**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, facility investigation review, medical record review, and interview, the facility failed to ensure current advance directive preferences were reflected in the electronic medical record (EMR) for 1 (Resident #5) of 89 residents reviewed. The findings include: Review of the policy titled, Cardiopulmonary Resuscitation dated [DATE], revealed .Cardiopulmonary resuscitation (CPR) will be attempted for any resident who is found to have no palpable pulse and/or no discernible respirations, unless there is a written physician order to the contrary and/or written advance directives .Cardiopulmonary resuscitation is defined as artificial respiration accompanied by external cardiac compressions .Upon identifying a resident with change of condition which presents as a unresponsive condition .check the medical record for advance directive status . Review of the policy titled Resident Rights dated [DATE] revised [DATE], revealed .All residents have the right to be treated with respect and dignity. These rights will be promoted and protected by the facility .When providing care and services, the stakeholders will respect the resident's individuality and value their input by providing them a dignified existence, through self-determination and communication with and access to persons and services inside and outside the facility .participate in decisions and care planning .Residents are entitled to exercise his/her rights and privileges as a resident of the facility and as a citizen or resident of the United States, to the fullest extent possible .The facility will make every effort to support watch resident in exercising his/her right to assure that the resident is always treated with respect, kindness and dignity .The facility provides equal access to quality care regardless of diagnosis, severity of condition . Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses which included Chronic respiratory failure, Acute on chronic diastolic (congestive) heart failure (CHF) and Chronic obstructive pulmonary disease (COPD). Resident #5 was admitted to hospice care on [DATE] and expired on [DATE]. Review of the Physician Order for Lift Sustaining Treatment (POLST) form dated [DATE] revealed, .DNR [Do Not Resuscitate] . The POLST was signed and dated by the physician on [DATE]. The POLST form dated [DATE] was not added Resident #5's medical record. Review of the Physician Order Report date XXX[DATE] Code Status: Do Not Resuscitate (DNR) .Admit to Hospice: Quality Hospice . Review of Care Plan for Resident revealed XXX[DATE] has potential for difficulty breathing XXX[DATE] has been diagnosed with a terminal condition .at risk for unavoidable significant declines .has pulmonary condition/DX [diagnosis] . Review of the Quarterly MDS assessment dated [DATE] revealed, a BIMS score of 12 which indicated a moderate cognitive impairment. Continued review revealed he had been receiving oxygen therapy. Review of the Nurse Practitioner (NP) Progress Notes dated [DATE], .Respiratory Failure with Pneumonia . CHF (Congestive Heart Failure . Comfort measures-patient to be admitted under [Named Hospice agency], will assist with Hospice company in making patient comfortable .Code Status: DNR [Do not resuscitate] . Review of the facility investigation dated [DATE], revealed LPN #3 was doing med pass she discovered Resident #5 to be unresponsive. There was no response to name being called,no pulse and no respiration. The electronic medical record (EMR)was checked, the banner and order entered on [DATE] read DNR, but the latest POLST form dated [DATE] read CPR full treatment. The DON (former DON) was contacted via phone by LPN #2 and LPN #3. The DON advised LPN #2 and LPN #3 to code him. LPN #5 obtained the crash cart, LPN #4 called 911, LPN #4 and LPN #5 were responsible for compressions, the NP was contacted, and the local emergency medical service (EMS) arrived at 5:44 AM. Review of the Resident Progress Notes dated [DATE] at 5:59 AM, revealed, res [resident] found around 530 am [5:30 AM] w [with]no apparent pulse or respirations, latest polst form [Physician order which tells what life sustaining treatment should have been done in the event of death] uploaded stated res was of full code status at 532 [5:32 AM] first compression performed. CPR performed until local EMS arrival at 544 am [5:44 AM]. The local EMS took over compressions at that time. res [resident] transported to local HSP [hospital] emergency room [ER]. NP [Nurse Practitioner], DON and resident rep [representative] notified of status. Review of facility investigation contained an email sent by CNA #4. The email dated [DATE] at 3:03 PM, revealed CNA #4 wrote,when I walked into named resident's room (Resident #5) he had his O2 on however he was not breathing and had no pulse. I started CPR immediately at that point. At the time it was 0532 [5:32 AM]. I was accompanied by two other nurses and two CNAs, we were giving breaths by using an ambu bag and giving compressions until EMS arrived which was approximately 30 minutes later . Review of the signed written statement dated [DATE], revealed LPN #2 had participated in the code involving Resident #5. During an interview on [DATE] at 12:25 PM, LPN #2 recalled her participation in the CPR conducted on [DATE]. She was on speaker phone along with LPN #3 and was told by the former DON to start CPR. During an interview on [DATE] at 12:35, LPN #6 was asked where she would go to find the code status, she responded she could look at the banner or under the documents in the EMR for the POLST form. LPN #6 also stated if the code status has been changed, the order must be entered into the EMR, the physician must sign the POLST form, and the form should be uploaded to the chart. During a phone interview on [DATE] at 4:35 PM, the NP stated (Resident #5) should have been listed as a DNR. During an interview on [DATE] at 10:00 AM, the DON was asked what the expectation was if a resident experienced cardiac arrest. The DON stated, .to follow [physician] orders, know where to find the POLST and follow it. During an interview on [DATE] at 11:01 AM, the former DON stated she was called when Resident #5 was found unresponsive and was told the banner said DNR and the POLST form in the EMR said full code. She instructed the staff to do CPR.

**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 Advanced Directive as ordered by the physician for 1 (Residents #3) of 84 residents reviewed. The findings include: Review of the facility policy titled, Advanced Directives, dated [DATE] revised [DATE] revealed, .The facility will ensure each resident has the right to request, refuse, and/or discontinue treatment .formulate an advance directive .Advance care planning, the process of communication between individuals and their healthcare agent to understand, reflect on, discuss and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions .Advance directive: a written instruction .for healthcare .related to the provision of healthcare when the individual is incapacitated . Review of the policy titled, Cardiopulmonary Resuscitation dated [DATE] revealed .Cardiopulmonary resuscitation (CPR) will be attempted for any resident who is found to have no palpable pulse and/or no discernible respirations, unless there is a written physician order to the contrary and/or written advance directives .Cardiopulmonary resuscitation is defined as artificial respiration accompanied by external cardiac compressions .Upon identifying a resident with change of condition which presents as a unresponsive condition .check the medical record for advance directive status .If circumstances are such that CPR is initiated on a resident, then the code status is clarified to indicate there is a current order to not initiate CPR in the event of death. Review of medical records revealed Resident #5 was admitted to the facility on [DATE] with diagnoses which included Chronic respiratory failure, Acute on chronic diastolic (congestive) heart failure (CHF) and Chronic obstructive pulmonary disease (COPD). Resident #5 expired [DATE]. Review of the Life Sustaining Treatment (POLST) form signed and dated by the physician on [DATE] revealed, .DNR [Do Not Resuscitate] . Review of Care Plan for Resident revealed [DATE] has potential for difficulty breathing XXX[DATE] has been diagnosed with a terminal condition .at risk for unavoidable significant declines .has pulmonary condition/DX [diagnosis] . Review of the Quarterly MDS assessment dated [DATE] revealed, a BIMS score of 12 which indicated no cognitive impairment. Continued review revealed he had received oxygen therapy. Review of the Physician Order Report dated XXX[DATE] Code Status: Do Not Resuscitate (DNR) XXX[DATE] Admit to Hospice: [named hospice agency] . Review of the Nurse Practitioner (NP) Progress Notes dated [DATE], revealed .Code Status: DNR [Do not resuscitate] . Review of the Resident Progress Notes dated [DATE] at 5:59 AM, revealed, res [resident] found around 530 am [5:30 AM] w [with] no apparent pulse or respirations, latest post form uploaded stated res was of full code status. at 532 [5:32 AM] first compression performed. CPR performed until [Named Emergency Medical Service [EMS] arrival at 544 [5:44] am [AM]. [Named EMS] took over compressions at that time. res [resident] transported to [Named Hospital]. Review of the signed employee statement dated [DATE] revealed LPN #3 discovered Resident #5 to be unresponsive. There was no response to name being called. During assessment, there was no pulse and no respiration. The electronic medical record was checked, the banner (header at the top of the electronic medical record face sheet) and physician order entered on [DATE] read DNR. The latest POLST form dated [DATE] stated CPR full treatment. LPN #5 obtained the crash cart, LPN #4 called 911, LPN #4 and LPN #5 were responsible for chest compressions, the NP was contacted, and local EMS arrived at 5:44 AM. Review of the signed written statement dated [DATE], revealed LPN #2 had participated in the code involving Resident #5. During an interview on [DATE] at 10:00 AM, LPN #2 stated she was on speaker phone with the former DON and was instructed that they should code the resident (Resident #5) because there was a discrepancy with the code status. During a phone interview on [DATE] at 4:35 PM, the NP stated the resident should have been listed as a DNR. During an interview on [DATE] at 11:01 AM, the former DON stated she was called by staff (LPN #2 and LPN #3) when Resident #5 was found unresponsive and was told the banner indicated the resident was a DNR. The POLST in the electronic record said full code. She instructed the staff to do CPR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interviews, the facility failed to follow their discharge policies and procedures and failed to meet the requirements for an appropriate discharge for 1 of 3 (Resident #1) residents reviewed for discharge requirements. The findings include: Review of the facility's policy titled, Transfer/Discharge Notice, revised 11/1/2022 revealed, .The appropriate notice will be provided to the resident and/or resident representative if it is necessary to transfer or discharge a resident from a facility .'Facility-initiated transfer or discharge': A transfer or discharge which the resident objects to, did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences .1. The facility will permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met by the facility. b. The transfer or discharge is appropriate because the resident's health has improved so the resident no longer needs the services provided by the facility. c. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident. d. The health of individuals in the facility would otherwise be endangered. e. The resident has failed, after reasonable and appropriate notice, to pay for (or have paid under Medicare or Medicaid) a stay at the facility. f. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay, For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge only allowable charges under Medicaid; or; g. The facility ceases to operate . Review of the medical record revealed Resident #1 was admitted to the facility on (1/26/2023) with diagnoses which included Paraplegia, Acute Disseminated Encephalomyelitis, and Muscle Weakness. Review of the insurance authorization revealed Resident #1 was approved for treatment at a skilled nursing facility from 1/26/2023 through 4/23/2023. Review of the admission Minimum Data Set (MDS) assessment for Resident #1 dated 1/31/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Continued review revealed resident exhibited no behaviors during the assessment period. Continued review revealed the resident received Occupational Therapy (OT) and Physical Therapy (PT) 4-5 days a week. Review of the OT Treatment Encounter Note(s) for Resident #1 dated 2/3/2023 through 2/28/2023 revealed treatment centered around improving trunk balance, postural control, improved sitting/standing tolerance, gross motor coordination, forward and lateral reach, and picking up objects from the floor. The notes revealed Resident #1 actively participated in all sessions. Review of the PT Treatment Encounter Note(s) for resident #1 dated 2/2/2023 through 3/2/2023 revealed treatment centered around dynamic balance training, lateral reach, sitting unsupported, range of motion, improved mobility, facilitate proprioception, balance, stretching, and ankle pumps. The notes revealed Resident #1 actively participated in all sessions. Review of the Transition of Care/Discharge summary dated [DATE] revealed Resident #1's goals of stay were core strengthening. The recapitulation of the stay revealed the resident participated in therapy services PT and OT 5 days weekly. Review of the discharge planning document for Resident #1 revealed the resident was discharged home on 3/2/2023. During an interview on 4/3/2023 at 12:33 PM, Resident #1 stated on 3/2/2023 the Administrator questioned the resident about smoking marijuana in her room, stated there was a strong smell coming from the room and requested consent to search her room. Resident #1 refused having her room searched, stating she had prescription medications (Gabapentin) from home in her room and knew she was not supposed to have them. The Administrator then stated she would call the police and Resident #1 said, OK. Resident #1 stated the police then arrived and asked consent to search her room and again she denied access to her room. Resident #1 stated on that day (3/2/2023) after that encounter, she was called to the Administrator's office and was told she was being discharged home that day. When Resident #1 asked the Administrator why she was being discharged so suddenly, she was told it was an emergency discharge and had been in the works for a while. Resident #1 stated the facility discharge planner arranged outpatient therapy for her with a clinic that didn't even have parallel bars, which she was using with progress at the facility. The resident stated after she got home, she had to set up her own therapy. The resident stated she was having amazing progress and did not understand why she was so abruptly and unfairly discharged . During an interview on 4/3/2023 at 1:53 PM, the Administrator stated on 3/2/2023 there was a smell of marijuana coming from Resident #1's room. When the Administrator requested consent to search the resident's room, the resident denied consent. The Administrator stated the resident was admitted to the facility for therapy. The Administrator stated the resident performed most all activities of daily living independently and did not require 24/7 nursing care. The Administrator stated Resident #1 was therefore discharged that day. When this surveyor asked the Administrator how much notice was given Resident #1 prior to discharge, she stated, we notified her that day. The Administrator stated the Medical Director agreed Resident #1 did not need 24/7 nursing care and gave an order for Resident #1 be discharged home. During an interview on 4/3/2023 at 2:17 PM the Registered Occupational Therapist (OTR) stated Resident #1 made excellent effort during therapy. She stated Resident #1 wanted to regain functional use of her legs. She stated Resident #1 participated well every day. During an interview on 4/3/2023 at 2:37 PM the Physical Therapy Assistant (PTA) stated Resident #1 was admitted to the facility to get muscle function back to be ambulatory again. The PTA stated Resident #1 had some muscle tone returning and her core had strengthened. The PTA stated the only thing she was told by her manager is that Resident #1 was being discharged that day. The PTA stated, It was a shock. During an interview on 4/3/2023 at 2:36 PM the Social Service Director (SSD) stated the Director of Nursing (DON) told her to start the discharge process for Resident #1 that day (3/2/2023.) During an interview on 4/3/2023 at 2:43 PM the Medical Director stated on 3/2/2023 he was told Resident #1 was ready to be discharged home. He stated he does not remember anyone communicating with him Resident #1 was experiencing great benefit with her OT and PT sessions. He stated he depended on the nursing staff/administration to be his eyes and ears and tell him what he needed to do. During an interview on 4/3/2023 at 3:00 PM, the Insurance Case Manager stated Resident #1's record revealed she was discharged from the facility due to illicit drug use. During an interview on 4/3/2023 at 3:30 PM the Assistant Chief of Police stated he received a from the facility regarding a resident smoking marijuana in her room. He stated upon arrival he questioned Resident #1, who refused to give consent for a room search. He stated he did not smell any scent of marijuana or see any drug paraphernalia from the doorway. He stated he left the facility without suspicion of drug use.

**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 ensure the call light was within reach for 1 of 84 residents (Resident #38) observed. The facility failed to ensure staff knocked and announced themselves when entering 2 of 84 resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]). The facility also failed to ensure dignity for 3 of 13 sampled residents (Resident #3, #18 and #61) who required assistance with meals, 1 of 2 residents sitting at the same table were served their meal at the same time, and 1 of 5 sampled residents (Resident #49) who required an indwelling urinary catheter. The findings include: Review of the facility's policy titled, Resident Rights, dated 8/16/2018, revealed, .All residents have the right to be treated with respect and dignity. These rights will be promoted and protected by the facility . Review of the facility's policy titled, Catheter Care Procedure, dated 5/23/2018, revealed, .Routinely check to ensure: Drainage bag is covered with a privacy cover . Review of the facility's policy titled, Assistance with Meals, dated 6/27/2018, revealed, .Residents who cannot feed themselves will be fed with attention to safety, comfort and required assistance with meals, dignity, for example .Note standing over residents while assisting them with meals . Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses which included Unspecified Diastolic (congestive) Heart Failure, Repeated Falls, and Chronic Obstructive Pulmonary Disease (COPD). Review of the Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated severe cognitive impairment. Observation and interview in Resident #38's room on 6/13/2022 at 10:56 AM, Registered Nurse (RN) #1 confirmed the call light was hanging on the light fixture above the bed out of the reach of the resident. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE], with diagnoses which included Unspecified Behavioral Syndromes Associated with Physiological Disturbances and Physical factors. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #25 had a BIMS score of 15, which indicated no cognitive impairment. Review of the medical record revealed Resident #84 was admitted to the facility on [DATE], with diagnoses which included Encounter for Other Orthopedic Aftercare, Difficulty in Walking, and Depression. Review of the Observation Detail List Report dated 6/13/2022, revealed Resident #84 had a BIMS score of 13, which indicated no cognitive impairment. Observation and interview on the 400 Hall on 6/13/2022 at 12:31 PM, revealed Certified Nursing Assistant (CNA) #3 entered room [ROOM NUMBER] without knocking on the door to announce himself when he delivered a lunch tray. CNA #3 confirmed he did not knock and announce himself when he entered room [ROOM NUMBER]. Observation and interview on the 400 Hall on 6/13/2022 at 12:39 PM, revealed CNA #2 entered room [ROOM NUMBER] without knocking to announce herself when she delivered a lunch tray. CNA #2 confirmed she did not knock and announce herself before entering room [ROOM NUMBER]. During an interview on 6/13/2022 at 12:42 PM, RN #1 confirmed staff was required to knock and announce themselves when entering all resident rooms. Review of the medical record revealed Resident #3 was readmitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Vascular Dementia with Behavioral Disturbances, Dysphagia, Unspecified Sequelae of Cerebral Infarction, and Unspecified Lack of Coordination. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #3 had a BIMS score of 0 which indicated severe cognitive impairment. Continued review revealed Resident #3 required total assistance from 1 staff member for eating. Review of the care plan revised 6/6/2022, revealed .Resident has an Activities of Daily Living [ADL] self-care deficit and is at risk for complications related to Deficits . Review of the Physician Order Report dated 6/13/2022, revealed Resident #3 required regular meals which needed to be pureed. Observation and interview in Resident #3's room on 6/14/2022 at 8:11 AM, revealed the Restorative Nurse Aide was standing while feeding Resident #3 his pureed breakfast. The Restorative Nurse Aide said she preferred to stand while feeding Resident #3 because he was unpredictable and would try to hit the staff. The Restorative Nurse Aide confirmed she was supposed to sit in a chair while assisting Resident #3 with his meal. During an interview on 6/15/2022 at 3:41 PM, the Director of Nursing (DON) stated she expected staff to be seated while feeding a resident who required assistance. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses which included Cerebral Palsy, Dysphagia, and Epilepsy. Review of the Quarterly MDS assessment dated [DATE], revealed a staff assessment for cognition that revealed poor memory recall. Continued review revealed Resident #18 required total assistance of 1 person for eating. Review of the medical record revealed Resident #61 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Contracture Right Hand, and Feeding difficulties. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #61 had a BIMS score of 3, which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #61 required extensive assistance of 1 person for eating. Observation and interview in Resident #18's room on 6/13/2022 at 12:09 PM, revealed CNA #6 standing over the resident while she assisted her with the lunch meal. CNA #6 stated, I couldn't find a chair, probably not supposed to stand. Observation and interview on the 600 hall at Resident #61's doorway on 6/13/2022 at 12:33 PM, revealed CNA #7 standing over the resident while she assisted her with the lunch meal. CNA #7 stated, Well I don't know why I wasn't sitting down but my knees hurt sometimes. During an interview on 6/13/2022 at 12:35 PM, Licensed Practical Nurse (LPN) #1 confirmed the two CNAs were standing and should be sitting while assisting residents with meals. Observation in the Main Dining Room on 6/13/2022 at 12:30 PM, revealed the CNA served 1 resident her lunch tray, and the 2nd resident sitting at the table was not served her meal tray until 12:47 PM. During an interview on 6/13/2022 at 12:50 PM, the Staff Development Coordinator (SDC) confirmed the residents seated at the same table were not served their meals at the same time and they should have been. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] with diagnoses which include Hepatic Failure End Stage Liver Disease, Alcohol Induced Chronic Pancreatitis, and Chronic Kidney Disease, stage 3. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #49 had a BIMS score of 8, which indicated moderate cognitive impairment. Review of the Care Plan for Resident #49 revealed a problem, .Indwelling Catheter .resident requires an indwelling urinary catheter . Observation and interview in the 200 hall on 6/13/2022 at 2:33 PM, revealed Resident #49 was self propelling in his wheelchair with the urinary catheter drainage bag attached to the arm of the wheelchair. The urinary catheter bag was not covered with a privacy cover. During an interview on 6/13/2022 at 3:39 PM, the Social Service Director (SSD) confirmed there was no privacy cover on the urinary drainage bag for Resident #49. During an interview on 6/15/2022 at 9:12 AM, the DON confirmed a privacy cover was to be placed on the urinary drainage bag at all times.

**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 honor 1 of 39 sampled residents (Resident #3) food preferences. The findings include: Review of the facility's policy titled, Assistance with Meals dated 6/27/2018, revealed .1. Residents will be encouraged to eat in the dining space of their choice. A. Facility staff will serve resident meals and will help residents who require assistance with eating. B. Employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling. C. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity . Review of the medical record revealed Resident #3 was readmitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Vascular Dementia with Behavioral Disturbances, Dysphagia, Unspecified Sequelae of Cerebral Infarction, and Unspecified Lack of Coordination. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 had a BIMS score of 0 which indicated severe cognitive impairment. Review of the care plan revised 6/6/2022 revealed .ADL Functional/Rehabilitation Potential: Resident has an ADL self-care deficit and is at risk for complications . Review of the Physician Order Report dated 6/13/2022 revealed Resident #3 required regular meals which needed to be pureed. Review of the meal ticket dated 6/15/2022 revealed, .Pureed BBQ Pork Loin . Review of the Dietary Interview dated 3/30/2021 revealed, .Dislikes/Intolerances: Pork, Pork Chop, Pork Roast . Observation in Resident #3's room on 6/15/2022 at 1:30 PM, revealed Resident #3 being assisted with his lunch meal which consisted of pureed BBQ pork loin. During an interview on 6/15/2022 at 3:01 PM, the Dietary Manager confirmed Resident #3's meal preferences had not been honored when he was served puree pork for lunch.

Based on facility policy review, observation, and interviews, the facility failed to maintain resident confidentiality. The findings include: Review of the facility's policy titled, Health Information Management, revised 2/3/2022, revealed, .facility will safeguard all resident records, whether medical .to protect the confidentiality of the information . Review of the facility's policy titled, Medication Administration General Guidelines, dated 09/2018, revealed, .Resident's health information needs to remain private .resident health information must remain closed or covered when not in direct use . Observation at the Medication Cart on 300 Hall on 6/14/2022 at 8:52 AM, revealed a laptop open on top of the Medication Cart with residents' personal information displayed. Continued observation revealed 4 staff members passed by the medication cart on the 300 Hall with the open resident information displayed on the laptop. Observation and interview at the Medication Cart on 300 Hall on 6/14/2022 at 8:54 AM, revealed, a laptop open on top of the Medication Cart with residents' personal information displayed. Licensed Practical Nurse (LPN) #3 stated, I normally minimize the screen for patient privacy, I totally forgot to do that when I walked away. Continued interview LPN #3 confirmed he left patient information displayed on the laptop. He stated, It is a HIPPA [Health Information Portability Privacy Act] violation. Observation at the Wound Care Cart on 400 Hall on 6/14/2022 at 9:52 AM, revealed a laptop open with several residents' identifiable information displayed. Continued observation revealed 2 staff members walked by the Wound Care Cart on 400 Hall with open resident information displayed on the laptop. Observation and interview at the Wound Care Cart on 400 Hall on 6/14/2022 at 9:55 AM, revealed laptop open with several residents' identifiable information displayed. Registered Nurse (RN) #2 (Wound Care Nurse) confirmed the laptop was open and unattended with residents' private information displayed. Continued interview RN #2 confirmed the laptop screen should have been closed for resident privacy. During an interview on 6/15/2022 at 9:27 AM, the Director of Nursing (DON) stated she expected the laptop screens containing resident information to be minimized, shut down, or where you cannot see it to protect the residents' information.

Based on facility policy review, observations, and interview, the facility failed to ensure a homelike environment for 2 of 4 residents observed in the Main Dining Room. The findings include: Review of the facility's policy titled, Resident Rights, dated 8/16/2018, revealed, .All residents have the right to be treated with respect and dignity. These rights will be promoted and protected by the facility . Observation in the Main Dining Room on 6/13/2022 at 12:29 PM, revealed the CNA did not take the plates, utensils and glasses off of the meal tray and place on the table for 2 of 4 residents. During an interview on 6/13/2022 at 12:50 PM, the Staff Development Coordinator confirmed the plates, utensils, and glasses were not removed from the serving tray and placed on the table.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to report 2 resident to resident altercations for 4 of 39 sampled residents (Resident #36 and Resident #52; Resident #34 and Resident #49) and failed to report an injury of unknown origin for 1 of 39 sampled residents (Resident #38). Review of the facility's policy titled, Abuse, Neglect and Misappropriation of Property, revised 4/14/2022, revealed, .It is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation .assure that all alleged violations of federal or State laws which involve abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property are investigated, and reported immediately to the Facility Administrator, the State Survey Agency, and other appropriate State and local agencies in accordance with Federal and State law .Injury of Unknown Source .means an injury that meets both of the following conditions .(1) the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident and (2) the injury is suspicious because of the extent of the injury; the location of the injury (for instance, the injury is located in an area not generally vulnerable to trauma) .Such occurrences will be investigated by the Administrator, Director of Nursing, or designee . Review of medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses which included Unspecified Dementia with Behavioral Disturbance and Unspecified Focal Traumatic Brain Injury. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Continued review revealed the resident required extensive to total assistance of one to two person physical assist with all Activities of Daily Living (ADL)s. Review of Resident #34's Event Report dated 4/2/2022 revealed .heard yelling coming from room, when entering elders room, elder yelling I will kill you S.O.B. and had legs in position and kicking roommate in the back, asking elder why he was kicking his roommate and he states I will kill him . Review of the Occurrence Investigation for Resident #34 dated 4/2/2022 revealed, .Resident was found lying in floor on mat next to roommate's bed lifting feet in the air kicking resident in back. Resident yelling/cursing at roommate . Review of medical record revealed Resident #49 was admitted to the facility on [DATE] with diagnoses which included Hepatic Failure, End Stage Liver Disease, and Alcohol Induced Chronic Pancreatitis. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #49 had a BIMS score of 8, which indicated moderate cognitive impairment. Continued review revealed the resident required extensive assistance of one to two person physical assist with all ADLs. Review of Resident #49's Event Report dated 4/2/2022 revealed, .resident roommate found lying on mat in floor next to bed lifting feet in the air kicking resident in back . During a telephone interview with LPN #6 (who completed event report) on 6/14/2022 at 5:51 PM, she stated, I heard yelling coming from the room, when I walked in the room [named Resident #34] had his foot up in the air and [named Resident #49] said he had been kicking him, [named Resident #34] was yelling and cursing at him. Review of medical record revealed Resident #36 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), Vascular Dementia, and Psychotic Disorder with Delusions. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #36 had a Staff Assessment for Mental Status which indicated poor memory recall. Continued review revealed the resident required extensive assistance to total assistance of one to two person physical assist with all ADLs. Review of the medical record revealed Resident #52 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease and Vascular Dementia without behavioral disturbance. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #52 had a Staff Assessment for Mental Status which indicated poor memory recall. Continued review revealed the resident required extensive to total assistance of one to two person physical assist with all ADLs. Review of Resident #52's Event Report dated 5/28/2020 revealed, .Resident was in scoot-n-go chair [a self propelled mobility chair] ambulating in hallway, another resident [named Resident #36] was also ambulating in hallway when resident went by, [named Resident #36] grabbed her wrist attempting to stop her. This caused resident to scream and pull her arm away, hitting herself in the chin, and caused a small skin tear on her chin .Residents were separated for safety . During an interview on 6/14/2022 at 4:45 PM, the Administrator confirmed the 2 Resident to Resident altercations were not reported to the State Agency. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses which included Unspecified Diastolic (congestive) Heart Failure, Repeated Falls, and Chronic Obstructive Pulmonary Disease (COPD). Review of the Significant Change in Status MDS assessment dated [DATE], revealed Resident #38 had a BIMS score of 5, which indicated severe cognitive impairment. Continued review revealed the resident required supervision to extensive assistance of one to two person physical assist with all ADLs. Review of the Nurse Progress Notes for Resident #38 revealed, .05/16/2022 10:39 .Resident's sister was updated and informed of new bruise on right lateral eye lid .05/15/2022 20:00 .[Recorded as Late Entry on 05/16/2022 06:45] .found res.[resident] sitting on side of bed, yelling to go to bathroom. Certified Nursing Assistants (CNAs) found that resident's rt. [right] eyelid was bruised. denies pain/discomfort. no change noted this shift . During an interview on 6/14/2022 at 5:20 PM, Licensed Practical Nurse (LPN) #4 stated she saw the bruise on Resident #38's right eye when she returned to work that week. She stated there wasn't an event note to follow up on related to the bruise. During a telephone interview on 6/14/2022 at 5:30 PM, family member #1 stated the facility notified her about the bruise on his right eye. She stated she had not heard anything else about the bruise from the staff. During an interview on 6/15/2022 at 9:00 AM, the Director of Nursing (DON) confirmed there was not an investigation/event note completed for the bruise over Resident #38's right eye. She confirmed the bruise was an injury of unknown origin and should have been reported. During a telephone interview on 6/15/2022 at 10:30 AM, Registered Nurse (RN) #1 stated LPN #6 notified her of the bruise in shift report on 5/16/2022, and she notified the sister. She stated she assumed Resident #38 had bumped his eye on the side rail getting out of bed, but did not know for sure. She confirmed no event report had been completed and the bruise was not reported. During an interview on 6/15/2022 at 5:30 PM, the Administrator confirmed an injury of unknown origin involving Resident #38 was not reported to the State Agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview, the facility failed to report an injury of unknown origin for 1 of 5 sampled residents (Resident #38) reviewed for potential abuse. The findings include: Review of the facility's policy titled, Abuse, Neglect and Misappropriation of Property, revised 4/14/2022, revealed, .It is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation .assure that all alleged violations of federal or State laws which involve abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property are investigated, and reported immediately to the Facility Administrator, the State Survey Agency, and other appropriate State and local agencies in accordance with Federal and State law .Injury of Unknown Source .means an injury that meets both of the following conditions .(1) the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident and (2) the injury is suspicious because of the extent of the injury; the location of the injury (for instance, the injury is located in an area not generally vulnerable to trauma) .Such occurrences will be investigated by the Administrator, Director of Nursing, or designee . Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses which included Unspecified Diastolic (congestive) Heart Failure, Repeated Falls, and Chronic Obstructive Pulmonary Disease (COPD). Review of the Nurse Progress Notes for Resident #38 revealed, .5/16/2022 10:39 .Resident's sister was updated and informed of new bruise on right lateral eye lid .5/15/2022 20:00 .[Recorded as Late Entry on 5/16/2022 06:45] .found res.[resident] sitting on side of bed, yelling to go to bathroom. Certified Nursing Assistants (CNAs) found that resident's rt. [right] eyelid was bruised. denies pain/discomfort. no change noted this shift . During an interview on 6/14/2022 at 5:20 PM, Licensed Practical Nurse (LPN) #4 stated she saw the bruise on Resident #38's right eye when she returned to work that week. She stated there wasn't an event note to follow up on related to the bruise. During a telephone interview on 6/14/2022 at 5:30 PM, family member #1 stated the facility notified her about the bruise on his right eye. She stated she had not heard anything else about the bruise from the staff. During an interview on 6/15/2022 at 9:00 AM, the Director of Nursing (DON) confirmed there was not an investigation/event note completed for the bruise over Resident #38's right eye. She confirmed the bruise was an injury of unknown origin and should have been investigated. During a telephone interview on 6/15/2022 at 10:30 AM, Registered Nurse (RN) #1 stated LPN #6 notified her of the bruise in shift report on 5/16/2022, and she notified the sister. She stated she assumed Resident #38 had bumped his eye on the side rail getting out of bed, but did not know for sure. She confirmed no event report had been completed and the bruise was not reported.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview the facility failed to provide a bed hold notification for 1 of 6 sampled residents (Resident #22). The findings include: Review of the facility's policy titled, Facility Bedhold, revised 11/12/2018 revealed, .The Facility will notify the resident/responsible party of the facility's bed hold .at admission and anytime a resident is transferred to the hospital .the facility will provide written notice of the bed hold .before a resident's transfer to the hospital . Review of the medical record for Resident #22 revealed she was admitted on [DATE] with diagnoses which included Acute Respiratory Failure, Generalized Osteoarthritis, and Acute Kidney Failure. Continued review of the medical record revealed Resident #22's last hospital stay from the facility was 2/27/2022 through 3/8/2022. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed recent admission entry date as 3/8/2022. Continued review of the MDS revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated severe cognitive impairment. Review of the resident documents revealed no bed hold notification in the medical record. During an interview on 6/15/2022 at 2:15 PM, Medical Record staff stated, The nursing staff fill out the bed hold notification but I do not have a bed hold for Resident #22 for 2/27/2022. During an interview on 6/15/2022 at 6:15 PM, the Director of Nursing (DON) confirmed the facility does not have a bed hold notification for Resident #22 for 2/27/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview, the facility failed to ensure the Residents and/or Residents' Representative were invited to care plan meetings for 2 of 39 sampled residents (Resident #2 and #19). The findings include: Review of the facility's policy titled, Comprehensive Care Plan, revised on 7/18/2018, revealed, .The resident and the resident representative will participate to the extent practicable . Review of the facility's policy titled, Resident's Rights, revised on 8/16/2018, revealed, .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: Participate in decisions and care planning . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses which included Unspecified Dementia Without Behavioral Disturbance and Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side. Review of the Minimum Data Set (MDS) assessment on 3/16/2022 for Resident #2, revealed no Brief Interview for Mental Status (BIMS) scored was documented. Review of the medical record revealed a care plan meeting was held on 3/16/2022 for Resident #2. Continued review revealed no documentation was found noting whether the resident and/or resident's representative attended the care plan meeting on 3/16/2022. There was no sign in sheet found in the medical record for the care plan meeting held on 3/16/2022. During an interview on 6/15/2022 at 8:51 AM, the MDS Coordinator confirmed she didn't reach out to resident's representative the day of the care plan meeting on 3/16/2022. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses which included Unspecified Dementia Without Behavioral Disturbance and Periprosthetic Fracture Around Internal Prosthetic Right Hip Joint, subsequent encounter. Review of the Significant change in status MDS assessment completed on 3/25/2022 for Resident #19, revealed a BIMS score of 2 which indicated severe cognitive impairment. Review of the medical record revealed a care plan meeting was held on 3/30/2022 for Resident #19. Continued review revealed no documentation was found noting whether the resident and/or resident's representative attended the care plan meeting on 3/30/2022. There was no sign in sheet found in the medical record for the care plan meeting held on 3/30/2022. During an interview on 6/15/2022 at 8:47 AM, the Social Service Director stated she kept a copy of the mailed care plan meeting notifications in a binder. Upon review of the binder, she confirmed there were no care plan meeting notifications found for Residents' #2 and #19 representatives.

**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 administer oxygen (O2) per physician's order for 1 of 22 sampled residents (Resident #21). The facility failed to date and properly store oxygen tubing and nebulizer mask with tubing when not in use for 4 of 26 sampled residents (Resident #21, Resident #22, Resident #38, and Resident #78). The findings include: Review of the facility's policy titled, Respiratory Oxygen Administration - Nasal Cannula Clinical Practice Guideline, reviewed 10/23/2020, revealed, .set the flow rate to the prescribed liter flow .Date and store in treatment bag when not in use . Review of the facility's policy titled, Medication Administration General Guidelines, dated 9/2018, .Medications are administered in accordance with written orders of the prescriber Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] with diagnosis which included Acute Respiratory Failure with Hypoxia, Acute Respiratory Failure with Hypercapnia, and Chronic Obstructive Pulmonary Disease. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated severe cognitive impairment. Continued review revealed Resident #21 required O2 therapy. Review of Resident #21's Physician's Order Report revealed, .3/29/2022 .O2 at 5 L/pm [Liters per minute] by NC [Nasal Cannula] for Acute Respiratory Failure with Hypoxia .6/15/2022 .Oxygen therapy: Change tubing every week once a day on Thursday . Review of Resident #21's Care Plan dated 3/28/2022, revealed plan of care for impaired oxygen gas exchange in place with intervention oxygen as ordered. Review of the medical record revealed Resident #22 was admitted on [DATE] with diagnoses which included Acute Respiratory Failure, Generalized Osteoarthritis, and Acute Kidney Failure. Review of the Annual MDS assessment dated [DATE] revealed Resident #22 had a BIMS score of 5, which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #22 required extensive to total assistance of 1 for Activities of Daily Living (ADL). Review of Resident #22's Physician Order Report dated 5/15/2022-6/15/2022, revealed, .Ipratropium-albuterol solution for nebulization .1 unit dose; inhalation .every 6 hours as needed for shortness of breath/wheezing . Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses which included Unspecified Diastolic (congestive) Hear Failure, Repeated Falls, and Chronic Obstructive Pulmonary Disease (COPD). Review of the Significant change in status MDS assessment dated [DATE], revealed Resident #38 had a BIMS score of 5, which indicated severe cognitive impairment. Review of the Physician Order Report for Resident #38 dated 5/15/2022-6/15/2022, revealed, .6/8/2022 albuterol sulfate solution for nebulization; 0.63 mg [milligram]/3 ml [milliliter] .Give nebulizer treatments every six hour for sob [shortness of breath] and wheezing . Review of the Comprehensive Care Plan for Resident #38 revealed care plans which included resident has a Pulmonary condition/DX (diagnosis) and has potential for difficulty breathing. COPD SOB at times CHF (Congestive Heart Failure). Review of the medical record revealed Resident #78 was admitted to the facility on [DATE], with diagnoses which included Urinary Tract Infection and COPD. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #78 received respiratory treatments while in the facility. Review of the physician's orders for Resident #78 revealed, .2/17/2022 albuterol sulfate HFA [hand held inhaler] aerosol inhaler; 90 mcg [microgram]/actuation; amt [amount]: 2 PUFFS; inhalation Every 4 Hours - PRN [as needed] .5/25/2022 ipratropium-albuterol solution for nebulization; 0.5 mg [milligram]-3 mg(2.5 mg base)/3 mL[milliliter]; amt: 1 nebule; inhalation .every 4 hours . Review of the Comprehensive Care Plan for Resident #78 revealed care plans which included Resident has a Pulmonary condition/DX (diagnosis). Observation in resident #21's room on 6/13/2022 at 10:31 AM and 10:45 AM, revealed Resident #21 lying in bed, call light in reach, O2 Per NC at 6 Liters per room O2 concentrator, humidified with bottle dated 6/9/2022, the O2 mask and tubing on top of personal refrigerator not dated and not in a bag, and portable O2 tank at foot of bed with NC tubing attached was not in bag and not dated. Observation and interview on 6/13/22 10:19 AM, revealed Resident #22 lying in bed. A nebulizer machine was sitting on her nightstand with a nebulizer mask laying uncovered open to air. Interview with Licensed Practical Nurse (LPN) #1, she stated the Respiratory Department performs the breathing treatments and confirmed the nebulizer mask should be kept in a bag when not in use. Observation and interview in Resident #38's room on 6/13/2022 at 10:56 AM, revealed a nebulizer mask and tubing on top of the bedside table uncovered. Registered Nurse (RN) #1 confirmed the nebulizer equipment was on the table uncovered. Observation and interview in Resident #78's room on 6/13/2022 at 10:23 AM, revealed an uncovered nebulizer mask and tubing on the window ledge. RN #1 confirmed the nebulizer mask and tubing was uncovered and lying on the window ledge. During an interview in Resident #21's room on 6/13/2022 at 10:50 AM, LPN #5 confirmed the mask attached to O2 tubing was not bagged or dated. She stated, The O2 tubing on the oxygen tank needs to be in a bagged and dated. She confirmed the O2 was set at 6 L/pm. She stated, The O2 should be set at 5 liters per doctor's orders. During an interview on 6/15/2022 at 9:27 AM, the Director of Nursing (DON) stated, The expectation is that medications including O2 are to be administered as ordered. I expect O2 tubing and masks to be labeled, dated, and stored in a bag. During an interview on 6/15/2022 at 3:48 PM, the DON stated, O2 tubing should be changed every 7 days.

Based on observation, and interview, the facility failed to post the daily staffing hours for 5 of 30 days reviewed. The findings include: Observation and interview on 100 Hall on 6/13/2022 at 4:30 PM, revealed the current posted staffing hours was dated 6/8/2022. The Administrator confirmed the posted staffing hours was dated 6/8/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview the facility failed to follow-up on a pharmacy recommendation for 1 of 5 sampled residents (Resident #3) reviewed for unnecessary medications. The findings include: Review of the medical record revealed Resident #3 was readmitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease and Vascular Dementia with Behavioral Disturbances. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 had a BIMS score of 0, which indicated severe cognitive impairment. Review of the care plan revised 6/6/2022 revealed .Psychotropic Drug Use. PROBLEM: Resident is at risk for drug related adverse effects related to antipsychotic and antidepressant medication use . Review of the Physician Order Report dated 6/13/2022 revealed .Remeron SolTab (mirtazapine) [antidepressant, appetite stimulant] tablet, disintegrating; 15 mg [milligram]; amt [amount]: 15 mg; oral Once A Day . Review of the Note to Attending Physician/Prescriber dated 4/12/2022, revealed .This resident has been taking the antidepressant REMERON 15 MG QD [everyday] since 12/20. Please evaluate the current dose and consider a dose reduction . Continued review revealed the note was signed by the Medical Director and the word .psych . was written on the note. The note was blank of a response. During an interview on 6/15/2022 at 10:44 AM, the Nurse Practitioner (NP) stated she did not review or sign off on the pharmacy recommendations. The Medical Director reviewed and signed off on the pharmacy recommendations. During a telephone interview on 6/15/2022 at 10:53 AM, the Psychiatric NP confirmed she had not followed up on the pharmacy recommendation to gradually reduce the Remeron or give a reason as to why it would be contraindicated. Continued interview revealed the Psychiatric NP was not aware of the pharmacy recommendation and the facility did not always notify her of any pharmacy recommendations regarding his psychotropic medications. During an interview on 6/15/2022 at 3:35 PM, the Director of Nursing (DON) confirmed no one followed up on the pharmacy recommendation for Resident #3. Continued interview revealed the Medical Director would look at the pharmacy recommendations. He would not make any changes if psychotropic medications were involved and would have the DON, Assistant Director of Nursing (ADON), or Unit Manager pass it along to the Psychiatric NP. No one informed the pharmacy recommendation for Resident #3 to the Psychiatric NP.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews the facility failed to store medications and biologicals appropriately. The findings include: Observation in room [ROOM NUMBER] on 6/13/2022 at 10:11 AM and 10:45 AM, revealed a bottle of Antifungal Powder on top of bedside table not labeled with any resident name. The Antifungal Powder label stated, Keep out of reach of children. During an interview in room [ROOM NUMBER] on 6/13/2022 at 10:48 AM, LPN #5 confirmed there was a bottle of antifungal powder on the bedside table. LPN #5 stated, It does not belong in a resident's room, it should be in the locked treatment cart. During an interview on 6/15/2022 at 9:27 AM, the Director of Nursing (DON) stated she expected medications and medication powders to be stored in a locked medication cart, locked treatment cart, or in a locked storage room, unopened, not in the resident's room.

Based on facility policy review, observation, and interview the facility failed to clean 1 of 2 ice machines, cover drinks in the walk-in refrigerator, separate staff food from the kitchen food in the reach-in refrigerator, label and date food in the reach-in refrigerator, have a thermometer in the reach-in refrigerator, and failed to serve food within the temperature safety zone for 1 of 10 trays. The findings include: Review of the facility's policy titled, Ice, revised 9/2017, revealed, .Ice Machines will be cleaned monthly and as needed . Review of the facility's policy titled, Food Storage Cold foods, revised 4/2018, revealed, .An accurate thermometer will be kept in each refrigerator and freezer .All foods will be stored wrapped or in covered containers, labeled and dated . Review of the undated facility policy titled, Meal Distribution: Infection Control Considerations, revealed, .All food items will be transported promptly for appropriate temperature maintenance . Observation in the kitchen on 6/13/2022 at 10:01 AM, the ice machine had a two pink spots on the flap inside of the ice machine. Observation and interview in the kitchen on 6/13/2022 at 10:07 AM, with the Dietary Manager, revealed the walk in refrigerator had 16 cups of water uncovered in the refrigerator. The Dietary Manager confirmed the cups of water should have been covered and she did not know why the cups were there uncovered. Observation and interview in the kitchen on 6/13/2022 at 10:11 AM, with the Dietary Manager, revealed the reach in refrigerator did not have a thermometer and a bottled juice drink was in the refrigerator. Continued observation revealed 2 wrapped sandwiches and a opened container of sour cream were undated. The Dietary Manager confirmed the reach in refrigerator was supposed to have a thermometer, staff food was not to be mixed with the kitchen food, and the 2 sandwiches and sour cream needed to be dated. Observation and interview in the kitchen on 6/13/2022 at 10:19 AM, the Dietary Manager confirmed the pink debris on the flap of the ice machine. Observation and interview in the kitchen on 6/13/2022 at 11:33 AM, revealed the Dietary Manager (DM) obtained a small carton of milk on ice from a plastic bin set aside for the trayline. Continued observation revealed the DM tested on e of the milk cartons from the plastic bin, and the temperature was 43 degrees Fahrenheit. Observation in the kitchen on 6/13/2022 at 11:36 AM, 11:39 AM, 11:40 AM, 11:43 AM, and 11:44 AM, revealed the dietary staff placed milk from the plastic bin on the meal trays for delivery to the residents. Observation and interview in the kitchen on 6/13/2022 at 11:46 AM, revealed the dietary staff removed and replaced milk from the meal trays when prompted by this surveyor. Observation in the kitchen on 6/13/2022 at 12:55 PM, revealed the dietary staff placed the test tray on cart #7. Observation and interview on the 400 Hall on 6/13/2022 at 1:20 PM, with the Dietary Manager, revealed the last tray was delivered. The test tray was removed and the food temperatures were obtained. The meatball's temperature was 133 degrees Fahrenheit, potatoes 127 degrees Fahrenheit, and a pint size carton of milk was 56 degrees Fahrenheit. The Dietary Manager confirmed the temperatures were not within the safety zone for consumption. During a telephone interview on 6/15/2022 at 4;18 PM, the District Certified Manager stated when delivering meals to the residents. the food temperatures should be within the danger zone (135 degrees Fahrenheit or higher for hot foods and 41 degrees Fahrenheit or lower for cold foods). During an interview on 6/15/2022 at 5:22 PM, the Maintenance Director stated the ice machine was cleaned every 6 months and he was responsible for cleaning it.

**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 post a Transmission Based Precaution (TBP) sign on 4 of 6 TBP rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) and failed to apply Personal Protective Equipment (PPE) prior to entering a TBP room, failed to properly label and store bedpans and urinals in shared bathrooms for 6 of 39 residents. The findings include: Review of the facility's policy titled, Isolation-Categories of Transmission-Based Precautions, dated October 2018, revealed, .Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents .When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution .a. The signage informs the staff of the type of CDC [Centers for Disease Control] precaution(s), instructions for use of PPE [Personal Protective Equipment], and/or instructions to see a nurse before entering the room .Transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected .Standard precautions are used when caring for residents at all times regardless of their suspected or confirmed infection status Review of the medical record revealed Resident #78 was admitted to the facility on [DATE] with diagnoses which included Urinary Tract Infection, Chronic Obstructive Pulmonary Disease (COPD), and MRSA. Continued review revealed Resident #78 was admitted to room [ROOM NUMBER]. Review of the Physician Order Report dated 5/14/2022-6/14/2022 for Resident #78 revealed, .5/31/2022 Isolation: Contact Isolation for: MRSA . Review of the medical record revealed Resident #84 was admitted to the facility on [DATE] with diagnoses which included Encounter for Other Orthopedic Aftercare, Peripheral Vascular Disease, and MRSA. Continued review revealed Resident #84 was admitted to room [ROOM NUMBER]. Review of the Physician Order Report dated 5/14/2022-6/14/2022 for Resident #84 revealed, .6/13/2022 Isolation: Contact Isolation for: MRSA . Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] with diagnoses which included Cerebral Palsy, Depression and Methicillin Resistant Staphylococcus Aureus Infection (MRSA). Continued review revealed Resident #27 was admitted to room [ROOM NUMBER]. Review of the Physician Order Report dated 5/14/2022-6/14/2022 for Resident #27 revealed, .5/31/2022 Isolation: Contact Isolation for: MRSA . Review of the medical record revealed Resident #386 was admitted to the facility on [DATE] with diagnoses which included Lobar Pneumonia and Malignant Neoplasm of Pharynx. Continued review revealed Resident #386 was admitted to room [ROOM NUMBER]. Review of the Physician Order Report for Resident #386 revealed, .6/11/2022-6/13/2022 .Nursing Staff provide education and support to resident and family regarding isolation precautions, reason for isolation, maintaining specified isolation precautions for duration of required isolation . Observation on the 500 Hall on 6/13/2022 at 10:15 AM, 12:25 PM, 12:50 PM, and 3:20 PM, revealed no TBP sign posted on room [ROOM NUMBER]'s door. Observation and interview on the 400 Hall on 6/13/2022 at 10:23 AM, revealed there was no isolation signage on the door of room [ROOM NUMBER]. Registered Nurse (RN) #1 confirmed the resident in room [ROOM NUMBER] was on TBP and there was no isolation signage on the door. Observation and interview on the 400 Hall on 6/13/2022 at 11:05 AM, revealed there was no isolation signage on the door of room [ROOM NUMBER]. RN #1 confirmed there was no signage on the door and the resident in room [ROOM NUMBER] was on TBP. Observation and interview on the 400 Hall on 6/13/2022 at 12:42 PM, revealed there was no isolation signage on the door of room [ROOM NUMBER]. RN #1 confirmed there was no signage on the door and the resident in room [ROOM NUMBER] was on TBP. Observation and interview on the 500 Hall on 6/13/2022 at 3:40 PM, revealed no TBP sign posted on room [ROOM NUMBER]'s door. Licensed Practical Nurse (LPN) #1 confirmed the resident in room [ROOM NUMBER] was on TBP and there was not a TBP sign posted on the door. During an interview on 6/15/2022 at 9:12 AM, the Director of Nursing (DON) stated a TBP sign was to be posted on the door of a TBP isolation room. Observation and interview on the 400 Hall on 6/13/2022 at 12:39 PM, revealed Certified Nursing Assistant (CNA) #2 entered room [ROOM NUMBER] without PPE in place. CNA #2 confirmed the resident in room [ROOM NUMBER] was on TBP and she did not don the PPE required to enter the room. During an interview on 6/13/2022 at 12:42 PM, RN #1 confirmed staff were required to don PPE before entering an TBP room. Observation and interview in room [ROOM NUMBER] on 6/13/2022 at 10:07 AM, revealed two unlabeled urinals on top of the commode and two unlabeled bed pans on the floor beside the commode. Registered Nurse (RN) #1 confirmed the urinals and bedpans were unlabeled in the shared bathroom. Observation and interview in room [ROOM NUMBER] on 6/13/2022 at 10:44 AM, revealed two unlabeled bed pans on the floor of the bathroom shared by room [ROOM NUMBER] and #408. CNA #2 confirmed the two bed pans were unlabeled and on the floor. Observation and interview in room [ROOM NUMBER] on 6/13/2022 at 11:23 AM, revealed an unlabeled bed ban in the bathroom shared with room [ROOM NUMBER]. CNA #3 confirmed the bed pan in the shared bathroom was unlabeled.

**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 nail care and grooming for 1 resident (#78) of 4 residents reviewed for activities of daily living of 19 sampled residents. The findings include: Review of the facility policy, Nail Grooming, revised 5/18/18, revealed .Regular fingernail care will promote cleanliness and prevent infection. The nursing staff will provide observation and care of nails for all residents daily and as necessary . Medical record review revealed Resident #78 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Arthritis, Other Abnormalities of Gait and Mobility, Osteoporosis, Heart Failure, Tremor, Unspecified. Observation and interview with Resident #78 on 05/13/19 at 10:31 AM, in the resident's room, revealed Resident #78's fingernails were long, jagged, and soiled with a dark substance under the fingernails. Interview with Resident #78 revealed, I have asked CNAs [Certified Nursing Assistants] to cut my nails and they tell me they aren't allowed to cut them. Interview with CNA #1 on 5/14/19 at 2:15 PM, at the #3 nurses station, revealed Resident #78 required total dependence with bathing and personal care. Continued interview revealed the CNAs are permitted to cut resident's fingernails, if they are not diabetic. Observation and interview with Licensed Practical Nurse (LPN) #2 on 05/14/19 at 2:29 PM, in Resident #78's room confirmed the Resident's nails were long, jagged, and soiled with dark substance under fingernails. Continued interview confirmed the facility failed to provide nail care and grooming for Resident #78. Interview with Registered Nurse (RN) Supervisor #1 on 5/15/19 at 11:37 AM, in her office, confirmed Resident #78's fingernails were long, dirty and in need of trimming.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to provide an assistive device for 1 resident (#42) of 3 residents reviewed with limited range of motion of 19 residents sampled. The findings include: Medical record review revealed Resident #42 was admitted to the facility on [DATE] with diagnoses of Dementia with Lewy Bodies, Contracture, Left Elbow, and Muscle Weakness. Medical record review of Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 2, indicating the resident had severe cognitive impairment. Continued review revealed Resident #42 had a functional limitation in range of motion for upper extremity (shoulder, elbow, wrist, hand) with impairment on both sides. Medical record review of an Occupational Therapy Discharge summary, dated [DATE], revealed .CNA/RNP [Certified Nursing Aide/Restorative Nursing Program] staff education .pt [patient] must receive manual ROM [Range of Motion] before and after hinged elbow brace is don/doffed [brace applied and taken off] with staff verbalizing good understanding .RNP education .splinting schedule for hinged elbow brace with staff returning good demonstration .Discharge Recommendations: FMP [Functional Maintenance Program]/ RNP .RNP/FMP: To facilitate patient maintaining current level of performance and in order to prevent decline, development of and instruction in the following RNPs has been completed .ROM [Passive] and splint or brace Care . Interview with the Assistant Director of Nursing (ADON) on 5/14/19 at 9:32 AM, in the ADON's office, revealed .[Resident #42] has no devices [splints/braces] that I'm aware of . Observation of Resident #42 on 5/15/19 at 9:05 AM, in the resident's room, revealed the resident lying in bed without a splint device, and without evidence of a device in the resident's room. Interview with the ADON on 5/15/19 at 11:03 AM, in the conference room, revealed nursing did not have an order for a splint device for Resident #42. Interview with the Occupational Therapist (OT) on 5/15/19 at 11:27 AM, in the Physical Therapy Gym, revealed .new goal for the resident to tolerate a left hinged elbow splint was added 9/25/18 to 10/8/18. Her recertification was 10/2/18 to 11/20/18 she was on goal for the elbow splint. She was making progress, and tolerated well .Staff was educated pertaining to ROM before and after the splint device was placed. She was discharged with a hinged elbow brace, and was recommended for the restorative nursing program for her hinged elbow brace . Medical record review of the Physician's Order Sheet for Resident #42, dated 11/1/18 to 11/30/18 revealed no order for restorative nursing or for splint device use. Interview with the Restorative Nurse on 5/15/19 at 11:44 AM, in the Director of Nursing's (DON) office, revealed Resident #42 never received restorative nursing services and was never referred by OT for restorative nursing. Observation and interview with the OT on 5/15/19 at 11:58 PM, in the resident's room, revealed ROM in the right upper extremity was the same with no further decline since the residents discharge from therapy services, despite having not received the recommended services. Interview with the DON on 5/15/19 at 12:08 PM, in the DON's office, confirmed the facility failed to provide an assistive device for limited range of motion for Resident #42.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure a sanitary environment for 1 room (Resident #15's) of 91 resident' rooms observed. The findings include: Medical record review revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including Transient Cerebral Ischemic Attack, Cerebral Vascular Disease, Ataxia, Hypertension, Major Depression, Anxiety, and Chronic Kidney Disease. Medical record review of a Minimum Data Set (MDS) dated [DATE] revealed Resident #15's Brief Interview for Mental Status (test for cognitive ability) score was 13, indicating the resident was cognitively intact. Continued review revealed the resident required one person physical assist with toileting and bathing and supervision with personal hygiene. Observations on 5/13/19 at 10:30 AM and 3:42 PM, in Resident #15's room revealed a strong odor of urine. Observation on 5/14/19 at 8:55 AM, of Resident #15's room revealed a strong odor of urine. Continued observation revealed a fly on the resident's arm and on the resident's computer. Interview with Licensed Practical Nurse #1 on 5/14/19 at 2:21 PM, on the 100 Hall confirmed she was aware of the odor in Resident #15's room. Interview with the Plant Operations Coordinator on 5/14/19 at 3:20 PM, at the 100/200 hall nurses' station confirmed he was aware of the odor in Resident #15's room. Observation on 5/15/19 at 8:32 AM, in Resident #15's room revealed a strong odor of urine. Further observation revealed flies flying around the resident. Continued observation revealed a fly landed on the resident's forehead, and the resident swatted the fly with his hand. Interview with Resident #15 on 5/15/19 at 8:40 AM, in the resident's room revealed the resident had occasionally seen flies in his room. Observation of Resident #15 and interview with the Director of Nursing (DON) on 5/15/19 at 8:50 AM, in Resident #15's room revealed a strong odor of urine and flies in the resident's room. Continued observation revealed a fly landed on the resident's forehead. Interview with the DON confirmed the presence of a strong urine odor and the presence of flies in his room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a facility job description, review of medical records, review of personnel records and interview, the facility failed to ensure 1 resident (#450) received transportation to a physician's follow-up appointment, of 3 residents reviewed for resident/facility transportation. The findings included: Review of the facility job description Transportation Aide (CNA) [Certified Nursing Assistant] revealed .transport residents to appointments and perform direct resident care duties under the supervision of licensed nursing personnel .notify family of arrangements in regards to appointments .report changes in condition to Charge Nurse . Medical record review revealed Resident #450 was admitted to the facility on [DATE] with diagnoses including Rheumatoid Arthritis without Rheumatoid Factor, Encounter for Orthopedic Aftercare, Presence of Right Artificial Knee Joint, Idiopathic Scoliosis, and Constipation. Medical record review of a Physician/Prescriber Order dated 4/16/18 revealed .F/u [follow-up] .5-14-18 .facility to transport . Telephone interview with the husband of Resident #450 on 6/11/18 at 1:15 PM revealed the facility did not transport the resident to her follow-up orthopedic appointment on 5/14/18. He revealed he was called on the phone by a staff member (could not recall name) and informed the facility was too busy . could not take her to the appointment. Interview with CNA #1 on 6/11/18 at 4:00 PM, in the Station 3 breakroom, confirmed she was scheduled to transport Resident #450 for a follow-up appointment with an orthopedic surgeon on 5/14/18 in the facility van. Further interview confirmed CNA #1 canceled the physician appointment .she had to go to the bathroom, she is a 2 person assist .I had to find help .it took her a long time to go .we would have been 10 minutes late . Continued interview confirmed CNA #1 did not notify the nurse or the family prior to canceling the appointment. Review of the personnel file for CNA #1, Coaching & Counseling Session, dated 5/14/18 revealed .insubordination, non performance of .duties or assignments .cancelled/rescheduled a resident's previously scheduled appointment without due cause .failed to properly notify family of the cancellation/rescheduling of the resident's appointment . Interview with the Director of Nursing (DON) on 6/12/18 at 10:50 AM, in the DON office, confirmed the facility failed to ensure Resident #450 was transported to a scheduled outside physician appointment; and failed to to notify the assigned nurse and family prior to the appointment cancellation.

Based on review of facility policy, observation, and interview, the facility failed to separate resident and staff food products in 1 of 3 nourishment refrigerators, failed to maintain a sanitary environment in 1 of 3 nourishment rooms, and failed to discard expired food in 1 of 3 nourishment refrigerators observed. The findings included: Review of the facility policy Food from Outside Sources revised 11/10/17 revealed .perishable food should be sealed and dated with a use-by-date . Review of the facility policy Food Storage revised 8/9/17 revealed .any expired or outdated food products should be discarded .the walls, ceiling, and floor should be maintained in good repair and regularly cleaned . Observation and interview with the Certified Dietary Manager (CDM) on 6/12/18 at 10:45 AM, of Station 3 nourishment room, in the refrigerator labeled resident food, revealed in the bottom drawer, a unlabeled, undated grocery bag with 1 opened bag of flatbread, 1 opened bag of snacking chocolate, 1 opened jar of peanut butter, 1 banana, and 1 ziplock bag of graham crackers. Further observation of Station 3 nourishment room revealed in the top drawer under the countertop, sawdust, from the decomposed drawer, along with ketchup, mustard, and other condiment packets. Continued observation in the cabinet under the working sink revealed a layer of sawdust with 1 coffee pot, 1 Christmas cup, and 1 plastic container. Interview with the CDM confirmed the food in the unlabeled, undated grocery bag was staff food not resident food and the facility failed to separate resident and staff food products , and failed to maintain a sanitary drawer and cabinets under the working sink. Observation and interview with the CDM on 6/12/18 at 11:00 AM, of Station 2 nourishment room, revealed in the refrigerator labeled resident food, 3 Vitamin D milk cartons (236 milliliters) expired 6/11/18. Interview with the CDM confirmed the facility failed to discard the expired milk and was available for resident use.