**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of facility documentation and interview, the facility failed to accurately assess restraints for 1 (#64); failed to accurately assess hospice for 1 (#48); and failed to accurately assess the discharge status for 1 (#84) of 28 resident assessments reviewed. The findings include: Medical record review revealed Resident #64 was admitted to the facilty on 9/13/2019 with diagnoses which included Hypertensive Heart And Chronic Kidney Disease With Heart Failure, Chronic Atrial Fibrillation and Polyneuropathy. Medical record review revealed no restraint assessment or consent form was completed for Resident #64. Medical record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 used a limb restraint less than daily. Observations of Resident #64 on 1/21/2020 at 10:05 AM and on 1/22/2020 at 9:30 AM in her room revealed no restraints were in use for Resident #64. Interview with the Director of Nursing (DON) on 1/23/2020 at 11:45 AM in the conference room confirmed there was an MDS discrepancy regarding restraints on the Quarterly MDS dated [DATE] for resident #64. Interview with the MDS Coordinator on 1/23/2020 at 12:00 PM in the conference room confirmed she made an error when entering the Quarterly MDS data dated for 12/21/2019 regarding restraints for Resident #64. Medical record review revealed Resident #48 was admitted to the facility on [DATE] with diagnoses which included Malignant Neoplasm Of The Left Female Breast, Secondary Neoplasm Of The Brain and Major Depressive Disorder. Medical record review of Resident #48's physician order dated 9/6/2019 revealed Admit to [named facility] under [named] Hospice. Medical record review of Resident #48's Quarterly (MDS) dated [DATE] revealed the resident received no hospice services. Interview with MDS Coordinator on 1/23/2020 at 11:59 AM in the conference room confirmed hospice service were not coded on the Quarterly MDS dated [DATE] for Resident #48. Medical record review revealed Resident #84 was admitted to the facility on [DATE] with diagnoses which included Hypertensive Chronic Kidney Disease Stage 3. Medical record review of Resident #84's discharge MDS dated [DATE] revealed resident #84's discharge status was Acute Hospital. Medical record review of Resident #84's Transition of Care/Discharge summary dated [DATE] revealed discharge destination: home. Interview with the MDS Coordinator on 1/23/2020 at 5:00 PM in the conference room confirmed the discharge MDS dated [DATE] was inaccurately coded as discharged to acute hospital instead of home on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation and interview, the facility failed to store nebulizer tubing in a safe and sanitary manner and date a humidifier for 4 (#4, #36, #134 and #140) of 20 residents reviewed receiving respiratory treatments. The findings include: Facility policy review, Respiratory Manual, revised 7/2014, revealed .Be sure nebulizer and tubing are labeled with the date and initials . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with diagnosis which included Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure with Hypoxia, and Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung. Medical record review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #4 required oxygen therapy. Medical record review of the physician orders dated 1/6/2020 revealed .Oxygen at 1 L [liter]/min [minute] via nasal cannula [device for inhalation of oxygen into the lungs] . Observation on 1/21/2020 at 10:18 AM in Resident #4's room revealed the humidifier was undated. Medical record review revealed Resident #36 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease. Medical record review of the care plan dated 7/9/19 revealed .Respiratory Conditions: At risk for complications due to COPD [chronic obstructive pulmonary disease], supplemental O2 [oxygen], and recent diagnosis of respiratory failure and pneumonia . Medical record review of the physician orders dated 12/7/2019 revealed .Oxygen at 2 L via nasal cannula [device for inhalation of oxygen into the lungs] continuous . Observation on 1/21/2020 at 10:04 AM, 1:45 PM, and 3:54 PM in the day area revealed Resident #36's humidifier was undated. Medical record review revealed Resident #134 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Pneumonia, Type 2 Diabetes Mellitus and Leukemia. Medical record review of Resident #134's Physician Orders dated 12/30/2019 revealed .Ipratropium-Albuterol [medication to treat Chronic Obstructive Pulmonary Disease] solution for nebulization [administer medication in the form of a mist inhaled into the lungs] 0.5 mg [milligram]-3 mg/3 mL [milliliter] give (3 ml) every 6 hours . Medical record review or Resident #134's Physician Order dated 12/30/2019 revealed .Change nebulizer tubing. Change and date nebulizer tubing, place in new respiratory equipment bag . Observation on 1/21/2020 at 8:57 AM and 2:02 PM in Resident #134's room revealed the resident's nebulizer tubing was not dated. Continued observation revealed the nebulizer tubing and mouthpiece was placed on the nebulizer machine not stored in a bag. Observation and Interview on 1/21/2020 at 4:05 PM in Resident #134's room with Registered Nurse (RN) #1 confirmed the nebulizer tubing and mouthpiece not dated or stored in a bag. Medical record review revealed Resident #140 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus with Diabetic Neuropathy and Chronic Kidney Disease, Stage 3. Medical record review of Resident #140's Physician Order dated 1/13/2020 revealed .ipratropium-albuterol solution for nebulization; 0.5 mg-3 mg 3 mL; Special Instructions: One (1) via [by] inhalation x 1 dose as needed for wheezing/dyspnea . Medical record review of Resident #140's Medication Administration Record revealed the resident received Ipratropium-albuterol solution for nebulization on 1/13/2020. Observation on 1/21/2020 at 2:07 PM and 3:45 PM in Resident #140's room revealed the resident's nebulizer tubing was not dated and the nebulizer mask was placed on top of the nebulizer machine not stored in a bag. Observation and Interview on 1/21/2020 at 3:55 PM in Resident #140's room with RN #1 confirmed the resident's nebulizer tubing and mask was not dated or bagged. Interview with the Director of Nursing (DON) on 1/22/2020 at 5:22 PM in the 1000 Hallway confirmed her expectations were for the oxygen and nebulizer tubing and mask to be dated and stored in a bag when not in use. Interview with the DON on 1/23/2020 at 1:34 PM in the conference room stated all the oxygen equipment should be changed Sundays with removing the old and throwing it away and dating the equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to complete a Quarterly Minimum Data Set (MDS) for 1 (#10) of 32 residents reviewed. The findings include: Medical record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses included Benign Neoplasm of Meninges, Nontraumatic Intracranial Hemorrhage, and Toxic Encephalopathy. Medical record review revealed Resident #10 had a Quarterly MDS dated [DATE] and a Significant Change MDS dated [DATE]. Further medical record review revealed no Quarterly MDS was completed in December 2018. Interview with Registered Nurse (RN) #1 on 1/23/19 at 4:20 PM in her office revealed Resident #10 did not have a Quarterly MDS completed in December 2018. RN #1 stated, The Quarterly MDS was due in December 2018 and I feel like I just missed it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility investigation, and interview, the facility failed to accurately assess 2 (#21 and #68) of 32 residents reviewed. The findings include: Medical record review revealed Resident #21 was admitted to the facility on [DATE] with diagnoses included Urinary Tract Infection, Shortness of Breath, and Falling. The resident had been discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #21 had no falls. Review of the facility investigation dated 12/20/18 revealed Resident #21's legs gave out and the staff present assisted the resident to the floor. Further review revealed the resident had no injury resulting from the fall. Medical record review of the Discharge MDS dated [DATE] revealed Resident #21 had no fall since admission/entry or reentry or prior assessment. Medical record review of the admission 5 day MDS dated [DATE] revealed Resident #21 had 1 fall with injury since admission/entry or reentry or prior assessment. Interview with Registered Nurse (RN) #1, responsible for the MDS, on 1/24/19 at 9:35 AM in the conference room, after reviewing the facility investigations, when asked if the 12/29/18 MDS failed to accurately assess Resident #21's fall on 12/20/18, the RN stated Yes. When the RN was asked if the 1/11/19 MDS was to identify the 12/20/18 fall the RN stated .No, the 12/20/18 fall would be on the 12/29/18 MDS . Further interview with the RN at 11:35 AM in the conference room confirmed the 12/29/18 and the 1/11/19 MDS's .were not correctly coded for falls . Medical record review revealed Resident #68 was admitted to the facility on [DATE] and discharged to the community with home health services on 12/11/18. Medical record review of the physician order dated 12/4/18 revealed .DC [discharge] home on [DATE] with home health, PT [Physical Therapy] , OT [Occupational Therapy] and nursing . Medical record review of the Discharge and Transfer Discharge Plan of Care and Recapitulation revealed Resident #68 was discharged to the community with home health on 12/11/18. Medical record review of the Discharge MDS dated [DATE] revealed Resident #68 was discharged to an acute hospital. Interview with the Director of Nursing on 1/24/19 at 5:55 PM in the conference room confirmed the 12/11/18 discharge MDS was not accurate for the discharge status to an acute hospital. Interview with RN #1, responsible for the MDS, on 1/24/19 at 6:10 PM in the conference room confirmed the discharge MDS dated [DATE] failed to accurately identify the discharge status as a community discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview, the facility failed to have a baseline care plan adressing falls for 1 (#50) of 32 residents reviewed. The findings include: Review of the facility policy, Care Plan Development dated 7/3/08 revealed .Interim plan of care within 48 hours of admission addressing the immediate needs of the patient . Medical record review revealed Resident #50 was admitted to the facility on [DATE] with diagnoses included Specified Disorders of the Brain, Generalized Osteoarthritis, Muscle Weakness and History of Falling. Medical record review of the care plan dated 12/6/18 revealed the baseline care plan was updated on 12/9/18 for falls risks. Interview with the Director of Nursing (DON) on 1/24/19 at 5:51 PM in the conference room confirmed .the baseline care plan is part of the admission process and should be completed in 48 hours . Further interview with the DON confirmed .looks like on the day she was entering the care plans he had a fall .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview, the facility failed to provide a sanitary environment for 3 of 86 rooms reviewed. The findings included: Review of facility policy Equipment Cleaning Guidelines dated 10/16/16 revealed .Equipment will be sprayed with appropriate chemical solution and allowed to air dry .equipment is then wiped down to remove particles and ensure equipment is ready for use .This equipment includes: IV poles, pumps, walkers, oxygen concentrators, nebulizers, bi-pap machines, and any extra furniture . Observation on 1/08/18 at 11:50 AM in room [ROOM NUMBER] revealed the feeding pump, pole, cord, and the wall behind the pole was splattered with tan dried debris. Interview with the Licensed Practical Nurse # 3 on 1/08/18 at 12:03 PM in room [ROOM NUMBER] confirmed The equipment and the wall should not be dirty. Observation on 1/10/18 at 8:39 AM in room [ROOM NUMBER], observation on 1/10/18 at 8:45 AM in room [ROOM NUMBER], and observation on 1/10/18 at 8:50 AM in room [ROOM NUMBER] with the Director of Nursing (DON) present revealed feeding pumps, poles, cords, and the wall had tan dried debris splattered on them. Interview with the DON on 1/10/18 at 9:00 AM in the chart room behind the nurses' station #2 confirmed tan dried splattered debris should not be present on the feeding pumps, poles, cords, or the wall. Further interview confirmed the facility failed to provide a sanitary environment for 3 of 86 rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview, the facility failed to follow the Care Plan, resulting in a fall for 1 Resident (#38). The findings included: Medical record review of facility policy,Incident and Accident Process dated 3/1/01, revised 8/13/13 revealed, .review the Care Plan for any possible updates that might be required related to a change/update . Review dated 11/10/17 revealed Resident #38 was admitted to the facility on [DATE] with a diagnosis of Nondisplaced Fracture of Base of Neck of Right Femur, Pneumonia, Chronic Obstructive Pulmonary Disease, Respiratory Disorder, Urinary Tract Infection, Neoplasm of the Bladder, Anemia, and Solitary Pulmonary Nodule. Medical record review of the Safety Interventions Document dated 12/10/17 revealed, additional intervention: out of room when up to wheelchair . Medical record review of Care Plan dated 12/13/17 revealed .no more falls, pull patient out of room when in wheelchair . Medical record review of .Post Falls Nursing Assessment . dated 1/5/18 revealed .Patient was heard yelling for help, found patient on the floor on his left side with arms extended and legs drawn up, fell from wheelchair . Interview with Nursing Assistant #5 on 1/10/18 at 9:18 AM at the Nurses Station revealed .we try to keep him in the hallway when he is up in his wheelchair . Interview with Licensed Practical Nurse (LPN) #1 on 1/10/18 at 9:30 AM at the Nurses Station #2 revealed, .He is confused and a fall risk. Yesterday he did have a fall he got up to the restroom and fell this makes his fourth fall he has had in the last two weeks . Further interview confirmed .I was working when he fell on 1/5/18, and he was in his room in the wheelchair and we do not know who left him in his room . LPN #1 confirmed the facility failed to follow the Care Plan for Resident #38 on 1/5/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview, the facility failed to update the Care Plan of 1 resident (#325). The findings included: Review of Facility policy Updating and Revising Care Plans . dated 7/3/08 revealed .Routine Reviews and Updates: Care plans updated as needed . Medical record review revealed Resident #325 was admitted to the facility on [DATE] with diagnosis including, Hypertension, Hyperlipedemia, Aphasia, Cerebral Vascular Accident, Transient Ischemia Attacks, Hemiplegia, and Malnutrition. Medical record review of Care Plan dated 1/7/18 revealed .UTI [Urinary Tract Infection] Cipro [Ciprofloxacin] [antibiotic] . Medical record review of a Physician Order dated 12/26/17 indwelling urinary catheter for urinary catheter. Interview with Licensed Practical Nurse #4 on 1/10/18 at 11:33 PM at the common area .She came to the facility without a foley catheter, and the doctor ordered an in and out catheter, and then the doctor ordered the foley Catheter. On the Foley catheter her output was no less than 350 ml [milliliter] for the whole shift . Interview with the Physician Assistance on 1/10/18 at 11:53 AM at Nurse Station #1 revealed that Resident #325 had urinary retention and an indwelling catheter was ordered. Interview with the Director of Nursing on 1/10/18 at 3:47 PM in the common area, after review of the care plan the DON confirmed the facility failed to update Resident #325 care plan to reflect the use of a indwelling foley catheter for urinary retention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure psychotropic medication behavior monitoring was completed for 1 resident (#12) of 17 residents reviewed. The findings included: Medical record review revealed Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Congestive Heart Failure, Hypertensive Heart Failure, Stage 3 Chronic Kidney Disease, Paroxysmal Atrial Fibrillation, Long Term Use of Anticoagulant, Lymphedema, Chronic Pain, Shortness of Breath, Difficulty Walking, Dementia without Behavioral Disturbance, Major Depressive Disorder and Generalized Anxiety Disorder. Medical record review of the admission Minimum Data Set (MDS) dated [DATE] and the Discharge MDS dated [DATE] revealed Resident #12 received antipsychotic medication during the assessment look-back period. Medical record review of a Physician Order dated 11/1/17 revealed Lorazepam (antianxiety) 1 milligram daily. Continued review revealed this order was discontinued on 11/7/17. Further review of a Physician Order dated 11/7/17 revealed Lorazepam 0.5 milligram daily. Medical record review of the November 2017 Medication Administration Record (MAR) revealed Resident #12 received the antipsychotic medication as prescribed. Continued review of the MAR revealed no behavior monitoring for the antipsychotic medication. Medical record review of a Physician Order dated 12/29/17 revealed Ativan (antianxiety) 1 milligram daily. Medical record review of the December 2017 and January 2018 MAR revealed Resident #12 received the antipsychotic medication as prescribed. Continued review revealed no behavior monitoring for the antipsychotic medication for the month of December 2017. Further review of the January 2018 MAR revealed behavior monitoring for the antipsychotic medication did not start until 1/2/18. Interview with the Director of Nursing (DON) on 1/10/18 at 2:40 PM in the conference room revealed she expected behavior monitoring to be completed when a resident received a antipsychotic medication. The DON confirmed the facility failed to complete antipsychotic medication behavior monitoring for Resident #12 as required.