**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 65. Review of the facility's policy titled, Homelike Environment, revised February 2021, showed: - Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible; - The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting which includes a clean, sanitary and orderly environment. Observations on 10/07/24 at 2:12 P.M., and 10/09/24 at 2:26 P.M., showed several areas of peeled paint and exposed sheetrock located at the head of the bed located by the window in room [ROOM NUMBER]. Observations on 10/08/24 at 2:16 P.M., and 10/09/24 at 2:30 P.M., showed a large area of peeled paint and exposed sheetrock on the wall beside the bed located by the window in room [ROOM NUMBER]. Observations on 10/08/24 at 2:19 P.M., and 10/09/24 at 2:34 P.M., showed a long, narrow opening in the wall with several areas of peeled paint and exposed sheetrock behind the headboard of the bed located by the window in room [ROOM NUMBER]. Observations on 10/09/24 at 3:04 P.M., and 10/09/24 at 4:02 P.M., of the shower room located by the Director of Nursing (DON) office, showed: - A trash can overflowed with gowns, gloves and miscellaneous trash; - Several used gloves lay on the floor by the trash can; - [NAME] stained areas on top of the toilet lid; - [NAME] smeared areas on the shower curtain by the toilet; - A shower drain broken and bent with a buildup of grime and dirt; - The bottom edges of the shower stall floor with a buildup of black grime and missing caulk; - A dried brown substance on a yellow trash can lid; - A dried brown substance on a green trash can lid; - A soiled wash cloth lay at the bottom of the whirlpool tub; - An open bag of potato chips lay on top of a towel on the clean linen shelf by the whirlpool tub. Observation on 10/10/24 at 9:16 A.M., showed several areas of peeled paint and deep scrapes on the bottom part of the door upon entering room [ROOM NUMBER]. During an interview on 10/10/24 at 9:19 A.M., the resident in room [ROOM NUMBER] said he/she would like someone to paint the door because it looked bad and was missing a door cover at the bottom of it. Observation on 10/10/24 at 1:12 P.M., showed a whole in the bottom of the bathroom door approximately four inches (in.) by two in. located in room [ROOM NUMBER]. Review of the Maintenance log, dated 09/05/24 through 10/05/24, showed no areas of concern addressed. During an interview on 10/10/24 at 8:36 A.M., Housekeeper B said he/she did not always report things that needed to be addressed by the maintenance department. He/She should be more proactive in this area. During an interview on 10/10/24 at 8:42 A.M., Housekeeper C said he/she had reported things to maintenance to be repaired and wrote them down on the maintenance log located at the nurse's station. He/She also verbally told maintenance when something needed to be repaired. Everything should be on the maintenance log that he/she had reported. During an interview on 10/10/24 at 11:44 A.M., Shower Aide E said whoever gave the showers should be cleaning up the shower room afterwards to ensure cleanliness. Staff should not be eating food and/or leaving food in the shower rooms. During an interview 10/10/24 at 11:59 A.M., the Maintenance Supervisor (MS) said staff would verbally tell him/her about environmental concerns. He/She would prefer staff to write down environmental concerns and repairs on the maintenance log at the nurse's station. Staff had been told to write down any issues needing addressed in the past. During an interview on 10/10/24 at 1:51 P.M., the Director of Operations (DOP) said she would expect staff to write down any environmental concerns or repairs needed for the MS to be addressed in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate personal hygiene for one resident (Resident #10) out of 16 sampled residents and two additional residents (Resident #2 and #57) and failed to provide showers at least twice a week for one resident (Resident #2) outside the sample. The facility census was 65. Review of the facility's policy titled, Dignity, revised February 2021, showed: - Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem; - Residents are treated with dignity and respect at all times; - The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs; - This begins with the initial admission and continues throughout the resident's facility stay; - Individual needs and preferences of the resident are identified through the assessment process; - When assisting with care, residents are supported in exercising their rights. For example, residents are: groomed as they wish to be groomed (hair styles, nails, facial hair, etc.); encouraged to attend the activities of their choice, including religious, political, civic, recreational, or social activities; encouraged to dress in clothing that they prefer; allowed to choose when to sleep, eat and conduct activities of daily living; and provided with a dignified dining experience. 1. Review of Resident #2's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 08/14/24, showed: - Partial or moderate assistance for personal hygiene; - Substantial/maximum assistance for bathing. Review of the resident's care plan, dated 07/18/24, showed: - Activities of daily living (ADL) self-care performance deficit related to paralysis and weakness. Required monitoring to ensure safe and adequate completion of ADL's due to weakness and impaired cognitive/communication ability; - Usually able to wash part of him/herself in the shower but needed substantial assist of one to complete a shower safely and adequately. Assess for adequate completion and offer assist as needed; - Assist as needed with transfers in and out of the bath/shower. Review of the facility's shower schedule showed Resident #2 scheduled for showers three days weekly on Tuesday, Thursday and Saturday. Review of the resident's shower sheets, dated 08/01/24-10/09/24, showed: - For August 2024, 13 missed out of 14 opportunities for showers and nail care; - For September 2024, 12 missed out 12 opportunities for showers and nail care; - For October 2024, three missed out of four opportunities for showers and nail care. Observations of the resident on 10/07/24 at 11:29 A.M., and 10/08/24 at 8:30 A.M., showed the resident's hair greasy and toenails long and untrimmed. During an interview on 10/09/24 at 11:50 A.M., the Assistant Director of Nursing (ADON) said there were only two shower sheets for Resident #2 because the resident was care planned to do showers by him/herself. During an interview on 10/09/24 at 3:48 P.M., Resident #2 said he was unable to wash his/her hair, back, lower legs and feet by him/herself. He/She would prefer to receive showers more often and would like his/her toenails trimmed. 2. Review of Resident #10's quarterly MDS, dated [DATE], showed: - Dependent on staff for assistance for personal hygiene. Review of the resident's care plan, dated 07/25/24, showed: - ADL self-care performance deficit due to history of a stroke. Needed assist to complete most ADL's; - Personal hygiene needed extensive to full assist of one staff to complete personal hygiene tasks. Observations of the resident on 10/107/24 at 11:32 A.M., 10/08/24 at 8:33 A.M., 10/09/24 at 2:00 P.M., and 10/10/24 at 10:08 A.M., showed he/she had facial hair on his/her chin and upper lip. During an interview on 10/07/24 at 11:32 A.M., Resident #10 said he/she had facial hair on his/her chin and upper lip and would like it to be shaved, but the staff would not shave it. 3. Review of Resident #57's annual MDS, dated [DATE], showed: - Dependent on staff for assistance for personal hygiene. Review of the resident's care plan, dated 07/30/24 showed: - Severely impaired cognitive, communication, and functional status, and dependent on staff for all ADL's; - Dependent on staff for completion of hygiene. Shave on shower days and as needed. Review of the facility's shower schedule showed the resident scheduled for showers three days weekly on Monday, Wednesday and Friday. Review of the resident's shower sheets, dated 08/24/24-10/10/24, showed: - For August 2024, 13 missed out of 13 opportunities for nail care; - For September 2024, 13 missed out of 13 opportunities for nail care; - For October 2024, four missed out of four opportunities for nail care. Observations on 10/07/24 at 3:38 P.M. and 10/9/24 at 3:20 P.M., showed the resident lay in bed with untrimmed toenails and fingernails and several areas of flaky dry skin. During an interview on 10/10/24 at 10:45 A.M., Shower Aide E said he/she didn't do all of the showers, because the Certified Nurse Assistants (CNAs) will do certain residents. He/She always completed a shower sheet even if the resident showered themselves or refused. He/She knew some of the CNAs forgot to complete the sheets. The nurses should be doing the diabetic residents' nails, but otherwise the CNAs should be doing them. Sometimes the staff would forget to document they checked/clipped the residents' nails. Any of the CNAs could cut the residents' nails unless they were diabetic. During an interview on 10/10/24 at 2:13 P.M., the Director of Nursing (DON) said she would expect a shower sheet to be completed every time a resident took a shower or refused a shower. She would expect the CNAs to complete nail care and nurses to complete nail care for the diabetic residents.

Based on observation, interview, and record review, the facility failed to store medications in accordance with accepted professional standards of practice. This deficient practice had the potential to affect all residents residing in the facility. The facility also failed to properly label medications in a safe and effective manner. The facility's census was 65. Review of the facility's policy titled, Medication Labeling and Storage, dated 2001, showed: - Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses station or other secured location. Medications are stored separately from food and are labeled accordingly; - Policy did not address checking and the appropriate refrigerator temperatures or labeling over the counter medications with an opened date. 1. Review of the Medication Refrigerator Temperature Log, dated 08/01/24 - 10/08/24, showed: - For August 2024, the medication refrigerator's temperature was not documented for 11 out 31 opportunities, and 18 out of the 20 completed temperatures were above 41 degrees; - For September 2024, the medication refrigerator's temperature was not documented for eight out of 30 opportunities, and 21 out of the 22 completed temperatures were above 41 degrees; - For October 2024, the medication refrigerator's temperature was not documented for two out of eight opportunities, and six out of the eight completed temperatures were above 41 degrees. 2. Observation on 10/08/24 at 10:27 A.M., of the medication cart showed: - An opened Byetta (an anti-diabetic medication) injection pen, undated and unlabeled; - One opened bottle of over the counter prenatal vitamins (supplements that contain vitamins for a healthy pregnancy), undated; - One opened bottle of over the counter geritussin (helps to thin mucus), undated; - One opened bottle of over the counter clearlax (used to treat constipation), undated; - One opened bottle of over the counter pepto bismuth (used to treat heartburn or upset stomach), undated; - One opened bottle of over the counter fiber powder (used to treat constipation), undated. During an interview on 10/08/24 at 10:35 A.M., the Assistant Director of Nursing (ADON) said sometimes the nurses forgot to write an open date on the over the counter medications when they were opened. The temperature log should be checked daily by the evening nurses. During an interview on 10/10/24 at 11:19 A.M., the Director of Nursing (DON) said that she expected nurses to be checking the refrigerator temperatures daily and the weekend evening nurse had not been doing it like he/she was taught. She did expect staff to write an opened date on over the counter medications when a new bottle was opened.

Based on observation and interview, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents who are served food from the kitchen. The facility census was 65. 1. Observation on 10/07/24 at 2:24 P.M., of the dry food storage room showed: - A large bag of elbow pasta opened with the top of the bag twisted, not sealed and undated; - Three bags of cereal opened, undated, and one unsealed; - Opened graham cracker crumbs in a labeled box with the bag unsealed. 2. Observation on 10/07/24 at 2:25 P.M., of the storage area showed: - Two large baking sheets with black carbon build up on the sides/bottom. 3. Observation on 10/07/24 at 2:26 P.M., of a white single door residential-style stand up freezer located in the front of the kitchen showed: - Two Ziploc bags of frozen items unlabeled and undated. 4. Observation on 10/07/24 at 2:27 P.M., of a white single door residential-style stand up freezer located in the back of the kitchen showed: - Six bags of frozen items unlabeled and undated. 5. Observation on 10/08/24 at 9:47 A.M., 1:00 P.M., 1:11 P.M., and 1:13 P.M., and 10/09/24 at 2:00 P.M., and 10/10/24 at 12:00 P.M., showed no dietary staff wore hair nets while working and preparing food in the kitchen. 6. Observation on 10/08/24 at 1:13 P.M., of the kitchen staff preparing food showed: - Dietary Aide D knocked two skillets onto the floor from a shelf and put the two skillets back on the shelf; - Dietary Aide D put on gloves, touched the refrigerator, a cutting board and a knife, and then touched a green pepper without changing gloves and performing hand hygiene; - Dietary Aide D used one of the skillets that was knocked onto the floor from the shelf to saute green peppers without changing gloves and performing hand hygiene. During an interview on 10/10/24 at 12:00 P.M., the Dietary Manager (DM) said he/she would expect opened packages of food to be wrapped or put into appropriate storage containers, and to be labeled and dated. He/She would expect kitchen cookware to be free from carbon buildup, the staff to wear hair nets in the kitchen, to change gloves after touching dirty surfaces, and to wash a skillet if it was dropped on the floor before using it to prepare food.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 53. Review of the facility's policy titled, Maintenance Service, revised December 2022, showed: - Maintenance shall be provided to all areas of the building, grounds, and equipment; - The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times; - Functions of maintenance personnel include maintaining the building in good repair and free from hazards and providing routinely scheduled maintenance service to all areas. Observation on 05/16/23 at 10:47 A.M., and 05/17/23 at 11:18 A.M., of the 100 Hall showed: - A ceramic figurine on top of a light fixture above the bed located by the door in room [ROOM NUMBER]; - Three, 4 inch (in.) x 5 in. and two 5 in. x 7 in. picture frames on top of a light fixture above the bed located by the window in room [ROOM NUMBER]. Observation on 05/16/23 at 12:03 P.M., and 05/18/23 at 12:18 P.M. of the 100 Hall shower room showed: - A six in. brown smeared substance on a vinyl curtain in front of five shelves containing miscellaneous items located to the left side of the door upon entering; - Three areas of a dried buildup substance on a vinyl privacy curtain located in front of the toileting area; - A six in. x 30 in. ceiling area with peeling paint and blue tape located by a light fixture and air vent; - A six in. x 34 in. area of peeling paint located above and behind the top of toilet lid; - Several missing ceramic tiles with exposed rigid wood edges located on the front of the sink basin. Observation on 05/17/23 at 06:18 P.M., of the 200 Hall shower room showed a build up of dust and debris on an air vent near the shower stall. Record review of the maintenance log binder dated 04/05/23 through 05/17/23 showed no current requests for areas of concern documented. During an interview on 05/18/23 at 09:12 A.M., Housekeeper E said he/she reported any concerns or repairs needed to the supervisor. There was also a maintenance log that staff could write down repairs at the nurse's station. He/she had not written down any thing recently that needed addressed. During an interview on 05/18/23 at 09:22 A.M., Nursing Assistant (NA) F said he/she reported any concerns to the supervisor and would sometimes write needed repairs in the maintenance log book. He/she had not seen anything to report in terms of repairs or environmental issues. During an interview on 05/18/23 at 09:26 A.M., Licensed Practical Nurse (LPN) G said there was a maintenance log book to write down any needed repairs. He/she had not reported any environmental issues or other areas of concern recently. During an interview 05/19/23 11:08 A.M., Certified Nursing Assistant (CNA) D said he/she informed his/her supervisor of any needed repairs and would sometimes write concerns down on the maintenance log. He/she had not reported any environmental concerns recently. During an interview on 05/22/23 at 09:56 A.M., the Administrator said she would expect staff to write down needed repairs or environmental concerns on the maintenance log to be addressed and followed up on in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS) (a federally mandated assessment tool completed by the facility) assessment for one resident (Resident #18) out of three sampled residents. The facility's census was 53. Review of the facility's policy titled, Comprehensive Assessments, dated March 2022 showed: - Significant change in status assessment is a comprehensive assessment for a resident that must be completed when the interdisciplinary team (IDT) (a group of health care professionals from diverse fields who work in a coordinated effort toward a common goal for a resident) has determined that a resident meets the significant change guidelines for either major improvement or decline. 1. Review of Resident #18's medical record showed: - The quarterly MDS, dated [DATE], showed the resident received hospice (health care focused on the quality of life of a terminally ill person) services; - A discharge date of 04/19/23 from hospice services; - The facility failed to complete a significant change MDS within 14 days after the discharge of the resident's hospice services. During an interview on 05/18/23 at 09:15 A.M., the MDS Coordinator said the resident discharged from hospice services on 04/19/23. He/she was new to the MDS role and was not aware of the significant change not being completed. During an interview on 05/18/23 at 02:54 P.M., the Resident Assessment Instrument (RAI) Coordinator said the facility had two different MDS Coordinators in the last month. The significant change MDS was missed on the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document preparation and orientation for transfer to the hospital for two residents (Resident #38 and #87) out of 12 sampled residents. The facility's census was 36. 1. Record review of Resident #38's progress notes showed: - The resident transferred to the hospital on 8/29/20 and not readmitted to the facility. Record review of the resident's medical record did not contain documentation which showed the resident was prepped and oriented for transfer out of the facility. 2. Record review of Resident #87's progress notes showed: - The resident transferred to the hospital on 8/27/20 and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 5/19/20 and readmitted to the facility on [DATE]. Record review of the resident's medical record did not contain documentation which showed the resident was prepped and oriented for transfer out of the facility. During an interview on 10/9/20 at 10:45 A.M., the Director of Nursing (DON) said she was sure the staff were doing that and it is just not documented but they will start doing that. Record review of the facility's policy titled, Discharge/Transfer of Resident, dated March 2015, showed the policy did not address documentation for preparation and orientation for transfer.

Based on observation, interview, and record review, the facility failed to ensure the accuracy of assessments for one resident (Resident #10) out of 12 sampled residents. The facility's census was 36. 1. Record review of Resident #10's medical record showed: - A quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by facility staff, dated 6/30/20, showed the resident had an indwelling urinary catheter (a flexible tube that drains urine from the bladder to a collection bag); - A Physician's Order Sheet (POS), dated 4/09/20, with orders to discontinue urinary catheter; - A care plan for an indwelling catheter, last reviewed 3/31/20. Observation on 10/06/20 at 1:33 P.M. showed Resident #10 had no indwelling urinary catheter. During an interview on 10/06/20 at 2:55 P.M., the Director of Nursing (DON) said the resident no longer had a urinary catheter. During an interview on 10/08/20 at 3:45 P.M., the MDS Coordinator said the urinary catheter should not have been on that MDS. He/she had looked through the nurse's notes but had not seen where the catheter had been discontinued. During an interview on 10/09/20 at 10:45 A.M., the DON said she would expect the MDS assessment to be accurate. Record review of the facility's policy titled, Resident Assessment Instrument, dated October 2019, showed Federal regulations require the assessment accurately reflect the resident's status.

Based on interview and record review, the facility failed to develop and implement an individualized comprehensive care plan with specific interventions for two residents (Resident #32 and #87) out of 12 sampled residents. The facility's census was 36. 1. Record review of Resident #32's Physician's Order Sheet (POS), dated 10/01/20 through 10/31/20, showed diagnoses of lack of coordination, abnormal gait and mobility, mild cognitive impairment, dizziness and giddiness, repeated falls, orthostatic hypotension (a form of low blood pressure that happens when standing up from sitting or lying down), and muscle weakness. Record review of the resident's quarterly the Minimum Data Set (MDS, a federally mandated assessment instrument completed by the facility) dated 8/15/20, showed: - Limited physical assistance of one staff for bed mobility, transfers, and toileting; - Extensive physical assistance of one staff for locomotion (moving from one place to another), dressing, personal hygiene, and bathing. Record review of the resident's Fall Risk Assessment, dated 5/22/20, showed moderate fall risk. Record review of the resident's progress notes, dated 8/23/20, showed resident found lying on the floor, able to move all extremities with no pain or discomfort. Resident stated he/she had a bump on his/her head that hurt. Hematoma noted to left side of the resident's head. No other injuries noted. Record review of the resident's comprehensive care plan, updated 3/20/20, showed no interventions or plan of care for falls. 2. Record review of Resident #87's POS, dated 10/1/20 through 10/31/20, showed: - Diagnosis of seizures; - An order, dated 9/4/20, for levetiracetam (an anticonvulsant medication) 500 milligram (mg) twice daily. Record review of the resident's progress notes, dated 5/22/20, showed readmit: - Resident on way back to facility; - New diagnosis of new onset seizures; - New order for Keppra (levetiracetam) 500 mg twice daily. Record review of the resident's comprehensive care plan, updated 3/20/20, showed no interventions or plan of care for seizures. During an interview on 10/9/20 at 10:45 A.M., the Director of Nursing (DON) said she would expect a resident at risk for falls to have a care plan addressing falls. She would expect a resident with seizures to have a care plan addressing seizures. Record review of the facility's policy titled, Care Plan Comprehensive, dated March 2015, showed: - An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being; - The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the Minimum Data Set (MDS, a federally mandated assessment instrument completed by the facility); - Assessment of each resident is an ongoing process and the care plan will be revised as changes occur in the resident's condition.

Based on observation, interview, and record review, the facility failed to revise and update comprehensive care plans with specific interventions to meet the individual needs of two residents (Resident #10 and #87) out of 12 sampled residents. The facility's census was 36. 1. Record review of Resident #10's Physician's Order Sheet (POS), dated 3/26/20 through 4/22/20, showed an order for discontinuation of urinary catheter (a small, flexible tube that drains urine from the bladder to a collection bag) on 4/09/20. An observation on 10/06/20 at 1:33 P.M. showed Resident #10 did not have an indwelling urinary catheter. Record review of Resident #10's care plan, last reviewed 3/31/20, showed a care plan in place for an indwelling catheter and did not reflect the catheter had been discontinued. 2. Record review of Resident #87's POS, dated 10/1/20 through 10/31/20, showed: - Diagnoses of Type 2 diabetes mellitus (a chronic metabolic disorder affecting blood sugar) with diabetic chronic kidney disease, dependent on renal dialysis, end stage renal disease (the final stage of chronic kidney disease when the kidneys are no longer able to work to meet the body's needs), seizures, hypertension, muscle weakness, toxic metabolic encephalopahy (brain dysfunction from failure of other internal organs)and coronary artery disease (a condition causing damage to the major blood vessels that supply the heart with blood, oxygen, and nutrients.) Record review of the resident's nurse's progress notes showed: - On 5/22/20, readmit, - New diagnosis of new onset seizures and hypertension (high blood pressure), New order for Keppra (an anticonvulsant medication) 500 milligram (mg) twice daily, Clonodine patch (an antihypertensive medication) 0.3 mg/24 hour change every 72 hours, and Hydralazine (an antihypertensive medication) 50 mg three times daily. - New order for 1500 milliliter (ml) fluid restriction; - On 8/17/20, resident refused dialysis today; - On 8/19/20, resident is refusing to go to dialysis again today; - On 8/26/20, resident refusing to go to dialysis on this day; - On 8/27/20, resident does not want to go to dialysis again on this day. Resident sent to hospital for altered mental status and seizures; - On 9/14/20, resident left dialysis on 9/11/20 before time to be done, stating he/she didn't feel good. Guardian called with concerns that resident continues to be at times non compliant with this; - On 9/22/20, resident found sitting on bottom in floor, beside bed. No apparent injuries noted. When asked what happened, the resident said he/she slid out of bed onto the floor because the wheelchair doesn't lock right. Denied striking head. Record review of the resident's comprehensive care plan, updated 3/20/20, showed: - Care plan not updated with new order for fluid restriction and not placed on intake and output monitoring; - Care plan not updated for refusals of dialysis; - Care plan not updated with new interventions following fall on 9/22/20. During an interview on 10/08/20 at 3:45 P.M., the Minimum Data Set (MDS, a federally mandated assessment completed by the facility) Coordinator said he/she is responsible for several homes. Some things may have been missed, but any nurse can update the care plans. During an interview on 10/9/20 at 10:45 A.M., the Director of Nursing (DON) said she would expect the care plan to be updated for a resident with a new order for fluid restriction, refusals of dialysis, new interventions after a fall and after an indwelling urinary catheter had been removed. The MDS Coordinator calls on the phone for updates on the residents and makes the residents' changes. The DON said she had not been shown how to make changes in the computer charting and would expect any nurse to be able to update the care plan. Record review of the facility's policy titled, Care Plan Comprehensive, dated March 2015, showed the interdisciplinary care plan team is responsible for the periodic review and updating of care plans when a significant change in the resident's condition has occurred, at least quarterly, and when changes occur that impact the resident's care. Record review of the facility's policy titled, Dialysis, Care of a Resident Receiving, dated March 2015, showed: - Residents with fluid restrictions due to dialysis: The resident will be placed on I&O to monitor the resident's fluid intake and output. The physician will be notified of non-compliance. All the above will be addressed on the care plan as indicated.

Based on interview and record review, the facility failed to follow physician's orders for one resident (Resident #87) out of 12 sampled residents. The facility's census was 36. Record review of the facility's policy titled, Dialysis, Care of a Resident Receiving, dated March 2015, showed: - Checking the Thrill Sensation: Nurses will check the thrill daily and document daily. This will be documented on the resident's treatment record. If no thrill sensation is felt, notify the physician; - Residents with Fluid Restrictions due to Dialysis: The resident will not have a water pitcher in their room. The resident will be placed on I&O (intake and output) to monitor the resident's fluid intake and output. The physician will be notified of non-compliance. All of the above will be addressed on the care plan as indicated. Record review of Resident #87's Physician's Order Sheet (POS), dated 9/01/20 through 9/30/20, showed an order written on 5/29/20 to check bruit (a sound associated with blood flow) and thrill (a tremor or vibration felt by touch to indicate blood flow) in right arm every shift. Record review of Resident #87's POS, dated 10/01/20 through 10/31/20, showed: - Diagnoses of Type 2 diabetes mellitus (a chronic metabolic disorder affecting blood sugar) with diabetic chronic kidney disease, dependent on renal dialysis, end stage renal disease (the final stage of chronic kidney disease when the kidneys are no longer able to work to meet the body's needs), seizures, hypertension, muscle weakness, toxic metabolic encephalopahy (brain dysfunction from failure of other internal organs)and coronary artery disease (a condition causing damage to the major blood vessels that supply the heart with blood, oxygen, and nutrients); - An order written on 5/29/20 to check bruit and thrill in right arm every shift not carried over to the October POS. Record review of the resident's Treatment Record showed: - For August 2020, four out of 31 opportunities to check bruit and thrill missed on day shift, 21 out of 31 opportunities missed on evening shift, and three out of 31 opportunities missed on night shift; - For September 2020, four out of 27 opportunities missed on day shift, 19 out of 27 opportunities missed on evening shift, and one out of 27 opportunities on night shift; - For October 2020, no treatment to check bruit and thrill in right arm every shift for 10/1/20 through 10/9/20. During an interview on 10/9/20 at 10:45 A.M., the Director of Nursing (DON) said she would expect treatment orders to be followed as written. She would expect the nurse to check the new POS to make sure it was correct.