**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Assessment Instrument (RAI) Version 3.0 Manual, record review, and interview the facility failed to complete a discharge Minimum Data Set (MDS) assessment timely for 1 resident (Resident #2) of 18 residents reviewed for MDS assessments. The findings include: Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, dated October 2019, showed .Chapter 2: ASSESSMENTS FOR THE RESIDENT ASSESSMENT INSTRUMENT (RAI) .Discharge assessment .Must be completed .within 14 days after the discharge date . Resident #2 was admitted to the facility on [DATE] with diagnoses including Deep Vein Thrombosis, Gastroesophageal Reflux Disease, Hyponatremia, Arthritis, Osteoporosis, Anxiety Disorder, and Depression. The resident was discharged from the facility on 7/12/2022. Record review revealed no documentation a discharge MDS assessment had been completed for Resident #2. During an interview on 10/12/2022 at 10:59 AM, the MDS Coordinator stated Resident #2 was discharged from the facility on 7/12/2022 and had not returned to the facility. Further interview confirmed the facility failed to complete a discharge MDS for the 7/12/2022 discharge from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Assessment Instrument Manual 3.0 (RAI), medical record review, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 resident (Resident #75) of 18 residents reviewed for MDS assessments. The findings include: Review of the RAI Manual 3.0 dated 10/2019 showed .the comprehensive assessment is considered complete on the date the RN [Registered Nurse] Coordinator indicates completion of the admission assessment .Assuming the resident does not have any significant changes in status or is not discharged from the facility the next assessment schedule is the Quarterly assessment . Resident #75 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer's Dementia, Type 2 Diabetes, Chronic Atrial Fibrillation. Diagnoses of Peripheral Artery Disease (PAD) was added on 9/16/2022. Review of a physician's progress note dated 9/16/2022 for Resident #75 showed a new diagnosis of PAD was added to Resident #75's medical record, due to the results of a doppler study of the right and left lower extremities. Review of Resident #75's quarterly MDS assessment dated [DATE], showed no documentation of the new diagnosis of PAD. During an interview on 10/12/2022 at 10:58 AM, the MDS Coordinator confirmed the diagnosis of PAD had not been added to the quarterly MDS assessment dated [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review, observation, and interview, the facility failed to implement an intervention to prevent falls for 1 resident (Resident #70) of 3 residents reviewed for falls. The findings include: Review of the facility policy titled, Fall Management, reviewed 9/29/2022, showed .The facility will assess the resident .and will identify appropriate interventions to minimize the risk of injury related to falls .Implement interventions .consistent with a resident's .care plan .in order to eliminate the risk .reduce the risk of an accident .a care plan will be developed and initiated .on any residents assessed to be at risk for falls . Resident #70 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Fracture of Unspecified Part of Neck of Left Femur, Gastrointestinal Hemorrhage, Unspecified Cirrhosis of Liver, History of Falling, Muscle Weakness (Generalized), Unspecified Dementia, and Macular Degeneration. Review of a comprehensive care plan dated 7/28/2022, showed Resident #70 was .at risk for falls r/t [related to] .hx [history] of falls, unsteadiness on feet. The care plan was updated on 8/8/2022 Mats at bedside while in bed . Review of a 5-Day Minimum Data Set (MDS) assessment dated [DATE], showed Resident #70 had a Brief Interview for Mental Status (BIMS) score of 6, indicating severe impairment. Resident #70 required extensive assistance of two persons for bed mobility and toilet use, required the extensive assistance of one person for transfer, and required total dependence of one person for locomotion on unit and bathing. During observations on 10/10/2022 at 2:50 PM; 10/11/2022 at 9:01 AM, 2:29 PM, and at 4:29 PM showed Resident #70 lying on the bed with no fall mats noted at the bedside. During an observation and interview on 10/11/22 at 4:32 PM, Licensed Practical Nurse (LPN) #1 confirmed the fall mats for Resident #70 were not in place and LPN #1 confirmed the .fall mats are supposed to be . LPN #1 reviewed Resident #70's care plan and confirmed the fall mats at bedside were an intervention on Resident #70's care plan. During an interview and record review on 10/12/2022 at 11:01 AM, the MDS Coordinator confirmed Resident #70's fall mats were to be in place when Resident #70 was laying on the bed, and the care plan was not followed if the mats were not in place for the resident's safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to maintain accurate and complete medical records for 1 resident (Resident #43) of 24 residents reviewed for accuracy of medical records. The findings include: Review of the facility policy titled, Auditing and Monitoring of Medical Records, revised [DATE], showed .Auditing and monitoring of medical record documents is conducted to ensure medical records are complete and accurate and reflect current standards of documentation practices .Additional focused audits that may be done .may include, but are not limited to .Care plan .Audit for consistency between the MDS [minimum data set assessment] and the care plan .Monitor to ensure the care plan is current .Code Status . Audit for consistency between physician orders, advanced directives and any communication system for this that the facility might use . Resident #42 was admitted to the facility [DATE], with diagnoses including Dementia without Behavioral Disturbance, Type II Diabetes Mellitus, Major Depressive Disorder Single Episode, and Need for Assistance with Personal Care. Record review of the current electronic physicians orders for Resident #43 showed status of FULL CODE with a revision date of [DATE]. Resident #43's Physician Orders for Scope of Treatment (POST) form dated [DATE], showed Do Not Resuscitate (DNR) with limited interventions. Resident #43's current electronic physicians orders showed .admit to hospice services effective [DATE] . with a revision date of [DATE]. Resident #43's comprehensive care plan created [DATE], revised [DATE], showed .Resident has Advanced Directive CPR [Cardiopulmonary Resuscitation]-Full Code with Full Treatment-no artificial nutrition . During an interview on [DATE] at 3:43 PM, the Assistant Nursing Coordinator confirmed the electronic medical record reflected a FULL CODE status and did not reflect Resident #43's wishes of Do Not Resuscitate (DNR). The ADON confirmed the medical record code status was inaccurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to keep the call light in reach for 1 Resident (#63) of 32 residents sampled. The findings include: Medical record review revealed Resident #63 was admitted to the facility on [DATE] with diagnoses including Fracture of the Lower End of the Right Radius, Dysphagia, Chronic Atrial Fibrillation, and Dementia. Medical record review of the 14 day Minimum Data Set, dated [DATE] revealed a Brief Interview for Mental Status score of 6 indicating severe cognitive impairment. Further review revealed the resident required extensive assist of 1 person for bed mobility, transfers, locomotion, dressing, toileting and personal hygiene. Medical record review of Resident #63's care plan revealed .ADL self-care performance deficit r/t [relate to] dementia, impaired mobility .Encourage the resident to use bell to call for assistance . further review revealed .At risk for falls r/t impaired mobility .Call light within reach . Observation of Resident #63 on 7/16/18 at 2:37 PM, in the resident's room, revealed the resident sitting up in a wheelchair at the bedside on the door side of the bed with the call light laying across the bed toward the window side of the bed out of the resident's reach. Observation of Resident #63 on 7/18/18 at 7:52 AM, in the resident's room, revealed the resident lying in the bed with the call light hanging over the right side of the bed below the side rail. Observation and interview with the Director of Nursing (DON) on 7/18/18 at 7:54 AM, in the resident's room, revealed the call light was hanging over the right side of the bed. The DON asked the resident if the call light could be reached. The resident was unable to reach the call light and stated it's hard. Continued interview confirmed this was the second observation of the call light not in the resident's reach. Further interview confirmed the facility failed to keep the call light in reach for Resident #63.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to develop an accurate Minimum Data Set (MDS) assessment for 1 Resident (#63) of 32 residents sampled. The findings include: Medical record review revealed Resident #63 was admitted to the facility on [DATE] with diagnoses including Fracture of the Lower End of the Right Radius, Dysphagia, Chronic Atrial Fibrillation, and Dementia. Medical record review of the 14 day MDS dated [DATE] revealed a Brief Interview for Mental Status score of 6 indicating severe cognitive impairment. Further review revealed weight of 96 and no significant weight loss was indicated. Medical record review of the comprehensive care plan dated 7/6/18 revealed to serve diet as ordered and to provide and serve supplements as ordered by the dietician or physician. Medical record review of the resident's weights revealed the weight on 6/23/18 of 96 pounds (lbs) and the weight on 7/3/18 was 91 lbs indicating a 5.21% weight loss. Medical record review of a nutrition/dietary note dated 7/5/18 revealed the resident's weight was down 5.2 % in one week. Further review revealed to continue weekly weights. Interview with the MDS Nurse on 7/18/18 at 9:02 AM, in the conference room, confirmed the resident had a weight on 7/3/18 of 91 lbs. Continued interview confirmed the 14 day MDS was dated 7/6/18 with weight indicated on MDS of 96 lbs and no weight loss was indicated. Further interview confirmed the weight should have been recorded as 91 lbs and a weight loss of 5% or more in the last month should have been indicated. Continued interview confirmed the facility failed to develop an accurate 14 day MDS assessment for Resident #63.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Medical record review revealed Resident #63 was admitted to the facility on [DATE] with diagnoses including Fracture of the Lower End of the Right Radius, Dysphagia, Chronic Atrial Fibrillation, and Dementia. Medical record review of the physician's orders dated 6/22/18 revealed .Oxygen at 2 liters/minute continuously per nasal cannula . Medical record review of the 14 day MDS dated [DATE] revealed a Brief Interview for Mental Status score of 6 indicating severe cognitive impairment. Further review revealed the resident required oxygen. Medical record review of Resident #63's care plan dated 6/25/18 and revised 7/6/18 revealed no documentation indicating the resident received oxygen. Observation of Resident #63 on 7/16/18 at 2:31 PM, in the resident's room, revealed the resident lying in the bed with oxygen in use via nasal cannula. Interview with the MDS Coordinator on 7/17/18 at 4:28 PM, in the conference room, confirmed that the oxygen use was not on the care plan. Further interview confirmed the facility failed to care plan the use of oxygen for Resident #63. Based on review of the facility policy, medical record review, observation and interview the facility failed to develop a comprehensive care plan for 3 residents (#51, #63 and #19) of 32 residents reviewed. The findings include: Review of the facility policy, Resident Assessment Instrument & Care Plan revised 11/28/16 revealed .The Care Plan includes Measure objectives, timeframes to meet the patient's, cultural, nursing, mental and psychological needs including services being provided to meet those needs . Medical record review revealed Resident #51 was admitted to the facility on [DATE] with diagnoses including Adult Failure to Thrive, Dysphagia, Diabetes, Depression, Gastro-Esophageal Reflux Disease and Esophageal Cancer. Medical record review of a Total Parental Nutrition (TPN) order dated 6/26/18 revealed .Rate .60 ml/hr [milliliters per hour] . Medical record review of an Admission/readmission Progress note dated 6/26/18 revealed .Diagnosis .Severe Protein Calorie Malnutrition, Severe Odynophagia [painful swallowing], with History of Esophageal Cancer .on TPN at 60 ml per hour per continuous pump via LUE [left upper extremity] picc [peripherally inserted central catheter] line . Medical record review of the residents comprehensive care plan dated 6/26/18 revealed it did not include the resident had TPN infused continuously by PICC line for nutrition. Observation of the resident on 7/16/18 and 7/17/18 at various times in the resident's room revealed the resident resting in bed with TPN infusing through a PICC line at 60 ml/hr. Interview with the Minimum Data Set (MDS) Coordinator on 7/17/18 at 4:30 PM, in the conference room, confirmed the facility failed to ensure a comprehensive care plan included the patient was receiving TPN for malnutrition through a PICC line. Medical record review revealed Resident #19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Osteomyelitis (infection of the bone) of Lumbar Vertebra, Diabetes Mellitus, Major Depression, Anxiety, and Morbid Obesity. Medical record review of the Order Summary Report printed on 7/17/18 revealed Resident #19 received Lantus (long acting) insulin 6 units daily, and to have her blood sugars checked before each meal and at bedtime, with administration of Humalog insulin (short acting) according to a prescribed scale. Medical record review of the July 2018, Medication Administration Record revealed Resident #19 had her blood sugars tested as ordered before each meal and at bedtime, with elevated blood sugars requiring Humalog insulin per the scale, with each test. Medical record review of the care plan dated 6/20/18 revealed no problem, goal, or approaches to address Resident #19 having elevated blood sugars especially while she is receiving antibiotics for the Osteomyelitis. Interview with Resident #19 on 7/18/18 at 11:30 AM, in the resident's room, revealed her blood sugars had been much higher since the antibiotic was started. Interview with the Director of Nursing on 7/18/18 at 1:10 PM, in the conference room confirmed the resident's elevated blood sugars were not addressed in her current care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to revise a comprehensive care plan to include risk for pain for 1 resident (#51) of 32 residents reviewed. The findings include: Medical record review revealed Resident #51 was admitted to the facility on [DATE] with diagnoses including Adult Failure to Thrive, Dysphagia, Diabetes, Depression, Gastro-Esophageal Reflux Disease and Esophageal Cancer. Medical record review of a Physicians order dated 6/26/18 revealed .Hydrocodone-Acetaminophen (narcotic pain medication) 7.5-325 mg [milligrams]. Give 1 tablet by mouth every 6 hours as needed for pain . Interview with the Minimum Data Set (MDS) Coordinator on 7/17/18 at 4:30 PM in the conference room, confirmed the facility failed to revise the comprehensive care plan for Resident #51 to include risk of pain. Interview with the Unit Manager for 200 and 300 hallway on 7/18/18 at 10:00 AM, in the conference room, confirmed Resident #51 had a diagnosis of esophageal cancer and the facility failed to revise his care plan to include the risk for pain.

**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 provide oxygen therapy per the physician's order for 1 Resident (#63) of 5 residents receiving oxygen of 32 residents sampled. The findings include: Review of the facility policy Oxygen Administration/Safety/Storage/Maintenance last revised 11/29/17 revealed .Oxygen will be administered by a licensed healthcare provider only when ordered by the physician. The physician must specify the number of liters, method of administration and length of time the oxygen is to be administered . Medical record review revealed Resident #63 was admitted to the facility on [DATE] with diagnoses including Fracture of the Lower End of the Right Radius, Dysphagia, Chronic Atrial Fibrillation, and Dementia. Medical record review of the physician orders dated 6/22/18 revealed .Oxygen at 2 liters/minute continuously per nasal cannula . Medical record review of the 14 day Minimum Data Set, dated [DATE] revealed a Brief Interview for Mental Status score of 6 indicating severe cognitive impairment. Further review revealed oxygen use while a resident. Observation of Resident #63 on 7/16/18 at 9:40 AM, in the resident's room, revealed Resident #63 was lying in the bed not wearing oxygen. Observation of Resident #63 on 7/17/18 at 7:41 AM, in the resident's room, revealed the resident lying in bed with oxygen not in use. Further observation revealed the nasal cannula and tubing were noted to be curled up and hanging on the humidifier bottle on the wall. Observation of Resident #63 on 7/17/18 at 7:53 AM, in the resident's room, revealed a staff member was observed exiting the resident's room. Further observation revealed the oxygen tubing and nasal cannula continued to be curled up and hanging on the humidifier bottle on the wall and not in use by the resident. Interview and observation with the Director of Nursing (DON) on 7/17/18 at 7:55 AM, in the resident's room, confirmed the oxygen tubing was wrapped on the humidifier bottle on the wall and not in use by the resident. Further interview confirmed that the oxygen was ordered continuous and had been observed to not be in use 3 times. Continued interview confirmed the facility failed to provide oxygen therapy per the physician's order for Resident #63.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to monitor the behavior of 1 (#28) of 5 residents reviewed for unescessary medications. The findings include: Medical record review revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including Dementia, Anxiety, Restlessness, and Agitation. Medical record review of the Order Summary Report printed on 7/17/18 revealed he received Haldol (antipsychotic) liquid concentrate 2mg/ml (milligrams/milliliters) Give 1 ml by mouth three times a day (TID) for anxiety. Review of the Medication Administration Record (MAR) for July 2018 revealed the resident received the Haldol TID as ordered. No behavior monitoring on the MAR or in the progress notes was found. Medical record review of the June 12, 2018, Pharmacist Review requested a diagnosis for Haldol, and a list of target behaviors. Further review revealed the physician wrote an order on 6/11/18 to refer the resident to psychiatric services for Anxiety, Combative, Agitation, and refuses meds and care. Medical record review of the physician's transfer orders dated 6/8/18 revealed the resident was to receive Haldol 1ml at 9:00 AM, 1:00 PM, and at 5:00 PM, and the Haldol cream was discontinued. Medical record review of Resident #28's care plan dated 6/15/18 revealed monitor for side effects of antipsychotic medication, and target behavior (does not list target behavior) .Observe for occurrence of target behavior symptoms and document per facility protocol . Medical record review and interview with Registered Nurse (RN) #1 on 7/18/18 at 10:05 AM, at the 100 nurses desk revealed no behavior monitoring sheet was found in the book the nurse's chart every shift. Further interview with RN #1 confirmed Resident #28's behavior was not monitored. Interview on 7/18/18 at 12:50 PM, with the Director of Nurses (DON) in the conference room, revealed .he hasn't had any behviors so we don't chart on behavior. Continued interview revealed the resident had a dosage reduction of the Hadol since being admitted and .hasn't had any behaviors .the resident was just expressing his rights to refuse care .The facility does not routinely monitor residents receiving antipsychotic medications . Interview on 7/18/18 at 1:22 PM, with RN #2 at the 100 nurse's desk revealed the resident .will yell out at times . Interview with Certified Nurse Assistant (CNA) #1 on 7/18/18 at 1:24 PM at the 100 nurse's desk revealed .will stiffen up and straighten his legs, yells no when he doesn't want to do something .other CNAs have told me he is combative . Interview with CNA #2 on 7/18/18 at 1:26 PM, at at the 100 nurse's desk, revealed .he is agitated a lot, he spits, he puts his hands up like he will hit you and he yells. Regularly acts like this especially with spitting . Interview with the DON on 7/18/18 at 1:35 PM in the conference room confirmed spitting and yelling out were not appropriate behaviors.

Based on review of the 2017 annual survey results and interview, the facility failed to maintain compliance with Care Plan implementation and revision process as evidenced by repeated deficient practice cited in the annual survey dated 7/18/18. The findings include: Review of the 2017 annual survey report revealed the facility had deficient practice identified at F-279 for failing to develop a comprehensive care plan, and F-280 for failing to revise the care plan. The plan of correction stated the facility was in substantial compliance with Medicare and Medicaid requirements. Medical record review of Resident #51's current care plan failed to reveal care for the resident, who required his nutrition via TPN (Total Parental Nutrition), and also was at risk for pain due to diagnosis of Esophageal (throat) Cancer. Medical record review of Resident #63's current care plan failed to reveal care for the resident who required continuous Oxygen. Medical record review of Resident #19's current care plan failed to reveal care for the resident who had elevated blood sugars. Interview on 7/18/18 at 1:35 PM with the Administrator, Regional [NAME] President, and at the end of the interview the Director of Nurses revealed the facility completed audits on care plans for 3 months after last year's annual survey, and did not find any problems. Continued interview confirmed no further audits to ensure the care plans were accurate had been conducted.

Based on observation and interview the facility failed to ensure dietary staff disinfected their hands before and after glove removal for 1 of 4 staff members observed. The findings include: Observation in the kitchen on 7/16/18 at 11:15 AM, revealed Dietary Staff #1 had been plating food at the steam table with bare bands. Continued observation revealed the staff member left the steam table, retrieved a loaf of bread from the bread rack, took it to the sandwich station, donned gloves, retrieved a knife from a drawer, retrieved cheese from the cooler, and began to prepare a sandwich. Further observation revealed the Dietary Manager finished preparing the sandwich and the dietary staff member discarded the gloves and returned to plate food at the steam table without disinfecting the hands. Interview with the Food Service Manager on 7/18/18 at 8:35 AM, in the hallway, confirmed the dietary staff are to disinfect their hands before and after glove removal. Interview with the Staff Development Coordinator on 7/18/18 at 1:30 PM, in the conference room confirmed dietary staff are included in the facility orientation which included handwashing education. Further interview confirmed all staff members are to disinfect their hands before and after glove removal.