**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility investigation review, facility policy review, and interviews, the facility failed to timely report an allegation of misappropriation. This affected one resident (#1) of three residents reviewed for abuse. The facility census was 42. Findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, diabetes mellitus, anemia, heart failure, major depressive disorder, and intermittent explosive disorder. The resident was cognitively intact. Review of complaint information received by the Ohio Department of Health (ODH) on 08/29/24 revealed on 08/27/24 at 10:27 P.M., Resident #1 reported to Licensed Practical Nurse (LPN) #40 that she checked her wallet and $60.00 was missing; the resident stated that she had $100.00 and now only $20.00. Concierge #54 confirmed she had not recently given the resident any monies from her fund. Resident #1's guardian visited on 08/27/24 and did not report any missing money. The resident has a history of confusion and diagnoses including anxiety disorder and intermittent explosive disorder. Interview on 10/04/24 at 11:15 A.M. with the director of nursing (DON) revealed she accidentally filed a complaint a with ODH rather than a Self-Reported Incident (SRI). She stated it was her first time filing and she submitted the wrong report, submitting a complaint instead of an SRI. The DON confirmed that she did not file an SRI. Review of the facility investigation revealed the allegation was unsubstantiated without evidence to support the allegation. Interview on 10/04/24 at 1:08 P.M. with the Administrator confirmed an SRI was not filed to report Resident #1's allegation of misappropriation as it should have been. Review of the facility's policy titled, Ohio Abuse, Neglect, Exploitation and Misappropriation of Resident Property, dated 10/27/21, revealed the Administrator or his designee will notify ODH of all alleged violations involving abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of resident property and injuries of unknown source as soon as possible, but no event later than 24 hours from the time the incident/allegation was made known to the staff member. This deficiency represents non-compliance investigated under Complaint Number OH00157339.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide appropriate discharge instructions, education and supplies prior to a resident discharge home. This affected one resident (Resident #45) of three residents reviewed for discharge services. The facility census was 44. Findings include: Review of Resident #45's medical record revealed an admission date of 03/15/23 with diagnoses that included rhabdomyolsis (damaged skeletal muscle breaks down rapidly), urinary tract infection, urinary retention and pressure ulcer to the sacrum. Resident #45 was admitted for therapy and intravenous antibiotic services. Additional review of the medical record revealed the use of an indwelling urinary catheter in place since admission due to urinary retention with orders to provide catheter care every shift. admission skin and wound assessments revealed a stage three pressure ulcer (full thickness skin loss, subcutaneous fat may be visible, but bone, tendon or muscle is not exposed) located to the coccyx. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderate cognitive impairment. Review of the Resident #45's discharge summary and instructions revealed the resident and husband were provided education on medications, home health services, medical equipment and physician follow up appointments at the time of discharge on [DATE]. Review of the resident's progress notes, discharge summary and instructions found no evidence of education given related to the care of the indwelling urinary catheter or wound and no wound care supplies were provided. Interview with the Director of Nursing on 04/28/23 at 11:15 A.M. verified Resident #45 and/or the resident's representative were not given education regarding indwelling catheter care, wound care and not provided with supplies for wound care upon discharge. This deficiency represents non-compliance investigated under Complaint Number OH00141951.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #33, who required staff assistance for activities of daily living care was provided adequate grooming and personal hygiene. This affected one resident (#33) of one resident reviewed for activities of daily living (ADL) care. Findings include: Review of Resident #33's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including major depressive disorder, severe intellectual disabilities and unspecified mood disorder. Review of Resident #33's Minimum Data Set (MDS) 3.0 assessment, dated 10/21/22 revealed the resident exhibited severe cognitive impairment and required extensive one person assistance for personal hygiene. On 11/21/22 at 3:35 P.M. Resident #33 was observed sitting in the dining room with multiple other residents. The resident's hair appeared dirty and she had a large amount of small facial hair on her chin area. The resident was not interviewable at the time of the observation. On 11/22/22 at 9:00 A.M. State Tested Nursing Assistant (STNA) #805 and STNA #807 were observed providing A.M./morning care to Resident #33. The staff provided incontinence care and then assisted the resident from the bed to a wheelchair. When questioned, STNA #805 indicated Resident #33 was shaved on shower days but she was unaware of the exact days she was scheduled for showers. At this point, Resident #33 was not shaved but her hair was combed. Her hair still appeared dirty and the facial hair was evident on her chin. The resident was taken from her room into the dining room and placed at a table with other residents who were in the dining room. On 11/22/22 at 11:19 A.M. interview with Resident #33's sister, who was visiting the resident in the main dining room revealed the resident was to receive showers two days per week on Wednesday and Saturday. At the time of the interview, Resident #33's sister voiced concerns the resident's hair was not clean and she was concerned about the facial hair on the resident's chin area. She stated her sister required (staff assistance) to be shaved and it was not provided adequately. On 11/22/22 at 11:27 A.M. interview with Registered Nurse (RN)/Clinical Director of Operations #808 confirmed Resident #33's hair appeared dirty and she had a large amount of small dark facial hair on her chin. Review of the Shower/Tub Bath policy, dated 02/2022 revealed the purpose of the procedure was to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure a fall investigation was completed after a resident reported a fall and failed to update the comprehensive care plan for Resident #37. The facility also failed to ensure adequate assistance using a mechanical (Hoyer) lift was provided to Resident #33 during a transfer to prevent a possible fall/injury. This affected two residents (#37 and #33) of three residents reviewed for accidents and hazards. Findings include: 1. Review of the medical record for Resident #37 revealed an admission date of 10/14/22 with diagnoses including metabolic encephalopathy, wedge compression fracture of T11 and T12, and multiple fractures of ribs on the right side. Review of fall risk observation tool completed on admission [DATE] and on 11/14/22 revealed Resident #37 was assessed to be at high risk for falls. Review of the admission Minimum Data Set 3.0 (MDS) assessment, dated 10/20/22 revealed Resident #37 had mild cognitive impairment. The assessment revealed Resident #37 was independent with bed mobility, required supervision with one-person physical assistance for transfers and toilet use and required extensive one-person physical assistance for dressing. A plan of care, dated 11/14/22 revealed Resident #37 would be at reduced risk of falls/injury through the next review date. Review of the nursing progress note, dated 11/19/22 at 6:15 A.M. revealed Resident #37 reported she fell in her room, (the fall was unwitnessed). The resident was assessed to have an open area on her right leg and reported she hit her heard. The resident was assessed, the physician and family were notified, and the resident was sent to the emergency room for evaluation and treatment. The resident returned to the facility on the same day. Record review revealed following the fall/incident on 11/19/22, the resident's plan of care was not updated or revised to ensure individualized and comprehensive fall/safety interventions were in place to prevent additional falls for the resident. On 11/21/22 at 10:30 A.M. interview with the Assistant Director of Nursing (ADON)/Registered Nurse (RN) #804 revealed following the fall, the facility did not complete a comprehensive fall investigation and indicated no new interventions were initiated following the fall. 2. Review of Resident #33's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including major depressive disorder, severe intellectual disabilities and unspecified mood disorder. Review of the physician's orders revealed an order dated 03/09/22 to transfer (resident) using a mechanical (Hoyer) lift and two staff assist every day and night shift. Review of Resident #33's fall plan of care, dated 08/26/22 revealed an intervention to transfer using a Hoyer mechanical lift and two staff assist. Review of Resident #33's MDS 3.0 assessment, dated 10/21/22 revealed the resident exhibited severe cognitive impairment. On 11/22/22 at 9:00 A.M. State Tested Nursing Assistant (STNA) #805 and STNA #807 were observed providing A.M. (morning) care to Resident #33. The STNA staff were observed to provide incontinence care and then assisted the resident to sit up on the side of the bed. Each STNA then picked Resident #33 up under the arms and lifted her from the bed to the chair. The resident had one foot on the floor, was not observed to be able to fully bear weight and a gait belt was not used during the transfer. On 11/22/22 at 9:10 A.M. interview with STNA #805 revealed she was unaware Resident #33 required a Hoyer mechanical lift to appropriately transfer from the bed to the wheelchair per the physician's order. Review of the facility Transfers and Lifts policy, dated 11/2022 revealed the facility would ensure all staff members were instructed in safe transfer and lifting techniques and how to report suspected injuries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure Resident #41 had a medical necessity for a urinary catheter. This affected one resident (#41) of two residents reviewed for urinary catheters. The facility identified two residents with indwelling urinary catheters. Findings include: Review of Resident #41's medical record revealed diagnoses included acute nephritic syndrome (a syndrome comprising signs of nephritis, which is kidney disease involving inflammation), infection and inflammatory reaction due to internal right knee prosthesis and type two diabetes mellitus. An admission assessment, dated 10/22/22 indicated Resident #41 had a urinary catheter (reason for use was not indicated) and was scheduled for dialysis on Tuesdays, Thursdays and Saturdays. An incision on the right knee was intact with 17 steri strips present. admission orders included use of an indwelling catheter, monitoring output, and providing catheter care twice a day. A care plan initiated 10/22/22 indicated Resident #41 had an indwelling urinary catheter which put her at risk for complications. The care plan did not indicate the rationale for the catheter use. A nursing note dated 10/23/22 at 9:36 P.M. indicated Resident #41 had a second knee surgery performed on 09/12/22. An admission Minimum Data Set (MDS) 3.0 assessment, dated 10/28/22 revealed Resident #41 was able to understand others, able to make herself understood and was cognitively intact. The MDS assessment noted the use of an indwelling urinary catheter. A skin assessment dated [DATE] indicated Resident #41's right knee incision was healed, well approximated and with no drainage. A nursing note dated 11/11/22 at 10:55 P.M. indicated Resident #41 was non-compliant with placement of the urinary catheter bag. The note indicated Resident #41 would lay it on floor even after education. A physician progress note, dated 11/16/22 at 9:04 A.M. indicated the nephrologist would be contacted for evaluation of removal of the urinary catheter. On 11/21/22 at 12:22 P.M. Resident #41 was observed to have a urinary catheter. Resident #41 stated she had the urinary catheter for a couple months but nobody was able to tell her why she had it. Resident #41 stated she did not think she should have the catheter. The resident indicated she was having no trouble voiding prior to the catheter being inserted. A nursing note, dated 11/22/22 at 7:48 A.M. revealed Resident #41 was requesting the urinary catheter be removed. The physician on call was notified and deferred to the nephrologist. The dialysis clinic was contacted and indicated they would speak with the nephrologist and inform the facility of his decision. No documentation was located indicating the rationale for the urinary catheter use. On 11/22/22 at 8:15 A.M. Registered Nurse (RN) #803 was seen/overheard on the phone informing an unidentified caller Resident #41 wanted the urinary catheter removed and stating she could see no diagnosis for use. On 11/22/22 at 8:19 A.M. RN #803 revealed Resident #41 had the urinary catheter when she was admitted . The catheter was in place because Resident #41 was having incontinence and it put her at risk for infecting her knee incision. Since the knee incision was healed and Resident #41 wanted the catheter out, the attending physician had her contact the dialysis center to ensure there would be no problem with removing it. On 11/22/22 at 11:18 A.M. interview with RN #810 revealed hospital records reflected the urinary catheter was placed on 10/07/22 when Resident #41 was having kidney issues and edema. The facility did not specifically do urinary catheter assessments. RN #810 revealed if the urinary catheter was placed to prevent infection of the knee incision, there would have been no further reason for the catheter once the skin was healed on 11/06/22. RN #810 verified she did not see any follow up on the physician progress note from 11/16/22 which indicated follow up with the nephrologist about catheter removal until 11/22/22. On 11/22/22 at 3:02 P.M. RN #803 revealed she received an order it was okay to discontinue the resident's urinary catheter on this date.

Based on observation, record review and interview the facility failed to ensure Resident #4's oxygen tubing and humidification bottle were maintained in a clean and sanitary manner and changed weekly as ordered by the physician. This affected one resident (#4) of two residents reviewed for oxygen use. Findings include: Review of the medical record for Resident #4 revealed an initial admission date of 09/11/22 a readmission date of 09/27/22 with diagnoses including acute and chronic respiratory failure, atrial flutter and anxiety disorder. Review of the physician's orders revealed an order, dated 09/11/22 to change oxygen tubing and humidifier bottle weekly every Sunday. Review of admission Minimum Data Set (MDS) 3.0 assessment, dated 10/03/22 revealed Resident #4 had intact cognition. The assessment revealed Resident #4 required extensive one-person physical assistance for bed mobility, transfers, and dressing, was independent with set up help only for eating and required staff supervision with one-person physical assistance for personal hygiene. The assessment also noted Resident #4 was occasionally incontinent of urine and always continent of bowel. Review of Resident #4's Treatment Administration Record for November 2022 revealed Resident #4 was to have oxygen tubing and bottle changed on 11/20/22. The administration record revealed these tasks were documented/signed off as being completed by the nurse. On 11/21/22 at 9:00 A.M. observation of Resident #4's oxygen tubing and humidifier bottle revealed they were dated 11/13/22. On 11/21/22 at 9:10 A.M. interview with Registered Nurse #505 verified Resident #4's oxygen tubing and bottle were dated 11/13/22 and had not been changed on 11/20/22 as per order.

Based on observation, record review and interview the facility failed to ensure Resident #11 received medication/treatment only while necessary by failing to discontinue an antibiotic medication cream after an area to the resident's back was healed. This affected one resident (#11) of five residents reviewed for unnecessary medication use. Findings include: Review of the medical record for Resident #11 revealed an admission date of 05/25/21 with diagnoses including Parkinson's disease, dysphagia and scoliosis. Review of the physician's orders revealed an order, dated 05/18/22 for Silvadene cream 1% silver (antibiotic cream) to affected areas topically every shift for purpura with drainage. Review of the Medication Administration Record and Treatment Administration Record from 05/18/22 to 11/22/22 revealed Resident #11 received this cream twice daily. Review of quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/01/22 revealed Resident #11 had severe cognitive impairment with memory problems. The assessment revealed the resident required extensive two-person physical assistance for bed mobility, transfers, dressing, and personal hygiene. The assessment noted the resident was always incontinent of urine and bowel. On 11/22/22 at 1:41 P.M. Licensed Practical Nurse (LPN) #506 was observed performing the treatment to Resident #11. At the time of the observation, there were no areas draining on Resident #11. Interview with LPN #506 at the time of the observation revealed Resident #11 was being treated for purpura on his back, but they had been healed for over a month. LPN #506 was unsure why the Silvadene cream was still being applied to his back as of this date. On 11/22/22 at 2:53 P.M. interview with Registered Nurse (RN) #808 confirmed Resident #11 had been receiving Silvadene cream to his back twice a day since it was originally ordered on 05/18/22. RN #808 verified the resident did not currently have any draining purpura and the areas of concern were not reddened. The RN was unable to provide justification for the continued use of the medicated treatment for the resident as of this date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review and interview the facility failed to ensure as needed (PRN) anti-anxiety medication (Xanax) ordered for Resident #33 was not ordered longer than 14 days, had a specific duration for use and stop date. The facility also failed to ensure an appropriate indication for use of the anti-psychotic medication (Seroquel) for Resident #26. This affected two residents (#26 and #33) of five residents reviewed for unnecessary medication use. Findings include: 1. Review of Resident #33's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including major depressive disorder, severe intellectual disabilities and unspecified mood disorder. Review of Resident #33's physician's orders revealed an order, dated [DATE] for the anti-anxiety medication, Xanax 0.5 mg (milligrams) by mouth every twelve hours as needed for behaviors. Record review revealed the medication was discontinued on [DATE] Review of Resident #33's physician progress note, dated [DATE] indicated to continue Xanax for three months for breakthrough anxiety (from [DATE] to [DATE]). Review of Resident #33's physician's orders revealed an order, dated [DATE] for Xanax 0.5 mg one tablet every eight hours as needed for behaviors related to restlessness and agitation. Record review revealed no stop date or discontinuation date for the medication. Review of Resident #33's physician's progress note, dated [DATE] and psychiatric progress note, dated [DATE] revealed no information related to the use of the Xanax. The notes did not include a specific duration for use or stop date. Review of Resident #33's Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #33's medication administration records (MAR) from [DATE] to [DATE] revealed staff administered the Xanax on [DATE] at 1:15 P.M., [DATE] at 8:38 P.M., [DATE] at 1:31 P.M., [DATE] at 10:35 A.M., [DATE] at 12:52 P.M., [DATE] at 8:03 A.M., [DATE] at 7:42 A.M., [DATE] at 10:51 A.M., [DATE] at 12:33 P.M., [DATE] at 12:20 P.M. and [DATE] at 10:28 A.M. On [DATE] at 10:55 A.M. interview with Registered Nurse (RN)/Clinical Director of Operations #812 confirmed Resident #33's Xanax anti-anxiety medication did not have a specific duration for use or stop date and was continued greater than 14 days after being ordered on [DATE]. 2. Review of Resident #26's medical record revealed an initial admission date of [DATE] with diagnoses including depression and anxiety disorder. A progress note by psychiatric Nurse Practitioner (NP) #812 on [DATE] indicated nursing requested Resident #26 be evaluated for severe depression. Resident #26 was in isolation for persistent Clostridium difficile (C-Diff). NP #812 indicated Resident #26 reported improved sleep with the use of Melatonin (treats insomnia) and Vistaril (anti-anxiety). Orders were given to discontinue Melatonin ordered on an as necessary basis, start Melatonin 5 milligrams (mg) every day at bedtime, discontinue Vistaril ordered on an as necessary basis, start Vistaril 25 mg every day at bedtime, and start Cymbalta (anti-depressant) 20 mg every day. A nursing note dated [DATE] at 5:35 A.M. indicated Resident #26 appeared frantic when staff went to her room to provide incontinence care. Resident #26 stated there was a man in the corner by her curtain then spoke of two cats in the register. A nursing note, dated [DATE] at 12:48 P.M. indicated Resident #26 had a change in mental status, experiencing hallucinations concerning people being in her room and fearing they would harm her. Resident #26 was transferred to the hospital for evaluation. Upon return from the hospital on [DATE], Resident #26 had an order for the anti-psychotic medication, Seroquel 25 mg at bedtime for anxiety disorder. A nursing note, dated [DATE] at 1:49 P.M. indicated a physician visited and addressed the use of Seroquel for anxiety. The physician referred Resident #26 to psychiatric services to address changes. On [DATE] psychiatric NP #812 documented nursing requested re-evaluation for Resident #26 since she returned from the hospital. The note indicated Resident #26 had a new order for Seroquel. Resident #26 was oriented with short term memory gaps. Resident #26 appeared to be in better spirits. Resident #26 indicated she had some trouble sleeping and worried a lot at night. Resident #26 denied depression. Mood had trended upwards. No delusions, hallucinations, or paranoia were noted. Orders were given to discontinue the Seroquel with a note to avoid anti-psychotic. Orders were given to administer Vistaril 25 mg every day at bedtime for anxiety/sleeplessness. Review of the [DATE] Medication Administration Record (MAR) revealed no Seroquel was administered on [DATE]. On [DATE] a physician order was written for Seroquel 25 mg every day at bedtime for schizoaffective disorder. The diagnosis was added to the diagnosis list. However, there was no documentation as to why the Seroquel was restarted. On [DATE] a note from psychiatric NP #812 revealed Resident #26 denied depression/anxiety. The note indicated Resident #26 was psychiatrically stable. Instructions included maintaining Cymbalta for anxiety, mood and pain. A gradual dose reduction would likely exacerbate target signs/symptoms thus decrease quality of life. The note did not address why the Seroquel was re-started or address how/why the resident had a schizoaffective disorder diagnosis. On [DATE] at 4:10 P.M. Registered Nurse (RN)/Clinical Director of Operations #808 was interviewed regarding the Seroquel use, why it was re-started, and who gave the diagnosis of schizoaffective disorder. No additional information was provided by RN #808 On [DATE] at 7:33 A.M. Licensed Practical Nurse (LPN) #811 was interviewed regarding the new diagnosis of schizoaffective disorder when the Seroquel was re-started when Resident #26 had no history of the diagnosis and prior to that diagnosis the physician had been indicating the Seroquel was used to treat anxiety. LPN #811 indicated the facility had been unable to locate additional information. On [DATE] at 11:13 A.M. psychiatric NP #812 was interviewed regarding the order to restart Seroquel for schizoaffective disorder. When asked how Resident #26 met the Diagnostic and Statistical Manual (DSM) of Mental Disorders criteria for schizoaffective disorder, psychiatric NP #812 stated if she added the diagnosis she would have indicated how Resident #26 met criteria. Psychiatric NP #812 stated she doubted she would have given such a diagnosis based on Resident #26's age as the symptoms for a schizoaffective or schizophrenia diagnosis generally were exhibited when a person was in their 20's or 30's. Psychiatric NP #812 revealed she did not document any notes when the facility called to indicate if a dose reduction was ineffective as the facility should be documenting why the medication was restarted. Psychiatric NP #812 stated the Seroquel was probably related to anxiety or breakthrough hallucinations although she had no way of knowing due to lack of documentation. Psychiatric NP #812 indicated the DSM revealed the symptoms of hallucinations had to last longer than what Resident #26 was experiencing for a diagnosis of schizoaffective disorder. Psychiatric NP #812 stated she did not know to what extent or if Resident #26 was having hallucinations when the Seroquel was restarted or if Resident #26 was experiencing distress. Psychiatric NP #812 voiced she hated that Seroquel was even classified as an anti-psychotic because at a lower dose of 25 or 50 mg there was no dopamine blockage and it acted more like an antihistamine. The NP revealed the Seroquel was likely ordered for the resident's anxiety. On [DATE] at 1:38 P.M. interview with Clinical Director of Operations #813 revealed the staff person who wrote the Seroquel order on [DATE] was an agency nurse. On [DATE] at 2:24 P.M. interview with Physician #814 revealed Resident #26 was sent to a local hospital on [DATE] then was sent to another hospital [DATE] due to seizures. Physician #814 stated he could not access records from the second hospital and it was notoriously hard to get information from that hospital. Physician #814 stated Resident #26 had a rough time as she was diagnosed with colon cancer, her son died, and she had been on isolation for C-Diff for a long time. Review of the facility Medications-Anti-psychotic policy, effective [DATE] revealed each resident was to receive only those medications, in doses and for the duration clinically indicated to treat a resident's assessed conditions. An antipsychotic medication was used only for the following conditions/diagnoses as documented in the record and as it met the definitions in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Training Revision (DSM-IV-TR) or subsequent editions: the conditions included schizophrenia, schizoaffective disorder, delusional disorder, mood disorders, schizophreniform disorder, psychosis, atypical psychosis, brief psychotic disorder, dementing illness with associated behavioral symptoms, medical illnesses or delirium with manic or psychotic symptoms and/or treatment-related psychosis or mania. The policy indicated the clinical condition also had to meet at least one of the following criteria: 1. The symptoms were identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations, delusions or 2. The behavioral symptoms presented a danger to the resident or to others or 3. The symptoms were significant enough that the resident was experiencing one or more of the following: inconsolable or persistent distress, significant decline in function, and/or substantial difficulty receiving needed care. The behavioral symptoms were: 1. Not due to a medical condition or problem that could be expected to improve or resolve as the underlying condition was treated AND 2. Persistent or likely to reoccur without continued treatment AND 3. Not sufficiently relieved by non-pharmacological interventions AND 4. Not due to environmental stressors that could be addressed to improve the psychotic symptoms or maintain safety AND 5. Not due to psychological stressors or anxiety or fear stemming from misunderstanding related to his or her cognitive impairment that could be expected to improve or resolve as the situation was addressed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review and interview the facility failed to ensure Resident #32's Levemir long-acting insulin was discarded once expired. This affected one resident (#32) of one resident identified during the medication storage review who had insulin stored in the medication storage cart on the East Wing. Findings include: Review of Resident #32's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including type one diabetes, muscle weakness and need for assistance with personal care. Review of Resident #32's Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #32's physician's orders revealed an order, dated [DATE] and discontinued [DATE] for Levemir (long acting insulin) inject 20 units subcutaneously at bedtime related to diabetes. Review of Resident #32's physician's orders revealed an order, dated [DATE] to inject Levemir 18 units subcutaneously at bedtime related to diabetes. Review of Resident #32's Medication Administration Records (MAR) from [DATE] to [DATE] revealed staff administered the Levemir insulin daily as ordered. On [DATE] at 12:10 P.M. observation with Registered Nurse (RN) #809 of the East Wing medication administration cart revealed Resident #32's Levemir long acting insulin was stored in the top drawer. A date on the insulin was noted to be [DATE]. On [DATE] at 12:12 P.M. interview with RN #809 revealed Resident #32's Levemir long acting insulin was only good for 42 days once opened. RN #809 confirmed the insulin was opened on [DATE], had expired on [DATE] and should have been discarded at that time. Review of the facility Medication Storage policy, dated 10/2022 revealed medications would be monitored to assure they were not expired, contaminated or unusable.

Based on observation, record review, and interview, the facility failed to ensure an Advanced Directive was clearly and accurately represented on a resident's medical record. This affected one resident (Resident #28) of one resident reviewed for Advanced Directives. Findings include: Review of Resident #28's medical record revealed an admission date of 01/06/19 with diagnoses that included, chronic atrial fibrillation, acute respiratory failure with hypoxia, and chronic kidney disease. Review of physician's orders revealed a 02/04/19 order for a code status Do Not Resuscitate-Comfort Care (DNR-CC). Review of Resident #28's medical record revealed a Do Not Resuscitate Comfort Care-Arrest (DNR-CCA). An Advanced Directive that was signed by the physician on 01/03/19. Observation on 11/12/19 at 5:39 P.M. of Resident #28's room revealed a red sticker outside of her door, on her name plate. There were no markings on the red sticker. Review of the facility policy, Code Status Determination, dated 08/2019 stated, to assist with quick identification for timely interventions, the facility will place stickers on names plates within the facility. Red is to identify a resident who wishes to not be resuscitated, and an A is placed on the red sticker if a DNRCC-A is in place. Interview on 11/12/19 at 5:39 P.M. with Clinical Operations Manager (COM) #128 verified that Resident #28's physician order stated that Resident #28's code status was a DNRCC. COM #128 verified the signed Advanced Directive in the resident's medical record would make it appear she had a DNR-CCA in place. It was further verified that resident had red sticker on her name plate which would indicate her code status as a DNRCC, not a DNR-CCA as signed by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the physician was notified with a change in condition for Resident #8's bruising and Resident #39's development of a pressure ulcer. This affected two of 12 residents (Residents #8 and #39) reviewed for notification of change. Findings include: 1. Record review revealed Resident #39 was admitted to the facility on on 10/10/19 with diagnoses which included fractured hip status post repair, multiple pressure ulcers and severe protein-calorie malnutrition. The resident was alert and oriented and able to make her needs known. Review of the nurse practitioner wound care assessment dated [DATE] revealed the resident had an Stage II pressure ulcer to the left inner thigh, an unstageable pressure ulcer to the left heel and an unstageable pressure ulcer to the coccyx. Further review of the 10/29/19 nurse practitioner wound care assessment revealed the above areas were healed and after 10/04/19 the heel was to be left open to air. There were no further assessments of the areas. On 11/14/19 at 9:45 A.M., observation of the resident's left heel revealed she had a dressing in place that was not dated. The dressing was loose and was removed by State Tested Nurse Aide (STNA) #141. The dressing had a scant amount of yellow drainage on it. STNA #141 verified the above observations at the time of the findings. The resident indicated the left heel was sore when laying on surfaces. Further observation of the left heel revealed the heel was red and mushy looking with a black scab the size of a pencil eraser in the middle of the heel. This was verified by STNA #141 at the time of the observation. Interview with the resident revealed the dressing had been on for at least several days. STNA #141 stated she would notify the nurse, Licensed Practical Nurse (LPN) #138 and she put the residents stockings on. On 11/14/19 at 3:55 P.M., interview with LPN #138 verified STNA #141 informed her of the area on the left heel but could not remember when. LPN #138 verified she observed the resident's heel at about 1:30 P.M LPN #138 identified the area as a darkened scabbed area. She verified she observed the heel about a week and a half ago and there were no areas on the left heel. LPN #138 verified she did not notify the physician of the new pressure area on the left heel and stated he should be in tomorrow and someone would let him know but she would write an order for it. On 11/14/19 at 4:10 P.M., interview with Registered Nurse (RN) #124 indicated she was not aware of the new pressure area to the resident's left heel. Nor that the resident had a dressing in place that was not ordered. RN #124 verified the physician should have been notified of the change of condition and was not. 2. Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease. Review of the quarterly MDS 3.0 dated 08/12/19 revealed the resident was severely cognitively impaired and needed extensive assistance with activities of daily living (ADL) with one or two staff. The resident was mobile in a wheelchair but was not able to stand independently. Review of the nursing notes from 07/01/19 until 11/14/19 revealed there was no evidence of the resident being aggressive or having any behaviors that would cause self inflicted bruising. Further review of the nursing note dated 09/27/19 revealed the resident was found to have a large area of bruising along her lateral right thigh. There were no further assessments related to the bruise. There was no evidence the physician was notified of the bruising. On 11/13/19 at 3:00 P.M., the resident was observed slowly propelling her wheelchair in the hall. Attempted interview revealed the resident just stared at the surveyor. On 11/13/19 at 4:32 P.M., the resident was observed being fed dinner by her family. On 11/14/19 at 11:00 A.M. and 4:25 P.M., the resident was observed slowly propelling her wheelchair in the hall. On 11/14/19 at 1:30 P.M., interview with the Director of Nursing (DON) verified the above concerns and was not able to provide any additional information the physician was notified of the bruising. The DON verified the physician should have been notified of the change in condition. Review of the notification of change policy, not dated, revealed that changes in a resident's condition or treatment are shared timely with the physician. The nurse's were educated to identify changes in the resident's status and define changes that require notification of the physician to ensure the best outcomes of care for the resident. The facility was required to notify the physician about any accident involving the resident, any significant change in the physical, mental or psychosocial status and for the need to alter treatment. Notification was provided to the physician to facilitate continuity of care and obtain input from the physician about changes, additional to or discontinuation of treatments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement the abuse policy when Resident #8, who was cognitively impaired, was found to have injuries of unknown origin (IUO). This affected one of one residents reviewed for abuse (Resident #8). Findings include: Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease. Review of the quarterly minimum data set (MDS) 3.0 dated 08/12/19 revealed the resident was severely cognitively impaired and needed extensive assistance with activities of daily living (ADL) with one to two staff. The resident was mobile in a wheelchair but was not able to stand independently. The resident was not receiving anticoagulants but had been on aspirin at 81 milligrams (mg) daily since 08/24/17. Review of the state's computerized tracking of facility self reported incidents (SRI) related to allegations of abuse revealed the last submission from the facility was on 09/17/18. Review of the nursing note dated 07/14/19 revealed the resident was found to have a large bruise to the left forearm. The area was swollen and tender to touch. There were no further assessments related to the bruise including description, size, when the bruise was found. No incident report was completed nor was the plan of care updated to reflect the bruise. There was no more information available in the medical record. Review of the typed one and a half page narrative completed by the Director of Nursing (DON) indicated ecchymosis of the left forearm which extended to the elbow with a raised area to the center. Staff were interviewed but did not indicate who nor were written statements obtained. The resident was severely cognitively impaired and was not able to give any information. The area remained as of 07/23/19. The cause of the IUO was undetermined. The only other attachment for the investigation was the care plan which indicated the resident received aspirin daily. The care plan which was initiated 06/22/18 did not indicate the resident had any prior bruising. Review of the nursing note dated 09/27/19 revealed the resident was found to have a large area of bruising along the lateral right thigh. There were no further assessments related to the bruising. No incident report was completed nor was the plan of care updated to reflect the bruise. There was no more information available in the medical record. Review of the typed half page narrative, dated 09/27/19, completed the by the DON revealed the resident was found to have ecchymosis of the right lateral thigh. There were no written statements from staff. The DON concluded the area was vulnerable to trauma related to transfers and believed no abuse occurred. On 11/14/19 at 1:30 P.M., interview with the DON verified both the bruising to the forearm and to the thigh were IUO because the resident was not able to be interviewed due to her severe cognition nor did any staff observe how the bruising occurred. The DON verified there were no assessments to describe the areas nor were any witness statements obtained because she did not think the areas were suspicious. The DON stated the areas are vulnerable to trauma but there was no indication of abuse seen by staff when questioned. The DON verified there was no indicate the resident bruised easily nor was she able to determine how the bruising occurred. The DON verified the policy was not implemented for the IUO. Review of the abuse, neglect, exploitation and misappropriation of resident property policy, dated February 2019, revealed an IUO was classified when both the source of the injury was not observed or able to be explained and the injury was suspicious because of the extent of the injury, the location of the injury or the incidence of injuries over time. The investigation protocol included if there were no direct witnesses, then interviews may be expanded to cover all employees on the unit, or as appropriate, the shift. For IUO the investigation may generally involve talking with both the shift on duty when the injury was discovered and prior shifts as well. Obtain a statement from the resident, if possible, the accused and each witness. Obtain all medical reports and statements from the physicians and review the residents medical records. Any allegations of abuse or IUO should be reported to the state agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report injuries of unknown origin (IUO) obtained by Resident #8, who was cognitively impaired, to the state agency as required. This affected one of one residents reviewed for abuse. Findings include: Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease. Review of the quarterly minimum data set (MDS) 3.0 dated 08/12/19 revealed the resident was severely cognitively impaired and needed extensive assistance with activities of daily living (ADL) with one to two staff. The resident was mobile in a wheelchair but was not able to stand independently. The resident was not receiving anticoagulants but had been on aspirin at 81 milligrams (mg) daily since 08/24/17. Review of the state's computerized tracking of facility self reported incidents (SRI) related to allegations of abuse revealed the last submission from the facility was on 09/17/18. Review of the nursing note dated 07/14/19 revealed the resident was found to have a large bruise to the left forearm. The area was swollen and tender to touch. There were no further assessments related to the bruise including description, size, when the bruise was found. No incident report was completed nor was the plan of care updated to reflect the bruise. There was no more information available in the medical record. Review of the typed one and a half page narrative completed by the Director of Nursing (DON) indicated ecchymosis of the left forearm which extended to the elbow with a raised area to the center. Staff were interviewed but did not indicate who nor were written statements obtained. The resident was severely cognitively impaired and was not able to give any information. The area remained as of 07/23/19. The cause of the IUO was undetermined. The only other attachment for the investigation was the care plan which indicated the resident received aspirin daily. The care plan which was initiated 06/22/18 did not indicate the resident had any prior bruising. Review of the nursing note dated 09/27/19 revealed the resident was found to have a large area of bruising along the lateral right thigh. There were no further assessments related to the bruising. No incident report was completed nor was the plan of care updated to reflect the bruise. There was no more information available in the medical record. Review of the typed half page narrative, dated 09/27/19, completed the by the DON revealed the resident was found to have ecchymosis of the right lateral thigh. There were no written statements from staff. The DON concluded the area was vulnerable to trauma related to transfers and believed no abuse occurred. On 11/14/19 at 1:30 P.M., interview with the DON verified both the bruising to the forearm and to the thigh were IUO because the resident was not able to be interviewed due to her severe cognition nor did any staff observe how the bruising occurred. The DON verified there were no assessments to describe the areas nor were any witness statements obtained because she did not think the areas were suspicious. The DON verified neither of the areas were reported to the state agency because the areas were vulnerable to trauma and there was no indication of abuse seen by staff when questioned. The DON verified there was no indication the resident bruised easily nor was she able to determine how the bruising occurred. Review of the abuse, neglect, exploitation and misappropriation of resident property policy, dated February 2019, revealed an IUO was classified when both the source of the injury was not observed or able to be explained and the injury was suspicious because of the extent of the injury, the location of the injury or the incidence of injuries over time. The investigation protocol included if there were no direct witnesses, then interviews may be expanded to cover all employees on the unit, or as appropriate, the shift. For IUO the investigation may generally involve talking with both the shift on duty when the injury was discovered and prior shifts as well. Obtain a statement from the resident, if possible, the accused and each witness. Obtain all medical reports and statements from the physicians and review the residents medical records. Any allegations of abuse or IUO should be reported to the state agency immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure Resident #8's injuries of unknown origin (IUO) were thoroughly investigated. This affected one of one residents reviewed for abuse. Findings include: Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease. Review of the quarterly minimum data set (MDS) 3.0 dated 08/12/19 revealed the resident was severely cognitively impaired and needed extensive assistance with activities of daily living (ADL) with one to two staff. The resident was mobile in a wheelchair but was not able to stand independently. The resident was not receiving anticoagulants but had been on aspirin at 81 milligrams (mg) daily since 08/24/17. Review of the state's computerized tracking of facility self reported incidents (SRI) related to allegations of abuse revealed the last submission from the facility was on 09/17/18. Review of the nursing note dated 07/14/19 revealed the resident was found to have a large bruise to the left forearm. The area was swollen and tender to touch. There were no further assessments related to the bruise including description, size, when the bruise was found. No incident report was completed nor was the plan of care updated to reflect the bruise. There was no more information available in the medical record. Review of the typed one and a half page narrative completed by the Director of Nursing (DON) indicated ecchymosis of the left forearm which extended to the elbow with a raised area to the center. Staff were interviewed but did not indicate who nor were written statements obtained. The resident was severely cognitively impaired and was not able to give any information. The area remained as of 07/23/19. The cause of the IUO was undetermined. The only other attachment for the investigation was the care plan which indicated the resident received aspirin daily. The care plan which was initiated 06/22/18 did not indicate the resident had any prior bruising. Review of the nursing note dated 09/27/19 revealed the resident was found to have a large area of bruising along the lateral right thigh. There were no further assessments related to the bruising. No incident report was completed nor was the plan of care updated to reflect the bruise. There was no more information available in the medical record. Review of the typed half page narrative, dated 09/27/19, completed the by the DON revealed the resident was found to have ecchymosis of the right lateral thigh. There were no written statements from staff. The DON concluded the area was vulnerable to trauma related to transfers and believed no abuse occurred. On 11/13/19 at 3:00 P.M., the resident was observed slowly propelling herself in the wheelchair down the hall. Attempted interview revealed the resident just stared at the surveyor. On 11/13/19 at 4:32 P.M., the resident was observed being fed dinner by her family. On 11/14/19 at 11:00 A.M., the resident was observed slowly propelling herself in the wheelchair down the hall. On 11/14/19 at 1:30 P.M., interview with the DON verified both the bruising to the forearm and to the thigh were IUO because the resident was not able to be interviewed due to her severe cognition nor did any staff observe how the bruising occurred. The DON verified there were no assessments to describe the areas nor were any witness statements obtained because she did not think the areas were suspicious. The DON verified there was no indicate the resident bruised easily nor was she able to determine how the bruising occurred. The DON stated the areas are vulnerable to trauma but there was no indication of abuse seen by staff when questioned. The DON verified the policy was not followed to complete a thorough investigation in an attempt to determine how the resident obtained the bruising. Review of the abuse, neglect, exploitation and misappropriation of resident property policy, dated February 2019, revealed an IUO was classified when both the source of the injury was not observed or able to be explained and the injury was suspicious because of the extent of the injury, the location of the injury or the incidence of injuries over time. The investigation protocol included if there were no direct witnesses, then interviews may be expanded to cover all employees on the unit, or as appropriate, the shift. For IUO the investigation may generally involve talking with both the shift on duty when the injury was discovered and prior shifts as well. Obtain a statement from the resident, if possible, the accused and each witness. Obtain all medical reports and statements from the physicians and review the residents medical records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, the facility failed to ensure nail and oral care were provided to a dependent resident. This affected one (Resident #191) of one resident reviewed for activities of daily living. Findings include: Review of Resident #191's medical record revealed the resident was admitted [DATE] with diagnoses including fractured left femur, severe protein calorie malnutrition, muscle wasting and atrophy, end stage renal disease with dialysis, and anemia. A comprehensive assessment was not due. Review of a 11/11/19 at 10:37 P.M. nurse note revealed the resident was having difficulty sucking from straw as well as difficulty swallowing, coughing on thin liquids and very weak. Observation 11/12/19 at 3:05 P.M. revealed the resident was in bed on his back, his nailbeds were dark with debris bilaterally. The resident's lips were dry and cracked. Resident #191's tongue was dry. His head was leaning against the side rail of the bed. He was unshaven. There was a water pitcher with a straw on his overbed table out of reach. There were no toothettes out to moisten his mouth. Interview 11/12/19 at 3:15 P.M. with State Tested Nurse Aide's (STNA) #105 and #212 revealed the resident broke his hip and was not responding well. He was getting weak. He used to take his own water but now needs them to give him fluids. Observation 11/13/19 at 10:22 A.M. revealed the resident lying in bed on his back. Head of bed elevated 45 degrees. Mouth and lips dry and cracked. His tongue had a white appearance. The water in a pitcher with a straw on the overbed table was out of reach. Resident was not able to lift his upper body up off the bed to reach it when he attempted to get water. He remained unshaven. The beds of his fingernails remained soiled. The right ring fingernail was broken and jagged. Observation on 11/13/19 at 11:19 A.M. revealed the water was still out of reach on the overbed table. Lips and tongue looked dry. There were no toothettes visible to moisten his mouth. Observation on 11/13/19 at 12:05 P.M. revealed the water was still in the same place out of reach. The resident remained on his back with upper body leaning to the right. Lunch of jello in a bowl and peaches with whipped cream in a bowl was on the overbed table. Part of the jello and fruit was gone. There was gingerale on the overbed table with a straw in the glass. The glass was full. The resident was not feeding himself. Observation 11/13/19 at 1:18 P.M. resident remains on back with head of bed elevated 45 degrees. Resident leaning further to the right. The water pitcher position was unchanged. The gingerale looked untouched. The residents nasal cannula was in his mouth. His mouth and lips remained dry in appearance and nails dark with debris. Interview on 11/13/19 at 1:35 P.M. with the Director of Nursing verified the resident was on his back with the head of bed elevated and upper body leaning to the right toward the siderail. The water and gingerale remain unchanged and out of reach. The resident's mouth, tongue and lips were dry. The resident's heels were on the bed. His fingernails were dark with dirt embedded in the nail beds. Some nails were broken and jagged. He remained unshaven. Interview on 11/13/19 at 3:57 P.M. with STNA's #105 and #212 verified the resident's nails were dirty. They revealed they were to clean them weekly and as needed. STNA #212 indicated the resident was not able to drink out of a straw. STNA #212 indicated the resident was too weak to suck on the straw that day and he had not told the nurse. STNA's #105 and #212 verified the resident was mouth breathing and they had not done mouth care for him. Review of the Activity of Daily Living Self Care Deficit plan of care revealed the deficit was due to dementia, weakness and cachexia (muscle loss). Interventions included inspect nails weekly/trim as needed and provide mouth care daily and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #191 revealed the resident was admitted [DATE] with diagnoses including fractured left femur, severe protein calorie malnutrition, muscle wasting and atrophy, end stage renal disease with dialysis, and anemia. A comprehensive minimum data set assessment had not yet been completed. Review of the admission Data Collection Tool included a Sacral pressure ulcer 0.75 cm x 0.75 cm x 0.2 cm and a left buttock pressure ulcer 2.0 cm x 2.0 cm x 0.1 cm both listed Stage 1 (superficial reddening of the skin (or red, blue or purple hues in darkly pigmented skin) that when pressed does not turn white (non-blanchable erythema). There was no other description of the ulcers color, drainage, odor, wound bed or periwound. The pressure ulcers were inaccurately Staged I when they had a depth, indicating the skin was broken. The Weekly Skin Integrity Review for 10/29/19 stated Sacral 0.75 cm x 0.75 cm depth none and a left buttock 2.0 cm x 2.0 cm depth none with no other description. Menthol-zinc oxide ointment 20% apply to the top of buttocks twice a day for skin care started at bedtime 10/29/19. There were no physician orders for the care of the pressure ulcers on admission. A Physician order obtained 10/30/19 was to pad and protect open area to coccyx and left buttock was not signed off as completed on 10/30/19. A 10/31/19 Physician Order was obtained to cleanse area to coccyx and left buttock with normal saline, pat dry, apply a small amount of medihoney to wound bed, cover wound bed with Calcium Alginate, apply skin prep to periwound, and cover with dry clean dressing daily and as needed every night shift for wound care and as needed for loose / soiled dressing. The resident was sent to the hospital 10/31/19 at 1:45 P.M. with a critical lab value. There was no evidence of the 10/30/19 order to pad and protect or the 10/31/19 dressing order being applied. Menthol-zinc oxide ointment was not signed off 10/31/19 day shift. There was not a comprehensive assessment of the pressure ulcers prior to being discharged to the hospital 10/31/19. The resident was readmitted [DATE]. The admission data collection said left buttock and sacrum pressure with no measurements or descriptions included. Review of the 11/02/19 Braden scale for predicting pressure sores revealed the resident was at risk with a score of 17. The risk was related to no sensory impairment, occasionally moist, walks occasionally, slightly limited mobility and probably inadequate nutrition, potential friction and shear problem. The 11/02/19 hospital discharge included the resident had an Unstageable Pressure Ulcer (obscured Full-Thickness Skin and Tissue Loss . within the ulcer cannot be confirmed because it is obscured by slough or eschar) to the right buttock 1.1cm X 1.0cm X less than 0.1 cm, wound bed 100% yellow slough and periwound intact, no exudate or signs of infection. The hospital discharge included a Stage II pressure ulcer (partial-thickness skin loss into but no deeper than the dermis. This includes intact or ruptured blisters and abrasions) to the right buttock 1.1cm x 1.0 cm x 0.1 cm wound bed 100% red epithelial tissue. The 11/03/19 Weekly Skin Integrity Review was not completed. The resident was sent to the emergency room [DATE] at 9:22 P.M. and returned 11/05/19 at 12:30 P.M The resident had been hospitalized for end stage renal disease with dialysis and hypotension. There was no evidence of pressure ulcer assessments prior to being sent to the emergency room or upon return. A 11/05/19 at 1:41 P.M. Nurses note included the STNA reports that resident now has an opened area on the buttocks. Nursing to assess and document on skin sheet. There was no evidence of an assessment/follow up on 11/05/19 upon return or on the Weekly Skin Integrity Review. A 11/05/19 nutritional note included a weight of 109 pounds and a Body Mass Index of 19.3. Poor oral intake. End Stage Renal Disease with dialysis. Diagnosis of severe protein calorie malnutrition and cachexia. Nepro, a nutritional supplement, with breakfast and dinner meals was recommended. There was no measurements or comprehensive assessment of the pressure ulcers by the facility between 10/29/19 and 11/10/19. A 11/10/19 weekly skin integrity review included left buttock 2cm x 2cm. There was no further description and only one area was listed. Observation on 11/12/19 at 3:05 P.M. revealed the resident was in bed on his back. Interview on 11/12/19 at 3:15 P.M. with State Tested Nurse Aide's (STNA) #105 and #212 revealed the resident broke his hip and was not responding well. He was getting weak. Observation on 11/13/19 at 10:22 A.M. revealed the resident lying in bed on his back. Head of bed elevated 45 degrees. Resident was not able to lift his upper body up off the bed when he attempted to get water. Observation on 11/13/19 at 11:19 A.M. remains on back, upper body leaning to the right. Head of bed elevated 45 degrees. Observation on 11/13/19 at 12:05 P.M. remains on back with upper body leaning further to the right. Observation on 11/13/19 at 1:18 P.M. resident remains on back with head of bed elevated 45 degrees. Resident leaning further to the right. Observation of the resident on 11/13/19 at 1:35 P.M. with the DON verified the resident was on his back with the head of bed elevated and upper body leaning to the right. Interview on 11/13/19 at 3:57 P.M. with STNA's #105 and #212 verified they were not turning the resident every two hours. The aides indicated they didn't know they were to turn him every two hours. They indicated he was on dialysis and rarely wet so he did not need to be changed every two hours. STNA's #105 and #212 verified during observations from 10:22 A.M. through 1:35 P.M. the resident had not been turned off his back and buttocks. Observation on 11/14/19 at 9:52 A.M. of the resident's skin impairments with LPN #215 revealed the resident had two pressure ulcers. One to the left inner buttock approximately 1cm x 1 cm with a small 2-3 millimeter area of yellow slough and red periwound and one to the coccyx approximately 3cm x 2 cm with a red periwound, unstageable, covered with yellow-white slough. A Nurse Note entered 11/14/19 at 10:00 A.M. included Sacrum--3.5cm x 2cm, No depth---90% Slough, 10% Granulation, edges adherent to base, no drainage and no odor. A left buttocks--1.5cm x 0.5cm, no depth---moist in appearance, pink in color, edges adherent to base, no drainage, no odor. There was no staging identified in the note. Interview on 11/14/19 at 5:16 P.M. with Clinical Operations Manager (COM) #178 revealed the resident was not listed as one of their residents with pressure ulcers. COM #178 verified the facility failed to obtain skin assessments, failed to comprehensively assess pressure ulcers, failed to follow physician orders and failed to put pressure relieving measures in place. COM # 178 verified the wound assessments were not descriptive enough for sure. COM #178 verified the admission assessment was not comprehensive, there was no evidence of treatment of the pressure ulcers from 10/29/19 till readmitted to the hospital 10/31/19 and no measurements or assessments on return 11/02/19. COM #178 verified there were no pressure ulcer measurements upon return from the hospital and the facility went 12 days without measuring and assessing the pressure ulcers. Based on observation, interview and record review revealed the facility failed to ensure Resident #39's multiple pressure areas were comprehensively assessed with ongoing tracking to ensure interventions were in place to prevent re-occurrence of the pressure area specifically the left heel. This affected two of two residents reviewed for pressure ulcers (Residents #39 and #191). Findings include: 1. Record review revealed Resident #39 was admitted to the facility on on 10/10/19 with diagnoses which included fractured hip status post repair, multiple pressure ulcers and severe protein-calorie malnutrition. The resident was alert and oriented and able to make her needs known. Review of the nursing data collection tool dated 10/11/19 revealed the resident was admitted to the facility without any pressure areas. Review of the nursing note dated 10/11/19 revealed the resident was sent to the hospital, was admitted for dehydration and urinary tract infection and returned to the facility on [DATE]. Review of the re-admission nursing note dated 10/14/19 revealed the resident was observed to a reddish pink mark to the left lateral aspect of the upper thigh that was not open. The coccyx and sacral area was red and pink with a small scabbed area in the middle. A blister was present to the left inner mid thigh and a small wound was noted to the left heel. Further review of the nursing data collection tool dated 10/14/19 revealed the resident had pressure areas to the left heel and sacrum, a blister to the left lateral thigh and bruising to the left inner thigh. There were no descriptions or measurements of the areas. Review of the potential for pressure ulcer development care plan initiated and updated 10/14/19 revealed the resident has pressure areas to the left lateral thigh and left heel (no indication of the coccyx area). The interventions included to administrator treatments as ordered and monitor for effectiveness, document changes in skin status including appearance, color, wound healing, signs and symptoms of infections, wound size and stage, complete the skin risk assessment and weekly skin inspections. Review of the physicians progress note dated 10/14/19 revealed the resident had a sacral ulcer. Review of the consultant nurse practitioner wound care assessment dated [DATE] revealed the resident had an Stage II pressure ulcer to the left inner thigh and ordered skin preparation twice a day and leave open to air. An unstageable pressure ulcer (defined as (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) to the left heel and ordered skin preparation twice a day and may cover with a gauze dressing if friction was a concern. Monitor the area for signs and symptoms of infection bogginess, drainage and erythema. An unstageable pressure ulcer to the coccyx and ordered to cleanse affected area with normal saline solution or wound cleanser, apply foam dressing daily and as needed. Monitor site for signs and symptoms of infection bogginess, drainage and erythema. There was no evidence any staff members were present during the wound care assessment. Review of the consultant nurse practitioner wound care assessment dated [DATE] revealed the pressure area to the left medial thigh has resolved. The unstageable pressure ulcer to the left heel was reclassified as a stage III (defined as full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) and a new treatment was ordered to include washing with normal saline solution, apply calcium alginate and cover with a foam dressing and change every three days and as needed. Monitor site for signs and symptoms of infection bogginess, drainage and erythema. The unstageable pressure ulcer to the coccyx continue treatment and monitoring. Review of the consultant nurse practitioner wound care assessment dated [DATE] revealed the pressure areas to the coccyx had resolved discontinue the foam dressing but continue the house barrier cream three times a day. The pressure ulcer to the left heel had resolved discontinue the alginate. New treatment for prevention only was to apply skin preparation and cover with a dry dressing daily for one week then discontinue and leave open to air while continuing to monitor the site. Review of the medical record, including but not limited to, nursing data collection tools, nursing notes and care plans, revealed there was no evidence of the facility monitoring the pressure areas including tracking to see if the current treatments were effective and if the areas were declining or improving. Review of the current physician orders revealed there was no indication the resident was receiving the house barrier cream to the coccyx three times a day as ordered and there were no orders for the heels. Further review of the treatment administration record (TAR) for October and November 2019 revealed there was no evidence the barrier cream was ever applied as ordered. Review of the physicians order dated 10/29/19 revealed to clean the left heel stage III pressure ulcer, cover with a foam dressing for seven days and then discontinue the dressing if it was still closed. Check the area every day shift for skin integrity for seven days. There was no documented evidence the heel was checked daily. The only documented skin check was on 11/10/19 with a check mark on the TAR for the weekly skin check. On 11/14/19 at 9:00 A.M., interview with Licensed Practical Nurse (LPN) #138 revealed she had only one dressing and one residents skin to check today and it was not Resident #39. On 11/14/19 at 9:45 A.M., observation of the resident's left heel revealed she had a dressing in place that was not dated. The dressing was loose and was removed by State Tested Nurse Aide (STNA) #141. The dressing had a scant amount of yellow drainage on it. STNA #141 verified the above observations at the time of the findings. The resident indicated the left heel was sore when laying on surfaces and had been for awhile. Further observation of the left heel revealed the heel was red and mushy looking with a black scab the size of a pencil eraser in the middle of the heel. This was verified by STNA #141 at the time of the observation. Interview with the resident revealed the dressing had been on for at least several days. STNA #141 stated she would notify the nurse, LPN #138. STNA #141 then put on the resident's stockings. On 11/13/19 at 10:10 A.M., interview with Registered Nurse (RN) #124, who was the unit manager, provided the consultant nurse practitioner notes and stated there was no other documentation in the medical record of the facility monitoring, assessing and/or tracking the pressure ulcers except the nursing data collection tool dated 10/14/19 that was not comprehensive. RN #124 verified the care plan was not comprehensive to include all the pressure areas and the facility was not following the plan of care. On 11/14/19 at 3:55 P.M., interview with LPN #138 verified STNA #141 informed her of the area on the left heel but could not remember when. LPN #138 verified she observed the resident's heel at about 1:30 P.M LPN #138 identified the area as a darkened scabbed area. She verified she observed the heel about a week and a half ago and there were no areas on the left heel. LPN #138 verified she did not notify the physician of the new pressure area on the left heel and stated he should be in tomorrow and someone would let him know but she would write an order for it (she did not indicate the nature of the order). On 11/14/19 at 4:00 P.M., observation of the resident's left heel, with LPN #138, revealed the resident's had on light stockings to treat edema in her legs and the resident's heels were laying on a pillow while she was in bed. The entire left heel was red and mushy to touch revealed LPN #138 when she was touching the heel. LPN #138 verified the heel also had a black scabbed area in the center of the heel. Observation of the white stocking revealed it had a significant amount of yellow, pink drainage surrounding the area of the heel. LPN #138 verified she was not aware of the extent of the area. LPN #138 indicated she was now going to notify the physician. On 11/14/19 at 4:10 P.M., interview with RN #124 indicated she was not aware of the new pressure area to the residents left heel. Nor that the resident had a dressing in place that was not ordered. RN #124 stated the wound nurse practitioner said the left heel was healed on 10/29/19 and her services were no longer and would not return unless contact by the facility. RN #124 verified the physician should have been notified of the change of condition and was not. Review of the weekly skin ulcer report, dated February 2019, revealed to monitor the status of residents skin on an ongoing basis to ensure potential issues are found timely. The nurse was to document findings including any abnormal or new issues with the skin in the medical record and notify the clinical operations manager. Information regarding skin breakdown or new skin issues would be relayed to the physician and dietitian. Recommendations and possible new interventions would be initiated and an order would be obtained from the attending physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure Resident #91 was properly assessed and had proper interventions in place when the resident was determined to be at risk for falls. After the resident sustained falls the facility failed to implement further interventions in an attempt to prevent the resident from further falls and injuries. This affected one of two residents reviewed for falls. Findings include: Record review revealed Resident #91 was admitted to the facility on [DATE] with diagnoses which included a history of falls and malnutrition. Review of the current fall care plan, initiated 11/05/19 revealed the resident was at risk for falls due to weakness and otitis media. The goal was to decrease the risk for falls. Interventions included to anticipate and meet the resident's needs, encourage the resident to use her call light for assistance, ensure the resident was wearing the appropriate footwear and have physical therapy evaluate and treat as needed. There had been no new interventions since the care plan had been initiated. Further review of the physicians order initiated 11/05/19 revealed there were no fall interventions ordered nor were there any fall interventions added after the resident sustained falls. Review of the brief assessment for mental status (BIMS) dated 11/07/19 revealed the resident had moderate cognitive impairment. Review of the nursing note dated 11/06/19 at 4:21 A.M., revealed upon rounds the resident was observed on her left side on the floor with a pillow under her head. The resident indicated she got up to go to the bathroom and fell. There were no injuries noted. Further review of the fall investigation revealed the resident was not using the walker and should not have been ambulating without assistance due to gait imbalance and causal factors could have included poor lighting. There was no indication of proper footwear was in place, if the walker was near the resident, where the resident was prior to falling, last time the staff observed the resident or toileted the resident. There were no assessments or intervention put into place. Review of the physical therapy initial evaluation dated 11/06/19 revealed the resident had difficulty walking with multiple falls at home prior to admission (there was no evidence therapy was informed the resident sustained a fall at the facility this morning). The resident wore glasses and had a recent ear infection. The resident had a kyphotic posture with impairment in gross motor coordination. The resident exhibited forward lean of her trunk with excessive knee flexion and inadequate trunk extension, inadequate toe clearance, muscle weakness and reduction in activity tolerance and muscle instability while ambulating. The resident was able to ambulate 30 feet with the walker. The goals included for the resident to be able to ambulate 150 feet with the walker, transfer herself from surface to surface with supervision and occasional verbal cues. Review of the nursing note dated 11/08/19 at 12:45 P.M., revealed the daughter approached the nurse and asked for a band aid for her mother. The daughter stated she needed it because the resident had fallen in the bathroom where she sustained a skin tear to her left outer elbow. The nurse instructed the resident on the importance of using the call light when she needed assistance. Further review of the investigation revealed the skin tear measured one centimeter (cm) by three cm's. There was no assessment to determine where the resident was prior to the fall, if the walker was used, the last time the resident was toileted, if the resident had on proper footwear or any other information surrounding the fall. Review of the nursing note dated 11/11/19 at 5:00 A.M., revealed the resident activated her call pendant and upon entering the room the resident was observed on the floor on her right side in the bathroom in front of the toilet with her knees slightly bent and her right arm under her head. The resident did not know what happened and stated she lost her balance. The resident was in her bare feet. The resident sustained a skin tear to her right forearm measuring 2.8 cm by 0.7 cm with a skin flap. The resident was instructed to wear proper footwear, staff availability. Further review of the fall investigation revealed the resident was wearing improper footwear, ambulating without assistance and was using a walker. There were no new interventions in place or no evidence causal factors were determined. Review of the nursing note dated 11/13/19, written at 7:50 P.M., revealed the STNA alerted the nurse the resident was observed on the floor in the bathroom. The resident was observed face down with facial grimacing and grunting noted when bilateral lower extremities moved. The resident was sent to the emergency room for evaluation. On 11/12/19 at 6:24 P.M., the resident was observed sleeping in bed with the walker at the bedside. On 11/13/19 at 8:28 A.M., the resident was wheeled into the common area to eat breakfast by State Tested Nurse Aide (STNA) #116. The resident had on non skid slippers but no glasses. On 11/13/19 at 10:25 A.M., interview with the resident's daughter revealed she was very upset with all the falls the resident was having and did not feel the facility was able to manage the resident because she was confused and they were used to dealing with alert and oriented residents. She stated this all started with an ear infection, the resident went to the hospital and had to come here for rehabilitation because she was so weak. The daughter stated the facility kept both the residents wheelchair and walker against the wall far away from the bed when she was in bed which she needed if she wanted to get up and go to the bathroom. The daughter stated the resident was at the far end of the hall and had to request she be moved closer to the common area where there was more traffic. The daughter was told the resident closes her door and tries to go to the bathroom but they indicated they were are on to her now. She stated the resident liked to wear the non skid slippers instead of shoes. The resident does not understand what the pendant is or that it can be used to call for assistance. On 11/13/19 at 12:50 P.M., the resident was observed sleeping in bed. The resident was sleeping with non skid socks on and the walker was in the middle of the room between the bed and the wall. On 11/13/19 at 1:00 P.M., interview with Registered Nurse (RN) #124, with review of the nursing notes and fall investigations, verified the above concerns with not putting new interventions in place after the falls, not assessing in attempt to determine the cause of the falls. When asked how the aids knew what interventions or what each resident's individual needs were she was not able to say. RN #124 verified there was no documentation for the aid to refer to related to each resident's individual needs. RN #124 verified the intervention was to have the resident use the call pendant but verified the resident was confused and she was not sure the resident would remember what the call pendant was for or that it was placed around her neck. RN #124 verified the fall plan of care had not been updated with any interventions and there was no evidence of physician involvement in the assessing in an attempt to determine the cause of the frequent falls. RN #124 verified the resident was receiving skilled therapy and they did not want the resident using her walker or wheelchair by herself without assistance. Therapy wanted the walker and wheelchair placed against the wall away from the bed so the resident would not attempt to independently transfer herself. RN #124 verified the resident was not on a toileting program despite all the resident's falls were related to toileting herself. RN #124 verified the resident was weak and needs assistance with all activities of daily living (ADL's). On 11/13/19 at 1:18 P.M., interview with Therapy Director (TD) #220, with RN #124 present, revealed the resident was in physical therapy with the goal to be able to get back to baseline and be able to walk with her walker independently. TD #220 verified the resident had difficulty with balance, was weak and had poor safety awareness, follow through and carry over with tasks. The resident did not remember to use the call pendant because of her decline in cognition. The resident required one person assistance with ADL's including ambulation with the walker and toileting. TD #220 verified the resident was not safe to toilet herself due to her having difficulty remembering what to do, her weakness and balance concerns. On 11/13/19 at 1:22 P.M., interview with STNA #116, with RN #124 present, revealed she thought the family requested they keep both the walker and the wheelchair against the wall and away from the resident. STNA #116 was not sure if the resident was suppose to toilet herself but she did. STNA #116 was not able to say the level of assistance the resident needed for ADL's including ambulation and toileting. Review of her iPad, where she documented the level of assistance provided, revealed there was no instruction for the level of assistance needed. On 11/13/19 at 6:50 P.M., the resident was observed sleeping in bed in her bare feet. The wheelchair seat was towards the head of bed but placed even with foot of bed and the walker against the wall. On 11/14/19 at 10:00 A.M., interview with STNA #141 verified the resident was confused and did not remember to use the call pendant. The resident was supposed to wear non skid footwear. When asked where the resident was STNA #141 stated she was informed the resident went to the hospital last evening but was unable to say why. On 11/14/19 at 4:10 P.M., interview with RN #124 verified the resident went to the hospital due to a fall shortly after the surveyor left the facility last evening. RN #124 did not have any other documentation other than the nursing note and had not spoken to the hospital. The surveyor informed the resident was in her bare feet on 11/13/19 at 6:50 P.M. and RN #124 verified the resident was not able to put on her own footwear. Review of the fall clinical protocol, dated February 2019, revealed as part of the initial assessment the facility would identify residents with a history of falls and risk factors (including lightheadedness, dizziness, multiple medications, gait and balance disorders, cognitive impairment, weakness, confusion, visual impairment and illnesses affecting the central nervous system and blood pressure) for subsequent falling which would be documented in the medical record. After a fall occurs evaluate and document details of the fall including where and when, observation of the events, where resident was prior to fall, circumstances around the fall, if witnessed and identify possible causes for the fall. After the first fall staff should watch the resident rise from a chair without using his or her arms, walk several paces, and return to to sitting. If the resident had difficulty or unsteadiness, further evaluation may not be needed. If the individual had difficulty or was unsteady in performing this test, additional evaluation should occur. If the cause of the fall was unclear or if the resident continued to fall after interventions include the physician in an attempt to help identify contributing causes. After more than one fall, the physician should review the residents gait, balance and current medications that may be associated with dizziness or falling. Continue to collect and evaluate information until the cause of the falls was identified. If underlying causes cannot be readily identified or corrected staff would try various relevant interventions based on the assessment until falling reduces or stops or the reason was identified for its continuation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a comprehensive nutritional plan was in place including accurate weights, monitoring/offering supplements and ensuring the resident's meal consumption was optimal for Resident #39, who sustained severe weight loss and developed multiple pressure ulcers. This affected one of three residents revealed for nutrition. Findings include: Record review revealed Resident #39 was admitted to the facility on [DATE] with diagnoses which included fractured hip status post repair, dehydration and severe protein-calorie malnutrition. The resident was alert and oriented and able to make her needs known. Review of the resident's weight on 10/11/19 was 242 pounds which was not determined to be an error until 10/16/19. Review of the 10/11/19 nutritional data collection tool form revealed there was no evidence the resident was interviewed but the liquid nutritional supplement, Ensure, was to be started (there was no documented evidence the Ensure was initiated). The albumin, which measures visceral protein stores, was 2.2 (normal was 3.1-4.5) which indicated severe depletion. The resident had skin impairment. The residents meal intake for this date was between 25 and 75 percent. The resident's weight was 242 pounds. The assessment was completed by Registered Dietitian (RD) #219. Review of the at risk for altered nutrition care plan initiated 10/15/19 revealed the resident ate small meals and liked to snack. The goal was to prevent significant weight loss. Interventions included discussing nutrition with the resident and family, offer favorite foods and substitutes for disliked foods, ensure the resident consumed 70-100 percent of her meals, any weight changes of five pounds or more the dietitian would be notified for recommendations and monitor weights for trends. Review of the wound care assessment dated [DATE] revealed the resident had a Stage II pressure ulcer to the left inner thigh, an unstageable pressure ulcer to the left heel and an unstageable pressure ulcer to the coccyx. Review of the resident's weight on 10/16/19 revealed her weight was 126 pounds. The admission weight of 242 pounds was an error. Review of the physician orders from admission through 10/21/19 revealed there was no evidence the resident was ordered the Ensure. Further review of the medication administration record (MAR) for October 2019 revealed there was no evidence the resident was receiving the Ensure. Review of the 10/21/2019 nutritional progress note revealed the resident was admitted with an urinary tract infection and dehydration. The resident was receiving a liquid nutritional supplement of Ensure with meals and the intake was varied. Interview with the resident with family present revealed the resident was not a big eater at one time and meals maybe small. The resident had snacks in room of protein food, crackers and fruit provided by the family. The resident denied trying to lose weight and may be down a few pounds from normal. The resident did not have any edema. The resident had a red area with scabbed center to the coccyx/sacral and deep tissue injury to the left heel. No nutritional recommendations were implemented. The resident was provided small meals. There was no evidence of monitoring the intake of the supplement Ensure or meal intake. There was no evidence of addressing the potential for significant weight loss from admission note. This assessment was completed by Registered Dietitian (RD) #219. Review of the 10/29/2019 nutritional progress note revealed the resident was seen for weight loss and wounds. The resident had sustained a 4.6 percent weight loss in one week from 109 pounds to 104 pounds. (The note did not address the fact the resident went from 126 pounds to 109 pound in one week which was a severe weight loss of 15 percent.) The resident was no longer drinking the liquid nutritional supplement, Ensure, stating her daughter told her it had too much sugar and the supplement was discontinued. The residents meal intake was between 25 and 75 percent. Discussed with the resident the importance of adequate nutritional intake and the resident agreed to try the liquid nutritional supplement, Glucerna, because she was not eating enough. The resident was worried about her blood sugar levels but explained her body was stressed and that could affect the fluctuations in blood sugar levels. Encouraged the resident have cottage cheese with fruit and yogurt also with meals. Recommended to add Glucerna with meals. The meal intake with supplement was expected to meet the resident's nutritional needs and promote healing. This assessment was completed by RD #219. Review of the RD to physician recommendation form dated 10/31/19 revealed RD #219 requested the physician order the liquid nutritional supplement, Glucerna, because the resident had significant weight loss and was not eating well. Review of the physicians order dated 10/31/19 revealed to provide the nutritional supplement, Glucerna, with meals. Further review of the 10/31/19 MAR revealed the resident took the Glucerna with the lunch meal but refused it for the dinner meal. Review of the November 2019 MAR indicated the resident was taking the nutritional supplement Glucerna (even though the resident was not). Review of the resident's weight on 11/07/19 revealed it was 103 pounds. On 11/12/19 at 11:00 A.M., interview with the resident revealed she did not have an appetite. The resident was not sure of how much weight she had lost. The resident stated her family wanted her to eat spinach every day. The resident stated she tried the liquid nutritional supplement, Glucerna, once but did not like it and family said it was not good for her body. The resident verified she had not tried any other nutritional supplement but would try a natural health nutritional supplement that was good for her body. Review of the breakfast meal ticket for 11/13/19 revealed it indicated no Ensure (but there was no indication of Glucerna and did not indicate the resident liked yogurt or cottage cheese). On 11/13/19 at 8:30 A.M., observation of the resident's breakfast tray revealed she was finished and ate one piece of toast except for the crust, half of the scrambled eggs and one once of the orange juice. There were no supplements including Glucerna on the tray nor yogurt or cottage cheese. On 11/13/19 at 8:31 A.M., interview with the resident verified she did not receive any nutritional supplements on her trays including this breakfast meal. She stated she did not receive any snacks between meals or yogurt or cottage cheese on her trays. On 11/13/19 at 8:35 A.M., interview with the Registered Nurse (RN) #124 and State Tested Nurse Aide (STNA) #116 verified there were no supplements including Glucerna put on the residents meal trays and the resident had been refusing the liquid nutritional supplement, Glucerna, and they were not aware of the resident being provided Ensure. On 11/13/19 at 8:37 A.M., interview with dietary aid (DA) #126 verified they had not been putting a nutritional supplement, yogurt or cottage cheese on the resident's trays. On 11/13/19 at 8:50 A.M., interview with STNA #116 (with RN #124 present), with review of the STNA documentation of supplements for 11/13/19 indicated the resident refused the supplement today. Further review of the STNA documentation for the supplement intake revealed it mostly said refused but STNA #116 verified it was never offered. On 11/13/19 at 9:15 A.M., interview with RN #124, with review of the MAR revealed the nurses were documenting the resident was consuming the supplement Glucerna despite the resident not even being offered the supplement because the resident tried it one time on 10/31/19, did not like it and was never offered anything else. RN #124 verified the MAR was inaccurate and the STNA documentation should not have indicated the resident was refusing when the resident was never being offered the supplement On 11/13/19 at 12:45 P.M., the resident fed herself half of a small portion of chili, a half of a cup of apple sauce and a couple bites of beets. The resident drank a few ounces of water and ate an apple the family brought in. On 11/13/19 at 12:50 P.M., interview with STNA #116 verified the above lunch meal intake. On 11/13/19 at 1:00 P.M., interview with unit manager revealed above concerns. On 11/13/19 at 6:58 P.M., interview with the resident revealed she was getting ready to drink an organic protein drink with 25 grams of protein her family brought in for her. Asked the resident if she was provided any snacks from the facility and she stated no but they said I could ask if I wanted anything. The resident stated I would not take yogurt in any shape or form and did not like cottage cheese but would take a few bites if it had lots of fruit in it. The resident stated she was born and raised on a farm and did not like milk products. On 11/14/19 at 9:55 A.M., interview with STNA#141 revealed the resident tried the supplement Glucerna but did not like it. STNA #141 verified she still had to document if the resident was taking the supplement and stated she marked she was taking the Glucerna supplement when the resident consumed some drink the family brought in for her. STNA #141 verified the resident received small portion meals, did not eat very much and the facility was not providing any snacks between meals. On 11/14/19 at 12:20 P.M., interview with RD #219 revealed the policy for the unit the resident was on was to obtain weights weekly. RD #219 stated the weights were usually obtained on a Sunday or Monday and she worked Tuesdays and Wednesdays. RD #219 verified she was not permitted to order supplements for the residents but had to use the RD to physician recommendation form to ask the physician to order the supplement. RD #219 verified there was no RD to physician recommendation form completed for the supplement of Ensure and no documented evidence the resident ever received the supplement despite her notes indicated the resident was receiving the Ensure supplement. RD #219 verified she did not talk with the resident when completing her initial assessment indicating the resident's weight was 242 pounds which was inaccurate. When asked about her note indicating the resident should consume yogurt or cottage cheese with fruit, she verified the resident could eat what she wanted and she just gave suggestions but did not implement any snacks between meals or any other type of nutrient dense foods despite the resident being severely nutritionally compromised. Reviewed the plan of care which indicated to talk to the resident and family and asked if this was done. RD #219 was not able to find any evidence of having a conversation about the resident's compromised nutritional status with the resident and her family in an attempt to determine the best plan for the resident. Asked how she was informed of weight changes and she verified there was not definitive process, she usually reviewed the weights on Wednesdays despite the policy stating the dietitian should be notified of any weight changes of five pounds or more. The dietitian would respond within 24 hours of receipt of written notification. Then interventions for undesirable weight loss should focus first on food such as extra food, snacks, calorie-dense foods etc. RD #219 verified this policy was not being followed. Review of the weight assessment and intervention policy, dated February 2019, revealed the dietitian should be notified of any weight changes of five pounds or more. The dietitian would respond within 24 hours of receipt of written notification. Interventions for undesirable weight loss should focus first on food such as extra food, snacks, calorie-dense foods etc. Liquid nutritional supplements may be considered if resident caloric intake remains inadequate to stabilize or increase weight. The physician may order tests, appetite stimulants or medications as appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to maintain a record of fluid intakes for a resident receiving dialysis who had orders for fluid restriction. This affected one (Resident #36) of one resident reviewed for dialysis. The facility identified three residents as receiving dialysis. Findings include: Review of Resident #36's medical record revealed an initial admission date of 09/26/19. Diagnoses included end stage renal disease, cardiomegaly, heart failure, and chronic pulmonary edema. A physician's order was written 10/04/19 indicating a 1000 milliliter (ml) fluid restriction according to the power of attorney (POA). Notify dialysis if resident intake was greater than 1000 ml in 24 hours. A five day Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #36 was severely cognitively impaired. A nursing note dated 10/17/19 at 12:10 P.M. indicated a state tested nursing assistant (STNA) reported she observed the speech therapist provide Resident #36 with several cups of coffee thus leaving her unable to maintain an accurate fluid count for the shift. A nursing note dated 10/19/19 at 12:39 P.M. indicated Resident #36 was non-compliant with the 1000 ml fluid restriction. A nursing note dated 10/24/19 at 9:40 P.M. indicated Resident #36 was non-compliant with the ordered fluid restriction. Review of the October 2019 and November 2019 Treatment Administration Record (TAR) revealed incomplete documentation as to the fluid intake. On the shifts when a nurse did record any information, the administration record was check marked, even if the daily intake was less than 1000 ml/24 hours. On 11/14/19 at 9:50 A.M., the Director of Nursing (DON) was interviewed regarding the incomplete records related to documentation of fluid intake for Resident #36 due to his having orders for fluid restrictions. The DON was interviewed regarding how staff documented intakes for a complete record so the fluids provided by each department/discipline were captured and if there were any guidelines as to who could provide the fluid and when. The DON was also questioned regarding notification of dialysis with non-compliance of fluid restrictions as the treatment administration records were not clear. On 11/14/19 at 3:15 P.M., Registered Nurse (RN) #120 provided documentation she stated was from the DON and verified there were shifts in which no fluid intake was recorded. RN #120 stated the facility had been addressing the fluid restriction with Resident #36 being permitted to have 300 ml of fluid with each meal and 100 ml provided by nursing. The fluids to be provided by nursing were not specific as to who was to provide the fluids and when. RN #120 stated after an earlier interview, the facility had clarified the 100 ml of fluid per day to be administered to Resident #36 by nursing. The plan was clarified to indicate 40 ml of fluid were to be administered with each medication administration and 20 ml could be administered for medications ordered on an as necessary basis. RN #120 stated dialysis was contacted about Resident #36's non-compliance with fluid restrictions and indicated they were aware but he had no evidence of fluid overload.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical record review revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, generalized anxiety disorder, and insomnia. Review of the 01/08/16 physician order for Resident #21 revealed an order for Remeron, an antidepressant, 30 milligrams (mg) daily. Review of the 11/13/18 pharmacy medication review revealed the pharmacist recommended Remeron 30mg for a gradual dose reduction (GDR). The physician reviewed the recommendation and wrote no change on the recommendation sheet. The physician did not date when he wrote no change and failed to give a rationale for not attempting a reduction. Review of the facility's monthly behavior flow sheets revealed Resident #21 did not have any documented behaviors for the months of October and November 2018. Resident #28 target behaviors were listed as depressed withdrawn and insomnia. Review of the Drug Regimen Review policy dated 02/19 revealed, if there is to be no change in the medication the attending physician should document his or her rationale in the resident's medical chart. Interview on 11/13/19 at 5:00 P.M. with the Director of Nursing verified that the physician had not given a rationale for the pharmacy recommendation to reduce Remeron 30mg on 11/13/18. Based on medical record review and staff interview, the facility failed to ensure there was medical justification for the use of psychotropic medication and failed to ensure recommendations for gradual dose reductions were addressed. This affected three (Residents #3, #8, and #21) of five residents reviewed for medication use. Findings include: 1. Review of Resident #3's medical record revealed diagnoses including Alzheimer's disease, psychosis, anxiety disorder, and depression. A plan of care initiated 09/14/18 indicated Resident #3 had diagnoses of Alzheimer's disease and dementia. Resident #3 could be disruptive at times and would sometimes yell out when care was provided but would usually calm soon after. Interventions included documenting moods and behaviors and administering medications as ordered. Redirect inappropriate behavior through distraction, activity, providing one on one supervision, and reducing environmental stimuli when Resident #3 became anxious. A plan of care initiated 02/07/19 indicated Resident #3 used anti-anxiety medications Ativan and Vistaril related to anxiety disorder. Interventions included administering anti-anxiety medications ordered by the physician and utilize the vistaril first. If the Vistaril was not effective, the Ativan could be administered in 30 minutes to one hour. A physician's order dated 08/12/19 revealed vistaril 50 milligrams (mg) could be administered every four hours as needed. If it was ineffective after 30 minutes to one hour, ativan 1 mg could be administered every four hours as needed. Review of the September 2019 Medication Administration Record (MAR) revealed ativan was ordered on an as needed basis on 09/02/19 at 5:31 P.M., 09/15/19 at 8:50 P.M., 09/20/19 at 10:02 P.M. and 09/27/19 at 9:48 A.M. The vistaril ordered on an as necessary basis was not administered prior to the use of the ativan on those dates. The September 2019 MAR revealed the administration of vistaril ordered on an as necessary basis on 09/07/19 at 3:35 P.M., 09/09/19 at 6:43 P.M., and 09/15/19 at 7:50 A.M. without documentation of non-pharmacological interventions being attempted prior to the administration of the vistaril. Review of the November 2019 MAR revealed vistaril was administered on an as necessary basis on 11/05/19 at 5:19 P.M. with no documentation of anxiety or associated behaviors. No non-pharmacological interventions were documented prior to the administration of the vistaril. On 11/13/19 at 2:35 P.M., Clinical Operations Manager #178 verified there was no record of vistaril ordered on an as necessary basis being administered prior to the administration of the ativan ordered on an as necessary basis on 09/02/19, 09/15/19, 09/20/19, and 09/27/19. Clinical Operations Manager #178 verified there was no documentation of non-pharmacological interventions attempted prior to the use of the vistaril ordered on an as necessary basis on 09/07/19, 09/09/19, 09/15/19 and 11/05/19. Review of the facility's psychotropic medication use policy (dated 11/17) indicated psychotropic medications were only to be used for conditions/diagnoses as documented in the record. For enduring psychiatric conditions, psychotropic medications would not be used unless behavioral symptoms were not due to a medical condition or problem that could be expected to improve or resolve as the underlying condition was treated, persistent or likely to reoccur without continued treatment, and not sufficiently relieved by non-pharmacological interventions. 2. Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's dementia, dementia with behaviors and brief psychotic disorder which was diagnoses on 02/04/18. Review of the quarterly minimum data set (MDS) 3.0 dated 01/13/19 revealed the resident was severely cognitively impaired. The resident had no concerns with mood or behaviors and the resident needed extensive assistance of one to two staff for activities of daily living (ADL). Review of the nursing note dated 05/03/19 revealed the resident was exit seeking. There was no evidence of non-pharmalogical interventions. Review of the nursing note dated 05/04/19 revealed the resident was rocking back and forth in her chair and was spitting out half chewed food. Review of the 05/06/19 psychiatric nurse practitioner (PNP) note revealed the resident was on Buspar, an anti-anxiety (AA) medication at five milligrams (mg) twice a day, Remeron, an anti-depressant (AD) medication at 15 mg at night and Dispersal, an anti-psychotic (AP) medication at 0.5 mg twice a day. The resident was alert to person only, the resident was rocking back and forth but unable to communicate why. There were no signs or symptoms of anxiety or depression. There were no changes in the plan of care. Review of the nursing note dated 05/09/19, 05/13/19, 05/20/19, 05/22/19, 05/23/19 and 05/24/19 revealed the resident was exit seeking. There was no evidence of non-pharmalogical interventions. Review of the nursing note dated 06/02/19 revealed the resident was propelling around the facility tearful. There was no evidence of any non-pharmacological interventions. Review of the nursing note dated 06/06/19 and 07/04/19 revealed the resident was exit seeking. There was no evidence of non-pharmalogical interventions. Review of the July 2019 MAR revealed the resident was receiving Remeron at 15 mg once a day, Buspar at five mg twice a day and Dispersal 0.5 mg three times a day until 07/28/19 when it was decreased to twice a day (despite the order for twice a day prior to 07/28/19). Review of the annual MDS 3.0 dated 07/12/19 revealed the resident was severely cognitively impaired. The resident had no concerns with mood or behaviors and the resident needed extensive assistance of one to two staff for ADL's. Review of the nursing note dated 07/21/19 revealed the resident was exit seeking. There was no evidence of non-pharmalogical interventions. Review of the nursing note dated 07/25/19 revealed the family requested the doctor see the resident due to her decline in condition, being more drowsy and sleeping more than usual. Review of the nursing note dated 07/28/19 revealed the resident was noted to be extremely lethargic and declining to eat or drink. The attending physician was notified and informed the nurse to contact the PCP. The PNP did not see the resident but ordered over the phone to decrease the Dispersal to 0.5 mg twice a day. Review of the nursing note dated 07/31/19 revealed the physician ordered to decrease the Remeron from 15 mg to 7.5 mg daily. Review of the August 2019 MAR revealed the resident was receiving Remeron at 15 mg once a day, Buspar at five mg twice a day and Dispersal at 0.5 mg twice a day (until 08/23/19 when it was decreased to once a day) and Dispersal at 0.25 mg once a day. Review of the nursing note dated 08/01/19 revealed the physician was at the facility to see the resident and assessed the previously reported lethargy. The resident was awake but non -verbal. The physician expressed concerns about all the medications the resident was receiving and her being so fragile. The physician request PNP see the resident and possibly re-evaluate some of her medications. However the physician will revert the residents Remeron back to the origin dose of 15 mg daily. There was no evidence the resident was seen by the PNP. Review of the nursing noted dated 08/02/19 revealed the resident was drowsy. Review of the nursing note dated 08/03/19 revealed the resident was fatigued and rested her head on the table after meals. Review of the nursing note dated 08/11/19 revealed the son informed the staff he took pictures of the resident with her head on the table after dinner because he was tired of no one taking her to bed. Review of the nursing note dated 08/12/19 revealed the resident was sleeping at the dining room table with her head on the table. Review of the quarterly MDS 3.0 dated 08/12/19 revealed the resident was severely cognitively impaired. The resident had no concerns with mood or behaviors and the resident needed extensive assistance of one to two staff for ADL's. Review of the nursing note dated 08/13/19 revealed the resident was sleeping at the dining room table with her head on the table. Review of the 08/15/19 interdisciplinary care conference revealed the resident's son was present. There was no evidence they discussed the son's concern with the residents increased lethargy. The meeting did not indicate the resident had any mood or behavior concerns. Review of the PNP note dated 08/23/19 revealed the resident was on Buspar at 5 mg twice a day, Remeron 15 mg at night, Risperdal 0.5 mg twice a day. The resident was non-verbal and did not shake her head yes or no to questions. The nursing notes indicated increased sleepiness during the day and sleeps well at night. The plan was to decrease the Dispersal to 0.25 mg daily and 0.5 mg at night. Review of the nursing note dated 08/23/19 revealed the PNP decreased the residents Dispersal from 0.5 mg to 0.25 mg at night. Further review of the MAR revealed Dispersal at 0.5 mg once a day and Dispersal at 0.25 mg once a day. Review of the nursing noted dated 08/24/19 revealed the resident was sleeping soundly and her night medications were not able to be given due to she was not able to be awoken. Review of the August 2019 behavior monitoring tool revealed the behaviors monitoring for including anxiety, depression, wandering and elopement. There were no behaviors noted on the tool. Review of the September 2019 MAR revealed the resident was receiving Remeron at 15 mg once a day, Buspar at five mg twice a day and Dispersal at 0.5 mg once a day and Dispersal at 0.25 mg once a day. Review of the nursing note dated 09/06/19 and 09/22/19 revealed the resident was exit seeking. There was no evidence on non-pharmalogical interventions. Review of the September 2019 behavior monitoring tool revealed the behaviors monitoring for including anxiety, depression, wandering and elopement. There were no behaviors noted on the tool. Review of the October 2019 MAR revealed the resident was receiving Remeron at 15 mg once a day, Buspar at five mg twice a day and Dispersal at 0.5 mg once a day and Dispersal at 0.25 mg once a day. Review of the October 2019 behavior monitoring tool revealed the behaviors monitoring for including anxiety, depression, wandering and elopement. There were no behaviors noted on the tool. Review of the November 2019 behavior monitoring tool revealed the behaviors monitoring for including anxiety, depression, wandering and elopement. There were no behaviors noted on the tool. Review of the November 2019 MAR revealed the resident was receiving Remeron at 15 mg once a day, Buspar at five mg twice a day and Dispersal at 0.5 mg once a day and Dispersal at 0.25 mg once a day. Review of the 11/07/19 interdisciplinary care conference revealed neither the resident nor any family representative was present, the notes did not address the residents increase in lethargy. The meeting did not indicate the resident had any mood or behavior concerns but had periodic exit seeking which was able to be redirected by staff. Review of the residents current physician orders as of 11/14/19 revealed the resident was receiving Buspar five mg twice a day, Remeron at 15 mg once a day, Dispersal at 0.25 mg once a day and Dispersal at 0.5 mg once a day. Review of the current dementia with behavior disturbance, Alzheimer's disease, brief psychotic disorder, generalized anxiety disorder and major depressive disorder plan of care revealed the goal was to decrease the depressant symptoms. The interventions included to administrator medication as ordered, encourage the resident to verbalize feelings and concerns, encourage the resident to make safe and appropriate decisions, provide reality orientation during care and notify the physician and psychiatrist of any negative mood symptoms. Review of the current depression care plan revealed the the goal was to reduce the the risk for onset of discomfort or adverse reactions related to AD therapy. Interventions included to educate the resident on the risks and benefits of taking the AD medications, give the AD medications as ordered, monitor and document any ongoing signs and symptoms of depression and/or changes in cognition and report to the physician. Review of the current psychotropic medications/antipsychotic drugs due to behavior management, disease process and anxiety care plan revealed the goal was to decreased behaviors. Interventions included to administer medications as ordered, monitor and record occurrence of target behavior symptoms and fatigue. Review of the current risk of elopement care plan revealed the goal was for the resident to not leave the facility unattended. Interventions included to encourage activities of interest, monitor the need for psychiatry services, supervise the resident and distract/redirect the resident when exhibiting exit seeking behaviors. On 11/13/19 at 3:00 P.M., the resident was observed slowly propelling down the hall in the wheelchair. Attempted interview revealed the resident just stared at the surveyor. No behaviors were noted. On 11/13/19 at 4:32 P.M., the resident was observed being fed by family in the dining room. No behaviors were noted. On 11/13/19 at 6:35 P.M., the resident was observed sleeping in bed. On 11/14/19 at 11:00 A.M., the resident was observed slowly propelling down the hall in her wheelchair while using the handrail for assistance. No behaviors were noted. On 11/14/19 at 12:41 P.M., interview with Social Service Coordinator (SSC) #148 revealed she completed the BIMS, mood and behavior sections of the MDS and was not aware of any mood or behavior concerns of the resident. The resident's typical day included self propelling around the halls looking around as she propels. The resident at times would stay at the table during meals but if she was focused on something else she would leave the table and would have to be redirected back to eat. SSC #148 verified she had not seen any ongoing concerns with anxiety, depression, yelling and/or screaming. SSC #148 verified she attended the care conferences and there were no concerns related to anxiety or depression brought up during the meetings. The only concern was the resident occasional exit seeking behaviors. On 11/14/19 at 1:55 P.M., interview with the Director of Nursing (DON) revealed there was not an interdisciplinary approach to ensure the resident was on the least amount of psychotropic medications when the resident had a significant change with increased lethargy and there was not timely interventions to address the psychotropic medications. The DON verified there was no documented evidence of addressing the residents continued need for the psychotropic medications and the only documentation in the medical record was related to the resident being exit seeking at times. The DON verified the behavior monitoring tool revealed the behaviors being monitored were anxiety, depression, wandering and elopement. The resident had not expressed any behaviors of anxiety or depression since prior to May 2019 but the resident had occasional wandering and exit speaking behaviors but this was not an appropriate diagnosis for the use of the psychotropic medications. Review of the psychotropic medication use policy, dated November 2017, revealed medication therapy would be used only when it was necessary to treat a specific conditions for which they are indicated and effective. The residents behavior, mood, function, medical condition, symptoms and risks would be documented. Acute psychiatric episodes would be differentiated from psychiatric conditions, target symptoms would be documented indicating the need of the use of the psychotropic medications and the effectiveness of the medications would be documented. Based on assessing the resident's symptoms and overall situation, the physician would determine whether to continue, adjust or stop existing psychotropic medications. Psychotropic medications would only be used for condition/diagnoses as documented in the medical record that was consistent with the definition of the Diagnostic and Statistical manual of Mental Disorders. For enduring psychiatric condition, psychotropic medications would not be used unless behavioral symptoms are: 1) not due to a medical condition or problem such as a headache or joint pain, fluid or electrolyte imbalance, pneumonia, hypoxia or hearing or visual impairment that can be expected to improve or resolve as the underlying condition was treated and 2) persistent or likely to reoccur without continued treatment and 3) not sufficiently relieved by non-pharmacological interventions and 4) not due to environmental stressor and 5) not due to psychological stressors such as loneliness, taunting, abuse, anxiety or fear stemming from misunderstanding related to cognitive impairment that an be expected to improve or resolve as the situation was addressed. Nursing staff would monitor and report any of the following side effects including sedation, lightheadedness or constipation. The physician would document why the benefits of the medication outweigh the risks. Review of the drug regimen review policy, dated February 2019, revealed the pharmacist would the medications monthly to ensure the resident had the highest practicable level of physical, mental and psychosocial well-being. A medication regimen review (MRR) would be completed monthly to ensure a thorough evaluation of the medication with the goal to promote positive outcomes and minimize adverse consequences and potential risks associated with medications. The MRR would involve collaborating with the facility's interdisciplinary team, the resident and/or their family.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure an accurate resident medical record. This affected two of 17 records reviewed (Residents #32 and #191). Findings include: 1. Review of Resident #191's medical record revealed the resident was admitted [DATE] with diagnoses including fractured left femur, severe protein calorie malnutrition, muscle wasting and atrophy, end stage renal disease with dialysis, and anemia. Review of the admission Data Collection Tool included a Sacral pressure ulcer 0.75 cm x 0.75 cm x 0.2 cm and a left buttock pressure ulcer 2.0 cm x 2.0 cm x 0.1 cm both listed Stage 1. The pressure ulcers were inaccurately Staged I when they had a depth, indicating the skin was broken. The Weekly Skin Integrity Review for 10/29/19 stated Sacral wound, 0.75 cm x 0.75 cm depth none and a left buttock 2.0 cm x 2.0 cm depth none with no other description. A 11/05/19 at 1:41 P.M. nurses note included the State Tested Nurse Aide (STNA) reports that resident now has an opened area on the buttocks. Nursing to assess and document on skin sheet. There was no evidence of an assessment/follow up on 11/05/19 upon return or on the Weekly Skin Integrity Review. A late entry on 11/05/19 put in on 11/14/19 at 8:23 A.M. included Areas previously documented, areas unchanged since admission on [DATE]. A 11/10/19 weekly skin integrity review included left buttock wound 2cm x 2cm. There was no further description and only one area was listed. A Weekly Skin Integrity Review provided 11/14/19 added to the 10/29/19 documentation. The Sacral wound 0.75 cm x 0.75 cm depth none and a left buttock 2.0 cm x 2.0 cm depth none with no other description; now included open Stage II pink and moist no drainage, odor or eschar with pink wound bed. A 11/10/19 weekly skin integrity review had the date changed to 11/05/19. The 11/10/19 entry originally read left buttock 2cm x 2cm/sacrum same. There was no further description until 11/14/19, when 0.75 cm x 0.75 cm Stage II pink and moist, no drainage, no odor, wound bed pink, was added. The Weekly Skin Integrity Review provided 11/14/19 added a new entry for 11/10/19 signed and dated by Clinical Operations Manager (COM) #178 reading sacrum 0.75 cm x 0.75 cm open Stage II pink and moist, no drainage. Buttocks 2cm x 2 cm open area Stage II pink and moist, no drainage, no induration and no edema. No evidence of pain demonstrated. There were no dates or initials included to indicate which documentation on the assessments were added. Review of the schedule revealed COM #178 did not work on 11/10/19. Interview 11/14/19 at 5:16 P.M. with COM #178 revealed she documented the weekly skin assessment 11/10/19 because it was due the 10th but she did it on Monday the 11th. Verification occurred they did not do an assessment on 11/05/19. COM #178 indicated she had the nurse that was here tell her what the areas looked like and she changed the documentation. COM #178 also added a description for 10/29/19 by calling the nurse and asking her what she saw. She verified what she added 11/14/19 as a late note for 11/05/19 was by asking the nurse if it was changed and she said it had not. COM #178 stated now she knows from the hospital documentation that was inaccurate. COM #178 verified she added information to the documents without dating and signing the added information. COM #178 verified the information was not accurate. 2. Review of Resident #32's medical record revealed an admission on [DATE] with diagnoses including disease of the gallbladder, heart failure, dry eye syndrome, gastroesophageal reflux disease, deep vein thrombosis, COPD, Protein calorie malnutrition, anxiety disorder, hypothyroidism, chronic atrial fibrillation, diabetes, hypertension, and malignant neoplasm of large intestine. Review of the Nurse Notes revealed a note on 11/10/19 at 2:59 P.M. including an open area to left inner buttocks measuring 0.7 centimeters x 0.9 cm x 0.2 cm depth. Cleansed and dressing applied. There was no description of color, drainage, odor, periwound, or of wound bed. Observations of Resident #32 on 11/12/19 at 11:10 A.M., 3:02 P.M., 11/13/19 at 10:18 .AM., 12:05 P.M. 3:02 P.M. and 4:34 P.M. revealed the resident was in bed on his back. Review of the STNA kiosk TASK documentation for the last 30 days revealed no refusal of care and the resident was being turned and repositioned. Interview on 11/13/19 at 3:55 P.M. with STNA's #105 and #212 revealed the resident refuses to be turned. The resident will turn for care but will not stay on his side. When questioned why in TASK the rejection of care said no rejection of care and turned and repositioned was being documented as completed; STNAs #105 and #212 verified they were documenting it wrong.

Based on observation and interview the facility failed to ensure wheelchairs were maintained in good condition. This affected two (Resident's #21 and #36) out of 16 residents in the initial pool. The facility's census was 45. Findings include: Observation on 11/12/19 at 9:30 A.M. revealed Resident #21's armrest on his wheelchair had a large rip. Observation on 11/14/19 at 9:05 A.M. with Maintenance Assistant (MA) #143 of the facility revealed the following; The arm rest of Resident # 21 wheelchair had a six-inch tear exposing the foam and various cracked plastic on the front half of the arm rest. Resident #36's wheelchair cushion was ripped; the inside of the cushion was visible and approximately one third of the surface material was off the cushion. Interview on 11/14/19 at the time of the observations with MA #143 confirmed that the arm rest on Resident #21 wheelchair had a six-inch chair exposing the foam, and Resident #36 wheelchair cushion was ripped with the inside of the cushion exposed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Review of Resident #32's medical record revealed an admission on [DATE] with diagnoses including disease of the gallbladder, heart failure, dry eye syndrome, gastroesophageal reflux disease, deep vein thrombosis, COPD, Protein calorie malnutrition, anxiety disorder, hypothyroidism, chronic atrial fibrillation, diabetes, hypertension, and malignant neoplasm of large intestine. Review revealed a non pressure skin impairment that was not comprehensively assessed and treated. Review of the 10/08/19 quarterly MDS revealed the resident was independent for daily decision making, with no behaviors, required extensive assist of two for bed mobility and was totally dependent of two for transfers. The Weekly Skin Integrity review revealed on 10/27/19 a treatment was in place for red area to right buttock. An old area was checked as open area. There was no description or explanation of the open area. There was no skin assessment for 11/03/19. Review of the physician orders included an order dated 11/03/19 for barrier cream to bilateral buttock twice a day and as needed for skin integrity and frequent breakdown. Review of the Nurse Notes revealed a note on 11/10/19 at 2:59 P.M. including an open area to left inner buttocks measuring 0.7 centimeters x 0.9 cm x 0.2 cm depth. Cleansed and dressing applied. There was no description of color, drainage, odor, periwound, or of wound bed. The Weekly Skin Integrity review revealed on 11/10/19 a left buttock area 0.7 cm x 0.9 cm x 0.2 cm treatment in place. There was no description of color, drainage, odor, periwound, wound bed or classification. Review of the physician orders included a 11/10/19 order for left buttocks open area- cleanse with normal saline pat dry, apply mepilex daily and as needed. Interview on 11/13/19 at 10:18 A.M. with Resident #32 revealed they had not told him what was wrong with his behind but he knew it hurt. Interview on 11/13/19 at 3:55 PM with STNA's #105 and #212 revealed the resident's soiled dressing was removed from his buttock over an hour ago during care. The aides indicated they had not told the nurse and the skin impairment remained uncovered. Observation on 11/13/19 at 4:34 P.M. of a dressing change with Licensed Practical Nurse #221 revealed the area presented as a scratch, deep initially and gradually thinning out toward the end. The wound was red and the periwound flesh color. Interview on 11/14/19 at 12:48 P.M. with Registered Nurse #120 verified there was no comprehensive assessment of the skin impairment of the buttock. The measurements did not include the character, color, wound bed, drainage and classification of the wound. The weekly skin assessment was missed for 11/03/19. Further verified the STNA's should have reported the dressing was off the impairment in a timely manner. 4. Review of Resident #3's medical record revealed diagnoses including Alzheimer's disease. A plan of care initiated 03/30/18 indicated Resident #3 was at increased risk for constipation related to her gastric tube feeding, nothing by mouth status, and decreased mobility. The goal was for Resident #3 to have a normal bowel movement at least every three days. Interventions included administering medication as ordered, recording bowel movement patterns every day, and following the facility bowel protocol for bowel management. A significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #3 required extensive assistance for toilet use and was always incontinent of bowel and bladder. Physician orders included 30 milliliters (ml) of lactulose every other day, a 10 milligram (mg) dulcolax suppository every 72 hours as needed for constipation, and 30 ml of milk of magnesia (MOM) every 24 hours as needed for constipation. Review of Resident #3's bowel movement records from 09/01/19 through 11/13/19 revealed no record of a bowel movement recorded 10/03/19-10/06/19, 10/27/19-10/31/19, or 11/09/19-11/13/19. Review of the October 2019 and November 2019 revealed no MOM or dulcolax suppository was provided during those periods. On 11/13/19 at 4:35 P.M., Clinical Operations Manager #178 verified the above recorded dates with no record of a bowel movement and verified the facility's bowel protocol was not implemented. 5. Review of Resident #27's medical record revealed diagnoses including dementia and depressive episodes. A plan of care initiated 05/07/19 indicated Resident #27 was at increased risk for constipation related to decreased mobility and medication side effects. The goal was for Resident #27 to have a normal bowel movement at least every three days. Interventions included following the facility bowel protocol for bowel management and recording bowel movement pattern each day. A physician's order dated 05/30/19 instructed nurses to administer 30 ml of MOM every 24 hours as needed for constipation. Bowel protocol step one was to administer the MOM if Resident #27 did not have a bowel movement in three days. A physician's order dated 06/20/19 indicated a dulcolax suppository was to be administered as needed if Resident #27 did not have a bowel movement in eight hours after the MOM was administered. A quarterly MDS dated [DATE] indicated Resident #27 required extensive assistance with toilet use and was frequently incontinent of bowel. Review of Resident #27's bowel movement records between 09/01/19 and 11/14/19 revealed there was no bowel movement recorded 09/29/19 to 10/02/19, 10/13/19 to 10/16/19, 10/21/19 to 10/30/19, and 11/10/19 to 11/13/19 without initiation of the bowel protocol/physician orders. On 11/14/19 at 3:01 P.M., the Director of Nursing (DON) was informed there was no recorded bowel movement and a lack of initiation of the bowel protocol 09/29/19-10/02/19, 10/13/19-10/16/19 with no intervention until 10/17/19, 10/21/19-10/30/19, and 11/10/19 - 11/14/19. On 11/14/19 at 3:36 P.M., Registered Nurse (RN) #120 verified no additional information was able to be located. Based on observation, interview and record review the facility failed to implement the bowel protocol for Resident's #3, #8, #18 and #27 and failed to comprehensively assess a non-pressure skin area for Resident's #32 and #8. This affected four of five residents reviewed for unnecessary medications and two of two residents reviewed for non-pressure skin areas. Findings include: 1. Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses which included constipation and Alzheimer's disease. Review of the quarterly minimum data set (MDS) 3.0 dated 01/13/19 revealed the resident was severely cognitively impaired and needed extensive assistance with activities of daily living (ADL) with one or two staff including toileting. Review of the bowel movement (BM) report revealed the resident had a BM in the morning of 09/20/19. Further review revealed the resident did not have another BM until the afternoon of 09/24/19. Review of the medication administration record (MAR) for September 2019 revealed there was no evidence of implementing the BM protocol which indicated the resident should have received milk of magnesia (MOM) in the morning of 09/23/19. There was no evidence of assessment for bowel sounds or fecal impaction. Review of the BM report revealed the resident had a BM in the morning of 09/28/19. Further review revealed the resident did not have another BM until the afternoon of 10/03/19. Review of the MAR for September 2019 revealed there was no evidence of implementing the BM protocol which indicated the resident should have received MOM in the morning of 10/02/19. The resident had a BM after administration of the MOM on 10/03/19 but further review of the MAR revealed the resident was given a dulcolax suppository on 10/04/19 which did not follow the BM protocol. There was no evidence of assessment for bowel sounds or fecal impaction. On 11/14/19 at 1:30 P.M., interview with the Director of Nursing (DON) verified the above concerns and verified there was no further documentation to support the facility followed the BM protocol. The DON verified the facility had recently implemented an alert on the computer to inform the nurses when a resident did not have a BM in three days in order for the nurses to implement the BM protocol. 2. Record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses which included cerebral vascular accident (CVA) and Alzheimer dementia. Review of the admission MDS 3.0 dated 09/24/19 revealed the resident was severely cognitively impaired and needed extensive assistance of one person for toileting. Review of the BM report revealed the resident had a BM in morning of 10/10/19. Further review revealed the resident did not have another BM until the afternoon of 10/14/19. Review of the MAR for October 2019 revealed there was no evidence of implementing the BM protocol. There was no evidence of assessment for bowel sounds or fecal impaction. On 11/14/19 at 1:30 P.M., interview with the DON verified the above concerns and verified there was no further documentation to support the facility followed the BM protocol. Review of the physician standing orders for constipation, not dated, revealed after three days without a BM 30 cubic centimeters (cc) of MOM would be given in the morning. If no BM after use of the MOM, the nurse was to check for fecal impaction and audible bowel sounds in all four quadrants, then a bisacodyl suppository may be inserted on the afternoon shift. If the suppository was unsuccessful and no fecal impaction was detected, the nurse on night shift may give a fleets enema. 3. Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease. Review of the quarterly MDS 3.0 dated 08/12/19 revealed the resident was severely cognitively impaired and needed extensive assistance with activities of daily living (ADL) with one or two staff. The resident was mobile in a wheelchair but was not able to stand independently. The resident was not receiving anticoagulants but had been on aspirin at 81 milligrams (mg) daily since 08/24/17. Review of the nursing note dated 07/14/19 revealed the resident was found to have a large bruise to the left forearm. The area was swollen and tender to touch. There were no further assessments related to the bruise including description, size, when the bruise was found. No incident report was completed nor was the plan of care updated to reflect the bruise. Review of the nursing note dated 09/27/19 revealed the resident was found to have a large area of bruising along the lateral right thigh. There were no further assessments related to the bruise. No incident report was completed nor was the plan of care updated to reflect the bruise. On 11/14/91 at 1:30 P.M., interview with the DON verified the above concerns and was not able to provide any additional information. Review of the care of non-pressure wounds, dated February 2019, revealed the purpose was to provide guidelines for prevention and treatment of the areas. Document the site and description of the area or wound with the date and time it was identified in the medical record. When inspecting the wound include all information in the assessment including if bleeding, size of wound, partial of compete tissue loss etc. Provide interventions that could prevent additional areas such as clothing to cover the arms and legs. Include the signature, title, time and date the wound was recorded. Upon discovery of an area an incident report should be completed. Record the following information on the incident report: the resident's name, name of the employee discovering the area, site and description of the area including measurements, appearance and shape of wound edges, color, odor and amount of drainage; the date and time the area was discovered, the date and time the injury occurred if known, names or employees who provided care to the resident for the previous 24 hours, site care rendered and evaluation of the incident, the name of any witnesses's to the incident, the date and time the physician and sponsor were notified and any other information relative to the incident.

Based on observation and interview, the facility failed to ensure the facility building was maintained. This had the potential to affect all the residents in the facility. The facility census was 45. Findings include: Observation on 11/14/19 at 9:05 A.M. with Maintenance Assistant (MA) #143 revealed the following: - the facility's shower room had eight two inch x two inch holes in the wall and one large hole, several feet long and six inches wide, from where a bath tub was removed in 2014; - the shower room mortar board, located on the wall to the right of the toilet, was separated from the wall from the floor up approximately 12 inches; - the heater in the bathroom had paint peeling away and visible rust; - Resident #32's room, the wall to the right side of the door had a moderate amount of paint missing with varies gouges approximately three feet in length; - Resident #14's light above her bed had not been in working order for some time according to the resident and since observation on 11/12/19, the light would not turn on; - Resident #28's room revealed rust above the door frame across the entire width of the door frame, her bathroom had a rusty toilet paper holder, and the wall beside her bed had a half dozen gouges six inches long with missing paint. Interview on 11/14/19 at 9:05 A.M. with MA #143 confirmed the above findings. MA #143 also revealed the holes in the shower room were previously covered with a board, and the board was removed three months ago. It was further revealed by MA #143 they knew about the gouges and scratching on the walls of Resident #28's bedroom and believed they were done by the beds half side rails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure medication was stored, labeled and disposed to meet professional standards. This had to the potential to affect all the residents at the facility. The facility's census was 45. Findings Include: Observation on [DATE] from 2:28 P.M. to 2:52 P.M. of the facility medication storage rooms, medication cart and refrigerator revealed, an open stock bottle of Calcium with vitamin D with an expiration date of 09/2019 in the medication room, an open bottle of eye drops being stored with an open bottle of ear drops, open nasal sprays being stored in the same bin as open eye drops in the top drawer of the medication cart, and an open undated vial of tuberculin that was dispensed on [DATE] in the medication refrigerator. Interview on [DATE] at 2:52 P.M. with Licensed Practical Nurse #400 confirmed the facility failed to remove the expired bottle of calcium, failed to store eye, ear, and nasal medication separately, and failed to label a vial of tuberculin when opened. Review of the Aplisol tuberculin insert for the tuberculin revealed that vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. Review of the facility's undated storage of medication policy revealed, medications given by different routes should be separated.

Based on review of survey findings and staff interview, the facility failed to ensure corrective plans were initiated and/or comprehensively evaluated in regard to identified concerns. This had the potential to affect all 45 residents. Findings include: During the survey, deficient practices were identified regarding inconsistencies in code status records, pressure ulcer assessments and care, falls, and use of psychotropic medications. On 11/14/19 at 5:40 P.M., Registered Nurse (RN) #120 stated a concern was identified in a sister facility regarding advance directives not matching so an audit was completed at this facility and no issues were identified. RN #120 stated the facility had identified concerns with pressure ulcers in October 2019. The facility instituted weekly visits by a wound care nurse. Nurses were educated on how to complete and accurately document skin assessments. Continuing education regarding pressure ulcers was planned for nurses upon hire and annually. On 10/01/19, the Quality Assurance (QA) committee identified concerns with falls and addressed the concerns. Concerns were identified in September 2019 regarding nurses administering psychotropic medications ordered on an as necessary basis prior to attempting non-pharmacological interventions and education was conducted. When asked how the QA committee was determining if education was effective and if identified issues had been resolved, RN #120 stated the unit managers were responsible for determining if nurses were following education or if the practice continued. Neither of the unit managers indicated the education was ineffective or that the areas remained a concern causing a need to re-evaluate or change the corrective measures. RN #120 indicated though audits had not been mandatory to evaluate effectiveness of the training of the identified concerns they would probably need to be made mandatory. Review of the facility's Quality Assurance and Performance Improvement (QAPI) plan and policy (not dated) revealed the QA committee was responsible for coordinating and evaluating QAPI program activities. The QA committee was responsible for analyzing the QAPI program performance to identify and follow up on areas of concern and/or opportunities for improvement and monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation on 11/13/19 at 11:03 A.M. revealed that Licensed Practical Nurse (LPN) #400 prepared to obtain a fingerstick glucose level on Resident #242 using the facility's glucometer. LPN #400 cleansed the glucometer, gathered supplies, and entered Resident #242's room. LPN #400 then sat the glucometer, lancet, and glucometer pouch on the bedside table without placing a barrier or cleaning the table first. LPN #400 obtained the blood glucose and exited the room. LPN #400 then threw the lancet into the regular trash at his medication cart instead of placing it in the sharps container, a safety storage container used for needles. He then cleansed the glucometer with a Clorox bleach wipe for approximately five seconds before discarding the wipe and putting away the glucometer. Interview on 11/13/19 at 11:27 A.M. with LPN #400 verified that he did not clean or place a barrier on Resident #242's bedside table prior to placing the supplies on the table. It was further verified that LPN #400 threw Resident #242's lancet in the regular trash and not the sharps container. It was lastly verified that LPN only cleaned Resident #242's glucometer for approximately five seconds instead of the manufacture recommended 60 seconds. Review of the manufacture recommendation for Bleach Germicidal Wipes revealed that to effectively kill viruses, and blood borne pathogens the wipe must have a least one minute of contact time with the object it is disinfecting. Review of the facility policy titled Obtaining a Fingerstick Glucose Level dated 02/2019 stated, Dispose of the lancet in the sharps container and clean reusable equipment according to the manufactures instructions. 3. Observation on 11/13/19 at 12:26 P.M. of catheter care for Resident #14 revealed State Tested Nursing Assistant (STNA) #11 carried an uncovered graduated container of urine that was drained from the resident's catheter out of the resident's room to the adjacent room (#20) and emptied the graduated container into the toilet. Resident #14's room did not have a bathroom. She then rinsed the graduate out in room [ROOM NUMBER]'s sink. Interview on 11/13/19 at 12:35 P.M. with State Tested Nurse Aide (STNA) #11 revealed, that she stated she has always wondered if she had to cover the urine before leaving the room but did not know. STNA #11 verified that she didn't cover the urine in the graduated container when she exited the room. 4. Observation on 11/13/19 at 12:39 P.M. of Resident #14's incontinence care, STNA #11 gathered supplies, washed hands, donned gloves, and began incontinence care. After providing the care, prior to removing her gloves, she opened the closet door to obtain an incontinence brief for Resident #14. She then continued care and removed her gloves. Interview on 11/13/19 at 12:45 P.M. with STNA #11 verified that she did not remove gloves, used for incontinence care, prior to opening the closet drawer to get a brief. Review of the facility's policy titled, Handwashing/Hand Hygiene dated 02/2019 stated, Employees must wash their hands for 10 to 15 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin. Based on observation, record review, review of infection control monthly tracking sheets and interview, the facility failed to ensure accuracy and completeness of the logs and failed to monitor infections on an ongoing basis in order to identify patterns or trends in a timely manner. The facility also failed to implement appropriate infection control practices during cleaning of glucometers and during provision of incontinence care. This had the potential to affect all 45 residents and affected Residents #14, #19, and #242. Findings include: 1. On 11/13/19 at 11:27 A.M., infection control logs were reviewed with Registered Nurse (RN) #120. RN #120 stated the October 2019 surveillance logs had not been completed as she did not usually start the logs until the beginning of the following month. RN #120 verified the September 2019 log indicated Resident #19 had a urine sample 09/19/19 which tested positive for extended spectrum beta lactamase (ESBL), escherichia coli, and proteus mirabilis. The log indicated Resident #19 had an elevated temperature of 101.3 on 09/17/19 and 101.1 on 09/20/19. Cefoxitin was started 09/27/19 and tetracycline was started 09/28/19. The log indicated the information obtained did not meet the criteria of a true infection and did not indicate Resident #19 was placed in isolation. RN #120 stated usually if residents tested positive for ESBL they were placed in isolation and she would have to review Resident #19's medical record to determine if the log was accurate. On 11/13/19 at 1:44 P.M. RN #120 provided an order dated 09/24/19 which indicated Resident #19 was placed on contact isolation on 9/23/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure Resident #20, who was dependent on staff for activities of daily living (ADLs), received nail care, oral care and was assisted out of bed as planned. This affected one of one residents reviewed for ADLs. Findings include: Resident #20 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury. Resident #20 was totally dependent for all care. The resident was ordered nothing by mouth and was on a continuous tube feeding for nutrition. Review of the 09/10/18 significant change minimum data set (MDS) 3.0 assessment revealed the resident was totally dependent on two or more staff for all ADL's including transfers and hygiene. Review of the current ADL care plan revealed the resident was to get up into his custom wheelchair daily to allow for mobility and socialization. The staff were to perform hygiene and grooming and the resident had cavities. Further review of the current oral care plan indicated the resident was edentulous (having no teeth) with many missing teeth and did not wear dentures or partials. The resident was at risk for oral complications. The goal included for the resident to be free of pain. The interventions included staff to monitor, document and report any signs of symptoms of oral and/or dental problems needing attention including pain, debris, missing, loose, broken, eroded, or decayed teeth. Staff were to provide mouth care according to the activities of daily living care (ADL) plan. Further review of the ADL care plan revealed the resident was totally dependent on staff including for oral care which indicated the resident was essentially edentulous with many missing teeth and oral care was to be provided every morning, evening and as needed. On 09/24/18 at 11:16 A.M. and 12:34 P.M., the resident was observed in bed with music on. On 09/25/18 at 12:00 P.M., 2:00 P.M., 3:40 P.M. and 5:00 P.M., the resident was observed in bed with music on. On 09/26/18 at 9:50 A.M., interview with State Tested Nursing Assistant (STNA) #12 revealed she was not sure when or how often the resident got out of bed. She verified she did not cut his finger nails but thought his mom did. She said she used a swab to clean the inside of his mouth but did not brush his remaining teeth. On 09/26/18 at 9:55 A.M., observation of the resident while in bed with STNA #12 revealed he had long finger nails with some being over three quarters of an inch long and many were broken and jagged and needed cut. Observation of his mouth revealed he had dentures but the gums were all black. Observation of the lower teeth revealed many were missing but those that were seen were jagged, black and not fully intact. STNA #12 verified it appeared the resident had cavities. She then stated the resident was reliable to answer yes/no questions. The resident was asked if his teeth hurt and he nodded his head yes. The resident was asked again and he again nodded yes. On 09/26/18 at 10:45 A.M., the resident was observed in bed with music on. On 09/26/18 at 10:46 A.M., interview with the resident's guardian verified she wanted him to get out of bed at least twice a week. She indicated the resident had only been out of bed one day in the last 30 days and that was to get his hair cut. She stated his nails were not cut unless she asked the staff to do it. The guardian stated before the resident was admitted his dentist put in an upper plate. She knew the resident had missing and broken lower teeth but was not sure about cavities. She said she thought he had tooth pain. She said the resident would be able to answer yes/no questions reliably. She said she wanted her concerns to be addressed with the staff. On 09/26/18 at 11:00 A.M., interview with Licensed Practical Nurse (LPN) #11 revealed she could not say the last time the resident was out of bed but when they had to give him medications in the evening for behaviors they did not want to get him up because he would be groggy. On 09/26/18 at 11:10 A.M., interview with STNA #13 revealed she could not remember the last time Resident #20 was out of bed because she thought the family did not want him up because he slide out of his wheelchair. She stated she was not allowed to cut the resident's finger nails and the nurses had to do it. She stated she used a swab to clean the inside his mouth but did not brush his teeth. On 09/26/18 at 12:36 P.M., 2:00 P.M. and 3:50 P.M., the resident was observed in bed with music on. On 09/26/18 at 4:00 P.M., interview with LPN #14 verified she looked Resident #20's mouth and there was evidence of cavities and erosion of the teeth on the bottom. She verified the resident's teeth were not being maintained and had gotten worse. On 09/27/18 at 10:05 A.M., the resident was observed in bed with music on. On 09/27/18 at 11:50 A.M., interview with the Director of Nursing (DON) verified she observed Resident #20's finger nails and teeth and they were not being cared for as planned. The residents teeth were black indicating cavities and the teeth were not maintained. She verified the STNA's were to cut the finger nails and the nurses were to oversee the care to ensure it was being done. She did not know why the resident was not getting out of bed as planned and requested by the guardian.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Resident #12 received the care and services to ensure she remained as continence as possible. This affected one of one residents reviewed for urinary incontinence. Findings include: Resident #12 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease and depression. She was mobile in a wheelchair and was dependent on staff for toileting needs. Review of the annual minimum data set (MDS) 3.0 assessment dated [DATE] revealed she was severely cognitively impaired and needed extensive assistance of two or more staff for transfers and toileting. The resident was on a toileting program but the response to the program was not assessed and the resident assessed to be frequently incontinent of urine. Review of the current incontinence care plan revealed the resident would at times let staff know when she needed to be toileted. Staff were to provide incontinence care as needed and offer to assist her to toilet upon rising, before and after meals, in the evening and as needed. Review of the current [NAME], the guide the state tested nursing assistants (STNA) use for each resident's individual care needs, revealed staff were to monitor the resident's bladder habits, continence and toilet as scheduled for the nursing rehabilitation toileting program. On 09/24/18 at 10:25 A.M., interview with the resident's guardian verified Resident #12 was able to say when she needed to urinate. She said Resident #12 would ask staff and at times, like during meals, the staff could not take her to the bathroom and she had to urinate in her incontinence brief. On 09/26/18 at 11:05 A.M., interview with STNA #15 revealed she checked and changed the resident every two hours as able. On 09/26/18 at 11:10 A.M., interview with STNA #13 revealed Resident #12 sometimes would ask to be taken to the toilet and would be able to urinate while on the toilet. Otherwise she was checked and changed every two hours. On 09/26/18 at 1:50 P.M., interview with the MDS/assessment nurse, Licensed Practical Nurse (LPN) #14 revealed there were no residents on a restorative toileting program despite the STNA [NAME] for Resident #12 indicating such. She stated she did not make any changes to any resident's programs when she started working at the facility a year ago. She used information entered by the STNA's into the point of care system to complete the MDS assessments. She verified this system did not indicate when the resident was toileted but was a summary of care for the shift. She verified bladder assessments were only completed on admission or with a significant change. She verified Resident #12's most recent comprehensive bladder assessment was completed on 10/18/16. She verified the care plan, [NAME] and what was being done with the resident were contradictory. On 09/26/18 at 2:05 P.M., interview with the Director of Nursing (DON) verified the concerns with the contraindications Resident #12's MDS assessment, [NAME] information, care plan and what the STNA's were providing. The DON verified Resident #12 did not have a comprehensive bladder program in place to help her maintain as much bladder continence as possible. Review of the urinary continence and incontinence assessment and management policy and procedure, dated March 2009, revealed were to periodically, referring to the criteria in the minimum data set (MDS), define each individual's level of continence. Part of the the assessment document related to continence included voiding patterns, if there was any associated pain or discomfort and whether incontinence occurred in relation to coughing or sneezing, and staff were to identify risk factors and evaluate medications. If the individual remains incontinent despite treatment for transient causes of incontinence, they were to initiate a toileting plan including scheduled toileting, prompted voiding or other interventions to try to manage incontinence. The results of the toileting trial would be documented in the medical record. If the individual responded well they were to continue the toileting program. If the individual did not respond they would use the check and change strategy to keep the person clean and dry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to obtain routine medications from the pharmacy for Resident #29 in a timely manner. This affected one of five residents reviewed for unnecessary medications. Findings include: Resident #29 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, implanted cardiac defibrillator, cardiac pacemaker, arteriosclerotic heart disease and myocardial infarction. The resident had a physician's order dated 04/23/18 for Xarelto (a blood thinning medication) 15 milligrams (mg) orally once a day. Review of the medication administration record (MAR) for August 2018 indicated the Xarelto was signed at HS (hour of sleep) on 08/27/18 and 08/28/18 with the nurse's initials and the number nine. The chart code indicated the number nine meant Other/See Nurses Notes. Review of the nurse's notes for Resident #29, dated 08/27/18 at 7:58 P.M., indicated the Xarelto 15 mg was not available and the pharmacy was aware. Nursing notes dated 08/28/18 at 8:29 P.M. indicated the Xarelto Tablet 15 mg was not administered pending pharmacy delivery. There was no evidence the Xarelto was administered to the resident on 08/27/18 or 08/28/18. Interview with the Director of Nursing (DON) on 09/26/18 at 10:15 A.M. verified the Xarelto was not administered as ordered on 08/27/18 or 08/28/18. She said when a resident's medication was not available or present in the emergency stock box, the pharmacy was notified to deliver it. If the medication was not available from the facility's pharmacy, the pharmacy was responsible for contacting an outside pharmacy to deliver the medication to the facility. Review of the list of medications in the emergency box revealed Xarelto was not included. On 09/27/18 at 2:30 PM, the DON provided copies of the orders faxed to the pharmacy for the Xarelto for Resident #29 on 08/26/18 and 08/27/18.

Based on medical record review, observation and staff interview, the facility failed to ensure medications orders were accurate regarding medication dosage. This affected one (Resident #17) of five residents reviewed for medications. The facility census was 39. Findings include: Review of Resident #17's open medical record revealed an admission date of 05/06/16 with diagnoses that included hypokalemia (low potassium level). Review of Resident #17's medication orders revealed on 11/23/17 the physician prescribed liquid potassium chloride solution, 20 milliequivalents (meq) per 15 milliliters (ml), six milligrams (mg) per milliliter every day. Review of the Medication Administration Record (MAR) revealed the same instructions as ordered by the physician. Review of Resident #17's monthly pharmacy review record and recommendations revealed no evidence they requested clarification of the order for the liquid potassium chloride. Interview with Licensed Practical Nurse (LPN) #10 on 09/27/18 at 9:20 A.M. confirmed the physician's order for liquid potassium chloride needed clarified as the order was confusing. She stated Resident #17's bottle of potassium chloride directed them to administer six milliliters of the medication. Observation of Resident #17's liquid potassium chloride bottle label indicated to administer six milliliters to equal eight meq of liquid potassium chloride. Interview with the Director of Nursing on 09/27/18 at 9:25 A.M. verified the physician order for Resident #17's liquid potassium chloride needed clarified to obtain the correct dosage to be administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure Resident #20, who was dependent on staff for activities of daily living (ADLs), received necessary dental services. This affected one of one residents reviewed for dental services. Findings include: Resident #20 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury. Resident #20 was totally dependent on staff for all care. The resident was ordered nothing by mouth and was on a continuous tube feeding for nutrition. His last dental visit was in 2016. Review of the most recent dental exam from 01/25/16 revealed Resident #20 had lots of debris and needed assistance with oral care but the oral tissue was normal. Review of the 09/10/18 significant change minimum data set (MDS) 3.0 assessment revealed Resident #20 was totally dependent on two or more staff for all ADL's including hygiene. The resident was assessed as having cavities or broken natural teeth. Review of the current nutritional care plan indicated the resident had his own teeth with tooth decay and some teeth missing. Review of the current oral care plan indicated Resident #20 was at risk for oral complications. The goals included staff to monitor, document and report any signs or symptoms of oral and/or dental problems needing attention including pain, debris, missing, loose, broken, eroded teeth or decayed teeth. On 09/26/18 at 2:00 P.M., interview with the Director of Nursing (DON) verified they changed dental companies in 2016 and Resident #20 had not seen a dentist since then because the facility did not make sure they obtained signed consent for him to be treated. On 09/26/18 at 4:00 P.M., interview with Licensed Practical Nurse (LPN) #14 verified she looked at Resident #20's mouth and verified there was evidence of cavities and erosion of the teeth on the bottom. She verified the resident's teeth were not being maintained and had gotten worse.