**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, medical record review and policy review, the facility failed to ensure residents received adequate nail care. This affected one (#15) of three residents reviewed for activities of daily living (ADLs). The facility census was 106. Findings include: Review of the medical record revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right non-dominant side, unspecified vascular dementia, unspecified contracture, unspecified epilepsy, and type II diabetes. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #15 had moderately impaired cognition, had no behaviors, did not reject care, and did not wander. Resident #15 required substantial/maximal assistance with personal hygiene, bathing, upper body dressing, and toileting. Review of the care plan dated 10/20/20 revealed Resident #15 had an ADL self-care performance deficit. Interventions included staff assistance with ADLs, mechanical (Hoyer) lift for all transfers, promoting dignity by ensuring privacy, right hand/forearm splint daily as tolerated up to 10 hours, and showers twice weekly on Wednesdays and Saturdays. Review of shower sheets dated 11/06/24, 11/09/24, 11/12/24, 11/16/24, 11/20/24, and 11/23/24 revealed Resident #15 received bed baths. There was no documentation which indicated whether fingernail care was offered and provided or refused. Observation on 11/27/24 at 9:00 A.M. revealed Resident #15's left hand, third fingernail appeared broken and jagged. Resident #15's left fourth and fifth fingernails were overgrown from the base of the finger pad by approximately one-third of an inch. During an interview on 11/27/24 at 9:00 A.M. Resident #15 stated staff trimmed his fingernails every once in a while, but not with every shower or bath. The resident did not recall the last time his fingernails were trimmed. During an interview on 11/27/24 at 10:31 A.M. Licensed Practical Nurse (LPN) #250 verified Resident #15's fingernails on the left hand were sharp and needed to be trimmed down. LPN #250 verified the fingernails appeared trimmed close to the finger pads on right hand. During an interview on 11/27/24 at 3:07 P.M. Corporate Registered Nurse (RN) #55 verified the facility had no documented evidence that fingernail care was offered or provided to Resident #15. Review of policy titled, ADL Care, dated 11/2023, revealed a resident who was unable to carry out activities of daily living received necessary services to maintain good nutrition, grooming, personal and oral hygiene. This deficiency represents non-compliance investigated under Complaint Number OH00158680.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and medical record review, the facility failed to ensure residents' private care information was not posted in areas visible to the public. This affected 14 (#85, #86, #87, #88, #89, #91, #95, #97, #98, #99, #101, #103, #106, and #108) of 16 residents reviewed for privacy. The facility census was 106. Findings include: 1. Review of the medical record revealed Resident #85 was admitted to the facility on [DATE]. Diagnoses included central cord syndrome at C6 level of the cervical spine, generalized muscle weakness, major depressive disorder, contracture right hand, unspecified anxiety disorder, and an unstageable pressure ulcer to the right heel. 2. Review of the medical record revealed Resident #86 was admitted to the facility on [DATE] and had diagnoses including unspecified dementia, unspecified anxiety disorder, type II diabetes, and repeated falls. 3. Review of the medical record revealed Resident #87 was admitted to the facility on [DATE] and had diagnoses including type II diabetes, stage III chronic kidney disease, chronic gout, unspecified anxiety, and unspecified depression. 4. Review of the medical record revealed Resident #88 was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease, major depressive disorder, and spondylolisthesis of the lumbosacral region. 5. Review of the medical record revealed Resident #89 was admitted to the facility on [DATE] and had diagnoses including unspecified dementia, unspecified anxiety disorder, and unspecified heart failure. 6. Review of the medical record revealed Resident #91 was admitted to the facility on [DATE] and had diagnoses including repeated falls, unspecified polyneuropathy, polyosteoarthritis, and unspecified pain. 7. Review of the medical record revealed Resident #95 was admitted to the facility on [DATE] and had diagnoses including type II diabetes, morbid obesity, repeated falls, major depressive disorder, and unspecified chronic pain. 8. Review of the medical record revealed Resident #97 was admitted to the facility on [DATE] and had diagnoses including unspecified dementia, an unstageable pressure ulcer to the sacral region, late-onset Alzheimer's disease, major depressive disorder, generalized anxiety disorder, and repeated falls. 9. Review of the medical record revealed Resident #98 was admitted to the facility on [DATE] and had diagnoses including end stage renal disease, type II diabetes, and unspecified anxiety disorders. 10. Review of the medical record revealed Resident #99 was admitted to the facility on [DATE] and had diagnoses including hypertension, unspecified depression, and history of falling. 11. Review of the medical record revealed Resident #101 was admitted to the facility on [DATE]. Diagnoses included anxiety disorder, type II diabetes, major depression disorder, stage III pressure ulcer to left heel, and heart failure. 12. Review of the medical record revealed Resident #103 was admitted to the facility on [DATE] and had diagnoses including unspecified heart failure, type II diabetes, unspecified dementia, and chronic kidney disease. 13. Review of the medical record revealed Resident #106 was admitted to the facility on [DATE] and had diagnoses including hemiplegia affecting left non-dominant side, unspecified chronic pain, and unspecified seizures. 14. Review of the medical record revealed Resident #108 was admitted to the facility on [DATE] and had diagnoses including spina bifida, repeated falls, and generalized muscle weakness with need for assistance with personal care. Observation on 11/27/24 at 8:35 A.M. revealed, midway down the hallway on the left hand side of the hall, a mounted computer monitor in a kiosk with a bedside table and chair in front. Further observation revealed papers were observed to be taped to the wall surrounding the kiosk and identified Resident #85, Resident #86, Resident #87, Resident #89, Resident #91, Resident #99, and Resident #106 were morning get-ups and Resident #86, Resident #95, Resident #97, Resident #98, Resident #99, and Resident #106 were lay-downs. Each resident's name and room number were identified on the papers. There was an additional list posted with the title, Dining Room List Lunch and Dinner, which included eight (#88, #89, #97, #98, #99, #103, #106, and #108) resident names and room numbers. Observation of the bedside table in the hall revealed shower sheets were visible on top of bedside table with names handwritten at the top of the page for Resident #88 and Resident #101. During an interview on 11/27/24 at 8:44 A.M. Certified Nurse Aide (CNA) #226 stated the papers were always displayed on the wall like that so the nurse aides would know what care was due for those residents. During an interview on 11/27/24 at 8:50 A.M. Licensed Practical Nurse (LPN) #242 stated the area in the hallway was the nurse aides' work station. LPN #242 verified the documents posted and viewable in the public area on the hall displayed resident names, room numbers, and clinical and personal information regarding care activities and dining location for 14 (#85, #86, #87, #88, #89, #91, #95, #97, #98, #99, #101, #103, #106, and #108) residents. This deficiency represents an incidental finding discovered during the complaint investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff interview and policy review, the facility failed to maintain a resident privacy when an employee took a photo of a resident without her permission and shared the photo via text message. This affected one (#150) of four residents reviewed for privacy. The facility census was 100. Findings included: Review of Resident #150's closed medical record revealed an admission date of [DATE], with diagnoses including: paranoid schizophrenia and Alzheimer's disease, unspecified. Resident expired on [DATE]. Review of Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had severe cognitive impairment. Resident #150 required supervision with eating, partial assistance with oral hygiene, substantial assistance with bathing, toileting hygiene, and personal hygiene, and was dependent with dressing and bed mobility. Review of the Care Plan dated [DATE] revealed Resident #150 had Alzheimer's dementia, cognitive / communication deficit, has short term / long term memory problems with impaired decision-making abilities, and the facility would preserve resident's dignity. Interview with on [DATE] at 11:06 A.M., with State Tested Nurse Assistant (STNA) #301 confirmed a text message was sent to her phone on [DATE] from STNA #352 of a picture of Resident #150. Observations, at the time of the interview, of STNA #301's phone, revealed a photo of Resident #150 sitting in bed, fully dressed, with a blanket over the lower portion of her body. STNA #352's name was at the top of photo and date shown on the right side of the phone as [DATE]. STNA #301 confirmed Resident #150 had severe cognitive impairment and was unable to give consent for photo to be taken and shared with others. Review of the policy titled Resident Rights - Advance Directives And Advance Care Planning dated [DATE], revealed taking photographs or recordings (audio or video), of a resident and/or the resident's private/personal space (i.e., resident's room or furnishings) without the resident's or designated representative's written consent is a violation of the resident's right to privacy and confidentiality. This deficiency represents non-compliance investigated under Complaint Number OH00154222.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and policy review, the facility failed to provide timely incontinence care to a resident who was dependent on staff for incontinence care. This affected one (#78) of four residents reviewed for incontinence care. The facility census was 100. Findings include: Review Resident #78's medical record revealed an admission date of 06/18/21, with diagnoses of central cord syndrome at C-6 level of cervical spinal cord, neuromuscular dysfunction of bladder, and neurogenic bowel. Review of the most recent annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #78 was cognitively intact, and was dependent on staff for all activities of daily living. Review of the Care Plan dated 06/29/21 revealed Resident #78 is incontinent of bowel/bladder, staff to keep call light within reach at all times, answer call light promptly, check and change every 3 hours and as needed. Pericare when incontinent, keep clean and dry, assist with hygiene and clothing as needed. Observation on 06/18/24 at 10:18 A.M., revealed State Tested Nursing Assistant (STNA) #336 and STNA #340 in Resident #78's room to perform incontinence care. Resident #78 was transferred to bed with Hoyer lift. The Hoyer pad was already under the resident in wheelchair. Resident #78' s Hoyer pad, sweat pants and incontinence brief were observed to be saturated with urine. Incontinence care was provided per the STNA's. Interview on 06/18/24 at 10:18 A.M., during incontinence care, with STNA #336 and STNA #340, stated they had not been in Resident #78's room since the start of the shift at 7:00 A.M. Both STNAs stated in shift change report this morning, they were told Resident #78 had last been changed at 3:00 A.M. and was up in the wheelchair since then. STNA #336 and #340 verified Resident #78's incontinence brief, sweatpants and the Hoyer pad were soaked through with urine. Review of the policy titled, Incontinence / Peri-Care dated November 2023 revealed the facility will provide care to minimize the risk of skin breakdown, prevent infections and promote comfort and dignity. This deficiency represents non-compliance investigated under Complaint Number OH00154222.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and policy review, the facility failed to provide timely incontinence care to a resident who was dependent on staff for incontinence care. This affected one (#78) of four residents reviewed for incontinence care. The facility census was 100. Findings include: Review Resident #78's medical record revealed an admission date of 06/18/21, with diagnoses of central cord syndrome at C-6 level of cervical spinal cord, neuromuscular dysfunction of bladder, and neurogenic bowel. Review of the most recent annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #78 was cognitively intact, and was dependent on staff for all activities of daily living. Review of the Care Plan dated 06/29/21 revealed Resident #78 is incontinent of bowel/bladder, staff to keep call light within reach at all times, answer call light promptly, check and change every 3 hours and as needed. Pericare when incontinent, keep clean and dry, assist with hygiene and clothing as needed. Observation on 06/18/24 at 10:18 A.M., revealed State Tested Nursing Assistant (STNA) #336 and STNA #340 in Resident #78's room to perform incontinence care. Resident #78 was transferred to bed with Hoyer lift. The Hoyer pad was already under the resident in wheelchair. Resident #78' s Hoyer pad, sweat pants and incontinence brief were observed to be saturated with urine. Incontinence care was provided per the STNA's. Interview on 06/18/24 at 10:18 A.M., during incontinence care, with STNA #336 and STNA #340, stated they had not been in Resident #78's room since the start of the shift at 7:00 A.M. Both STNAs stated in shift change report this morning, they were told Resident #78 had last been changed at 3:00 A.M. and was up in the wheelchair since then. STNA #336 and #340 verified Resident #78's incontinence brief, sweatpants and the Hoyer pad were soaked through with urine. Review of the policy titled, Incontinence / Peri-Care dated November 2023 revealed the facility will provide care to minimize the risk of skin breakdown, prevent infections and promote comfort and dignity. This deficiency represents non-compliance investigated under Complaint Number OH00154222.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, the facility failed to ensure residents had access to call lights. This affected one resident (Resident #20) of the 32 residents sampled for call lights. The facility census was 108. Findings include: Review of the medical record for Resident #20 revealed the resident was admitted to the facility on [DATE]. Diagnoses included unspecified dementia; hemiplegia/hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non-dominant side; contracture to left wrist, left hand, and left knee; Chronic Obstructive Pulmonary Disease (COPD); and psychotic disorder with delusions related to a known physiological condition. Review of the most recent Minimum Data Set (MDS) assessment 3.0 dated 09/21/23 for Resident #20, revealed the resident had moderately impaired cognition, had verbal behaviors, did not wander, and occasionally rejected care. Observation of Resident #20 on 10/25/23 at 9:16 A.M., revealed the resident lying in bed with eyes closed. The call light was draped across the nightstand and was not within the resident's reach. Observation of Resident #20 on 10/25/23 at 9:29 A.M., revealed Activities Director #116 entered the resident's room with Surveyor to find the October activities calendar on the top of the dresser top, and did not notice or check to ensure Resident #20 had access to her call light. Observation of Resident #20's room on 10/25/23 at 9:45 A.M., revealed Maintenance Staff #16 verified the wall was torn up due to the bed scraping against the wall. Maintenance Staff #16 stated he was not aware of the damage and stated he would fix it. Resident #20 laid in bed with her eyes closed with the call light located on the nightstand and out of the resident's reach. Maintenance Staff #16 did not notice or address that the resident did not have access to the call light. Observation of Resident #20 on 10/25/23 at 12:25 P.M., revealed the resident was lying on her back with eyes closed and was mouth breathing. The call light remained draped over the side of the nightstand and was not within the resident's reach. The damage to the wall had been spackled over. Observation of Resident #20 on 10/25/23 at 12:34 P.M., revealed State Tested Nursing Assistant (STNA) #115 knocked on the resident's door, delivered, and set up Resident #20's lunch tray. STNA #115 left the resident's room without ensuring Resident #20 had access to her call light. Observation of Resident #20 on 10/25/23 at 12:41 P.M. revealed the resident was tapping her spoon on her bedside table. This Surveyor alerted STNA #08 that Resident #20 needed assistance. STNA #08 stated Oh she does that sometimes when she doesn't like her food. STNA #08 briefly looked into the resident's room from the hallway and continued to deliver meal trays on the hallway. STNA #08 did not return to check on Resident #20. Observation of Resident #20 on 10/25/23 at 12:45 P.M. revealed this Surveyor alerted STNA #151 that Resident #20 had dropped her spoon on the floor. STNA #151 gave the resident a new spoon. Resident #20 stated she did not want her food anymore and asked the STNA if she could have a Coke. STNA #151 took the insulated lid from the nightstand, covered the food on the tray, and left the room with the tray. Resident #20's call light was observed to be draped over the nightstand and was not within reach of the resident. STNA #151 did not ensure Resident #20 had access to her call light before leaving the room. Observation of Resident #20 on 10/25/23 at 1:54 P.M. revealed Activities Staff #117 informed Resident #20 of the afternoon activities, answered the resident's questions, and left room without ensuring resident had her call light. Resident #20's bed was visible from hallway, and the call light was not visible or within the resident's reach. Observation and interview with Licensed Practical Nurse (LPN) #29 on 10/25/23 at 2:11 P.M. confirmed Resident #20's call light was on nightstand and was not within the resident's reach. LPN #29 verbalized policy and stated the staff were to ensure the residents had access to their call lights before leaving the resident's room. Review of policy titled Call Light Policy & Procedure dated 11/2022 revealed residents will have a means to contact staff directly when in their rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure the Ombudsman was notified when residents were discharged to the hospital. This affected one (#33) out of three residents reviewed for discharges. The facility census was 108. Findings include: Review of the record review for Resident #33, revealed the resident was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), pressure ulcer of right heel, functional quadriplegia, atrial fibrillation, epilepsy, and peripheral vascular disease (PVD). Review of the admission Minimum Data Set (MDS) assessment 3.0 dated 07/21/23 for Resident #33, revealed the resident was not able to complete a Brief Interview for Mental Status (BIMS) and a score of 99 was assessed which indicated severe cognitive impairment. Review of the medical chart for Resident #33 revealed the resident was hospitalized four different times between July and August 2023 with no documented evidence the Ombudsman was notified. Interview on 10/26/23 at 9:17 A.M. with the Social Service director (SSD) #51 verified the Ombudsman was not notified when Resident #33 was discharged to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews and record review, the facility failed to provide furniture suitable for the comfort of the residents and/or the visitors. This affected one (#29) out of 24 residents reviewed. The facility census was 108. Findings include: Review of the medical record for Resident #29 revealed the resident was admitted to the facility on [DATE]. Diagnosis included, but is not limited to, asthma, essential hypertension, bipolar disorder, anxiety, irritable bowel syndrome, dysphagia, age related osteoporosis, chronic obstructive pulmonary disease (COPD), and metabolic encephalopathy. Review of the most recent Minimum Data Set (MDS) assessment 3.0 dated 07/28/23 for Resident #29, revealed the resident was cognitively intact. Observation of Resident #29's room on 10/23/23 11:54 A.M., revealed there was no chair for the resident and/or visitors to sit on. Interview at the same time with Resident #29 revealed she was concerned with not having a chair to sit on in her room. Interview with the Administrator on 0/25/23 at 10:32 A.M., revealed every resident's room should have a chair for the resident and/or a visitor to sit on. The Administrator verified Resident #29 did not have a chair available for the resident to sit in and was unaware the resident's room did not have a chair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) Review of the medical record for Resident #59 revealed an admission date of 11/02/21. Diagnoses included acute and chronic respiratory failure with hypercapnia, chronic kidney disease, heart failure, COPD, and major depressive disorder. Further review of the medical record revealed no documented evidence that a care conference had been completed for the last 12 months. Review of the quarterly MDS assessment dated [DATE] for Resident #59 revealed the resident had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. Interview with SSD #51 on 10/26/23 at 9:17 A.M. verified Resident #59 had not had a care conference completed in the last 12 months. Review of policy titled, Policy and Procedure for Resident Rights, Advanced Directives, and Advanced Care Planning last revised 09/01/22, revealed the facility will routinely review with the resident and his/her representative to ensure that existing care instructions were in line with the resident's wishes and establish to continue or change these instructions. This was completed at a minimum quarterly and with significant change in status. Based on record review, staff and resident interviews, and policy review, the facility failed to ensure residents received quarterly care conferences. This affected four (#20, #70, #74 and #59) of thirty two residents sampled for care planning. The facility census was 108. Findings include: 1) Review of the medical record for Resident # 20 revealed the resident was admitted to the facility on [DATE] and had diagnoses including unspecified dementia, hemiplegia/hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non-dominant side, chronic obstructive pulmonary disease (COPD) and psychotic disorder with delusions. Further review of the medical record revealed Resident #20's last documented care conference was held on 06/28/23. Review of the most recent Minimum Data Set (MDS) assessment 3.0 dated 09/21/23 for Resident #20, revealed the resident had moderately impaired cognition. Interview with Resident #20 on 10/24/23 at 10:09 A.M. revealed the resident's brother was her guardian and she did not remember having any care conferences. Interview with Social Worker #10 and Social Services Director (SSD) #51 on 10/26/23 at 9:09 A.M. verified Resident #20's last recorded care conference was 06/28/23 and the resident did not have a care conference during the third quarter (July, August, September 2023). SSD #51 indicated care conferences were to be held quarterly. 2) Review of the medical record for Resident # 70 revealed the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, diabetes mellitus and chronic kidney disease. Further review of the medical record revealed Resident # 70's last documented care conference was dated 03/23/23. Review of the most recent MDS assessment dated [DATE] for Resident # 70, revealed the resident had moderately impaired cognition. Interview with Resident #70 on 10/23/23 at 11:55 A.M., revealed the resident did not remember having any care conferences. Interview with Social Worker #10 and SSD # 51 on 10/26/23 at 9:16 A.M., verified Resident #70's last care conference was on 03/23/23 and should be done quarterly. 3) Review of the medical record for Resident #74 revealed the resident was admitted to the facility on [DATE] and had diagnoses including diabetes mellitus, atherosclerotic heart disease, dysarthria following unspecified cerebrovascular disease, and COPD. Further review of the medical record revealed the resident's last care conference was dated 09/20/22. Review of the most recent MDS assessment dated [DATE] for Resident # 74, revealed the resident had moderately impaired cognition. Interview with Resident #74 on 10/23/23 at 12:21 P.M., revealed the resident stated he did not receive care conferences. Interview with SSD #51 and Social Worker #10 on 10/26/23 at 9:07 A.M. verified Resident #74's last documented care conference was dated 09/20/22 and should be done quarterly.

Based on observations, staff interview, and policy review, the facility failed to ensure resident's meal trays were delivered in a hygienic manner. This affected four residents (#61, #06, #77 and #79) out of 24 residents observed for dining service. The facility census was 108. Findings include: Observation the third floor during lunch tray meal delivery on 10/23/23 revealed the following: At 12:36 P.M., State Tested Nursing Assistant (STNA) #152 was observed pulling multiple food trays from the food carts and delivering them to residents in the Skyline lounge with gloved hands. STNA #152 was observed to deliver and set up resident's trays without changing her gloves and/or completing any hand hygiene. STNA #152 assisted Resident #61 with positioning in her wheelchair and moved the resident closer to table. STNA #152 continued to pull food trays and deliver them to the residents in the Skyline Lounge without changing her gloves and/or performing any hand hygiene. At 12:39 P.M., STNA #152 pulled the meal tray for Resident #06 and delivered it to the resident's room. STNA #152 placed the meal tray on the resident's bedside table and exited the room with the same pair of gloves on. At 12:47 P.M., STNA #152 pulled the meal tray for Resident #77 and delivered it to the resident's room. STNA #152 set up the meal tray for the resident by removing the cover to all items with the same pair of gloves on. At 12:58 P.M., STNA #152 pulled the meal tray for Resident #79 and delivered it to the resident's room. STNA #152 set up the meal tray for the resident by removing the cover to all items and placed condiments on the resident's food with the same pair of gloves on. Interview with STNA #152 on 10/23/23 1:04 P.M. verified she did not change her gloves and /or complete any hand hygiene as she delivered and set the residents lunch trays. STNA #152 stated she did not know what the process was for appropriately delivering and setting up meal trays. Review of 03/01/23 facility policy titled General Infection Control Hand Washing / Hand Hygiene revealed the facility will assure a safe sanitary and comfortable environment and control the development and transmission of infections and diseases. All staff will perform hand hygiene after removing gloves or other personal protective equipment before eating, drinking, or handling food.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to provide a copy of the transfer or discharge notification to the Ombudsman for discharges from the facility. This affected eight Residents (#1, #51, #54, #66, #89, #91, #99 and #122) of nine residents reviewed for discharge notification. The facility census was 125. Findings include: 1. Record review revealed Resident #66 was admitted to the facility on [DATE] with the following diagnoses; spinal stenosis, scoliosis, essential hypertension, osteoarthritis, other non specific abnormal finding of lung field, muscle weakness, heart failure, anxiety disorder, osteoarthrosis and venous insufficiency. Review of Resident #66's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, transfers, eating, dressing, toileting and personal hygiene. Further review of Resident #66's medical record revealed the resident was discharged to the hospital on [DATE] for bruising of the left wrist. Resident #66 readmitted to the facility on [DATE]. Resident #66 also discharged to the hospital on [DATE] for pneumonia and was readmitted on [DATE]. There was no documentation that the Ombudsman was notified of Resident #66's discharges to the hospital on [DATE] and on 10/15/19. Interview with the Administrator on 10/30/19 at 2:51 P.M. verified the Ombudsman was not notified of Resident #66's discharges to the hospital on [DATE] and on 10/15/19. 2. Record review revealed Resident #89 was admitted to the facility on [DATE] with the following diagnoses; malignant neoplasm of bones of skull and face, nontraumatic subdural hemorrhage, other specified disorder of nose and nasal sinuses, anoxic brain damage, unspecified convulsions, hypertension, type two diabetes mellitus, insomnia, muscle weakness, unspecified dementia without behavioral disturbance, and anxiety disorder. Review of Resident #89's significant change MDS assessment dated [DATE] revealed the resident to be moderately cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, toileting, eating and personal hygiene. Further review of Resident #89's medical record revealed the resident was discharged to the hospital for a change in mental status on 09/08/19. Resident #89 was readmitted to the facility on [DATE]. There was no documentation that the Ombudsman was notified of Resident #89's discharge to the hospital on [DATE]. Interview with the Administrator on 10/30/19 at 2:51 P.M. verified the Ombudsman was not notified of Resident #89's discharge to the hospital on [DATE]. 7. Medical record review revealed Resident #54 was admitted to the hospital on [DATE] with a re-entry date of 09/28/19. Diagnosis included left hip fracture. Further medical record review revealed Resident #54 was transferred to the hospital from the facility and hospitalized [DATE] to 09/28/19 for a closed femur fracture and 10/01/19 to 10/03/19 for a dislocated left hip. The medical record did not contain any documentation of the ombudsman being notified about the need for transfers and hospitalizations. Interview on 10/28/19 at 4:14 P.M. with Resident #54 reported he had required to be hospitalized from the facility due to problems with his left hip. 8. Medical record review revealed Resident #99 was admitted to the hospital on [DATE] with a re-entry date of 08/23/19. Diagnoses included osteomyelitis of left ankle and foot, sepsis, congestive heart failure, peripheral vascular disease, and multiple sclerosis. Further medical record review revealed Resident #99 was transferred to the hospital and hospitalized [DATE] to 08/23/19 for osteomyelitis and sepsis, 09/02/19 to 09/04/19 for acute blood loss anemia, 09/10/19 to 09/12/19 for a urinary tract infection (UTI) and sepsis, and 10/02/19 to 10/06/19 for a UTI, acute kidney injury, dehydration, and sepsis. The medical record did not contain any documentation of the ombudsman being notified about the need for transfers and hospitalizations. Interview on 10/30/19 at 2:51 P.M. with the Administrator reported the facility had not notified the ombudsman about resident transfers and hospitalizations since 06/26/19. Review of Emergency Transfer to Hospital Policy and Procedure revised 11/28/18 revealed a list of emergency hospital transfers would be sent to the State Ombudsman on a monthly basis. 3. Resident #51 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), chronic embolism and thrombosis of left popliteal vein, major depressive disorder, bronchopenumoni, hypertension, vascular dementia with behavioral disturbance, psychotic disorder with delusion, atherosclerotic heart disease, and fibromyalgia. The facility completed a quarterly MDS of the resident cognitive and physical functional status dated 10/09/19. The 10/09/19 assessment identified the resident as having moderate cognitive impairment and requiring the extensive assistance of one staff person to complete most activities of daily living. Further review of Resident #51's paper medical record revealed hospital records indicating the resident was sent out to the hospital on [DATE] and remained there until 08/23/19 at which time she was discharged back to the facility. The hospitalist evaluating the resident at the emergency department assessed the resident as having acute chronic respiratory failure and pneumonia due to COPD. Review of Resident #51's electronic health records (EHR) failed to reveal any nursing progress notes or social services progress notes indicating why or when the resident was transported to the hospital. There was a transfer form in the assessment section of the EHR dated 08/21/19 indicating the resident's representative was provided with all transfer notices and a bed hold information. However, there was no documentation to support a copy of the discharge/transfer notice information was sent to the Long-Term Care (LTC) Ombudsman. On 10/30/19 at 12:15 P.M. the Administrator was asked to provide documented evidence that a copy of Resident #51's 08/21/19 transfer/discharge notices information was sent to the LTC Ombudsman. She stated she was having difficult gathering the information as different staff persons had been completing different tasks regarding transfer/discharge notices, bed hold notices, and notification of the LTC Ombudsman. On 10/30/19 at 2:53 P.M. the Administrator reported that she was able to locate the last list of residents' transfer/discharge notices sent to the LTC Ombudsman. The list which she provided indicated the last time the Ombudsman was notified of any resident transfer/discharge, and provided with copies of the required information, was on 06/26/19. The Administrator affirmed there had been no notification of the LTC Ombudsman of resident transfer/discharges since 06/26/19. She reported that she personally worked completing sending the LTC Ombudsman notification of all the residents that had been transferred/discharged from the facility since 06/26/19 through 10/30/19. 4. Resident #91 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Parkinson's disease, hypertension, Alzheimer's disease, unspecified dementia with behavioral disturbance, major depressive disorder recurrent without psychotic features, anxiety disorder, dysphagia, muscle wasting and atrophy, diabetes mellitus type 2, and adult failure to thrive. The facility completed a quarterly MDS of the residents cognitive and physical functional status dated 10/02/19. The 10/02/19 assessment identified the resident as having moderate to severe cognitive impalements, and requiring the extensive assistance of on staff person to completed all activities of daily living with the exception of eating, which she was able to completed with only supervision. Review of Resident #91's nursing progress notes revealed an entry by Registered Nurse (RN) #143 dated 08/13/19. RN #143 documented the resident was noted with increased behaviors and outbursts. The resident was refusing all medications, was difficult to redirect, and was verbally aggressive towards staff and residents. One on one interaction was ineffective. The resident was threatening physical aggression toward roommate, but no physical contact was observed. The resident had not displayed any attempts to harm herself. RN #143 then noted she contacted the resident's attending physician and her psychiatrist. The resident's attending physician ordered that Resident #91 be transported to a psychiatric hospital facility for further evaluation. On 08/14/19 Licensed Social Worker (LSW) #179 made a note in Resident #91's EHR. LSW #179 documented that she spoke with the nurse liaison from the psychiatric unit where the resident had been transferred to. She noted the resident was admitted to the psychiatric facility, and the nurse liaison communicated the average length of staff for individuals was two weeks, but each case varied. On 08/30/19 RN #143 documented in Resident #91's nursing progress notes the resident returned to the facility on [DATE]. Review of Resident #91's EHR and paper record failed to revealed any mention, or any documentation to support, the resident and their representative received the required transfer/discharge notice information before transfer to the hospital, or as soon as practicable. In addition there was no documented evidence to support the LTC Ombudsman received notice of the residents transfer/discharge to the hospital and a copy of the information that should have been provided to the resident. On 10/31/19 at 1:00 P.M. the Director of Nursing (DON) was asked to provide documentation that Resident #91 and her representative were provided with the required transfer/discharge notice information regarding her 08/13/19 discharge to the psychiatric facility, and evidence the LTC Ombudsman was notified of the transfer/discharge and a copy of the required information provided to the LTC Ombudsman. She provided a copy of the 08/13/19 progress note showing why the resident was sent out to the hospital. The DON affirmed there was no documentation to support any of the required notices before transfer/discharge had been provided to the resident or their representative in writing for the resident's 08/13/19 discharge to the psychiatric facility, or notification of the LTC Ombudsman. 5. Resident #1 was admitted to the facility on [DATE], then readmitted on [DATE] after a scheduled surgery. The resident's diagnoses as listed in her medical record including unspecified bacterial pneumonia, secondary kyphosis cervicothoracic region, spinal stenosis, scoliosos, intervertebral disc degeneration lumbosacral region, muscle weakness, bipolar disorder, anxiety disorder, dysphagia, chronic pain syndrome, and chronic kidney disease. The facility completed a five day Medicare assessment (MDS) of the resident's cognitive and physical functional status dated 10/15/19. The 10/15/19 assessment identified the resident as having fair to food cognitive skills and requiring the physical assistance of at least one staff person to complete all activities of daily living. The resident received all food and liquid via a gastrostomy tube feeding. The resident was her own responsible party. Review of Resident #1's nursing progress notes revealed an entry by RN #153 on 10/02/19. RN #153 noted the resident arrived at the facility via ambulance from a local hospital. She documented the resident had a surgical incision from a recent spinal fusion, and in a C-collar due to recent cervical spinal surgery. RN #153 assessed the resident as alert and oriented, with no unknown irregularities were noted. On 10/03/19 RN #153 noted that Resident #1 was having disorientation and changes in her mental status. The nurse notified the resident's physician regarding the changes in mental status and the resident was transferred to a local hospital for evaluation. RN #153 documented that she was sending a transfer form and medication list with the resident for continuity of care. In addition, the notice of transfer and bed hold information was also sent with resident. However, there was no documentation to support a copy of the discharge/transfer notice information was sent to the LTC Ombudsman. On 10/04/19 RN #122 documented in the resident's EHR the resident was admitted to the hospital with systemic inflammatory response and pneumonia. The resident returned to the facility on [DATE]. On 10/30/19 at 2:53 P.M. the Administrator reported that she was able to locate the last list of residents' transfer/discharge notices sent to the LTC Ombudsman. The list which she provided indicated the last time the Ombudsman was notified of any resident transfer/discharge, and provided with copies of the required information, was on 06/26/19. The Administrator affirmed there had been no notification of the LTC Ombudsman of resident transfer/discharges since 06/26/19. She reported that she personally worked completing sending the LTC Ombudsman notification of all the residents that had been transferred/discharged from the facility since 06/26/19 through 10/30/19. 6. Resident #122 was admitted to the facility on [DATE] and discharged to an acute care hospital on [DATE]. The resident did not return to the facility. Resident #122 had diagnoses including dislocation of right ankle, anemia, thyrotoxicosis with diffuse goiter, chronic obstructive pulmonary disease, diabetes mellitus, obesity, and bariatric surgery status. The resident was her own responsible party. The facility completed an admission MDS of Resident #122's cognitive status dated 09/18/19. The resident was assessed as having good memory, recall, and decision making skills. Review of Resident #122's EHR, discharge record, revealed an entry by RN #34 on 09/26/19. RN #34 documented she was called to the resident's room, the resident had pronounced left side weakness and left side facial drooping, and slurred speech. She noted emergency medical services were called and the resident's physician was notified. RN #34 documented she then called the receiving hospital to give report. The resident did not return to the facility. Review of discharged Resident #122's EHR and paper record failed to revealed any mention, or any documentation to support, the resident and their representative received the required transfer/discharge notice information before transfer to the hospital, or as soon as practicable. In addition there was no documented evidence to support the Long-Term Care (LTC) Ombudsman received notice of the residents transfer/discharge to the hospital and a copy of the information that should have been provided to the resident. On 10/31/19 at 1:00 P.M. the DON was asked to provide documentation that discharged Resident #122 and her representative were provided with the required transfer/discharge notice information regarding her 09/26/19 discharge to the hospital, and evidence the LTC Ombudsman was notified of the transfer/discharge and a copy of the required information provided to the LTC Ombudsman. She provided a copy of the 09/26/19 progress note showing why the resident was sent out to the hospital. The DON affirmed there was no documentation to support any of the required notice information before transfer/discharge had been provided to the resident or her representative in writing for the resident's 09/26/19 discharge to the hospital, or notification of the LTC Ombudsman.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medial record review, observation, and staff interview, the facility failed to ensure that each residents written plan of care was implemented regarding interventions to prevent further decreases in range of motion via the use of splinting devices. This affected one (Resident #102) of one resident reviewed for positioning. The facility census was 125. Findings include: Resident #102 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, vascular dementia with behavioral disturbance, contracture right hand, contracture right knee, chronic obstructive pulmonary disease, and aphasia. The facility completed an annual comprehensive assessment of Resident #102's cognitive and physical functional status dated 10/02/19. The 10/02/19 assessment identified the resident as having poor memory, severely impaired cognitive skills, and requiring the physical assistance of one to two staff persons to complete all activities of daily living. The resident was assessed as having functional limitations in his range of motion due with impairments to his upper and lower extremity on one side. Review of Resident #102's physician's orders revealed a current physician's order to wear a right hand splint and right knee brace for up to six hours a day as tolerated. Review of Resident #102' comprehensive plan of care revealed a current plan of care with a goal date of 12/31/19 which addressed the residents activity of daily living self care performance deficits. The care plan identified the resident as being at risk for joint stiffness, muscle atrophy, falls, skin breakdown, and loss of dignity related to his self care performance deficits. The care plan goal was for the resident to be neat, clean, and odor free through the next review date The interventions for the resident included wearing a ranger knee brace to his right knee three to six hours as tolerated each day, and to wear a resting hand splint up to six hours per day as tolerated. Review of Resident #102's October 2019 treatment record (TAR) revealed that there was a place on the TAR to document where the hand and knee splint was used during the day and/or night shifts of duty. The October 2019 TAR where the splint order was noted, and was supposed to be documented for each day of the week, was blank for all days of the month. Resident #102 was observed in his room in bed on 10/28/19 at 5:09 P.M. The resident appeared to have significant contractures of his right wrist/hand, and his right knee. The resident was not wearing any splints. Resident #102 was observed up dressed in his wheel chair in the unit activity/dining room on 10/29/19 at 9:17 A.M. The resident was not wearing any splints to his right hand or right knee. Resident #102 was observed on 10/30/19 at 11:57 A.M. up in his wheel chair in the unit activity/dining room. The resident's right arm was dangling straight down the side of his wheel chair towards the floor, his hand appeared slightly swollen. The resident was not wearing any splints to his right hand or right knee. State Tested Nurse Aide (STNA) #74 who was nearby was asked to view the resident and address his dangling right arm. STNA #74 repositioned the residents arm/hand on the pillow. The nurse aide was then interviewed to ascertain if the resident had a right hand and/or a right knee splint. STNA #74 stated he was familiar with the resident, and the resident was to wear the hand splint when he was in bed, but was not aware of the resident having a right knee splint. The nurse aide went and found the hand splint in the resident's night stand and applied the right hand splint although it was not at night with no resistance by the resident while the resident was sitting in his wheel chair. An interview was conducted with STNA #25 on 10/30/19 at 12:01 P.M. regarding Resident #102's splints. The nurse aide was assigned to the unit where the resident was located. The nurse aide was asked if the resident wore splints to his right hand or right leg, and she reported that the resident did have a right hand splint, but voiced no awareness of the resident wearing a knee brace/splint. STNA #25 reported she thought the resident was supposed to wear the hand splint when he was up in his wheel chair, and then off at night. On 10/30/19 at 5:56 P.M. unit manager, Licensed Practical Nurse (LPN) #139 was made aware that Resident #102's right hand and knee splint was not observed in use, that there was a current physician's order for the use of the splints, and a care plan was evident for the use of the splints. In addition, LPN #139 indicated there was a place for nursing staff to note the application of the splint on the TAR during either the day or night shift of duty daily, but the TAR was blank regarding the application for the splint for the month of 10/01/19 through 10/30/19. Additional information regarding the status of Resident #102's splint usage, and the whereabouts of the knee splint, was requested from LPN #139. No additional information was provided by the facility regarding the resident's splints. An interview was conducted with Certified Occupational Therapy Assistant, Therapy Manager (TM) #305 on 10/31/19 at 10:01 A.M. regarding Resident #102's hand and knee splints. She reviewed the last information regarding the knee splint from when the resident was discharged from physical therapy on 07/02/19. TM #305 affirmed the resident was treated for flexion contracture of the right knee, and the intervention was for the resident to wear a right knee brace. She had no additional information regarding the status of the knee brace since the 07/02/19 discharge. Resident #102's physical therapy (PT) Discharge summary dated [DATE] was provided by TM #305 and reviewed. Review of the PT discharge summary revealed the following documentation related to the resident's right knee brace: the resident, spouse, and nursing staff were educated on proper donning and doffing of the right knee brace and instructed in a brace (wearing) schedule going forward in order to maximize the benefit of wearing the brace and to maintain his active and passive range of motion gains to his right knee. The therapist also noted the resident's progress was good as evidence by his improved right knee range of motion and established plan of use of the knee brace going forward in order to prevent further contractures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews the facility failed to ensure a resident was given the opportunity to participate in the care planning process. This affected one (Resident #103) of four residents reviewed for care plan participation. The facility census was 125. Findings include: Record review of Resident #103's medical record revealed the resident was admitted to the facility on [DATE] with the following diagnoses; other non specified abnormal findings of lung field, heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris, essential hypertension, candidiasis, transient cerebral ischemic attack, rheumatoid arthritis, major depressive disorder, acute respiratory failure with hypoxia, dysphagia, constipation, obstructive sleep apnea, osteoarthritis, anxiety disorder and hypothyroidism. Review of Resident #103's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident to have moderate cognitive impairment and required extensive assistance with bed mobility, transfers, dressing, toileting, eating and personal hygiene. Review of Resident #103's medical record revealed the resident had not been invited to or had a care conference to participate in the development and revision of her care plan since 12/28/18. Interview with Resident #103 on 10/28/19 at 10:20 A.M. revealed she had not been invited to care conference and had not been given the opportunity to participate in care planning. Interview with the Director of Nursing (DON) on 10/30/19 at 1:43 P.M. verified the facility did not have any documentation that Resident #103 was invited or given the opportunity to participate in care planning since 12/28/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to ensure diabetic ulcer and surgical wound treatments were completed as ordered. This affected one Resident (#113) of two reviewed for skin conditions. The facility census was 125. Findings include: Medical record review revealed Resident #113 was admitted to the facility on [DATE] with diagnoses including osteomyelitis of the left ankle and foot, partial traumatic amputation of the left great toe, non-pressure chronic ulcer of the left foot with fat layer exposed, pyogenic arthritis, sepsis, protein calorie malnutrition, diabetes, atrial fibrillation, anemia, and diabetic foot ulcer. Review of admission minimum data set (MDS) dated [DATE] revealed intact cognitive skills for daily decision making, extensive assistance was required with bed mobility, toileting, personal hygiene, and Resident #113 was totally dependent upon staff for transfers. A wheelchair was utilized for mobility. Resident #113 had one unstageable deep tissue injury (DTI), a diabetic foot ulcer, and a surgical wound. Review of physician orders dated 10/23/19 revealed to cleanse ulcers to right dorsal foot, left metatarsal surgical site, and left heel with wound cleanser. Apply alginate to right foot ulcer, collagen and alginate to left metatarsal surgical site, and skin prep to left heel. Cover all areas with dry clean dressing and secure with kling. Apply ace wraps to bilateral lower extremities from toe to knee, change daily and as needed. Review of wound specialist progress note dated 10/23/19 revealed Resident #113 was admitted to the hospital in late September 2019 with gas gangrene of the left foot and septic right knee joint. Surgical incision and drainage were completed on both. The left foot required transmetatarsal amputation (TMA), a surgery to remove part of the foot, but only partial closure was possible. The remaining open wound was being treated with a wound vac. Resident #113 also had a ulcer to the right foot and left heel. Resident #113 had a diabetic wound/ulcer of the right, lateral, plantar foot which measured 1.0 centimeter (cm) by 0.7 cm by 0.2 cm. Subcutaneous tissue was exposed with serosanguineous drainage and red, pink granulation tissue, new tissue, within the wound bed. An open surgical wound to the left foot with exposed support structures measured 19 cm by 3 cm by 0.6 cm. Bone, muscle, and subcutaneous tissue was exposed with a small amount of serosanguineous drainage, medium granulation within the wound bed and a small amount of necrotic tissue. Treatment included to cleanse right, lateral, plantar foot wound with saline, apply silver alginate to the wound bed and kerlix daily and as needed. Cleanse the left foot surgical wound with saline, apply collagen over the bone on lateral aspect and sliver alginate on top of collagen to the medical aspect of the wound bed, wrap with kerlix and ace bandage daily and as needed. Review of treatment administration record (TAR) for October 2019 revealed all wound treatments including to cleanse ulcers to right dorsal foot, left metatarsal surgical site, and left heel were grouped together. The boxes for completion of treatments on 10/25/19 and 10/27/19 were left blank and the medical record did not include any evidence treatments were completed on these dates as ordered. Observation on 10/28/19 at 2:31 P.M. revealed Resident #113 was seated in a wheelchair in his room. The left foot had a kling wrap dressing and a heel boot was in place. The right foot had a kling wrap dressing in place along with a non-skid sock. No heel boot was in place to the left foot. Resident #113 was moving the right foot from the wheelchair footrest to the floor, attempting to reposition self in the wheelchair. An interview with Resident #113, at the time of the observation, reported inability to remain up in wheelchair for extended periods of time as he became uncomfortable. Resident #113 reported he had a surgical wound to the right knee and left foot. Treatments were completed weekly at medical follow up appointments in the community for these surgical wounds. Resident #113 also reported a small diabetic wound to the right foot which was supposed to be changed daily but had only been completed twice since 10/23/19, even though the resident reported mentioning it to staff, and reported staff just push it off to the next shift and it was never completed daily. Interview on 10/29/19 at 3:12 P.M. with Resident #113 reported wound treatment was completed last night to the right diabetic wound and the nurse planned to change the left surgical wound dressing later since a wound vac was no longer in place. Resident #113 was in bed with a heel boot in place only to the left foot. Interview with registered nurse (RN) #163 on 10/29/19 at approximately 3:15 P.M. reported Resident #113 had a small wound to the right lateral foot. The right foot wound treatment and the peripherally inserted central catheter (PICC) dressing were changed on 10/28/19. RN #163 reported she had clarified, since the wound vac had been removed from the right foot surgical wound, this treatment also needed to be completed daily. This had been explained to the resident with plans to complete this treatment later in the evening. Observation on 10/30/19 at 7:44 A.M. of wound treatments by Advanced Practice Registered Nurse (APRN) #300 and licensed practical nurse (LPN) assistant director of nursing (ADON) #126 revealed a partially closed surgical wound to the left foot which measured 17.5 centimeters (cm) by 2.9 cm by 0.5 cm with a red wound bed and scattered slough. Observation of the right lateral foot revealed a dried wound bed with no drainage which measured 1.5 cm by 0.8 cm by 0.1 cm. Resident #113 informed the providers treatments were not being completed daily as ordered. Interview on 10/30/19 at 10:06 A.M. with APRN #300 reported the surgical wound to the left foot was not completely closed due to an active infection within the foot. All wounds were assessed weekly and the surgical wound to the left foot and diabetic right foot ulcer had improved over the past week. Interview on 10/30/19 at 3:33 P.M. with LPN/ADON #126 verified all wound treatments were grouped together on the TAR and there wasn't any documentation of treatments being completed as ordered on 10/25/19 and 10/27/19. Review of the wound specialist progress note dated 10/30/19 revealed the diabetic wound/ulcer to the right, lateral, plantar foot measured 1.5 cm by 0.8 cm by 0.1 cm and was limited to skin breakdown without any drainage. There wasn't any granulation within the wound bed or necrotic tissue. The area was dry and scabbing without drainage. The surgical wound to the left foot measured 17.5 cm by 2.9 cm by 0.5 cm with a small amount of serosanguineous drainage, medium red, pink granulation within the wound bed, and a small amount of necrotic tissue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, interview, and review of National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury Stages, the facility failed to ensure pressure ulcer interventions were in place and treatments were completed as ordered. This affected one (Resident #113) of five reviewed for pressure ulcers. The facility identified two residents with pressure ulcers, present upon admission. The facility census was 125. Findings include: Medical record review revealed Resident #113 was admitted to the facility on [DATE] with diagnoses including osteomyelitis of the left ankle and foot, partial traumatic amputation of the left great toe, non-pressure chronic ulcer of the left foot with fat layer exposed, pyogenic arthritis, sepsis, protein calorie malnutrition, diabetes, atrial fibrillation, anemia, and diabetic foot ulcer. Review of admission minimum data set (MDS) dated [DATE] revealed intact cognitive skills for daily decision making, extensive assistance was required with bed mobility, toileting, personal hygiene, and Resident #113 was totally dependent on staff for transfers. A wheelchair was utilized for mobility. Resident #113 had one unstageable deep tissue injury (DTI), a diabetic foot ulcer, and a surgical wound. Review of the care plan dated 10/09/19 revealed Resident #113 was admitted with surgical wound to left foot, a DTI to the left heel, and a diabetic ulcer to the right foot complicated by diabetes, amputation of the left toes, neuropathy, anemia, hypertension, and chronic atrial fibrillation. Interventions included heel boots to be worn at all times as tolerated. Review of physician orders dated 10/09/19 revealed heel boots to bilateral lower extremities at all times as tolerated. Review of physician order dated 10/23/19 revealed to cleanse ulcers to right dorsal foot, left metatarsal surgical site, and left heel with wound cleanser. Apply alginate to right foot ulcer, collagen and alginate to left metatarsal surgical site, and skin prep to left heel. Cover all areas with dry clean dressing and secure with kling. Apply ace wraps to bilateral lower extremities from toe to knee, change daily and as needed. Review of wound specialist progress note dated 10/23/19 revealed Resident #113 was admitted to the hospital in late September 2019 with gas gangrene of the left foot and septic right knee joint. Surgical incision and drainage were completed on both. The left foot required transmetatarsal amputation (TMA), a surgery to remove part of the foot, but only partial closure was possible. The remaining open wound was being treated with a wound vac. Resident #113 also had an unstageable pressure ulcer, suspected DTI, to the left heel which measured 2 centimeters (cm) by 3.5 cm by 0.1 cm, was purple in color, non blanchable intact discoloration. Treatment included to offload heels with boots and continue current order of skin prep to left heel daily. Review of treatment administration record (TAR) for October 2019 revealed all wound treatments including to cleanse ulcers to right dorsal foot, left metatarsal surgical site, and left heel were grouped together. The boxes for completion of treatments on 10/25/19 and 10/27/19 were left blank and the medical record did not include any evidence treatments were completed on these dates as ordered. Observation on 10/28/19 at 2:31 P.M. revealed Resident #113 was seated in a wheelchair in his room. The left foot had a kling wrap dressing and a heel boot was in place. The right foot had a kling wrap dressing in place along with a non-skid sock. No heel boot was in place to the left foot. Resident #113 was moving the right foot from the wheelchair footrest to the floor, attempting to reposition self in the wheelchair. An interview with Resident #113, at the time of the observation, reported inability to remain up in wheelchair for extended periods of time as he became uncomfortable. Resident #113 reported he had a surgical wound to the right knee and left foot. Treatments were completed weekly at medical follow up appointments in the community for these surgical wounds. Resident #113 also reported a small diabetic wound to the right foot which was supposed to be changed daily but had only been completed twice since 10/23/19, even though the resident reported mentioning it to staff, and reported staff just push it off to the next shift and it was never completed daily. Follow up interview on 10/29/19 at 3:12 P.M. with Resident #113 reported wound treatment was completed last night to the right diabetic wound and the nurse planned to change the left surgical wound dressing later since a wound vac was no longer in place. Resident #113 was in bed with a heel boot in place only to the left foot. Interview with registered nurse (RN) #163 on 10/29/19 at approximately 3:15 P.M. reported Resident #113 had a small wound to the right lateral foot. The right foot wound treatment and the peripherally inserted central catheter (PICC) dressing were changed on 10/28/19. RN #163 reported she had clarified, since the wound vac had been removed from the right foot surgical wound, this treatment also needed to be completed daily. This had been explained to the resident with plans to complete this treatment later in the evening. Observation on 10/30/19 at 7:44 A.M. of wound treatments by Advanced Practice Registered Nurse (APRN) #300 and licensed practical nurse (LPN) assistant director of nursing (ADON) #126 revealed Resident #113 was in bed with a heel boot in place to the left foot only. Resident #113 had a partially closed surgical wound to the left foot and a unstageable pressure ulcer which measured 1.5 cm by 4.8 cm by 0.1 cm black eschar to the left heel. Observation of the right lateral foot revealed a diabetic ulcer with a dried wound bed and no drainage. Black eschar was observed to the right heel and the area was assessed upon request of the surveyor. The right heel measured 5 cm by 4 cm by 0.1 cm, black eschar. APRN #300 reported he assessed Resident #113's wounds weekly, area to right heel was not present last week, and he was not aware of the area to the right heel until this time. Resident #113 reported wound treatments were not being completed daily as ordered and denied any discomfort to the right heel. Interview with Resident #113, immediately following wound treatment observation, reported staff applied heel boots to both feet for a couple of days and then stopped applying the boot to the right foot for unknown reasons, reporting it just remained on the chair in his room. Interview on 10/30/19 at 10:06 A.M. with APRN #300 acknowledged Resident #113 did not have a heel boot in place to the right foot upon entrance to the room to complete wound assessments, and reported the resident should have had heel boots in place to both feet. Resident #113 was at high risk for skin breakdown related to diagnosis of uncontrollable diabetes, peripheral vascular disease, neuropathy, and was currently being treated for a septic knee with elevated inflammatory lab results despite antibiotic treatment. Resident #113 also required a blood transfusion late last week resulting in being on a stretcher for hours and reported the right heel was most likely a DTI which progressed into eschar with inability to determine when this occurred. With a treatment always being in place to the right foot, the heel would not have been visible during care and even during treatments, with the resident experiencing pain from the knee, it was difficult to raise the foot up to clearly observe the heel. Resident #113 also had decreased sensation and never complained about pain to the area. Interview on 10/30/19 at 11:31 A.M. with state tested nursing assistant (STNA) #30 reported Resident #113 only had a boot applied to the left surgical foot but was unaware of the exact reasons but thought it had something to do with the resident only being permitted to bear weight on one foot. Interview on 10/30/19 at 2:31 P.M. with RN #163 reported Resident #113 wore heel boots to both feet for the first few days but then just the left foot. RN #163 reported she thought the resident only wore the heel boot to the left foot based upon preference in order to utilize a leg lift device on the right foot. RN #163 reported she had always completed treatments to the right foot but had just started completing treatments to the left foot, since the wound vac was discontinued a week ago. RN #163 reported the dark black area to the right heel had been present for a while, the resident reported it wasn't anything new, and the area continued to be wrapped with gauze. Interview on 10/30/19 at 3:33 P.M. with LPNADON #126 verified all wound treatments were grouped together on the TAR and there wasn't any documentation of treatments being completed as ordered on 10/25/19 and 10/27/19. Review of wound specialist progress note dated 10/30/19 revealed an unstageable pressure ulcer, suspected DTI, located on the left heel which measured 1.5 cm by 4.5 cm by 0.1 cm, was purple in color, non blanching intact discoloration along the edges and black dry peeling skin in the central portion with pink epithelialization underneath when lifted up. The area was stable with dry peeling revealing epithelial tissue underneath. Continue skin prep and offloading boots. An unstageable pressure ulcer was also discovered on the right heel which measured 5 cm by 4 cm by 0.1 cm without drainage, with a large amount of necrotic tissue within the wound bed including eschar (dead tissue), and a black eschar cap. Initial assessment of the right heel unstageable pressure ulcer was likely unavoidable due to complications from loss of protective sensation, neuropathy, diabetes, peripheral vascular disease, and right knee surgical site pain contributing to lack of mobility in the right lower extremity. In addition, Resident #113's hemoglobin was down to 6.1 on 10/21/19 and resident ended up requiring a blood transfusion late last week for which the resident was gone from the facility for several hours on a stretcher. Furthermore, lab tests remain elevated contributing to systemic inflammation, despite antibiotic therapy. Treatment included betadine daily and heel offloading boots. Review of NPUAP Pressure Injury Stages revealed an unstageable pressure injury was defined as full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. A DTI was defined as persistent non-blanchable deep red, maroon or purple discoloration of intact or non-intact skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff and resident interview, the facility failed to ensure that one resident in need of foot care received podiatry services in a timely manner. This affected one (Resident #11) of three residents reviewed for Activities of Daily Living (ADL). The facility census was 125. Findings include: Resident #11 was initially admitted to the facility on [DATE], and readmitted to the facility on [DATE]. The resident had diagnoses including acute renal failure, dyspnea, benign neoplasm of brain, acute pulmonary edema, diabetes mellitus type 2 with hyperglycemia, chronic kidney disease stage 3, dementia without behavioral disturbance, chronic obstructive pulmonary disease, hypertension, idiopathic peripheral autonomic neuropathy, and mood disorder. The facility completed a quarterly minimum data (MDS) of the resident's cognitive and physical functional status dated 10/11/19. The 10/11/19 assessment identified the resident as having mild to moderate cognitive deficits, and requiring the physical assistance of at least one staff person to complete all ADL, including grooming and personal hygiene The resident was her own responsible party. Review of Resident #11's admission packet information from the initial admission revealed the resident signed/authorized professional ancillary services including podiatry services on 04/11/19. The authorization for professional services dated 04/11/19 included the following language: I understand that the medical professionals identified in the contact list on the attached page titled Professionalshave agreed to provide services to residents of this facility, and that the facility will refer me to those Professionals to receive services when such services are ordered by my physician, requested by me or my representative, or otherwise deemed medically appropriate. Review of Resident #11's electronic health record, and paper record, failed to reveal any documentation to support that ancillary services were every discussed with the resident, the condition of the residents toe nails were ever documented, the resident was ever offered podiatry services, or ever refused podiatry services. An interview was conducted with Resident #11 on 10/29/19, and observations of the resident's grooming and hygiene were made. The resident's feet were visible at that time and her toenails were noted to be excessively long, thick and curling over the tops of several of her toes. Resident #11 affirmed her toe nails were very long and it bothered her to see them that long. The resident denied that the podiatrist had seen her since admission, and the facility never offered for her to see a podiatrist. On 10/30/19 at 11:45 A.M. Licensed Practical Nurse (LPN) #139 was asked to observe the resident's toe nails with the resident's permission. LPN #139 examined the resident's toe nails and affirmed the toe nails of the residents 2nd, 3rd, and 4th toe on both feet were very long and curled over the tops of the toes and were thick. She also affirmed the toe nail of the right great toes was excessively long and thick. On 10/30/19 at 11:48 A.M. LPN #139 reported she thought she recalled the resident having a history of refusing podiatry visits. She stated she was aware the resident was a diabetic and the implications if the resident's long toe nails dug into her skin and caused trauma. LPN #139 stated that typically the State Tested Nurse Aides (STNAs) would note that the resident's nails were trimmed on the shower sheets, but the resident was a diabetic and they would not trim her nails. An interview was conducted with Licensed Social Worker (LSW) #179 on 10/31/19 at 8:13 A.M. regarding the condition of Resident #11's toe nails, and to determine if she had ever been offered, or received, any podiatry services since admission to the facility in April of 2019. LSW #179 reported she reviewed the social service progress notes and affirmed there was no documentation to support the resident had ever been offered podiatry services, or refused any podiatry services. She reported that she talked with the resident on 10/30/19 after the condition of the resident's toe nails were brought to her attention, and the resident consented to seeing the podiatrist. LSW #179 stated the resident was going out to the podiatrist today 10/31/19 for an appointment. An interview was conducted with STNA #115 on 10/31/19 at 8:33 A.M. to ascertain if the STNA was aware of the condition of the resident's toe nails, and what STNAs were responsible for in regards to resident nail care. She reported that STNAs were responsible for clipping finger nails but not toe nails. STNA #115 reported that she assumed all residents at the facility saw the podiatrist. When asked if she had recently worked with the resident she stated she had and affirmed the resident's toe nails were very long. STNA #115 then stated she was aware the podiatrist was just at the facility but the resident was not on the list to see the podiatrist, and she did not know if the resident had been on the list and refused. She added that she does not know how residents get on the list to see the podiatrist but she could let the nurse know and they could communicate the resident needed to be seen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation,and staff interview, the facility failed to ensure that each resident with a limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. This affected one (Resident #102) of one resident reviewed for positioning. The facility census was 125. Findings include: Resident #102 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, vascular dementia with behavioral disturbance, contracture right hand, contracture right knee, chronic obstructive pulmonary disease, and aphasia. The facility completed an annual comprehensive assessment of Resident #102's cognitive and physical functional status dated 10/02/19. The 10/02/19 assessment identified the resident as having poor memory, severely impaired cognitive skills, and requiring the physical assistance of one to two staff persons to complete all activities of daily living. The resident was assessed as having functional limitations in his range of motion due with impairments to his upper and lower extremity on one side. Review of Resident #102's physician's orders revealed a current physician's order to wear a right hand splint and right knee brace for up to six hours a day as tolerated. Review of Resident #102's comprehensive plan of care revealed a current plan of care with a goal date of 12/31/19 which addressed the residents activity of daily living self care performance deficits. The care plan identified the resident as being at risk for joint stiffness, muscle atrophy, falls, skin breakdown, and loss of dignity related to his self care performance deficits. The care plan goal was for the resident to be neat, clean, and odor free through the next review date The interventions for the resident included wearing a ranger knee brace to his right knee three to six hours as tolerated each day, and to wear a resting hand splint up to six hours per day as tolerated. Review of Resident #102's October 2019 treatment record (TAR) revealed that there was a place on the TAR to document where the hand and knee splint was used during the day and/or night shifts of duty. The October 2019 TAR where the splint order was noted, and was supposed to be documented for each day of the week, was blank for all days of the month. Resident #102 was observed in his room in bed on 10/28/19 at 5:09 P.M. The resident appeared to have significant contractures of his right wrist/hand, and his right knee. The resident was not wearing any splints. Resident #102 was observed up dressed in his wheel chair in the unit activity/dining room on 10/29/19 at 9:17 A.M. The resident was not wearing any splints to his right hand or right knee. Resident #102 was observed on 10/30/19 at 11:57 A.M. up in his wheel chair in the unit activity/dining room. The resident's right arm was dangling straight down the side of his wheel chair towards the floor, his hand appeared slightly swollen. The resident was not wearing any splints to his right hand or right knee. State Tested Nurse Aide (STNA) #74 who was nearby was asked to view the resident and address his dangling right arm. STNA #74 repositioned the residents arm/hand on the pillow. The nurse aide was then interviewed to ascertain if the resident had a right hand and/or a right knee splint. STNA #74 stated he was familiar with the resident, and the resident was to wear the hand splint when he was in bed, but was not aware of the resident having a right knee splint. The nurse aide went and found the hand splint in the residents night stand and applied the right hand splint with no resistance by the resident while the resident was sitting in his wheel chair. An interview was conducted with STNA #25 on 10/30/19 at 12:01 P.M. regarding Resident #102's splints. The nurse aide was assigned to the unit where the resident was located. The nurse aide was asked if the resident wore splints to his right hand or right leg, and she reported that the resident did have a right hand splint, but voiced no awareness of the resident wearing a knee brace/splint. STNA #25 reported she thought the resident was supposed to wear the hand splint when he was up in his wheel chair, and then off at night. On 10/30/19 at 5:56 P.M. unit manager, Licensed Practical Nurse (LPN) #139 was made aware that Resident #102's right hand and knee splint was not observed in use, that there was a current physician's order for the use of the splints, and a care plan was evident for the use of the splints. In addition, LPN #139 was made aware there was a place for nursing staff to note the application of the splint on the TAR during either the day or night shift of duty daily, but the TAR was blank regarding the application for the splint for the month of 10/2019. Additional information regarding the status of Resident #102's splint usage, and the whereabouts of the knee splint, was requested from LPN #139. No additional information was provided by the facility regarding the resident's splints. An interview was conducted with Certified Occupational Therapy Assistant, Therapy Manager (TM) #305 on 10/31/19 at 10:01 A.M. regarding Resident #102's hand and knee splints. She reviewed the last information regarding the knee splint from when the resident was discharged from physical therapy on 07/02/19. TM #305 affirmed the resident was treated for flexion contracture of the right knee, and the intervention was for the resident to wear a right knee brace. She had no additional information regarding the status of the knee brace since the 07/02/19 discharge. Resident #102's physical therapy (PT) Discharge summary dated [DATE] was provided by TM #305 and reviewed revealed the following documentation related to the resident's right knee brace: the resident, spouse, and nursing staff were educated on proper donning and doffing of the right knee brace and instructed in a brace (wearing) schedule going forward in order to maximize the benefit of wearing the brace and to maintain his active and passive range of motion gains to his right knee. The therapist also noted the resident's progress was good as evidence by his improved right knee range of motion and established plan of use of the knee brace going forward in order to prevent further contractures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure fall interventions were in place. This affected one (Resident #54) of four residents reviewed for falls. The facility census was 125. Findings include: Medical record review revealed Resident #54 was admitted to the facility on [DATE] with a re-entry date of 09/28/19. Diagnosis include left hip fracture. Review of minimum data set (MDS) assessment dated [DATE] revealed intact cognitive skills for daily decision making, limited assistance was required with bed mobility, transfers, and a walker and wheelchair were utilized for mobility. Review of care plan dated 08/28/19 revealed Resident #54 had a potential for injuries related to a history of falls, status post left hip surgery. An intervention was added on 09/27/19 to place non skid strips in front of the toilet to increase safety during toileting. Review of nursing progress note dated 09/26/19 at 12:55 P.M. revealed Resident #54 sustained a fall while in the bathroom while attempting to wipe self. Assessment was completed and revealed complaints of pain to the left hip and shoulder. X-rays were ordered. On 09/26/19 at 5:48 P.M., Resident #54 was transported to the hospital and admitted with a closed femur fracture. On 09/27/19 at 11:21 A.M., the interdisciplinary team (IDT) met, reviewed the fall and investigation and recommended non skid strips to the bathroom floor in front of the toilet to increase safety during toileting. Review of physician order dated 09/27/19 for Resident #54 revealed to place non skid strips in front of the toilet to increase safety during toileting. Interview on 10/28/19 at 4:15 P.M. with Resident #54 reported one fall at the facility, in the bathroom, resulting in an injury to the hip which had just been surgically repaired. Observation on 10/31/19 at 10:02 A.M. revealed there weren't any non skid strips on the floor in Resident #54's bedroom or bathroom. Observation on 10/31/19 at 10:25 A.M. of Resident #54's room including the bathroom with registered nurse unit manager (RNUM) #168 confirmed there weren't any non skid strips in place to the floor. Interview on 10/31/19 at 11:58 A.M. with RNUM #168 reported Resident #54 had one fall at the facility. On 09/26/19 at 11:00 A.M., Resident #54 fell while in the bathroom, attempting to wipe self. Interventions in place at the time of the fall included non-skid footwear, utilize call light as needed, and therapy services. Resident #54 was transported to the hospital and treated for a hip injury. Due to the residents level of independence, non skid strips to the bathroom floor were ordered for a new intervention. RNUM #168 reported the non skid strips were ordered, the intervention was added to the care plan, and he was unaware the reason the non skid strips were not in place to the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview the facility failed to ensure a resident was monitored and peritoneal dialysis flowsheets were accurately completed to ensure appropriate treatment. This affected one (Resident #72) of one reviewed for dialysis. The facility identified two residents on dialysis. The facility census was 125. Findings include: Medical record review revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including end stage renal disease and dependence on renal dialysis. Review of quarterly minimum data set (MDS) assessment dated [DATE] revealed intact cognitive skills for daily decision making, extensive assistance was required with bed mobility, and limited assistance was required with transfers, eating, and toileting. A walker and wheelchair were utilized for mobility. Review of the care plan dated 08/22/19 revealed Resident #72 received peritoneal dialysis related to end stage renal failure. Interventions included daily weight, notify nephrologist for greater than two pound weight gain in a day or three to five pounds in a week, fax daily peritoneal dialysis flowsheet to nephrologist daily and file original in medical record, choose daneal solution bag for dialysis: below 140 pounds use one green bag and one yellow bag; 140 pounds, use two green bags; above 140 pounds use one green bag and one red bag. Review of active physician orders revealed obtain weight twice daily, before and after dialysis. If greater than two pound weight gain in a day or three to five pounds in a week notify the nephrologist, a physician who specializes in treatment of kidney disease. Call nurse every Friday for count on dialysis bags and supplies. Choose daneal, solution utilized for peritoneal dialysis, according to residents target weight of 140 pounds: below 140 pounds use one green bag and one yellow bag; 140 pounds use two green bags; above 145 pounds use one green bag and one red bag; and above 150 pounds use two red bags every night shift. Obtain vital signs every morning after dialysis. Fax daily peritoneal dialysis treatment flowsheet to nephrologist and file original sheet in medical record. Call nephrologist office for any dialysis questions or concerns. Review of daily peritoneal dialysis treatment flowsheets for the month of October 2019 revealed on 10/02/19, 10/07/19, 10/12/19, 10/13/19, 10/14/19, and 10/21/19 Resident #72's weight and vital signs were not obtained following dialysis treatment. On 10/08/19, 10/15/19, and 10/25/19 Resident #72's weight was not obtained prior to dialysis. There weren't any peritoneal dialysis sheets in the medical record for 10/09/19 or 10/19/19. Observation on 10/30/19 at 4:41 P.M. revealed Resident #72 was awake in bed, independently repositioning self. Interview with Resident #72, at the time of the observation, reported dialysis was started nightly around 7:30 P.M. or 8:00 P.M. and took approximately seven to eight hours to complete. Resident #72 reported weights were obtained before and after treatments. Interview on 10/31/19 at 11:32 A.M. with registered licensed dietician (RDLD) #500 reported she communicated with the renal dietician on a monthly basis to ensure nutrition treatment needs were met. Resident #72 was weighed twice daily with dialysis treatment solution bags adjusted as needed according to weights. Resident #72 had some weight fluctuations but upon discussion with renal dietician this was not of concern as long as the facility utilized proper treatment solution bags. Interview on 10/31/19 at 2:05 P.M. with registered nurse unit manager (RNUM) #168 reported peritoneal dialysis treatment flowsheets were completed daily and faxed to the nephrologist to monitor and provide dialysis treatment orders to meet the needs of the resident. Information included on the flowsheet included weights before and at completion of dialysis, vital signs following dialysis, and information from dialysis cycler machine. There were two dates, 10/09/19 and 10/19/19, which the flowsheet was unable to be located at the facility in the medical record and contact with the nephrologist office reported inability to locate a faxed flowsheet for those dates. RNUM #168 verified Resident #72's flowsheets did not contain weights prior to dialysis on 10/08/19, 10/15/19, or 10/25/19 and did not contain a weight or vital signs following dialysis treatment on 10/02/19, 10/07/19, 10/12/19, 10/13/19, 10/14/19, or 10/21/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of facility policy the facility failed to ensure residents received written bed hold notifications within 24 hours of their discharges from the facility. This affected four Residents (#89, #91, #99 and #122) of nine residents reviewed for discharge notification. The facility census was 125. Findings include: 1. Record review revealed Resident #89 was admitted to the facility on [DATE] with the following diagnoses; malignant neoplasm of bones of skull and face, non-traumatic subdural hemorrhage, other specified disorder of nose and nasal sinuses, anoxic brain damage, unspecified convulsions, hypertension, type two diabetes mellitus, insomnia, muscle weakness, unspecified dementia without behavioral disturbance, and anxiety disorder. Review of Resident #89's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, toileting, eating and personal hygiene. Furhter review of Resident #89's medical record revealed thr resident was discharged to the hospital for a change in mental status on 09/08/19. Resident #89 was readmitted to the facility on [DATE]. There was no documentation that Resident #89 or Resident #89's representative were provided a written bed hold notification upon Resident #89's discharge to the hospital on [DATE]. Interview with the Administrator on 10/31/19 at 8:48 A.M. verified Resident #89 or Resident #89's representative did not receive a written bed hold notifications within 24 hours of Resident #89's discharge to the hospital on [DATE]. Review of the facility's emergency transfer to the hospital policy dated 11/28/19 revealed the resident or representative will be notified prior to or as soon as practicable thereafter but not greater than 24 hours of the facility's bed hold policy. 4. Medical record review revealed Resident #99 was admitted to the hospital on [DATE] with a re-entry date of 08/23/19. Diagnoses included osteomyelitis of left ankle and foot, sepsis, congestive heart failure, peripheral vascular disease, and multiple sclerosis. Further medical record review revealed Resident #99 was transferred to the hospital and hospitalized [DATE] to 08/23/19 for osteomyelitis and sepsis, 09/02/19 to 09/04/19 for acute blood loss anemia, 09/10/19 to 09/12/19 for a urinary tract infection (UTI) and sepsis, and 10/02/19 to 10/06/19 for a UTI, acute kidney injury, dehydration, and sepsis. The medical record did not contain any evidence of a written bed hold notice being provided to the resident and the resident representative upon hospitalizations. Interview on 10/31/19 at 1:49 P.M. LSW #402 verified bed hold notices were not provided to Resident #99 or the residents representative upon hospitalizations. Review of Emergency Transfer to Hospital Policy and Procedure revised 11/28/18 revealed should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, the facility would implement the following procedures including the resident and/or representative would be notified prior to or as soon as practicable thereafter (but no greater than 24 hours) of the facility's bed hold policy and permitting residents to return to facility protocol. 2. Resident #91 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Parkinson's disease, hypertension, Alzheimer's disease, unspecified dementia with behavioral disturbance, major depressive disorder recurrent without psychotic features, anxiety disorder, dysphagia, muscle wasting and atrophy, diabetes mellitus type 2, and adult failure to thrive. The facility completed a quarterly MDS of the residents cognitive and physical functional status dated 10/02/19. The 10/02/19 assessment identified the resident as having moderate to severe cognitive impalements, and requiring the extensive assistance of on staff person to completed all activities of daily living with the exception of eating, which she was able to completed with only supervision. Review of Resident #91's nursing progress notes revealed an entry by Registered Nurse (RN) #143 dated 08/13/19. RN #143 documented the resident was noted with increased behaviors and outbursts. The resident was refusing all medications, was difficult to redirect, and was verbally aggressive towards staff and residents. One on one interaction was ineffective. The resident was threatening physical aggression toward roommate, but no physical contact was observed. The resident had not displayed any attempts to harm herself. RN #143 then noted she contacted the resident's attending physician and her psychiatrist. The resident's attending physician ordered that Resident #91 be transported to a psychiatric hospital facility for further evaluation. On 08/14/19 Licensed Social Worker (LSW) #179 made a note in Resident #91's electronic health record (EHR). LSW #179 documented that she spoke with the nurse liaison from the psychiatric unit where the resident had been transferred to. She noted the resident was admitted to the psychiatric facility, and the nurse liaison communicated the average length of staff for individuals is two weeks, but each case varied. On 08/30/19 RN #143 documented in Resident #91's nursing progress notes the resident returned to the facility on [DATE]. Review of Resident #91's EHR and paper record failed to reveal any mention, or any documentation to support, the resident and/or their representative received the required information in writing regarding the facility's bed hold policy and return and remaining bed hold days as applicable before transfer to the hospital, or as soon as practicable. On 10/31/19 at 1:00 P.M. the Director of Nursing (DON) was asked to provide documentation that Resident #91 and her representative were provided with the required bed hold information regarding her 08/13/19 discharge to the psychiatric facility. She provided a copy of the 08/13/19 progress note showing why the resident was sent out to the hospital. The DON affirmed there was no documentation to support the required bed hold information was provided in writing to the resident or her representative at the time of the 08/13/19 transfer/discharge to the psychiatric facility. 3. Resident #122 was admitted to the facility on [DATE] and discharged to an acute care hospital on [DATE]. The resident has not returned to the facility. Resident #122 had diagnoses including dislocation of right ankle, anemia, thyrotoxicosis with diffuse goiter, chronic obstructive pulmonary disease, diabetes mellitus, obesity, and bariatric surgery status. The resident was her own responsible party. The facility completed an admission MDS of Resident #122's cognitive status dated 09/18/18. The resident was assessed as having good memory, recall, and decision making skills. Review of Resident #122's EHR, discharge record, revealed an entry by RN #34 on 09/26/19. RN #34 documented she was called to the resident's room, the resident had pronounced left side weakness and left side facial drooping, and slurred speech. She noted emergency medical services were called and the resident's physician was notified. RN #34 documented she then called the receiving hospital to give report. The resident did not return to the facility. Review of discharged Resident #122's EHR and paper record failed to reveal any mention, or any documentation to support, the resident and/or their representative received the required information in writing regarding the facility's bed hold policy and return and remaining bed hold days as applicable before transfer to the hospital, or as soon as practicable. On 10/31/19 at 1:00 P.M. the DON was asked to provide documentation that discharged Resident #122 and her representative were provided with the required bed hold information regarding her 09/26/19 discharge to the hospital. She provided a copy of the 09/26/19 progress note showing why the resident was sent out to the hospital. The DON affirmed there was no documentation to support any of the required bed hold notice information was provided to the resident or her representative at the time of the 09/26/19 discharge to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide residents and their representatives with a summary of the baseline care plan. This affected ten residents (#1, #11, #20, #38, #42, #43, #54, #66, #72, and #99) of 16 residents reviewed for baseline care plans that were admitted within the past year. The facility census was 125. Findings include: 1. Record review revealed Resident #66 was admitted to the facility on [DATE] with the following diagnoses; spinal stenosis, scoliosis, essential hypertension, osteoarthritis, other non specific abnormal finding of lung field, muscle weakness, heart failure, anxiety disorder, osteoarthrosis and venous insufficiency. Review of Resident #66's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, transfers, eating, dressing, toileting and personal hygiene. Review of Resident #66's baseline care plan revealed resident's baseline care plan was completed on 07/05/19. Further review of Resident #66's medical record revealed no documentation that a written summary of Resident #66's baseline care plan was provided to the resident or resident's representative. Interview with the Director of Nursing (DON) on 10/30/19 at 1:43 P.M. verified Resident #66's medical record contained no documentation that Resident #66 or Resident #66's representative was given a written summary of Resident #66's baseline care plan. 2. Record review revealed Resident #42 was admitted to the facility on [DATE] with the following diagnoses; unspecified fracture of shaft of left tibia, unspecified fracture of shaft of left fibula, type two diabetes mellitus with foot ulcer, non pressure chronic ulcer of left calf with fat layer exposed, non pressure chronic ulcer of other part of unspecified foot with unspecified severity, chronic venous hypertension, venous insufficiency, dysuria, gastro esophageal reflux disease without esophagitis, anemia, hypoglycemia, and chronic kidney disease stage three. Review of Resident #42's quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Resident #42 also required limited assistance with eating. Review of Resident #42's baseline care plan revealed the resident's baseline care plan was completed on 07/09/19. Further review of Resident #42's medical record revealed no documentation that a written summary of Resident #42's baseline care plan was provided to the resident or resident's representative. Interview with the DON on 10/30/19 at 1:43 P.M. verified Resident #42's medical record contained no documentation that Resident #42 or Resident #42's representative was given a written summary of Resident #42's baseline care plan. 3. Record review revealed Resident #43 was admitted to the facility on [DATE] with the following diagnoses; unspecified dementia with behavioral disturbance, chronic fatigue, hypertension, mixed incontinence, unspecified abnormalities of gait and mobility, iron deficiency anemia, pure hypercholesterolemia, epistaxis, acute angle closure glaucoma, muscle weakness, difficulty in walking, repeating falls, cognitive communication deficit, dysphagia, cerebral infarction, presence of left artificial hip joint and vascular dementia with behavioral disturbance. Review of Resident #43's quarterly MDS assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, toileting and eating. Resident #43 also required limited assistance with personal hygiene. Review of Resident #43's baseline care plan revealed the resident's baseline care plan was completed on 07/10/19. Further review of Resident #43's medical record revealed no documentation that a written summary of Resident #43's baseline care plan was provided to the resident or resident's representative. Interview with the DON on 10/30/19 at 1:43 P.M. verified Resident #43's medical record contained no documentation that Resident #43 or Resident #43's representative was given a written summary of Resident #43's baseline care plan. 4. Record review revealed Resident #20 was admitted to the facility on [DATE] with the following diagnoses; anxiety disorder, chronic diastolic heart failure, paroxysmal atrial fibrillation, essential tremor, hyperlipidemia, asthma with acute exacerbation, gastro esophageal reflux disease, repeated falls, history of falling, abnormal weight loss, muscle weakness and need for assistance with personal care. Review of Resident #20's quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, transfers, dressing, personal hygiene, toileting and eating. Review of Resident #20's baseline care plan revealed the resident's baseline care plan was completed on 03/07/19. Further review of Resident #20's medical record revealed no documentation that a written summary of Resident #20's baseline care plan was provided to the resident or resident's representative. Interview with the DON on 10/30/19 at 1:43 P.M. verified Resident #20's medical record contained no documentation that Resident #20 or Resident #20's representative was given a written summary of Resident #20's baseline care plan. 7. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with the diagnosis of Parkinson disease. Further medical record review revealed a baseline care plan was developed upon admission on [DATE]. The medical record did not contain any evidence Resident #38 and the residents representative were provided a written summary of the baseline care plan. Interview on 10/31/19 at 12:54 P.M. with LSW #402 verified there wasn't any documentation in the medical record to indicate a summary of the baseline care plan was provided to Resident #38 and their representative. 8. Medical record review revealed Resident #54 was admitted to the facility on [DATE] with a re-entry date of 09/29/19 with the diagnosis of a left hip fracture. Further medical record review revealed a baseline care plan was developed upon admission on [DATE]. The medical record did not contain any evidence Resident #54 and the residents representative were provided a written summary of the baseline care plan. Interview on 10/31/19 at 12:54 P.M. with LSW #402 verified there wasn't any documentation in the medical record to indicate a summary of the baseline care plan was provided to Resident #54 and their representative. 9. Medical record review revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including end stage renal disease and diabetes. Further medical record review revealed a baseline care plan was developed upon admission on [DATE]. The medical record did not contain any evidence Resident #72 and the residents representative were provided a written summary of the baseline care plan. Interview on 10/31/19 at 12:54 P.M. with LSW #402 verified there wasn't any documentation in the medical record to indicate a summary of the baseline care plan was provided to Resident #72 and their representative. 10. Medical record review revealed Resident #99 was admitted to the facility on [DATE] with a re-entry date of 08/23/19. Diagnoses included osteomyelitis of the left ankle and foot, sepsis, peripheral vascular disease, and congestive heart failure. Further medical record review revealed a baseline care plan was developed upon admission on [DATE]. The medical record did not contain any evidence Resident #99 and the residents representative were provided a written summary of the baseline care plan. Interview on 10/31/19 at 12:54 P.M. with LSW #402 verified there wasn't any documentation in the medical record to indicate a summary of the baseline care plan was provided to Resident #99 and their representative. 5. Resident #1 was admitted to the facility on [DATE], then readmitted on [DATE] after a scheduled surgery. The resident's diagnoses included unspecified bacterial pneumonia, secondary kyphosis cervicothoracic region, spinal stenosis, scoliosis, intervertebral disc degeneration lumbosacral region, muscle weakness, bipolar disorder, anxiety disorder, dysphagia, chronic pain syndrome, and chronic kidney disease. The facility completed a five day MDS of the resident's cognitive and physical functional status dated 10/15/19. The 10/15/19 assessment identified the resident as having fair to food cognitive skills and requiring the physical assistance of at least one staff person to complete all activities of daily living. The resident received all food and liquid via a gastrostomy tube feeding. The resident was her own responsible party. Review of Resident #1's nursing and social service progress notes failed to reveal any documentation to support the resident and/or her representative was provided with an initial care conference or received a summary of a baseline care plan which included the resident goals, a summary of the resident's medications and dietary instructions, any services/treatment needed, or any updated information as needed per the comprehensive plan of care. An interview was conducted with Resident #1 on 10/31/19 at 10:39 A.M. to ascertain if she had been involved in developing her individualized care plan, and if she had been provided with a copy of her baseline care plan after admission to the facility. Resident #1 stated she did not recall getting a copy of her baseline care plan, or signing that she received a written plan of care. An interview was conducted with Licensed Social Worker (LSW) #402 on 10/31/19 at 11:51 A.M. to determine if Resident #1 was included in her initial care planning and received a baseline care plan. She reported the resident was first admitted to the facility on [DATE] and she did not have any documentation to support the resident actually participated in developing, and received a written copy of, her baseline care plan at the time of the first admission. LSW #402 did provide documentation that Resident #1 had participated in a comprehensive care planning conference on 10/02/19 which was also attended by family members. However, the form the resident signed on 10/02/19 specified only the resident reviewed her plan of care and participated in care plan decisions including goal setting and interventions. No where on the form did it specify the resident was given a written copy of the care plan, which was affirmed by LSW #402. 6. Resident #11 was initially admitted to the facility on [DATE], and readmitted to the facility on [DATE]. The resident had diagnoses including acute renal failure, dyspnea, benign neoplasm of brain, acute pulmonary edema, diabetes mellitus type 2 with hyperglycemia, chronic kidney disease stage 3, dementia without behavioral disturbance, chronic obstructive pulmonary disease, hypertension, idiopathic peripheral autonomic neuropathy, and mood disorder. The facility completed a quarterly MDS of the resident's cognitive and physical functional status dated 10/11/19. The 10/11/19 assessment identified the resident as having mild to moderate cognitive deficits, and requiring the physical assistance of at least one staff person to complete all activities of daily living. The resident was her own responsible party. Review of Resident #11's nursing and social service progress notes failed to reveal any documentation to support the resident and/or her representative was provided with an initial care conference or received a summary of a baseline care plan which included the resident goals, a summary of the resident's medications and dietary instructions, any services/treatment needed, or any updated information as needed per the comprehensive plan of care. An interview was conducted with Resident #11 on 10/29/19 at 11:07 A.M. to ascertain if she had been involved in developing her individualized care plan, and if she had been provided with a copy of her baseline care plan after admission to the facility. The resident stated that she did not recall being involved in a care plan meeting or getting a copy of her baseline care plan. An interview was conducted with LSW #402 on 10/31/19 at 11:51 A.M. to determine if Resident #11 was included in her initial care planning and received a baseline care plan. She reported the resident was first admitted to the facility on [DATE] and she did not have any documentation to support the resident actually participated in developing, and received a written copy of, her baseline care plan.

Based on observation, interview, review of controlled substances count and shift verification records, and Controlled Substances Policy, the facility failed to ensure controlled substances were counted at the end of each shift. This affected 15 Residents (#10, #15, #20, #23, #25, #27, #38, #42, #43, #65, #88, #89, #95, #103, and #109) whom had narcotic medications stored on the Sycamore one medication cart. The facility census was 125. Findings include: Observation on 10/30/19 at 5:49 P.M. of the Sycamore one medication cart with licensed practical nurse (LPN) #44 revealed the controlled substances count and shift verification for October 2019 was not completed by two nurses between each shift. Directions at the top of the controlled substances count and shift verification form revealed indicate appropriate shift schedule and use the form to verify that the controlled drugs on hand have been counted and that each medication count is in agreement with the quantity stated on the controlled drug record. Notify appropriate facility staff according to the facility policy regarding any discrepancies. LPN #44 verified missing signatures. Interview on 10/31/19 at 11:00 A.M. with LPN unit manager #126 revealed upon receipt of narcotic medications, the medication was added to the controlled substance count and shift verification form. Every time a medication was removed from the cart, this was documented on the controlled substance count and shift verification form. The medication cart was kept secured and when the keys to the cart were passed from one nurse to another nurse, all narcotic medications in the cart were counted and compared to the controlled substance count and shift verification form to ensure accuracy. LPN unit manager #126 verified, upon review of the controlled substances count and shift verification form for October 2019, on 10/06/19 at 7:00 A.M. the nurses signed but did not complete the form by documenting the number of narcotic sheets for reconciliation, on 10/15/19 there wasn't any documentation of the controlled substances being counted at the 7:00 A.M. shift change, and on 10/17/19 at 7:00 P.M. and 10/21/19 at 7:00 P.M. and 1:20 A.M. only one nurse, the off-going nurse, signed the controlled substances count and shift verification form. Review of facility Controlled Substances Policy revised February 2018 revealed nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must count together. They must document and report any discrepancies to the Director of Nursing Services.

Based on medical record review, observation, interview, review of facility Instillation of Eye Drops and Administering Medications Through an Enteral Tube Procedures, and review of drug manufacturer recommendations the facility failed to ensure medication error rate was below five percent (%). Observation of administration of 26 medications revealed ten errors for a medication error rate of 38.46 %. This affected two Residents (#1 and #43) of five observed for medication administration. The facility census was 125. Findings include: 1. Observation on 10/31/19 at 7:40 A.M. revealed licensed practical nurse (LPN) #212 administered brimonidine tartrate ophthalmic solution 0.15% to Resident #43, one drop in each eye. At 7:43 A.M., three minutes later, LPN #212 administered dorzolamide HCL timolol maleate ophthalmic solution 22.3 milligrams (mg)/6.8 mg per milliliter (ml) to Resident #43, one drop in each eye. (This counted as two errors). Interview with LPN #212 at the time of the observation confirmed she only waited three minutes in between administering the two different medicated eye drops. Review of facility Instillation of Eye Drops Procedure revealed if administering different eye drop medications wait the appropriate amount of time between medications by following manufacturer's recommendations and/or physician orders. Review of physician orders for Resident #43 revealed no specific time was specified to wait in between the administration of different eye drops. Review of brimonidine tartrate ophthalmic solution manufacturer recommendations revealed the ophthalmic solution may be used concomitantly with other topical ophthalmic drug products to lower intraocular pressure. If more than one topical ophthalmic product is to be used, the different products should be instilled at least five minutes apart. Review of dorzolamide HCL timolol maleate ophthalmic solution manufacturer recommendations revealed if more than one topical ophthalmic drug is being used, the drugs should be administered at least ten minutes apart. 2. Observation of medication administration on 10/31/19 at 7:56 A.M. to Resident #1 by registered nurse (RN) #119 revealed ferrous sulfate 325 mg, one multivitamin with minerals, vitamin C 500 mg, vitamin D 1000 international unit (IU), lamotrigine 200 mg, and dicyclomine hydrochloride 20 mg were all crushed together and placed in a four ounce cup. One linzess 145 micrograms (mcg) capsule was opened and the contents were added to the cup with the other crushed medications. 17 grams of miralax was measured and placed into a different cup. Upon entrance to Resident #1's room, the miralax was combined with the other medications and the cup was filled with approximately 120 milliliters (ml) of water. RN #119 obtained another cup of approximately 120 ml of water, turned off Resident #1's tube feeding, detached the tubing, flushed the gastric tube with approximately 30 ml of water, and then poured the cup of water with all the medications mixed together into the gastric tube. (This counted as eight errors). Interview with RN #119, at the time of the medication administration to Resident #1, verified all medications were combined together in a cup with water and administered per the gastric tube. Interview on 10/31/19 at 1:43 P.M. with the director of nursing (DON) reported unless there was a specific physician order to combine all medications for administration through a gastric tube, the medications should be administered one at time with a flush of water in between each medication. Review of physician orders for Resident #1 revealed there wasn't any order to combine medications during administration through the gastric tube. Review of facility Administering Medications Through an Enteral Tube revealed if administering more than one medication, flush with five to 15 ml of water between medications.

Based on observation, interview, and drug manufacturer recommendations, the facility failed to ensure medications were properly labeled and stored. This directly affected six Residents (#38, #79, #99, #120, #121, and #220) whom had medications stored on the Recovery one and Recovery two medication carts. Four out of seven medication carts were inspected during the survey. The facility identified eight residents (Residents #1, #7, #53, #79, #99, #120, #121 and #220) with eye drops on the Recovery one and two medication carts and two residents (Residents #38 and #99) with insulin on the Recovery two medication cart. The facility census was 125. Findings include: 1. Observation on 10/30/19 at 5:17 P.M. of the Recovery two medication cart with registered nurse (RN) #153 revealed a vial of lantus insulin labeled with Resident #38's name was in a lantus box labeled with Resident #99's name. RN #153 verified the insulin vial was labeled with one residents name but stored in a box labeled with another residents name. Continued observation of the Recovery two medication cart revealed three Levemir FlexTouch insulin pens opened but not labeled with any resident name or prescribing information. At the time of the observation, RN #153 verified the Levemir FlexTouch pens were not properly labeled with prescribing information including a residents name. Also present in the Recovery two medication cart was timolol maleate ophthalmic gel forming solution 0.25 percent (%) gel solution opened but not dated for Resident #120, which was verified by RN #153 at the time of the observation. Review of Levemir FlexTouch manufacturer recommendations revealed each FlexTouch was for use by a single patient and must never be shared between patients, even if the needle was changed. 2. Observation on 10/30/19 at 5:30 P.M. of the Recovery one medication cart with licensed practical nurse (LPN) #27 revealed timolol 0.5% eye drops were opened and not dated for Resident #121 and lumigan 0.01% eye drops for Resident #220 were opened and not dated. At the time of the observation LPN #27 verified the eye drops were opened and not dated. Also in the Recovery one medication cart were two bottles of unopened latanoprost 0.005% eye drops for Resident #79. Instructions on the package revealed to protect from light and refrigerate until opened. This was verified during an interview with LPN #27 at the time of the observation, whom reported the package indicated the eye drops were filled on 09/27/19. Review of latanoprost manufacturer recommendations revealed store unopened containers in the refrigerator at 36 to 46 degrees Fahrenheit (F).

Based on observation, staff interview, and review of planned menus, the facility failed to ensure the planned menu, approved by the facility's Registered Dietitian (RD) was followed as written. This had the potential to affect all 27 Residents (#3, #4, #5, #6, #14, #21, #29, #30, #31, #35, #36, #45, #51, #57, #61, #64, #67, #85, #91, #92, #98, #104, #106, #110, #115, #117, and #170) who resided on the secured Diamond unit. The facility census was 125. Findings include: Meal service was observed on the Diamond unit, the secured unit for resident's with dementia, on 10/29/19 at 4:49 P.M. Registered, Licensed Dietitian (RD LD) #446 was present and observed the meal period with the surveyor. Hot food carriers were delivered to the unit by dietary staff, and the temperatures of the hot food were taken by State Tested Nurse Aide (STNA) #191 and was found to be in acceptable ranges. STNAs were responsible for taking the temperatures of the food, as well as plating and serving the food on the Diamond unit. The hot food sent included lasagna, baked beans, and mashed potatoes. Cookies were also sent for dessert. Review of the planned menu, approved by the RD LD revealed that residents were supposed to receive 6 ounces of beef lasagna, 4 ounces of broccoli, one breadstick, and a cookie for supper. In addition, alternatives including a 3 ounces of grilled sausage with peppers and onion, and 4 ounces of baked beans were to also be available for service. No broccoli, breadsticks, or sausages with peppers and onions had been delivered to the Diamond unit for the 10/29/19 evening meal. An interview was conducted with STNA #191 on 10/29/19 at 5:05 P.M. while she was dipping the food and placing it on the plates for residents. The nurse aide was observed plating various meal combinations like lasagna and baked beans, and lasagna and mashed potatoes. When asked if she had a planned menu to follow when serving food to residents, including menus for special diets and portion sizes for each menu items, she reported she did not. STNA #191 stated she served what was sent up from the kitchen, and used the scoops/dipping utensil that were sent. When asked, STNA #191 affirmed there was no broccoli, breadsticks, or the alternate menu item sausage with peppers and onion. RD LD #446 also observed the evening meal service on the Diamond unit and affirmed that no broccoli, breadsticks, or alternative menu items were send up from the kitchen to the unit for service. At that time RD, LD #336 called down to the kitchen to have the missing menu items delivered to the unit. On 10/30/19 at 12:32 P.M. STNA #67 was observed to have just completed serving the lunch time meal on the Diamond unit. STNA #67 was interviewed at that time to ascertain how she knew if she had all the planned menu items to serve, and what portion sized to serve. The nurse aide was also asked if she had a planned menu, approved by RD LD #446 to follow when serving residents. She reported that she served what was sent up by the dietary department, and that she was not aware of any menu being provided to nursing staff, or being posted anywhere on the unit.

Based on observation, staff interview, review of dish machine temperature and sanitizer logs, and review of facility policy and procedures, the facility failed to ensure that food was stored and prepared under sanitary conditions, and ensured that resident dishes, silverware, and food preparation and service equipment was thoroughly sanitized after use. This had the potential to affect 122 of 125 residents of the facility. The facility identified three Residents (#1, #12 and #82) as not receiving nothing by mouth (NPO). The facility census was 125 residents. Findings include: 1. A tour of the central kitchen was conducted with Dietary Director (DD) #95 on 10/28/19 beginning at 9:38 A.M. While touring the central kitchen the following was observed: a) In the refrigerated salad preparation station and refrigerator there was a 1/3 steam table pan of vanilla pudding that was not dated, a 1/3 pan of butterscotch pudding that was dated 10/14/19 with a white patch of unidentified matter on the surface of the pudding, a 1/3 pan of pears that were only partially covered and was not dated, a 1/3 pan of chocolate pudding that was not dated, and a 1/3 pan of vanilla pudding that was not dated, a pre-made container of Coleslaw which had been opened and partially used with a manufacture's use by date of 10/16/19, a 1/3 pan of pineapple dated 1014/19 which was only partially covered. DD #95 verified the contents of the salad preparation station and refrigerator as described and began throwing out all the items observed in the salad station. He stated the facility's policy was to use all items like fruit or pudding three days after opening. b) In the top section refrigerated sandwich preparation and station and refrigerator there were 15 1/6th steam table pans filled with lunch meat, cheese, and other food items used for making sandwiches. The 15 pans were loosely covered and none of the items were dated. The partially covered, undated items included ham, turkey, corned beef, roast beef, chicken salad, tuna salad which appeared to be dried out on top, egg salad that appeared to be discolored and dried out on top, a partial pan of mayonnaise, Swiss cheese, American cheese, provolone cheese of which the top slice was dried out and hard, thousand island dressing, sauerkraut, and pickles. None of the items were labeled, or dated with the prepared or dispose of date. DD #95 verified the contents of the sandwich preparation station and refrigerator as described and began disposing of all the food items. He reported that all the items should have been dated with the open or preparation date, and tightly covered. c) The interior of the microwave in use in the kitchen was heavily soiled with an accumulation of dried on food debris throughout. Dietary Staff (DS) #33 affirmed the interior of the microwave was heavily soiled, and it appeared to be an accumulation over time and not just a recent problem. d) The walk-in refrigerator was examined with DD #95. In the refrigerator there was a five pound pre-made container of egg salad with a manufacture's use by date of 09/25/19, a five pound container of pre-made egg salad with a manufacture's use by date that was illegible. DD #95 affirmed the date and lack of a date on the pre-made egg salad and threw the containers out. e) While touring the central kitchen was observed to use hot food holding cabinet, for holding hot food, prior to using it on the steam table and/or sending it up to the Diamond unit. The temperature of the cabinet was set at 180 Fahrenheit (F). Observation of the interior of the hot food holding equipment at 10:13 A.M. revealed several foil covered pans of food. The cook preparing lunch, [NAME] #172, was interviewed at that time to ascertain what food was in the cabinet, and what time the food had been put in the cabinet. [NAME] #172 reported the food in the hot cabinet was for lunch that day and it would go on the steam table about noon. When asked what time the food was prepared and placed in the hot cabinet she stated about 9:45 A.M. [NAME] #172 was then asked why the food was prepared and placed in the hot cabinet nearly two and one half hours before it was going to be served she only commented, I'll know better next time. When asked if she had taken the temperature of the hot food before putting it in the hot cabinet she stated she had not. DD #95 was then asked to take the temperature of select items of food in the hot cabinet. DD #95 was made aware that [NAME] #172 stated that she had put the food in the cabinet and not taken the temperature of the food prior to placing it in the hot cabinet was shared. DD #95 using a sanitized thermometer took the temperature of several lunch menu items in the hot cabinet. The temperature of the pureed steak hoagies, and the mechanically soft steak hoagies, was 130 F. DD #95 returned both menu items to the oven for proper heating and affirmed they were not at the correct temperature, and should not have been put in the hot cabinet without having achieved a safe temperature, and so far in advance. The facility policy titled Refrigerators and Freezers dated 07/02/19 was reviewed. Review of the policy revealed the following language: all food shall be appropriately labeled and dated to ensure proper rotation and safe sanitary food; perishable food or cooked food shall be discarded in 2 -3 days if unused; left overs from meals served will note be saved for use for another meal; supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. 2. While touring the central kitchen on 10/28/19 beginning at 9:38 A.M., Dietary Staff (DS) #33 was observed washing the breakfast dishes using the facility's commercial dish washer. DS #33 stated it was a low temperature dish washer and used a chemical to sanitize the dishes versus hot water. DS #33 was then asked to run a rack of dirty dishes so the temperatures of the dish machine could be taken, and for him to test the concentration of the sanitizing solution (sodium hypochlorite/bleach). The temperature of the wash water was 162 degrees F, and the rinse water was 157 F. DS #33 then attempted to test the concentration of the sanitizing solution. He tested the sanitizing solution three times using the appropriate test strip and it registered zero, or no solution, each time. DS #33 affirmed that no bleach was registering on the test strip. On further observation the pump which was supposed to dispense the sanitizing solution into the dish washer was not working. DS #33 stated that he had the chemical supply service company out last night as the bleach pump/dispenser was not working right and it was working when they left. When asked if he had checked and recorded the temperatures of the dish washer wash and rinse water prior to running the dish washer, and checked the concentration bleach sanitizing solution, prior to washing dishes he stated he had not. DS #33 stated that he came in and started helping where needed and DD #95 may have checked the sanitizing solution. Review of the dish washer sanitation log revealed that no dietary staff member had recorded the wash/rinse temperatures of the dish machine, or the concentration of the sanitizing solution, the morning of 10/28/19. The log did indicate that the dish washing machine sanitizing solution was checked and recorded on the log during the evening meal on 10/27/19 and was within acceptable range. DS #33 stopped washing the dishes at 9:54 A.M. He stated he would not wash any more dishes using the commercial dish washer, and would contact the chemical service company again. DS #33 was then asked what was supposed to happen if the dish washer was not effectively washing or sanitizing the dishes, he reported that washing was to stop and let DD #95 know about the situation. DD #95 then reported that all the dishes that had been washed thus far that morning would be corralled and not used until they could be run through the dish washer when it was working properly, and that paper products would be used to serve residents' food and beverages. The three compartment sink was still available for food preparation equipment and utensils. DD #95 stated that the chemical service and supply company was contacted, as well as the dish machine repair company. On 10/28/19 at 2:39 P.M. a service technician from the chemical service/supply company was interviewed regarding the dish machine and the problem with the sanitizer not being dispensed into the machine. He stated a technician from the company was out yesterday, 10/27/19, and repaired the problem with the bleach not dispensing and would not have left if was not working, or would have let staff know that it was not working. He reported that he was going to be back out to the facility tomorrow with a new chemical dispenser box for all the wash, rinse agent, and sanitizer for the dish washing machine. The technician reported it was not something he could fix at that time. On 10/28/19 at 3:37 P.M., Director of Clinical Service (DCS) #301 reported to the surveyor, along with the service technician from the chemical service/supply company, that due to the wash and rinse temperature of the dish washing machine being so high the sanitizing solution (sodium hypocholite/bleach) could not be used with the machine to effectively sanitize. They shared the water temperatures of the dish washing machine would have to be adjusted to 120 F to 140 F for the wash and rinse. On 10/29/19 at 1:20 P.M. DCS #301 reported the dish washing machine was repaired and dietary staff were in-serviced regarding proper operational water temperatures, and sanitizing solution concentration. The dish washing machine was then tested and had a wash temperature of 135 F, and rinse temperature of 127 F, and the bleach sanitizing solution registering 50 - 100 parts per million. The facility policy titled Dishwashing Machine Use was requested and reviewed. Review of the policy revealed the following language for low temperature dishwashing machines: the wash temperature must be greater than or equal to 130 F, and the dishwashing machine chemical sanitizer chlorine solution must be at least 50 parts per million. The policy did not specify the maximum wash water temperature, did not specify an acceptable rinse temperature range, and did not specify a maximum chlorine solution range.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a resident's code status was documented accurately and consistently between the electronic health record and the hard chart. This affected one (#68) of two residents reviewed for advanced directives. The facility census was 117. Findings include: Record review revealed Resident #68 was admitted to the facility on [DATE] with diagnoses including pneumonia, chronic kidney disease, and end stage renal disease. Review of the admission Minimum Data Set (MDS) assessment, dated 08/07/18, documented the resident had significant cognitive impairment and the resident's involvement with hospice services. Review of the physician's orders in the electronic health record revealed the resident was a full code. Review of the physician's orders in the hard chart record revealed a DNR (Do Not Resuscitate) Identification form that was not marked to indicate the resident's election of either the Do Not Resuscitate Comfort Care (DNRCC) or the Do Not Resuscitate Comfort Care - Arrest option. The form contained the resident's undated signature and the physician's signature next to an illegible date. Interviews on 09/19/18 at 4:44 P.M. with Licensed Practical Nurse (LPN) #23 and at 4:52 P.M. with the Assistant Director of Nursing (ADON) #136 revealed the nurses were unable to determine the resident's correct code status when observing the DNR Identification Form. During the interviews, both LPN #23 and ADON #136 verified the DNR Identification Form on the hard chart did not document the resident's code status election and the physician's order in the electronic health record listed the resident as a full code.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, medical record review, review of facility self-reported incidents and review facility Abuse, Neglect, Exploitation and Misappropriation of Resident Property policy, the facility failed to ensure their abuse policy was implemented to investigate an allegation of abuse. This affected one (#85) of two residents reviewed for abuse. The facility census was 117. Findings include: Medical record review revealed Resident #85 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, diabetes with neuropathy, and heart failure. Review of admission Minimum Data Set (MDS) assessment, dated 08/20/18, revealed intact cognitive skills for daily decision making, extensive assistance was required with bed mobility, transfers, toileting, personal hygiene, and a wheelchair was utilized for mobility. Review of nursing progress note dated 09/15/18 at 4:14 P.M. revealed the resident complained of discomfort to her right knee, reported no trauma but stated the pain started that morning. No redness, slight swelling noted to bilateral lower extremities from knee to toes. An order was obtained for the right knee x-ray, which was obtained and negative for fracture. The leg was elevated in a position of comfort. Review of physician assistant progress note dated 09/18/18 revealed Resident #85 complained of right knee pain and reported falling on her knee. X-ray was negative for a fracture. The plan was to apply ice to right knee three times daily for three days for pain. Interview on 09/17/18 at approximately 11:32 A.M. with Resident #85 reported she was upset and reported a fall on the night of 09/14/18, upon being transferred to bed which resulted in a bruise to the top of the left hand and right knee pain. Resident #85 reported the State Tested Nursing Assistants (STNAs) rushed the transfer and would not permit her, upon request, from utilizing techniques taught by therapy. The STNAs unexpectedly grabbed her by the pants as the she attempted to stand, prior to obtaining balance, and was unable to support the resident's weight, and the STNAs dropped the resident onto the floor between the night stand and bed. They then picked her up and tossed her back into the bed. Resident #85 reported the STNAs were abusive. Resident #85 reported originally informing the resident council president of the abuse allegation and fall as the resident was unsure whom to report the allegation to and then informed Registered Nurse Supervisor (RNS) #192 about the incident. Resident #85 reported everybody knew about the fall and abuse allegation and Registered Nurse Assistant Director of Nursing (RNADON) #124 questioned the resident about the incident earlier today. She reported RNADON #124 was rude and insulting, reported accusing someone of abuse was a very serious accusation, and accused Resident #85 of discriminating against staff. She reported feeling insulted and like dirt during the questioning. The resident reported being asked if the staff intended to cause harm and Resident #85 informed RNADON #124 of the inability to read minds but their behavior was abusive, and their definitions of abuse must be different. Review of facility self-reported incidents from 09/15/18 to 09/17/18 revealed no submission of an allegation of abuse for Resident #85. Interview with STNA #74 on 09/20/18 at 10:07 A.M. reported being informed during morning report, upon arrival to work on 09/15/18, that Resident #85 had a fall. After morning report, STNA #74 asked Resident #85 what had happened and the resident reported being dropped the previous night by the STNAs. Interview on 09/20/18 at 1:47 P.M. with RNS #192 reported Resident #85 informed her on 09/15/18 the two STNAs whom helped her transfer the previous night treated her/him rough. RNS #192 reported she contacted the nurse whom had been on duty. The nurse reported Resident #85 had lost balance during a transfer, the STNAs did what they could to try and prevent the resident from falling, grabbed on to the resident to prevent the resident from falling all the way to the floor. Resident #85's knee hit the floor. An x-ray was obtained and was negative. RNS #192 reported she could see how the actions taken by the STNAs in an attempt to prevent a fall could have been perceived as rough, and the x-ray was negative for fracture, so no other action was needed, taken, and an allegation of abuse was not reported. Interview on 09/20/18 at 2:44 P.M. with the Director of Nursing (DON) reported Resident #85 did not have any falls at the facility. Interview on 09/20/18 at 2:57 P.M. with RNADON #124 reported the resident council president informed her the morning of 09/17/18 that Resident #85 had called on 09/16/18 and reported staff had abused her/him. The resident council president advised Resident #85 to notify staff. RNADON #124 reported immediately interviewing Resident #85 whom reported on 09/14/18, two STNAs, one tall and one short with poofy hair abused her/him. After talking with Resident #85 further, the resident reported the STNAs were rough with care and threw her/him on the floor the night of 09/14/18. Upon asking Resident #85 what exactly was meant by abusive, the resident reported the STNAs were rushed, and wouldn't permit the resident to rock back and forth like therapy instructed. RNADON #124 reported it sounded as if the STNAs were trying to be encouraging but Resident #85 initially reported it was abusive and resulted in a fall. RNADON #124 then asked Resident #85 if staff were intentionally trying to cause harm and what abusive meant to her/him. Resident #85 then reported the STNA's rushed care and questioned why everyone had been informed about the abuse allegation. By the end of the interview, Resident #85 reported if she/he wanted to cause trouble she/he would have contacted the senator and did not make any further allegations of a fall or abuse. RNADON #124 reported a fall was any unexpected decline in elevation, even if not witnessed and all falls were investigated. All allegations of abuse were to be reported to the DON and Administrator immediately. RNADON #124 acknowledged both the resident council president and Resident #85 reported an allegation of abuse but upon interviewing Resident #85, the allegation did not meet the definition of abuse, and the resident then denied any issues by the end of the interview so an allegation of abuse wasn't reported. Review of facility's policy on Abuse, Neglect, Exploitation and Misappropriation of Resident Property, revised November 2017, revealed it was the facility's policy to investigate all alleged violations involving abuse and staff should report all incidents/allegations of abuse immediately to the Administrator or designee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, medical record review, review of facility self -reported incidents and review of facility's policy, the facility failed to ensure an allegation of abuse was reported timely to the State Agency. This affected one (#85) of two residents reviewed for abuse. The facility census was 117. Findings include: Medical record review revealed Resident #85 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, diabetes with neuropathy, and heart failure. Review of admission Minimum Data Set (MDS) assessment, dated 08/20/18, revealed intact cognitive skills for daily decision making, extensive assistance was required with bed mobility, transfers, toileting, personal hygiene, and a wheelchair was utilized for mobility. Review of nursing progress note dated 09/15/18 at 4:14 P.M. revealed the resident complained of discomfort to her right knee, reported no trauma but stated the pain started that morning. No redness, slight swelling noted to bilateral lower extremities from knee to toes. An order was obtained for the right knee x-ray, which was obtained and negative for fracture. The leg was elevated in a position of comfort. Review of physician assistant progress note dated 09/18/18 revealed Resident #85 complained of right knee pain and reported falling on her knee. X-ray was negative for a fracture. The plan was to apply ice to right knee three times daily for three days for pain. Interview on 09/17/18 at approximately 11:32 A.M. with Resident #85 reported she was upset and reported a fall on the night of 09/14/18, upon being transferred to bed which resulted in a bruise to the top of the left hand and right knee pain. Resident #85 reported the State Tested Nursing Assistants (STNAs) rushed the transfer and would not permit her, upon request, from utilizing techniques taught by therapy. The STNAs unexpectedly grabbed her by the pants as the she attempted to stand, prior to obtaining balance, and was unable to support the resident's weight, and the STNAs dropped the resident onto the floor between the night stand and bed. They then picked her up and tossed her back into the bed. Resident #85 reported the STNAs were abusive. Resident #85 reported originally informing the resident council president of the abuse allegation and fall as the resident was unsure whom to report the allegation to and then informed Registered Nurse Supervisor (RNS) #192 about the incident. Resident #85 reported everybody knew about the fall and abuse allegation and Registered Nurse Assistant Director of Nursing (RNADON) #124 questioned the resident about the incident earlier today. She reported RNADON #124 was rude and insulting, reported accusing someone of abuse was a very serious accusation, and accused Resident #85 of discriminating against staff. She reported feeling insulted and like dirt during the questioning. The resident reported being asked if the staff intended to cause harm and Resident #85 informed RNADON #124 of the inability to read minds but their behavior was abusive, and their definitions of abuse must be different. Review of facility self-reported incidents from 09/15/18 to 09/17/18 revealed no submission of an allegation of abuse for Resident #85. Interview with STNA #74 on 09/20/18 at 10:07 A.M. reported being informed during morning report, upon arrival to work on 09/15/18, that Resident #85 had a fall. After morning report, STNA #74 asked Resident #85 what had happened and the resident reported being dropped the previous night by the STNAs. Interview on 09/20/18 at 1:47 P.M. with RNS #192 reported Resident #85 informed her on 09/15/18 the two STNAs whom helped her transfer the previous night treated her/him rough. RNS #192 reported she contacted the nurse whom had been on duty. The nurse reported Resident #85 had lost balance during a transfer, the STNAs did what they could to try and prevent the resident from falling, grabbed on to the resident to prevent the resident from falling all the way to the floor. Resident #85's knee hit the floor. An x-ray was obtained and was negative. RNS #192 reported she could see how the actions taken by the STNAs in an attempt to prevent a fall could have been perceived as rough, and the x-ray was negative for fracture, so no other action was needed, taken, and an allegation of abuse was not reported. Interview on 09/20/18 at 2:44 P.M. with the Director of Nursing (DON) reported Resident #85 did not have any falls at the facility. Interview on 09/20/18 at 2:57 P.M. with RNADON #124 reported the resident council president informed her the morning of 09/17/18 that Resident #85 had called on 09/16/18 and reported staff had abused her/him. The resident council president advised Resident #85 to notify staff. RNADON #124 reported immediately interviewing Resident #85 whom reported on 09/14/18, two STNAs, one tall and one short with poofy hair abused her/him. After talking with Resident #85 further, the resident reported the STNAs were rough with care and threw her/him on the floor the night of 09/14/18. Upon asking Resident #85 what exactly was meant by abusive, the resident reported the STNAs were rushed, and wouldn't permit the resident to rock back and forth like therapy instructed. RNADON #124 reported it sounded as if the STNAs were trying to be encouraging but Resident #85 initially reported it was abusive and resulted in a fall. RNADON #124 then asked Resident #85 if staff were intentionally trying to cause harm and what abusive meant to her/him. Resident #85 then reported the STNA's rushed care and questioned why everyone had been informed about the abuse allegation. By the end of the interview, Resident #85 reported if she/he wanted to cause trouble she/he would have contacted the senator and did not make any further allegations of a fall or abuse. RNADON #124 reported a fall was any unexpected decline in elevation, even if not witnessed and all falls were investigated. All allegations of abuse were to be reported to the DON and Administrator immediately. RNADON #124 acknowledged both the resident council president and Resident #85 reported an allegation of abuse but upon interviewing Resident #85, the allegation did not meet the definition of abuse, and the resident then denied any issues by the end of the interview so an allegation of abuse wasn't reported. Review of facility's policy on Abuse, Neglect, Exploitation and Misappropriation of Resident Property, revised November 2017, revealed the Administrator or his/her designee would notify the state agency of all alleged violations involving abuse as soon as possible, but in no event later then 24 hours from the time the incident/allegation was made known to the staff member.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, medical record review, review of facility self-reported incidents and review of facility policy, the facility failed to investigate an allegation of abuse. This affected one (#85) of two residents reviewed for abuse. The facility census was 117. Findings include: Medical record review revealed Resident #85 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, diabetes with neuropathy, and heart failure. Review of admission Minimum Data Set (MDS) assessment, dated 08/20/18, revealed intact cognitive skills for daily decision making, extensive assistance was required with bed mobility, transfers, toileting, personal hygiene, and a wheelchair was utilized for mobility. Review of nursing progress note dated 09/15/18 at 4:14 P.M. revealed the resident complained of discomfort to her right knee, reported no trauma but stated the pain started that morning. No redness, slight swelling noted to bilateral lower extremities from knee to toes. An order was obtained for the right knee x-ray, which was obtained and negative for fracture. The leg was elevated in a position of comfort. Review of physician assistant progress note dated 09/18/18 revealed Resident #85 complained of right knee pain and reported falling on her knee. X-ray was negative for a fracture. The plan was to apply ice to right knee three times daily for three days for pain. Interview on 09/17/18 at approximately 11:32 A.M. with Resident #85 reported she was upset and reported a fall on the night of 09/14/18, upon being transferred to bed which resulted in a bruise to the top of the left hand and right knee pain. Resident #85 reported the State Tested Nursing Assistants (STNAs) rushed the transfer and would not permit her, upon request, from utilizing techniques taught by therapy. The STNAs unexpectedly grabbed her by the pants as the she attempted to stand, prior to obtaining balance, and was unable to support the resident's weight, and the STNAs dropped the resident onto the floor between the night stand and bed. They then picked her up and tossed her back into the bed. Resident #85 reported the STNAs were abusive. Resident #85 reported originally informing the resident council president of the abuse allegation and fall as the resident was unsure whom to report the allegation to and then informed Registered Nurse Supervisor (RNS) #192 about the incident. Resident #85 reported everybody knew about the fall and abuse allegation and Registered Nurse Assistant Director of Nursing (RNADON) #124 questioned the resident about the incident earlier today. She reported RNADON #124 was rude and insulting, reported accusing someone of abuse was a very serious accusation, and accused Resident #85 of discriminating against staff. She reported feeling insulted and like dirt during the questioning. The resident reported being asked if the staff intended to cause harm and Resident #85 informed RNADON #124 of the inability to read minds but their behavior was abusive, and their definitions of abuse must be different. Review of facility self-reported incidents from 09/15/18 to 09/17/18 revealed no submission of an allegation of abuse for Resident #85. Interview with STNA #74 on 09/20/18 at 10:07 A.M. reported being informed during morning report, upon arrival to work on 09/15/18, that Resident #85 had a fall. After morning report, STNA #74 asked Resident #85 what had happened and the resident reported being dropped the previous night by the STNAs. Interview on 09/20/18 at 1:47 P.M. with RNS #192 reported Resident #85 informed her on 09/15/18 the two STNAs whom helped her transfer the previous night treated her/him rough. RNS #192 reported she contacted the nurse whom had been on duty. The nurse reported Resident #85 had lost balance during a transfer, the STNAs did what they could to try and prevent the resident from falling, grabbed on to the resident to prevent the resident from falling all the way to the floor. Resident #85's knee hit the floor. An x-ray was obtained and was negative. RNS #192 reported she could see how the actions taken by the STNAs in an attempt to prevent a fall could have been perceived as rough, and the x-ray was negative for fracture, so no other action was needed, taken, and an allegation of abuse was not reported. Interview on 09/20/18 at 2:44 P.M. with the Director of Nursing (DON) reported Resident #85 did not have any falls at the facility. Interview on 09/20/18 at 2:57 P.M. with RNADON #124 reported the resident council president informed her the morning of 09/17/18 that Resident #85 had called on 09/16/18 and reported staff had abused her/him. The resident council president advised Resident #85 to notify staff. RNADON #124 reported immediately interviewing Resident #85 whom reported on 09/14/18, two STNAs, one tall and one short with poofy hair abused her/him. After talking with Resident #85 further, the resident reported the STNAs were rough with care and threw her/him on the floor the night of 09/14/18. Upon asking Resident #85 what exactly was meant by abusive, the resident reported the STNAs were rushed, and wouldn't permit the resident to rock back and forth like therapy instructed. RNADON #124 reported it sounded as if the STNAs were trying to be encouraging but Resident #85 initially reported it was abusive and resulted in a fall. RNADON #124 then asked Resident #85 if staff were intentionally trying to cause harm and what abusive meant to her/him. Resident #85 then reported the STNA's rushed care and questioned why everyone had been informed about the abuse allegation. By the end of the interview, Resident #85 reported if she/he wanted to cause trouble she/he would have contacted the senator and did not make any further allegations of a fall or abuse. RNADON #124 reported a fall was any unexpected decline in elevation, even if not witnessed and all falls were investigated. All allegations of abuse were to be reported to the DON and Administrator immediately. RNADON #124 acknowledged both the resident council president and Resident #85 reported an allegation of abuse but upon interviewing Resident #85, the allegation did not meet the definition of abuse, and the resident then denied any issues by the end of the interview so an allegation of abuse wasn't reported. Review of facility's policy on Abuse, Neglect, Exploitation and Misappropriation of Resident Property, revised November 2017, revealed it was the facility's policy to investigate all alleged violations involving abuse and staff should report all incidents/allegations of abuse immediately to the Administrator or designee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of facility policy, the facility failed to notify the resident and/or the resident representative in writing of bed hold policies upon transfer to the hospital. This affected two (Resident #24 and #101) of three residents reviewed for hospitalization. The facility census was 117. Findings include: 1. Record review revealed Resident #101 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, dementia, and osteoarthritis. Review of the Minimum Data Set (MDS) assessment, dated 08/27/18, revealed Resident #101 was cognitively impaired. Review of nurse's progress notes for Resident #101 revealed the resident was transferred to the hospital and was admitted with a diagnosis of fracture to the right femur on 07/23/18. Further review of the record revealed there was no notification of the facility's bed hold policy upon transfer to the hospital to either the resident or the resident's representative in Resident #101's chart. During an interview on 09/20/18 at 10:35 A.M., the Director of Nursing confirmed that neither the resident nor resident's representative had been notified in writing of the facility bed hold policy upon Resident #101's transfer to the hospital on [DATE]. 2. Record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus and non-Alzheimer's dementia. Review of the admission Minimum Data Set Assessment (MDS) assessment, dated 07/06/18, revealed she had a moderate cognitive impairment. A review of the resident's face sheet revealed she was her own responsible party. Review of nursing notes, dated 08/16/18 at 11:15 A.M., documented the resident went out for an appointment at the wound clinic located in the hospital. The resident was admitted to the hospital from the appointment due to infection in her left foot. There was no evidence in the medical record the resident and/or responsible party was provided written notice of the transfer to the hospital. Interview on 09/19/18 at 12:04 P.M. with the Director of Nursing (DON) stated the resident was admitted to the hospital from [DATE] to 08/24/18 from a physician's appointment related to her left foot infection. On 09/20/18 at 6:30 P.M., the DON verified the facility did not issue a bed hold notice to the resident in writing as she was a direct admit to the hospital from her physician's appointment. Review of the facility's policy titled Facility Initiated Discharge Notification Policy, dated 11/28/17 revealed the resident and/or resident representative would be notified in writing of the facility bed hold policy upon resident transfer to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed Resident #47 was admitted to the facility on [DATE]. Diagnoses included peripheral vascular disease, stroke, non-Alzheimer's dementia, seizure disorder, anxiety, chronic lung disease, and cognitive communication deficit. Review of the resident's admission Minimum Data Set (MDS) assessment, dated 07/24/18, revealed it was very important to him to listen to music he liked and to do things with groups of people. Review of his 60-day MDS assessment, dated 09/11/18, revealed he had a moderate cognitive impairment and required the assistance of staff with his activities of daily living. Review of the resident's plan of care for therapeutic recreation, initiated on 07/26/18, revealed pertinent interventions included he would be informed of activities and assisted to them. Also, he would be invited to music performances, as this was his favorite activity. On 09/19/18 at 10:36 A.M., an interview with Resident #47 revealed he would like more physical activities. The resident said he enjoyed music. On 09/19/18 at 3:20 P.M., an observation of a karaoke music activity was occurring in the dining room. An interview with Activity Assistant #122 revealed she had not invited the resident to this activity. Activity Assistant #122 said she did not go down the resident's hallway to invite him. On 09/19/18 at 3:39 P.M. an interview with Resident #47 revealed he received an activity calendar about an hour ago. The resident said he was not aware of the karaoke music activity. He said that might have been fun and he probably would have attended. On 09/09/18 at 3:45 P.M. an interview with State Tested Nurse Aide (STNA) #37 revealed she was assigned to the resident's care. STNA #37 said she was unaware a musical activity was going to occur this afternoon and had not invited the resident to attend this activity. On 09/19/18 at 3:48 P.M., interview with Activity Aide #122 stated she was responsible for inviting the resident to the music karaoke music activity. Activity Aide #122 said she did not invite him as 15 things were going on, time was running short and she did not invite him. Based on observation, record review, and resident and staff interview, the facility failed to ensure resident's received individual and group activities to meet their needs. This affected two (#47 and #90) of three residents reviewed for activities, received individual and group activities to meet their needs. The facility census was 117. Findings include: 1. Review of Resident #90's record, revealed he was admitted to the facility on [DATE]. Diagnoses included cerebral infarction due to embolism of right middle cerebral artery, atrial fibrillation, right heart failure, aphasia, chronic ischemic heart disease, acute respiratory failure. Review of the admission Minimum Data Set (MDS) assessment, dated 08/17/18, revealed the resident experienced short and long term memory losses and required extensive assistance of two or more staff with bed mobility, transferring, dressing, personal hygiene, and toilet use tasks. Further review of the MDS, revealed under the area of activity preferences, it was very important for the resident to keep up with the news and to have books, newspapers, and magazines to read. Review of the activity assessment, dated 08/22/18, revealed the resident liked to watch sports and used to coach baseball. When not involved in activities, the resident liked to read and watch television. Review of the activity care plan, dated 08/22/18, revealed the resident needed activities for cognitive stimulation and social interaction related to cognitive deficits and physical limitations. Interventions included the provision of one to one bedside/in-room visits and activities if unable to attend out of room events, the resident's preferred activities were watching television, sports, and keeping up with the news, staff to provide the activities calendar monthly, and review activity participation and wishes with the family/representative. During review of the Activity Logs for the months of 08/2018 and 09/2018, it was revealed the activity staff would sign off on any activity the resident participated in on each day. During review of the current events portion of the activity logs, it was revealed there were no check marks or staff initials indicating the resident was engaged in any current event activities. During observation of Resident #90 on 09/19/18 at 10:24 A.M., the resident was observed seated in a recliner in his room. He was unable to speak, but was able to communicate by a thumbs up signal for yes, and a back and forth flip with his hand or thumbs down for no. Observation and interview with Resident #90 on 09/19/18 at 11:07 A.M., revealed the resident was in his bed per his request. He was positioned on his right side with his back away from the television. When asked if he would like to read a newspaper, he gave the thumbs up sign. When asked if staff brought in newspapers or magazines for him to read, he flipped his hand back and forth, answering no. During interview with the Activity Director on 09/19/18 at 11:20 A.M., she stated the resident had one on one activities and during these one on one activities, the staff read portions of the newspaper to him to keep him current with sports and the news. The surveyor entered the resident's room with the Activity Director at that time. She looked in his drawers and on his tables for a newspaper or any other reading material. The Activity Director verified there was no reading material. The surveyor then asked the resident if anyone had come in on this day or the prior day to read the news to him. He flipped his hand in a back and forth motion indicating no.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure a resident's edema was monitored and treated as ordered. This affected one (#262) of one residents reviewed for edema. The facility census was 117. Findings include: Medical record review revealed Resident #262 was admitted to the facility on [DATE]. Diagnoses included left hip fracture, atrial fibrillation, hypertension, chronic peripheral insufficiency, and generalized edema. Review of admission Minimum Data Set (MDS) assessment, dated 09/07/18, revealed the resident was independent for cognitive skills for daily decision making, supervision was required with bed mobility, transfers, personal hygiene, and the resident had bilateral lower extremity edema. Review of physician orders dated 09/11/18 revealed daily weights were ordered and to notify the medical doctor if weight gain was greater than five pounds in three days. A physician order, dated 09/13/18, was to apply ace wraps (elastic bandages) when up, on in the morning and off at bedtime. Review of a care plan, initiated on 09/15/18, revealed Resident #262 had a potential for alteration in cardiac output/arrhythmia/cardiorespiratory distress related to atrial fibrillation, congestive heart failure, and hypertension. Interventions included daily weights at 6:00 A.M., and to notify the medical doctor if weight gain was greater than five pounds in three days. Review of treatment administration record (TAR) for September 2018 revealed Resident #262's weights were obtained on 09/12/18, 09/14/18, 09/17/18, and 09/20/18. Weights for 09/13/18, 09/15/18, 09/16/18, 09/18/18, and 09/19/18 were left blank. Observation on 09/18/18 at 10:45 A.M. revealed Resident #262 was up in the wheelchair with feet on the floor without ace wraps in place to legs. Edema was noted to both ankles. Ace wraps were observed folded on arm of recliner chair. Interview with Resident #262 at the time of the observation reported staff still had the remainder of the day to apply the ace wraps and they were never applied prior to getting out of bed. Observation on 09/18/18 at 12:14 P.M. revealed Resident #262 remained up in a wheelchair without ace wraps in place. Interview with Licensed Practical Nurse (LPN) #510 at the time of the observation confirmed Resident #262 did not have ace wraps in place as ordered. Interview on 09/20/18 at 3:47 P.M. with Registered Nurse Assistant Director of Nursing (RNADON) #124 reported all weights obtained for Resident #262 were documented on the TAR and verified weights were not obtained daily as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, medical record review, and review of facility policy, the facility failed to ensure a fall was investigated, interventions were implemented and monitored for effectiveness. This affected one (#85) of six residents reviewed for accidents. The facility census was 117. Findings include: Medical record review revealed Resident #85 was admitted to the facility on [DATE]. Diagnoses included peripheral vascular disease, diabetes with neuropathy, and heart failure. Review of the admission Minimum Data Set (MDS) assessment, dated 08/20/18, revealed the resident's cognition was intact, decision making, extensive assistance was required with bed mobility, transfers, toileting, personal hygiene, and a wheelchair was utilized for mobility. Review of a care plan, initiated 08/13/18, revealed potential for injuries/falls related to advanced aging, impaired decision making abilities, generalized weakness with gait and balance disturbance due to non-weight bearing to right foot, incontinence, use of diuretic, hyperglycemic agent, pain medications, history of falls, and new to environment. Interventions included assist with transfer with use of sliding board or Hoyer into wheelchair as needed, encourage non-skid footwear at all times, monitor safety/preventative devices for application. Instruct on use of adaptive equipment as needed. Observe and report unsafe conditions. Provide a safe environment and therapy as ordered. No interventions had been added to the care plan since 08/24/18. Review of a nursing progress note, dated 09/15/18 at 4:14 P.M., revealed the resident complained of discomfort to her right knee, reported no trauma but she had pain started this morning. No redness, and slight swelling was noted to bilateral lower extremities from knee to toes. An order was obtained for an x-ray to her right knee, which was obtained and negative for fracture. The leg was elevated in a position of comfort. Review of a physician assistant progress note, dated 09/18/18, revealed Resident #85 complained of right knee pain and reported falling on her knee. X-ray was negative for a fracture. The plan was to apply ice to right knee three times daily for three days for pain. The medical record did not include any documentation about the circumstances of the fall or implementation of any additional interventions. Interview on 09/17/18 at approximately 11:32 A.M. with Resident #85 reported she was upset and reported a fall on the night of 09/14/18, upon being transferred to bed which resulted in a bruise to the top of the left hand and right knee pain. Resident #85 reported the State Tested Nursing Assistants (STNAs) rushed the transfer and would not permit her, upon request, from utilizing techniques taught by therapy. The STNAs unexpectedly grabbed her by the pants as the she attempted to stand, prior to obtaining balance, and was unable to support the resident's weight, and the STNAs dropped the resident onto the floor between the night stand and bed. They then picked her up and tossed her back into the bed. Resident #85 reported the STNAs were abusive. Resident #85 reported originally informing the resident council president of the abuse allegation and fall as the resident was unsure whom to report the allegation to and then informed Registered Nurse Supervisor (RNS) #192 about the incident. Resident #85 reported everybody knew about the fall and abuse allegation and Registered Nurse Assistant Director of Nursing (RNADON) #124 questioned the resident about the incident earlier today. Interview with STNA #74 on 09/20/18 at 10:07 A.M. reported being informed during morning report, upon arrival to work on 09/15/18, that Resident #85 had a fall. Interview on 09/20/18 at 1:47 P.M. with RNS #192 reported Resident #85 informed her on 09/15/18 the two STNAs whom helped her transfer the previous night treated her/him rough. RNS #192 reported she contacted the nurse whom had been on duty. The nurse reported Resident #85 had lost balance during a transfer, the STNAs did what they could to try and prevent the resident from falling, grabbed on to the resident to prevent the resident from falling all the way to the floor. Interview on 09/20/18 at 2:44 P.M. with the Director of Nursing (DON) reported Resident #85 did not have any falls at the facility. Interview on 09/20/18 at 2:57 P.M. with RNADON #124 verified there was a report of the resident falling and all falls were investigated. Interview on 09/20/18 at 5:10 P.M. with the Director of Nursing (DON) reported Resident #85's fall was not investigated as she was not aware a fall had occurred, and interventions were not implemented as a result of the fall but were implemented due to the knee injury. The DON reported facility protocol was to investigate all falls, witnessed and unwitnessed including resident reported falls. Review of the facility policy on fall prevention, revised 11/14/17, revealed in the event of a fall, the resident will be assessed for injury by the nurse and an investigation will be initiated to determine a root cause of the fall. A new intervention/change in care plan will be made to reduce the risk of a reoccurrence and/or to prevent injury as indicated. The resident and/or responsible party will participate in the care planning process as able. A interdisciplinary team meeting will be held after all falls to re-evaluate the plan of care and determine the need for further interventions or care plan adjustments. This deficiency substantiates Complaint Number OH00099742.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of medical record and review of facility policy, the facility failed to ensure a resident received proper catheter care and a catheter was discontinued as ordered. This affected one (#263) of one resident reviewed for catheter. The facility identified four residents (#4, #25, #62 and #263) with catheters at the facility. The census was 117. Findings include: Medical record review revealed Resident #263 was admitted to the facility on [DATE] with diagnoses of right hip fracture, urinary retention, and Alzheimer's disease. Review of the admission Minimum Data Set (MDS) assessment, dated 09/10/18, revealed the resident had severely impaired cognition and had a catheter for urinary retention. Review of the care plan, initiated 09/10/18, revealed Resident #263 was admitted with an indwelling catheter due to urinary retention. Interventions included to keep the foley bag below the level of the bladder at all times. Review of a physician order, dated 09/11/18, revealed an indwelling catheter for urine retention and catheter care every shift. On 09/12/18, a physician was to remove the indwelling catheter and begin voiding trial on 09/19/18, which was marked as completed. Review of a physician progress note, dated 09/17/18, revealed an assessment and plan was discussed with nursing and included ongoing urinary retention, voiding trial to begin on 09/19/18, and after seven days on Flomax (urinary retention medication), to continue Flomax. Observation on 09/18/18 at 11:18 A.M. of Resident #263 with State Tested Nursing Assistants (STNAs) #119 and #121 revealed Resident #263 remained in bed with catheter leg bag attached on top of the left thigh, above the level of the bladder. Both STNA's verified location of the catheter leg bag and provided no additional information. Interview on 09/20/18 at 3:47 P.M. with Registered Nurse Assistant Director of Nursing (RNADON) #124 reported the order to remove the catheter was missed and as a result Resident #263's catheter was not removed and voiding trial was not initiated on 09/19/18 as ordered. Review of the facility's list of residents with catheters revealed Resident #4, #25, #62 and #263 had catheters in place. Review of facility Urinary Catheter policy, revised November 2017, revealed the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.

Based on observations, interviews, and record reviews the facility failed to store foods in a safe manner by not dating opened foods. This affected 114 of 117 who receive food from the kitchen (Residents #42, #69, and #90 receive nothing by mouth). Findings include: Observations during the kitchen and kitchenettes tour on 09/17/18 at 10:15 A.M. revealed the Bistro refrigerator contained an undated bowl of mixed fruit, an undated half-full pitcher of lemonade, and several hard-boiled eggs with shells removed in an undated plastic resalable bag. In the air curtain refrigerator, there were two full trays of undated individually covered bowls of sliced pears and one full tray of undated individually covered cups of varying juice flavors. The refrigerator located in the Diamond Unit contained an undated half-full pitcher of of orange juice, an undated half-full pitcher of cranberry juice, an undated and a grocery store bag in the bottom drawer which contained a clear undated bag of what appeared to be two empanadas. An interview of Dietary Manager #150 on 09/17/18 at 10:15 A.M. verified the contents of the refrigerators listed above were undated and opened and stated they all should be dated if opened. Review of a list of residents who received meals from the kitchen revealed Residents #42, #69, and #90 did not receive meals from the kitchen. A review of the facility policy titled, Proper Food Storage, dated 11/01/17, revealed it was important that all foods be stored properly to prevent potential contamination and food borne illnesses. This included securely covering and dating foods. All items not in a dated manufacturer's container, must be dated by the use of a marker or date gun. Once opened, ready to use items were to be dated with the date they were opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record reviews, review of manufacturer guidelines, and review of Centers for Disease Control and Prevention guidelines, the facility failed to ensure proper cleaning according to manufacturer instructions of a blood glucose monitor machine used for multiple residents. The facility also failed to ensure staff were knowledgeable of isolation precautions. The facility identified eight residents (Residents #7, #15, #28, #38, #45, #46, #54, and #62) who utilized the glucometer machine and one resident (Resident #24) who was in isolation precautions at the time of the survey. This had the potential to affect all 117 residents residing at the facility. Findings include: 1. Record review revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus. Observation of Licensed Practical Nurse (LPN) #78 on 09/20/18 at 8:20 A.M. perform a fingerstick glucose on Resident #15 using a Quintec AC blood glucose monitor. LPN #78 placed a blood glucose strip in the monitor, wiped the resident's finger with an alcohol pad, and used a lancet to to obtain the blood sample, placed the monitor with the strip to obtain the blood, and waited for the result. LPN #78 placed the monitor back in the box with the alcohol and gauze pads and returned to the medication cart. LPN #78 then picked up the blood glucose monitor and cleansed it with an alcohol pad. Interview of LPN #78 on 09/20/18 at 8:20 A.M. verified the blood glucose monitor was used on all patients requiring blood glucose monitoring and stated she always cleans the blood glucose monitors with alcohol pads between resident use. LPN #78 verified she did not know the manufacturer cleaning instructions or the facility policy for cleaning the blood glucose monitor. Interview of the Director of Nursing (DON) on 09/20/18 at 9:00 A.M. verified the blood glucose monitor should have been cleaned according to manufacturer instructions with a sanitizing wipe and stated she had trained LPN #78 on the cleaning of the blood glucose monitor two weeks ago. A review of the Quintec AC manufacturer instructions for cleaning revealed all glucometers that were shared between patients must be cleaned and disinfected after use with each patient to help prevent the transmission of bloodborne pathogens. Review of the Nurse Skill Checklist for LPN #78 for Blood Glucose Testing was signed as completed satisfactorily and observed by the DON on 08/29/18. Review of the facility's list of residents who utilized the glucometer machine revealed Residents #7, #15, #28, #38, #45, #46, #54, and #62 utilized the glucometer machine. 2. Medical record review revealed Resident #24 was admitted to the facility on [DATE]. Diagnoses included cellulitis and diverticulosis. Review of the admission Minimum Data Set (MDS) assessment, dated 07/06/18, revealed the resident had moderately impaired cognitive skills and required extensive assistance was required with all activities of daily living (ADL's). Review of physician order revealed antibiotics were ordered until 10/11/18 for clostridium difficile (C-diff), a bacterium that caused symptoms ranging from diarrhea to life-threatening inflammation of the colon. Resident #24 was placed on contact isolation precautions. Observation on 09/18/18 at 9:13 A.M. revealed an isolation cart in the hall outside of Resident #24's room. The cart didn't contain any gowns. Observation on 09/18/18 at 11:28 A.M. revealed Licensed Practical Nurse (LPN) #33 was in Resident #24's room interacting with the resident without any personal protective equipment in place. Interview with LPN #33 upon exiting the room, about what equipment needed to be worn to enter the room, replied she was unsure why Resident #24 had an isolation cart outside the door and reported she would check. At 11:53 A.M., LPN #33 returned and reported Resident #24 was on contact isolation precautions for C-diff and intravenous antibiotics for C-diff and cellulitis. Review of the Centers for Disease Control and Prevention (CDC) guidelines on contact isolation precautions, last revised 02/28/17, revealed to use personal protective equipment appropriately, including gloves and gown.