B) Further review of Resident #72's medical record revealed that the resident was on Quetiapine Fumarate (Seroquel) for depression. Seroquel is an antipsychotic medication. Review of the care plan resident is a risk for complications r/t the use of psychotropic drugs had the intervention complete behavior monitoring flow sheet. Review of the electronic and paper medical record failed to produce behavioral monitoring flowsheets. On 1/8/19, Staff #35 confirmed that behavioral monitoring was not being done. The care plan was not followed. 5) Observation was made, on 1/8/19 at 9:48 AM, of Staff #2 preparing medications to be administered to Resident #45 via G-tube. Staff #2 walked into the residents room and was fumbling around the resident's gown, trying to find where the G-tube was located. Staff #2 found the end of the G-tube. Staff #2 proceeded to pour water into a 120 ml plastic cup. Staff #2 then opened the cap to the end of the G-tube and flushed the tube with approximately 50 ml of water. Staff #2 then poured the first medication down the tube followed by a 30 ml water flush. Staff #2 poured the second medication down the tube followed by a 30 ml water flush and then poured the third medication down the tube followed by a 30 ml water flush and then a 230 ml water flush. Review of the January 2019 physician's orders on 1/8/19 revealed an order to flush the tube with 15 ml of water before each medication pass, and to flush tube with at least 15 ml of water between each medication. Review of the care plan resident has an enteral feeding tube to meet nutritional needs r/t dysphagia, increased nutrient needs r/t wound healing, abnormal labs, concern for hydration states and weight loss trends had the intervention free H2O (water) as ordered. The care plan was not followed as the amount of milliliters before, during and after medication pass exceeded the ordered amount. 6) The surveyor accompanied Staff #2 to Resident #47's room to observe medication administration on 1/8/19 at 10:16 AM. Staff #2 prepared the medications. Staff #2 then proceeded to remove the tube feeding cap and flush the feeding tube with 50 cc. of water, gave the first medication and then the second medication, flushed with 30 cc. of water, gave another flush, gave the third medication, a 30 cc water flush, the fourth medication, a 25 cc. water flush, the fifth medication, a 30 cc. water flush and then a 180 cc. water flush. Staff #2 failed to check for tube placement and residual prior to medication administration. After the medication administration on 1/8/19, the surveyor reviewed Resident #47's January 2018 physician's orders. The physician's orders stated, flush tube with at least 15 ml. of water after final medication and flush tube with at least 15 ml. of water between each medication. Staff #2 gave an additional 270 ml. of water flushes beyond what was ordered by the physician. In addition, Resident #47 was ordered, enteral feed order 5 times a day TwoCal NH 237 ml. bolus at 6:00 AM, 10:00 AM, 2:00 PM, 6:00 PM and 10:00 PM. As of 11:45 AM the 10:00 AM feeding had not been signed off. Resident #47 did not receive a tube feed bolus during medication administration at 10:25 AM. The surveyor went back to Staff #2 on 1/8/19 at 11:45 AM and brought up about Resident #47's not receiving the 10:00 AM feeding. Staff #2 stated, I just gave the feeding at 11:30 AM. The surveyor asked why it was late and Staff #2 stated again, I just gave it. The feeding was not signed off as given. Review of Resident #47's care plan, Resident has an enteral feeding tube to meet nutritional needs, CVA, dysphagia had the interventions feeding (2 cal HN) at room temperature as ordered and NSS (water) flushes as ordered. The care plan was not followed. 7) Review of Resident #58's medical record on 1/3/19 documented that the resident received Risperdal (antipsychotic medication) twice per day for dementia with behavioral disturbance. The resident also received Mirtazapine (antidepressant) for mood, Escitalopram (antidepressant) for depression and Trileptal (anti-seizure medication) for mood stabilization. Review of the medical record revealed there were no behavior monitoring notes or flowsheets and there was no documentation that side effects of the medications were being monitored. An interview was conducted with Staff #35 on 1/8/19 at 12:20 PM who confirmed that behavioral monitoring was not being done. Staff #5, the unit manager, stated on 1/9/19 at 11:08 AM, we fell off doing behavioral monitoring. Review of the care plan resident exhibits or has the potential to demonstrate verbal and physical behaviors related to cognitive loss/dementia had the interventions monitor medications, especially new/changed/discontinued, for side effects and resident's/patient's response contributing to verbal behaviors including: antipsychotics, anticholinergics, opioids, benzodiazepines. The care plan was not followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9) Resident #78 was interviewed on 1/2/19 at 2:06 PM, and reported that on 11/17/18, while being transported to be weighed, blacked out and fell out of the wheelchair. On 1/8/19, a review of the facility's incident report confirmed the resident had a fall. Further review of the medical record revealed a nursing progress note, dated 12/24/18, that indicated the resident had a number of fainting episodes that day including one that resulted in a fall with injury. Review of the resident's care plan revealed that the resident was at risk for falls related to limited mobility however, further review revealed that the care plan was not updated to indicate the 11/17/18 or the 2/24/18 incidents. Administrator and Director of Nursing made aware at time of exit conference on 1/10/19. Based on observation and review of medical records, it was determined that the facility failed to perform appropriate revision to care plan goals and interventions as resident care needs became apparent or changed over time, and failed to ensure that a resident's representative was offered an opportunity to participate in development of the care plan. This was evident for 9 ( #10, #24, #58, #63, #72, #71, #30, #33, #78) of 35 residents reviewed during the investigation phase of the survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1) Resident #10's medical record was reviewed on 1/9/19 at 10:45 AM in relation to two facility-reported elopements that involved this resident in November and December, 2018. The resident was determined by the facility to have traveled off of the premises via wheelchair on two separate instances. This was confirmed by survey investigation. However, at the time of review on 1/9/19 at 10:45 AM, the resident's care plan focus of Resident/Patient is at risk for elopement related to: his/her desire to leave the building without prior authorization had not been updated to reflect the second of these two elopements. The Administrator was interviewed on 1/9/19 at 12:26 PM. During the interview, the Administrator indicated several new interventions that were being utilized to reduce the risk of resident elopement. These new strategies and interventions were confirmed by the Administrator to not be part of the elopement care plan. 2) Resident #24's medical record and care plan were reviewed on 1/2/19 at 10:05 AM. The resident was found to be receiving hospice services since November of 2018, however, there was no evidence of hospice care being added to the resident's care plan since that time. This was confirmed in interview with the facility's Minimum Data Set (MDS) coordinator on 1/8/19 at 11:27 AM. 8) Review of Resident #33's medical record revealed a care plan Resident requires assistance for ADL care (specify: bathing, grooming personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting) related to: limited mobility with the goal Residents/Patient's ADL care needs will be anticipated and met throughout the next review period had the interventions 1) Monitor conditions that may contribute to ADL decline, 2) Monitor for decline in ADL function. Refer to rehabilitation if decline in ADLs is noted and 3) Monitor for pain. Attempt non-pharmacologic interventions to alleviate pain and document effectiveness/side effects. The care plan was not comprehensive with measurable goals and resident centered interventions. On 12/12/18, in a care plan evaluation note, the nurse documented that the resident was dependent for bed mobility, transferring, toileting and set up for eating. The care plan evaluation did not measure the residents progress or lack of progress toward reaching her goals. Continued review of Resident #33's care plans revealed a care plan, the resident has impaired/decline in cognitive function or impaired thought processes related to a condition other than delirium: Alzheimer's disease, with the goals will be able to make simple decisions by responding yes or no on most days during the review period, will maintain a pattern of sleep sufficient to promote health and well-being throughout review period and had the interventions 1. Monitor for decline in function. Refer to rehabilitation therapy if decline in ADLs is noted; 2. Allow resident/patient to make daily decisions. Use verbal cues, gestures and demonstration to assist in decision making, if needed and 3. Provide consistent, trusted caregiver and structured daily routine, when possible. The plan of care did not identify what the resident's current level of cognitive function was or the measurable objectives that the staff were to use when determining the resident's progress or lack of progress toward reaching his/her goal. Review of the medical record failed to reveal that the resident's progress toward his/her goal was evaluated. A quarterly MDS with an assessment was done on 11/8/19. Review of the medical record failed to reveal the care plan had been reviewed after each assessment and failed to reveal evidence the care plan had been updated based on the needs of the resident or in response to current interventions. 7) Resident #30's medical record was reviewed on 1/9/19 at 1:09 PM. A plan of care had been developed on 10/5/16 for nutritional risk related to therapeutic diet related to Congestive heart failure/cardiac pmhx, mechanically altered diet related to dysphagia, history of polysubstance abuse, morbid obesity, poor nutritional quality of diet, non-compliance with diet as patient visits vending machines often and consumes high sodium foods. The plan identified the resident's goal as Resident will lose 4-5 pounds per month to promote a goal towards BMI (body mass index) < (less than) 50 for the next 90 days. A nutritional assessment, dated 12/10/18, indicated that the resident said he/she would like to stay at his/her current weight for now. Would like to lose 50 pounds in the future but not now. During an interview on 1/10/19 at 9:39 AM Staff #41 indicated that the resident was not on a calorie controlled diet, but was on a small portion diet. Staff #41 was asked why Resident #30's care plan goal did not reflect the resident's goal identified during the nutritional assessment. He/She indicated the resident was educated on the small portion diet and the resident said he/she wanted to lose weight, but his/her compliance with his/her diet fluctuated. Staff #41 confirmed that Resident #30's plan of care was not revised after the resident assessment. The Director of Nursing and Corporate Nurse were made aware of these findings on 1/10/19 at 10:22 AM. 3) Review of Resident #58's medical record on 1/9/19 revealed a care plan, while in the facility, resident states that it is important that he/she has the opportunity to engage in daily routines that are meaningful relative to the preferences. The interventions included: provide 1:1 unstructured check in visits, provide verbal invites, reminders, encouragement and redirection as needed during recreation groups, enjoys listening to music and prefers live entertainment, keep up with the news on tv and looking at tv related to the [NAME], news, variety and cars, and go outside for fresh air in good weather. A review of activity logs was conducted on 1/9/19 at 1:15 PM for Resident #58 for September, October, November, December 2018 and January 2019. The logs lacked documentation of any activities/interventions that were attempted for the resident. The December 2018 activity log revealed the last documentation of any type of activity was on 12/15/18. For November 2018, the only documentation was listening to music on 11/18/18 and visiting family on 11/27/18. The October 2018 activity log revealed the last documentation was on 10/9/18 and the September 2018 activity log had documented a visit by family on 9/9/18, 9/18/18 and 9/25/18. Staff #39 confirmed that he/she did not update the care plan to reflect what additional interventions could be tried and that there was no coordinated effort between nursing and activities. 4) Review of Resident #63's care plan, resident requires assistance for ADL care in bathing, grooming, personal hygiene, dressing, bed mobility, transfer, locomotion, toileting related limited mobility was not resident specific as to Resident #63's needs. The care plan did not state what the resident's preferences were. There have been no updates to the care plan since 5/7/18. The resident has had a decline in health over the past 9 months, according to Staff #5 on 1/4/19 at 9:49 AM. 5) On Wednesday, 1/2/19 at 11:50 AM, the surveyor spoke with Resident #72 who stated he/she wanted to get up and out of bed. Staff #3 walked in the room and the surveyor asked why Resident #72 was still in bed. Staff #3 stated we alternate between Resident #72 and another resident due to the geri chairs. If resident #72 stayed in bed yesterday, then another resident would get up. If the other resident stayed in bed, then Resident #72 would have gotten up. The surveyor asked if there were enough geri-chairs and the response was, I have to go downstairs to see if I can find one for him/her. Resident #72 was observed again on 1/2/19 at 2:50 PM and the resident was still in bed. On 1/3/19, a review of the care plan Resident is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting r/t failure to thrive and cognitive deficit with the goal Resident's ADL Care needs will be anticipated and met throughout the next review period was not measurable. Interventions on the care plan failed to address the Hospice recommendation that was written on 9/12/18 which stated, assist pt. to geri-chair and place in hallway on Monday, Wednesday and Friday. On 1/3/19 at 12:29 PM, the surveyor asked the unit manager, Staff #5 about the order. Staff #5 stated he/she was aware of the order yesterday. Staff #5 confirmed the care plan had not been updated to reflect getting the resident out of bed. 6) Resident #71 was interviewed on 1/2/19 at 9:50 AM. During interview, the resident expressed that he/she was uncertain that s/he wasinvited to attend care plan meetings. Resident #71's medical record was reviewed on 1/10/19. The resident was admitted in December of 2017. Information in the medical record related to care plan meetings was sparse. There was not any quarterly care plan meeting documentation for 2/18, 5/18, and 8/18. There was a care plan meeting sign in sheet with three staff and the resident's surrogate decision maker for 11/18. An interview was conducted with the Unit Manager (staff # 5) at 12:54 PM on 1/10/18. Upon discussion and review of the care plan meeting sign in sheets, staff #5 indicated that there was not/or staff #5 did not know of any more documentation or additional information as to what was discussed in the care plan meeting held in November of 2018. Staff # 5 did not know if Resident #71 was invited to attend care plan meetings. Staff #5 was unaware how residents and/or family members were notified of quarterly care plan meetings.

Based on interview with facility staff, it was determined that the facility failed to ensure that the individual designated as the director of food and nutrition services was nationally certified for food service management and safety. This had the potential to affect all residents. The findings include: During interview with the Dietary Manager on 1/4/19 at 11:00 AM, the Dietary Manager was asked if s/he was certified as a dietary manager or a food service manager. The Dietary Manager stated that s/he was not certified in either but that the plan was to get me certified in a few months. It was verified with the business office that no dietician was employed in a full time basis at the facility.

Based on observation and interview with facility staff, it was determined that the facility failed to ensure that food was prepared and that kitchen equipment was cleaned and in a sanitary manner. This was evident for 2 of 2 tours of the kitchen performed during the survey. The findings include: During an initial tour of the kitchen that took place on 1/2/19 at 8:42 AM, it was found that records of the concentration of the sanitizer solution in the three compartment sink still only had dates from December. When asked about whether sanitizer solution concentration had been checked for the month of January, the [NAME] was unable to provide any documentation that the solution was documented. During a follow-up kitchen tour that took place on 1/4/19 at 11:10 AM, no temperature logs could be provided for the food being prepared for lunch. The Dietary Manager instructed staff to start over preparing the food item in question.

Based on review of facility records, it was determined the facility staff failed to accurately assess the resources necessary to care for its residents during both day-to-day operations and emergencies by failing to accurately assess 1) resident acuity, 2) staffing plan and 3) staff competencies necessary to provide the level and types of care needed for the resident population. This was evident during Sufficient and Competent Nurse Staffing review. The findings include: The facility assessment was reviewed on 1/10/19 at 12:50 PM. The facility's licensed bed capacity was 113. The assessment was dated 10/18/18, and indicated the average daily census was 100. 1) The Acuity section of the assessment provided a table in which the facility recorded the number of residents in the facility on the assessment date divided into 3 levels of assistance needed (independent, assist of 1-2 staff or dependent) for 5 categories of activities of daily living (ADL's). The facility's documentation for the total number of residents for each ADL was inconsistent - Dressing reflected 95 residents, Bathing reflected 93 residents, Transfer reflected 73 residents, Eating reflected 93 residents and toileting reflected 93 residents. 2) Section 3.2 of the facility assessment was the staffing plan which required the facility to describe their general approach to staffing to ensure that they had sufficient staff to meet the needs of the residents at any given time. The plan reflected the facility's staffing hours for both licensed nurses and direct care staff and was based on 101 patients per day not the total bed capacity of 113 which would have reflected the maximum number of residents at any given time. 3) Review of employee files and staff training revealed that the facility had no system in place to provide required staff training and record of hours and type of annual in-service training completed by each staff member to accurately evaluate and ensure competency of staff. Cross reference F 947.

Based on surveyor observation, interviews with staff and review of resident and facility records, it was determined that the facility failed to have an effective quality assessment and assurance program by failing to implement effective plans of action to correct quality deficiencies identified during the prior annual quality indicator survey. The findings include: On 1/10/19 at 3:00 PM, the surveyor reviewed the results of the facility's last quality indicator survey. The corrective actions implemented by the facility after the last annual survey failed to effectively correct deficiencies related to failing to notification of changes, failing to administer blood pressure medications according to parameters, MDS (Minimum Data Set) assessment accuracy, develop/implement comprehensive care plans, care plan timing and revision, quality of care, unnecessary drugs and infection control. The Quality Assessment and Improvement program was reviewed with the Staff #9 on 1/10/19 at 3:53 PM. Staff #9 was asked to describe the facility's QAPI plan. He/She indicated that the facility had no specific QAPI plan, but had a generic corporate plan and that he/she decided what needed to be focused on. Some focus areas were identified during the weekly Customer at Risk meetings, during morning meetings, by the business office, company benchmarks, some are triggered by company thresholds. Deficient practices cited during the last annual survey and identified again during the current survey were reviewed. The corrective actions the facility implemented after the last annual survey failed to effectively correct these deficiencies and resulted in a continuation of the deficient practices. Staff #9 indicated that the repeat deficiencies were because there had been several different Directors of Nursing, that QAPI plans had been attempted, but felt that the changes in staff had led to inconsistencies. He/She indicated that he/she wanted to redo the facility's QAPI plan now that there was a new Director of Nursing. Review of the facility's Quality Assessment and Performance Improvement Plan revealed that it was last reviewed/updated on November 13, 2017 by a previous administrator.

Based on review of facility documentation and interview with staff, it was determined that the facility failed to ensure staff competency by failing to provide required in-service training for nurse aides for no less than 12 hours per year including dementia management, cognitive impairment and resident abuse training. This was evident during Sufficient and Competent Nurse Staffing review. The findings include: The employee files of Staff #42, #43, #27 and #44 were reviewed on 1/10/19 at 12:50 PM. The files for Staff #42, #43 and #27 contained a 72 question Annual Competency test questionnaire and an OSHA Expo Quiz. Staff #44's file did not contain the questionnaire. The questionnaire covered 19 topics that included 5 questions related to Abuse Prohibition and 4 questions related to Psychophysical & Psychosocial Needs of the Aged. The instructions included Please review the information on all annual mandatory in-services and answer all questions in this packet. No documentation was found to indicate what, if any, training had been provided, nor the number of training hours. During an interview, on 1/10/19 at approximately 2:00 PM, Staff #8 indicated that his/her employment started at the facility in October 2018 and that he/she had been filling in as nurse educator after the previous nurse educator left in November. Staff #8 provided a binder labeled Inservices 2018. The binder was divided by months and contained various in-service sign in sheets, but did not indicate if any of the training was mandatory annual training or if it was provided in response to an identified need. Sign in sheets were present from January 2018 - June 2018 however the binder contained no evidence of any in-service training after June 2018. Staff #8 indicated that he/she was not sure what if any system the prior nurse educator had used for providing and tracking mandatory in-service training and confirmed that there was no system in place to provide and track annual competency training at the time of the survey. During an interview on 1/10/19 at 2:39 PM, Staff #45 indicated that an online training program was completed by staff annually, but added it did not include dementia care or abuse training. He/She was unsure of how many hours the training involved. Cross reference F 838.

Based on medical record review and staff interview, it was determined the facility staff failed to notify the POA when medications were changed for Resident # 42; failed to notify the physician when medication was not administered for Resident # 89 and failed to notify the physician of a finger stick above 250 and an elevated blood pressure for Resident # 191. This was evident for 3 of 28 residents selected for review in the stage 2 survey sample. The findings include: 1. The facility staff failed to notify the POA when medications were changed for Resident # 42. Medical record review for Resident # 42 revealed on 1/25/11, 2 physicians examined the resident and determined the resident was unable to: understand and sign facility documents; to understand the nature, extent or probable consequences of the proposed treatment; to make a rational evaluation of the burdens risks, benefits of the treatments and to effectively communicate a decision. At that time, the resident's son was appointed as the resident's Power of Attorney (POA). A health care power of attorney grants the agent authority to make medical decisions for the resident if he/she is unconscious, mentally incompetent, or otherwise unable to make decisions on your own. Once Resident # 42 was certified as unable to make their own decisions and a POA was appointed, all care involving Resident # 42 needed to be communicated with the POA (including the initiation of and/or discontinuation) medications. Further medical record review revealed on 4/4/17 the physician ordered: discontinue Remeron and ordered: Gabapentin 100 milligrams by mouth 2 times a day; however, failed to notify the POA. Remeron is an antidepressant and is used to treat major depressive disorder. Gabapentin is used to prevent and control seizures. It is also used to relieve nerve pain; however, the facility staff failed to communicate with the POA the change of medications for Resident # 42 and failed to allow for input from the POA. Interview with the Director of Nursing on 8/31/17 at 1:30 PM confirmed the facility staff failed to notify the POA of changes in medications for Resident # 42. 2. The facility staff failed to notify the physician when a medication was not administered. Record review revealed Resident # 89 was admitted to the facility with a diagnosis that caused uncontrolled movements. On 11/18/16 the physician ordered: Xenazine 25 milligrams via G-tube, 4 times a day for dystonia (uncontrolled movements). Xenazine is used to treat uncontrolled muscle movements. A gastrostomy tube (also called a G-tube) is a tube inserted through the abdomen that delivers nutrition, medications or fluids directly to the stomach. Further record review of the Medication Administration Record revealed the facility staff failed to administer the medication 5/27/17-5/31/17 at 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM and 6/13/17 - 6/22/17 at 9:00 PM; however, failed to notify the physician the medication was not available and not administered. Interview with the Director of Nursing on 8/31/17 at 1:30 PM confirmed the facility staff failed to notify the physician for Resident # 89 when medications were not administered. 3 A. The facility staff failed to notify the physician or certified registered nurse practitioner (CRNP) of blood sugar results above 250. Medical record review for Resident # 191 revealed on 8/13/17 the physician ordered: blood sugars for 1 week. Notify MD/NP if BS < (less than) 60 or > (greater) than 250. A blood sugar is a blood glucose test that measures the amount of a type of sugar, called glucose, in the blood. The site, free of surface arterial flow, where the blood is to be collected is sterilized with a topical germicide, and the skin pierced with a sterile lancet and a small drop of blood is obtained. Review of the Medication Administration Record revealed the facility staff obtained and documented the blood sugar results as: 272 on 8/13/17 at 9:00 PM; 312 on 8/14/17 at 11:00 AM; 264 on 8/21/17 at 5:00 PM and 269 on 8/21/17 at 9:00 PM; however, the facility staff failed to notify the MD or CRNP as ordered of the blood glucose above 250. 3 B. The facility staff failed to notify the physician or CRNP of elevated blood pressure. Medical record review for Resident # 191 revealed on 8/11/17: the physician ordered: Metoprolol 25 milligrams (mgs) by mouth 2 times a day for high blood pressure. Metoprolol is used alone or together with other medicines to treat high blood pressure (hypertension). This medicine is a beta-blocker. It works by affecting the response to nerve impulses in certain parts of the body, like the heart. As a result, the heart beats slower and decreases the blood pressure. When the blood pressure is lowered, the amount of blood and oxygen is increased to the heart. Stage 1 hypertension: The systolic (top) number is between 140 and 159 mm Hg, or the diastolic (bottom) number is between 90 and 99 and Stage 2 hypertension: This stage of hypertension is severe and dangerous. A systolic number over 160 mm Hg or a diastolic number over 100 mm Hg is a sign of an advanced stage of hypertension On 8/11/17 at 6:13 PM the facility staff documented the resident's blood pressure as 170/100 and on 8/15/17 at 10:00 PM documented the blood pressure as 199/107. On 8/21/17 (no time) the CRNP ordered: Metoprolol 50 mgs 2 times a day. On 8/22/17 at 8:21 PM the facility staff documented the resident's blood pressure as 181/107. On 8/24/17 at 4:00 PM the CRNP ordered: Metoprolol 75 mg 2 times a day. On 8/25/17 (no time) the resident's discharge summary revealed the facility staff documented the resident's blood pressure as 175/102; however, failed to notify the MD or CRNP of the continued blood pressure for Resident # 19 (It is the expectation the facility staff notify the CRNP or physician of an elevated blood pressure especially since the CRNP is changing the dose of the Metoprolol in order to control the resident's blood pressure). Interview with the Director of Nursing on 8/31/17 at 1:30 PM confirmed the facility staff failed to notify the physician or CRNP for Resident # 191 of elevated blood pressure at the time of discharge.

Based on observation and interview, it was determined the facility staff failed to provide the most dignified existence for Resident (# 42). This was evident for 1 of 28 residents selected for review in the stage 2 survey sample. The findings include: Surveyor observation of Resident # 42 on 8/28/17 at 8:30 AM revealed the resident's breakfast tray was in the room. The tray was on the bedside table, to the side of the bed. The resident was not eating. There was no facility staff in the room. At 8:55 AM the facility staff entered the room and started to feed the Resident # 42, at least 25 minutes after the food had been delivered to the resident and the facility staff also failed to re-heat the food. Interview with the Director of Nursing on 8/31/17 at 1:30 PM confirmed the facility staff failed to provide Resident # 42 with the most dignified existence by failing to feed Resident # 42 in a timely manner.

2. The facility staff failed to accurately document a Resident's (#132) height and weight. Based on staff interview and review of the medical record, it was determined the facility staff failed to accurately document a Residents (#132) height and weight during the admission assessment completed on 2/24/17. Resident #132 has diagnoses of but not limited to Dysphagia (difficulty in swallowing) and Failure to Thrive (indicating insufficient weight gain or inappropriate weight loss). The inaccurate information was then conveyed to the Dietician's assessment on 3/01/17 and section K0200 of the MDS (Minimum Data Set) coded assessment completed on 3/03/17. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. When completing the admission assessment RN # 1 failed to obtain a correct height measurement for Resident # 132, entering 62 inches when in fact the resident was 70 inches tall which was not corrected until 4/09/17 by RN # 2 during a readmission assessment. In addition a weight obtained on 2/24/17 of 167.5 pounds was entered and a recheck of Resident # 132's weight of 162.1 pounds was entered on 2/25/17. The inaccurate height and weight measurements were both recorded on the dietician's assessment completed on 3/01/17 where a Body Mass Index (BMI) of greater than 30 indicating that Resident # 132 was obese. Resident # 132's actual height of 70 inches and weight of 162.1 pounds indicates a BMI of 23 which places him/her in a normal weight category. The inaccurate height, weight and BMI measurements were then used to develop a plan of care for Resident # 132's Nutritional risk related to mechanically altered diet and poor oral intake of 0-25%, with a goal to maintain a stabilized weight of 152 pounds. Or gradual weight loss is also desirable for BMI < (greater than) 30 during next 90 days. Based on medical record review and staff interview it was determined the facility staff failed to document accurate MDS assessments for Residents (# 55 and # 132). This was evident for 2 of 28 residents selected for review in the stage 2 survey sample. The MDS is a federally-mandated assessment tool that helps nursing home staff gathers information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. Categories of MDS (Minimum Data Set) are: Cognitive patterns, Communication and hearing patterns, Vision patterns, Physical functioning and structural problems which includes the assessment of range of motion, Continence, Psychosocial well-being, Mood and behavior patterns, Activity pursuit patterns, Disease diagnosis, Other health conditions, Oral/nutritional status, Oral/dental status, Skin condition, Medication use and Treatments and procedures. At the end of the MDS assessment the interdisciplinary team develops the plan of care for the resident to obtain the optimal care for the resident. The findings include: 1. The facility staff failed to accurately document an assessment on the MDS. Medical record review revealed on 3/9/17 the facility staff assessed Resident # 55 and documented on the MDS Section E- Behavior: E 0900- Wandering-Presence of and Frequency-1-the behavior of wandering occurred 1-3 days during the look back period. The facility staff assessed and documented E 1000- Wandering Impact- A- Does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs, outside the facility) and the facility staff answered- Yes. Interview with the Director of Nursing on 8/30/17 at 8:30 AM revealed the MDS documentation was an error, there is no evidence of the resident wandering to a potentially dangerous place. Interview with the Director of Nursing on 8/31/17 at 1:30 PM confirmed the documented MDS assessment for Resident # 55 wandering to a dangerous place was an error. There is no evidence of that behavior.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and review of the medical record it was determined the facility staff failed to implement a comprehensive person-centered care plan for a resident who is dependent for nutritional risk related to mechanically altered diet and poor oral intake for Resident (# 132). This was evident for 1 of 28 residents selected for review in the stage 2 survey sample. The findings include: Resident # 132 has diagnoses of but not limited to Dysphagia (difficulty in swallowing) and Failure to Thrive (indicating insufficient weight gain or inappropriate weight loss). Review of the Medical record revealed that when completing the admission assessment RN # 1 failed to obtain a correct height measurement for Resident # 132, entering 62 inches when in fact the resident was 70 inches tall which was not corrected until 4/09/17 by RN # 2 during a readmission assessment. In addition a weight obtained on 2/24/17 of 167.5 pounds was entered and a recheck of Resident #132's weight of 162.1 pounds was entered on 2/25/17. The inaccurate information was then conveyed to the Dietician's assessment on 3/01/17 and section K0200 of the MDS (Minimum Data Set) coded assessment completed on 3/03/17. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. The inaccurate height and weight measurements were used to calculate Resident # 132's Body Mass Index (BMI) calculating a BMI of greater than 30 indicating that Resident # 132 was obese. Resident # 132's actual height of 70 inches and weight of 162.1 pounds calculate a BMI of 23 which places him/her in a normal weight category. On 3/01/17 the inaccurate height, weight and BMI measurements were used to develop a plan of care for Resident # 132's Nutritional risk related to mechanically altered diet and poor oral intake of 0-25%. Review of Resident # 132's MDS dated [DATE] revealed the correct height of 70 and a weight documented in the electronic medical record on 7/07/17 revealed a current weight of 142.8 pounds. Review of the Nutritional risk care plan with a goal to maintain a stabilized weight of 152 pounds. Or gradual weight loss is also desirable for BMI < (greater than) 30 during next 90 days. which was revised on 6/15/17 did not accurately reflect Resident # 132's most recent height, weight and BMI measurements. The care plan was unchanged and did not provide accurate information to effectively monitor and ensure proper management of nutritional risk factors and prevention of potentially avoidable decline in nutritional status. The Administrator, Director of nursing (DON) and the Dietician were made aware of these concerns on 8/30/17 at 12:15 PM, additional information was provided by the Dietician on 8/30/17 at 3:03 PM.

Based on medical record review, observation and staff interview, it was determined the facility staff failed to review and revise the interdisciplinary care plans to reveal accurate interventions for Resident (# 89). This was evident for 1 of 28 residents reviewed during the stage 2 survey process. The findings include: Once the facility staff completes an in-depth assessment of the resident, the interdisciplinary team meet and develop care plans. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions and assure the resident's needs are attended to. The care plan is to be reviewed and revised at each assessment time of the resident to ensure the interventions on the care plan is accurate and appropriate for the resident. Medical record review for Resident # 89 revealed on 3/29/16 the facility staff assessed the resident and completed a side rail evaluation and determined: side rails to be used as boundaries for uncontrolled movements. The resident was admitted to the facility with a condition that caused uncontrolled movements. Side rails are long narrow members connecting the headboard and footboard of a bed. They are widely used to reduce the risk of falls or to enable a resident to assist with self-movement in bed. At that time the facility staff initiated a care with the intervention of: 1/2 side rails to set boundaries for uncontrolled movements. On 4/21/16 the physician ordered: low air loss mattress. A low air loss mattress contains tiny laser made air holes in the mattress top surface continually blow out air causing the patient to float. This is the preferred method of treatment (and prevention) of skin ulcers. It is an excellent way of reducing skin interface pressure at the mattress surface. On 7/14/16 the physician ordered: full side rails related to air mattress. Surveyor observation of the resident throughout the survey process and with the Director of Nursing on 8/30/17 at 9:00 AM revealed the resident in bed with full side rails on both sides of the bed (2, 1/2 side rails on each side). It was determined the side rails fit well with the low air loss mattress and it was revealed Resident # 89 felt comfortable with the side rails up. On 3/8/17, 6/8/17 and 8/11/17 the facility staff assessed the resident; however, failed to review and revise the resident's care plan to reflect the use of full side rails Interview with the Director of Nursing on 8/31/17 at 1:30 PM confirmed the facility staff failed to review and revise a care plan for Resident # 89 to reflect the current status of side rail use.

Based on medical record review, observation and interview, it was determined the facility staff failed to administer a medication to Resident # (# 15) as ordered by the physician and failed to: obtain an MRI as ordered by the physician; failed to obtain a neurology consultation as ordered by the physician; failed to obtain orthostatic blood pressures as ordered by the physician and failed to thoroughly clarify with the physician an order for strict I+O for Resident (# 167). This was evident for 2 of 28 residents selected for review in the stage 2 survey sample. The findings include: 1. The facility staff failed to administer a medication to Resident # (# 15) as ordered by the physician. Medical record review for Resident # 15 revealed on 6/7/17 the physician ordered: Hydrocortisone 10 milligrams by mouth every day for adrenal gland. Hydrocortisone is the chemical form of the cortisone your adrenal gland produces. The average daily production of hydrocortisone in your body is about 30 to 40 mg. If you have adrenal insufficiency (low adrenal function or adrenal fatigue), you may be producing much less and have symptoms as a consequence. The adrenal glands produce a hormone called cortisol (or hydrocortisone) which is released into the blood. The adrenal gland and making cortisol/hydrocortisone is controlled by hormones from the pituitary gland called adrenocorticotrophin hormone, ACTH for short, which travel in the blood to the adrenal glands. Surveyor observation of medication pass on 8/29/17 at 8:35 AM revealed CMA (Certified Medication Aide) # 1 failed to administer the medication as ordered. Observation of the medication cart at that time revealed no evidence of the medication being in the facility. Review of the Medication Administration Record revealed the facility staff failed to administer the medication 8/29/17. Interview with the Director of Nursing on 8/31/17 at 1:30 PM confirmed the facility staff failed to obtain and administer a medication as ordered by the physician for Resident # 15. 2 A. The facility staff failed to obtain an MRI as ordered by the physician for Resident # 167. Medical record review for Resident # 167 revealed on 5/30/17 the physician ordered: MRI with and without contrast. Magnetic resonance imaging (MRI) of the body uses a powerful magnetic field, radio waves and a computer to produce detailed pictures of the inside of your body. It may be used to help diagnose or monitor treatment for a variety of conditions. Further record review revealed the facility staff failed to obtain the MRI as ordered by the physician. 2 B. The facility staff failed to obtain a neurology consultation as ordered: Medical record review for Resident # 167 revealed on 5/30/17 the physician ordered: follow up with neurology and on 8/9/17 and 8/24/17 the physician again ordered: neurology consultation. Neurology is the branch of medicine concerned with the study and treatment of disorders of the nervous system. The nervous system is a complex, sophisticated system that regulates and coordinates body activities. Further record review revealed the facility staff failed to obtain the neurology consultations as ordered by the physician for Resident # 167. 2 C. The facility staff failed to obtain orthostatic blood pressures as ordered by the physician Medical record review for Resident # 167 revealed on 8/10/17 at 10:45 AM the Certified Registered Nurse Practitioner (CRNP) ordered: orthostatic blood pressure now and report results to CRNP. Orthostatic blood pressure is a vital sign gathered from a patient who has potential blood pressure problems. Something called orthostatic hypotension occurs when a resident's blood pressure drops considerably when transitioning positions (going from lying down to sitting up, sitting to standing, etc.) and results in a feeling of light-headedness and dizziness, even fainting. Specifically, if the systolic blood pressure (the higher number) drops by 20 units upon standing, or the diastolic blood pressure (the lower number) drops by 10 units upon or within three minutes of standing, the person is said to have orthostatic hypotension. You can measure a person's blood pressure in different positions in order to determine whether or not they have orthostatic hypotension. Further record review revealed the facility staff failed to obtain the orthostatic blood pressure on 8/10/17 as ordered by the CRNP. 2 E. The facility staff failed to thoroughly clarify with the physician or CRNP the order: Strict I+O every shift for 5 days. Medical record review for Resident # 167 revealed on 6/19/17 the CRNP ordered: strict I+O (intake and output) every shift for 5 days. Measurement of a resident's fluid intake by mouth, feeding tubes, or intravenous catheters and output from kidneys, gastrointestinal tract, drainage tubes, and wounds. Accurate 24-hr measurement and recording is an essential part of patient assessment. On an average, strict I+O is not conducted on residents in the facility. Interview with the Director of Nursing on 8/29/17 at 1:00 PM revealed the facility staff failed to thoroughly clarify with the CRNP or physician the exact intent of the order; therefore, the facility staff failed to conduct any I+O on Resident # 167. Interview with the Director of Nursing on 8/31/17 at 1:30 PM confirmed the facility staff failed to: obtain a MRI; failed to obtain neurology consultation; failed to obtain orthostatic blood pressure and failed to thoroughly clarify an order for strict I+O for Resident # 167.

2. The facility failed to administer a resident's blood pressure medication in accordance with parameters established by a physician's order. A review of Resident # 120's medical record reveals the following physician's order, entered into the medical record on 5/22/2017: Midodrine HCL Tablet 10 MG (milligrams). Give 1 tablet by mouth three times a day for hypotension (low blood pressure). Hold for SBP (Systolic Blood Pressure) greater than 130. Continued record review reveals that the medication was administered on the following dates when Resident #120 had a recorded systolic blood pressure above 130 and outside of the physician ordered parameters. June 13, 2017 at 10:00 PM. Blood Pressure 140/72 June 23, 2017 at 10:00 PM. Blood Pressure 144/62 June 24, 2017 at 6:00 AM. Blood Pressure 138/62 June 30, 2017 at 10:00 PM. Blood Pressure 132/68 July 1, 2017 at 2:00 PM. Blood Pressure 133/89 July 6, 2017 at 6:00 AM: Blood Pressure 146/90 July 7, 2017 at 6:00 AM. Blood Pressure 136/72 July 7, 2017 at 10:00 PM: Blood Pressure 132/76 July 10, 2017 at 10:00 AM. Blood Pressure 132/78 July 15, 2017 at 6:00 AM. Blood Pressure 138/78 July 15, 2017 at 2:00 PM. Blood Pressure 138/78 July 20, 2017 at 10:00 PM. Blood Pressure 140/80 August 13, 2017 at 10:00 PM. Blood Pressure 132/96 August 14, 2017 at 6:00 AM. Blood Pressure 132/60 The findings were shared with the Director of Nursing on 8/30/2017 who confirmed that facility staff had failed to administer Resident # 120's medication in accordance with physician ordered parameters on the aforementioned dates. Based on medical record review and interview, it was determined the facility failed to clearly identify target symptoms for the administration of psychotropic medications and establish a plan for the ongoing monitoring of those symptoms for Resident (# 55). and failed to hold medication when the blood pressure or heart rate was below the set parameter as ordered by the physician for Residents (# 120 and # 76) .This was evident for 3 of 28 residents selected for review in the stage 2 survey sample. The findings include: 1. The facility failed to clearly identify target symptoms for the administration of psychotropic medications and establish a plan for the ongoing monitoring of those symptoms for Resident # 55. Medical record for Resident # 55 revealed on 3/13/17 the physician ordered: Ativan .5 milligrams by mouth 3 times a day as needed for agitation and sundowning. Sundowning is a symptom of Alzheimer's disease and other forms of dementia. It's also known as late-day confusion. If someone for has dementia, the confusion and agitation may get worse in the late afternoon and evening. Ativan belongs to a class of drugs known as benzodiazepines which act on the brain and nerves (central nervous system) to produce a calming effect. This drug works by enhancing the effects of a certain natural chemical in the body. Further record review revealed the facility staff failed to clearly identify target symptoms for the administration of the Ativan and establish a plan for the ongoing monitoring of those symptoms. Review of the Medication Administration Record revealed the facility staff documented the administration of the Ativan on: 3/15/17 at 9:50 PM, 3/17/17 at 10:30 PM, 3/19/17 at 10:00 PM and 3/26/17 at 4:00 PM; however, the facility staff failed to identify specific targeted behaviors for the administration of the medication. Interview with the Director of Nursing on 8/31/17 at 1:30 PM confirmed the facility staff failed clearly identify specific targeted symptoms for the use of Ativan for Resident # 55. 3. A review of Resident # 76's clinical record revealed that the resident's primary physician wrote an order for the resident to be administered Isosorb Dinitrate-Hydralazine 20-37.5 mg (a cardiac medication) twice a day and Carvedilol 3.125 mg (a cardiac medication) twice a day. Both medications had parameters ordered: Hold for SBP [systolic blood pressure -- the top number] <110 or HR [heart rate] <60. A review of the resident's Medication Administration Review Sheet (MAR) revealed that on Saturday 8/26 the resident's pulse was 55 for the evening doses but the nurse still administered the medication. The Director of Nursing was interviewed on 8/30/17 at 11:20 AM. The order and the MAR were shown to her and she said she would look into it. The Director of Nursing was interviewed on 8/30/17 at 12:30 PM. She confirmed that the medication was administered and that the physician was not called regarding the pulse.

Based on observation of the kitchen on August 28, 2017, it was revealed that sanitary conditions were not being maintained as was possible. The findings included: On August 28, 2017, the kitchen was inspected as part of the Medicare Recertification survey. Observation of the kitchen revealed that the corners of the kitchen were in need of cleaning and a metal shelving unit full of clean kitchenware was located within 24 inches of a hand washing sink. All kitchen must be maintained in a clean and sanitary manner, and all clean kitchen ware must be stored in a manner to protect it from contamination. All nursing care centers must assure that the kitchen and all of the food storage areas would be maintained in a clean and sanitary manner.

Based upon the review of employee files on August 29 and 30, 2017, it was revealed that all employees were not screened for Tuberculosis (TB) as required. The findings included: A review of the files of newly hired employees, both those working for the entity and for a vendor that provides dietary and housekeeping/laundry services, was conducted to determine if these employees were screened for TB at the time of hire and annually thereafter. After the review of new employees revealed that two employees were not screened for TB at the time of hire, the sample was expanded to employees working at this center for more than one year. Based on this review, it was confirmed that all staff were not being screened initially, and annually thereafter, for TB. The employees found to be lacking the required screening for TB included the following: Employee 1, dietary, no screen for TB until after surveyor intervention on August 29, 2017, where this employee was hired on June 15, 2017. Employee 2, dietary, no screen for TB until after surveyor intervention on 8/29/17, where this employee was hired on August 1, 2017. Employee 3, environmental services (EVS), no annual Signs and Symptoms Screen (S/S) for TB. Employee 4, EVS, no annual S/S for TB. Employee 5, EVS, no annual S/S for TB Employee 6, EVS, no annual S/S for TB Employee 7, EVS, no annual S/S for TB Employee 8, EVS, no annual S/S for TB Employee 9, EVS, no annual S/S/ for TB Employee 10, EVS, no annual S/S for TB Employee 11, dietary, no annual S/S for TB Employee 12, dietary, no annual S/S for TB Employee 13, dietary, no annual S/S for TB All nursing centers must maintain an effective infection control program. The program must include the monitoring of employees for infectious diseases both at the time of hire, and annually thereafter.

Based on medical record review and staff interview, it was determined that the facility staff failed to obtain laboratory blood test as ordered by the physician for Resident (# 3) and failed to obtain a stool specimen as ordered for Resident (# 167). This was evident for 2 of 28 residents selected for review in the stage 2 survey sample. The findings include: 1. The facility staff failed to obtain laboratory blood test as ordered by the physician. Medical record review for Resident # 3 revealed on 7/23/15 and 5/15/17 the physician ordered: NH 3 (ammonia) level every 2 weeks on Monday. Ammonia is a waste product naturally produced in the body. It primarily comes from the digestion of protein by bacteria in the intestines. If not processed by the liver and cleared from the body appropriately, excess ammonia can accumulate in the blood and pass from the blood into the brain, where it is toxic. The ammonia test is used to detect an elevated level in the blood that can be caused by severe liver disease kidney failure. The test may be used to help investigate the cause of an individual's changes in behavior and consciousness. Record review revealed the facility staff obtained NH 3 on 12/22/16, 1/10/17, 6/19/17 and 7/17/17; however, failed to obtain the laboratory blood specimen every 2 weeks as ordered. Interview with the Director of Nursing on 8/31/17 at 1:30 PM confirmed the facility staff failed to obtain laboratory blood test as ordered by the physician for Resident # 3. 2. The facility staff failed to obtain a stool specimen as ordered by the physician for Resident # 167. Medical record review for Resident # 167 revealed on 6/15/17 the Certified Registered Nurse Practitioner ordered: stool for C-diff X 1. The stool C difficile toxin test detects harmful substances produced by the bacterium Clostridium difficile (C difficile). This infection is a common cause of diarrhea after antibiotic use; however, the facility staff failed to obtain the stool specimen as ordered. Interview with the Director of Nursing on 8/31/17 at 1:30 PM confirmed the facility staff failed to obtain the stool for C-diff as ordered for Resident # 167.

Based on medical record review and interview, it was determined the facility staff failed to maintain the medical record in the most accurate form for Residents (# 3 and # 114). This was evident for 2 of 28 residents selected for review in the stage 2 survey sample. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. Medical record review for Resident # 3 on 8/29/17 at 9:00 AM revealed the Physicians' Order Sheets for Resident # 114 in the medical record. The unit manager was made aware of the same at that time. Interview with the Director of Nursing on 8/31/17 at 1:30 PM confirmed the facility staff failed to maintain the medical records for Residents # 3 and # 114 in the most complete and accurate form.

2. The facility staff failed to obtain the dietary consultation as ordered. Medical record review for Resident #132 revealed on 5/11/17 the physician's assistant ordered: Dietician consultation related to fluid needs and on 7/20/17 the Nurse Practitioner ordered: Nutrition Consult to evaluate tube feedings related to a weight loss of 30 pounds in 5 months. Further record review revealed the facility staff failed to obtain the dietary consultations as ordered. Based on medical record review and interview, it was determined the facility staff failed to obtain a dietary consultation as ordered by the physician for Resident (# 3 and # 132) and failed to provide Resident (# 167) with a dietary supplement as ordered by the dietician. This was evident for 3 of 28 residents selected for review in the stage 2 survey sample. The findings include: 1. The facility staff failed to obtain a dietary consultation as ordered by the physician for Resident # 3. Medical record review for Resident # 3 revealed on 3/8/17 the physician ordered: Dietary consultation related to hyponatremia. Further record review revealed the facility staff failed to obtain that dietary consultation as ordered. Hyponatremia is a low sodium level in the blood; however, the facility staff failed to obtain that dietary consultation as ordered by the physician. Interview with the Director of Nursing on 8/31/17 at 1:30 PM confirmed the facility staff failed to obtain a dietary consultation as ordered for Resident # 3. 2. The facility staff failed to provide a resident with yogurt each meal as indicated by the dietician. Medical record review for Resident # 167 revealed on 8/8/17 the dietician ordered: provide resident with yogurt with each meal. Interview with Resident # 167 on 8/29/17 at 1:00 PM revealed the resident was not being provided the yogurt as ordered by the dietician. Interview with the Director of Nursing on 8/29/17 at 2:00 PM revealed resident # 167 indicating yogurt was not being provided and it was determined the yogurt was sent to the resident's floor; however, there was no name on the yogurt to indicate which resident it belonged to. (Interview with Resident # 167) revealed the resident was provided with yogurt at dinner on 8/29/17 and breakfast on 8/30/17. Interview with the Director of Nursing on 8/31/17 at 1:30 PM confirmed the facility staff failed to provide Resident # 167 with yogurt as each meal as ordered by the dietician.