**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 1 of 23 sampled residents, that the facility failed to ensure that a resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. Specifically, individualized accommodations to keep a resident's telephone and radio within reach was not provided. Resident identifier: 50. Findings include: Resident 50 was admitted to the facility on [DATE] with diagnoses which included dementia, neurocognitive disorder with lewy bodies, pain, insomnia, hypertension, major depressive disorder, anxiety, type 2 diabetes mellitus, post-traumatic stress disorder, glaucoma, and fibromyalgia. On 2/26/24 at 9:50 AM, an observation was made of resident 50's room. Resident 50 was in bed. Resident 50's bed was placed against a wall that had peeling paint and 4 screws with nothing attached to them. There was a telephone, a radio, and a large cup of fluid with a lid on it sitting on the bed between the resident and the wall. On 2/26/24 at 9:50 AM, an interview was conducted with resident 50. Resident 50 stated his radio and telephone were on his bed because they got knocked off when they were put on his bedside table. Resident 50 stated he had requested to have a shelf placed on the wall to put his items on, so they were not on his bed. Resident 50 stated he had asked facility staff and put in a ticket for maintenance about three months ago, but that it had not been put up yet. Resident 50 further stated he was blind and needed his items within reach. Resident 50's medical record was reviewed from 2/26/24 through 2/28/24. A quarterly Minimum Date Set (MDS) dated [DATE] revealed resident 50 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated cognitive status was intact. It further indicated that resident 50 required extensive assistance with bed mobility. Bed mobility was how resident moved to and from lying position, turned side to side, and positioned body while in bed or alternate sleep furniture. On 2/28/24 at 12:04 PM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated resident 50 liked to have his tape player and radio on a shelf on the right side of his bed. CNA 2 stated that the facility needed to leave them within reach because he was blind. CNA 2 stated resident 50 had a shelf on the wall but it fell off approximately four to five months ago and had not been put back up. CNA 2 stated resident 50 requested to have the shelf replaced about two to three months ago and that they filled out a work order for the shelf to be put back up. On 2/28/24 at 1:06 PM, an interview was conducted with the Maintenance Manager. The Maintenance Manager stated he had put items up on resident 50's wall, which included a shelf, but that resident 50 ripped them down. The Maintenance Manager stated he did not have a request to replace his shelf. The Maintenance Manager stated resident 50's phone was hung directly on the wall, but it was ripped down too. The Maintenance Manager stated he was aware of the wall missing paint and having screws but that he had not told his helper to paint it. On 2/28/24 at 2:22 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the shelf had been fixed several times but that it had been pulled off the wall because resident 50 tried to reposition himself with it. The DON stated that if a work order was placed it should have been fixed and that the shelf should have been reaffixed to resident 50's wall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not send a copy of resident 30-day discharge notices or hospitalizations to the Long-Term Care Ombudsman. Resident identifiers: 30. Findings include: 1. Resident 30 was admitted to the facility on [DATE] with diagnoses which included Schizophreniform disorder, dementia, heart failure, nausea and neuromuscular dysfunction of bladder. A nursing progress note dated 5/3/23 at 6:15 AM revealed, .Sent to ER [emergency room] for uro-sepsis .decision made to send to ER for further evaluation . A nursing progress note dated 5/4/23 at 3:45 PM revealed, [Resident 30] returned from the VA hospital this afternoon . On 2/28/24 at 2:04 PM, an interview was conducted with the Office Specialist. The Office Specialist stated the facility Licensed Clinical Social Worker (LCSW) was the staff member in charge of notifying the Ombudsman of discharges. On 2/28/24 at 2:15 PM, an interview was conducted with the LCSW. The LCSW stated if there were concerns about a residents, then she contacted Adult Protective Services (APS) or ombudsman. The LCSW stated she did not notify the Ombudsman about discharges. On 2/28/24 at 2:17 PM, an interview was conducted with the Administrator. The Administrator stated she was not aware the Ombudsman needed to be notified of a residents transfer or discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, for 1 of 23 sampled residents, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident who required substantial two person assistance for transfers was left unattended on the side of her bed and sustained a fall. Resident identifier: 6. Findings include: Resident 6 was admitted to the facility initially on 11/29/21, and re-admitted on [DATE] with diagnoses that included cerebral infarction due to embolism, fracture left lower leg, anxiety disorder, hemiplegia and hemiparesis, aphasia, multiple sclerosis, age related osteoporosis, major depressive disorder and Post Traumatic Stress Disorder (PTSD). On 2/26/24 at 10:07 AM, an interview was conducted with resident 6 who stated she had fallen earlier on that day. Resident 6 stated she was on the floor for a while and was unable to push her call light due to it being on the bed and she was on the floor. Resident 6 stated she fell on her right side. Resident 6 was observed to have large contusion above her right eye, bruising and swelling on the right side of her face. Resident 6 stated she was experiencing pain. Resident 6's medical records were reviewed. An annual Minimum Data Set (MDS) assessment dated [DATE] revealed that resident 6 required 2 person physical assistance to move between surfaces. A fall risk evaluation dated 1/13/24 revealed that resident 6 was at risk for falls related to having had multiple falls, decreased muscular condition, and that the resident was non-ambulatory. An additional fall risk assessment dated [DATE] revealed that resident 6 was at risk for falls related to having had multiple falls, decreased muscular condition, and that the resident was non-ambulatory. Resident 6's care plan included that resident 6 had an ADL [activities of daily living] self-care performance deficit related to left middle cerebral artery stroke. The goal was, Will improve current level of function being able to go from substantial to moderate to minimal with part of her upper body dressing through the review date. Interventions included, .Transfer: [resident 6] relies on one to two-person substantial to total assist with gait belt for transferring safety from bed to w/c [wheelchair] and back . Initiated on 10/28/22 and revised on 12/12/23. Resident 6's care plan also included that, [Resident 6] has limited physical mobility r/t [related to] her left sided stroke. She does not walk and is moderate to total assist for mobility and transfers. The goal was, [Resident 6] will remain free of complications related to decreased mobility, including contractures, thrombus formation, skin break-down, fall related injury through the next review date. Interventions included, LOCOMOTION: [Resident 6] uses a motorized wheelchair. She relies on staff to put her in the chair and take her out for her safety. Initiated on 10/28/22 and revised on 7/6/23. The Certified Nursing Assistant (CNA) [NAME] for informing CNA's of resident's care needs included, Safety .11/6/23 Education provided to staff on safe transfers. [Resident 6] needs two person max assist with transferring on to scale or use of wheelchair .4/27/23 Staff to remain with [resident 6] when she is attempting to get up on her own and call for more assistance if needed. [Resident 6] often will not wait for staff to get more assistance and will continue to attempt to get up on her own. In the CNA task management, documentation for transfers revealed that within the past 30 days, resident 6 received supervision or touching assistance 1 time, partial to moderate assistance 12 times, substantial to maximal assistance 28 times, and was completely dependent 8 times. A progress note dated 2/26/24 at 8:43 AM revealed, Patient was found face down on the floor bedside. CNA left patient unattended sitting up in bed and went looking for extra help to transfer patient into wheelchair. Patient states she lost balance and fell over to the floor. [Family member's name removed] was left a voicemail. No emergency contacts answered. Patient's right upper quadrant of face, temporal, and eyebrow area swollen. Patient says she feels pain in her shoulder and general pain on right side due to falling on it. ROM [range of motion] intact. No other injuries found. Neurology checks initiated. A progress note dated 2/27/24 at 1:42 PM revealed, Follow-up note in regard to recent ground fall. Patient's right upper face/eyebrow/eye/temple continues to be swollen and appears bruised. No open areas noted. Patient continues to verbalize discomfort and pain in right neck/shoulder/arm region. Regular pain medications and pain relieving gel applied . A progress note dated 2/27/24 at 1:46 PM revealed, Resident had a previous fall. A new bruise was noted from post fall assessment on the top right of her lip . A physician progress note dated 2/27/24 at 4:35 PM revealed, Reason for visit/cc: fall, head trauma. Medical necessity visit to evaluate patient after unwitnessed GLF [ground level fall] where patient hit right side of head. Found face down on floor at bedside. NO LOC [loss of consciousness]. Sustained contusion to right temple and cheek, as well as right upper lip. Patient states she lost balance and fell over to the floor. Neurology checks initiated .HEENT [head, ears, eyes, nose, and throat examination]: Contusion of right eye, right temple, right zygomatic arch. Eyelids swollen but still able to keep eye open. Area is swollen and tender to touch. Right upper lip with bruising but minimal swelling .Assessment and Plan: #GLF; #Head trauma; #Hx [history] of CVA [cerebral vascular accident] on DOAC [Direct Oral Anticoagulant] and ASA [Aspirin]; #Headache .Alerted both floor RN [Registered Nurse] and nurse supervisors to monitor headache and for focal neurologic findings, increased irritability or lethargy, notify provider immediately to send to ED [emergency department] for trauma eval. On 2/28/24 at 12:40 PM, an interview was conducted with CNA 1. CNA 1 stated if she found a resident who had an un-witnessed fall she would go and get a nurse before moving the resident to ensure there were no injuries. CNA 1 stated she would complete her part of the incident report and check the resident's vital signs. CNA 1 stated that resident 6 was a 2 person transfer. On 2/28/24 at 2:14 PM, an interview was conducted with CNA 2 who stated resident 6 needed a 1 to 2 person extensive assistance depending on how she was doing or if she was feeling weak. CNA 2 stated sometimes resident 2 was not very steady. CNA 2 then stated resident 2 needed 2 staff members to assist with transfers so that she would not fall. On 2/28/24 at 1:25 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the CNAs should ensure that a resident was in a safe position before going to get another staff member for assistance with transferring a resident. The DON stated, related to resident 6's fall on 2/26/24, a new aid was working with resident 6. The DON stated the new CNA was provided education on how to use the [NAME] and review the fall interventions for residents. The DON stated that most of the things in the care plan transferred over to the [NAME] for the CNAs. On 2/28/24 at 2:34 PM, a follow-up interview was conducted with the DON. The DON stated, in the CNA task management area for transfers, if it was checked under supervision/touching assistance or partial/moderate that it indicated the resident had received a 1 person assist. The DON stated if it was checked under substantial/maximal or dependent that it indicated the resident had received a 2 person assist.

Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety, Specifically, food service staff were not wearing hair restraints while preparing and serving food. Findings include: On 2/27/24 at 11:19 AM, an observation of trayline was conducted. [NAME] 1 was observed to be wearing a mask and gloves, and was preparing to serve the lunch meal at the steam table. [NAME] 1 was not wearing any type of hair covering. On 2/27/24 at 11:19 AM, an observation was made of the Maintenance Manager. The Maintenance Manager was observed walking through the kitchen with no hair covering. On 2/27/24 at 12:18 PM. an observation was made of the Assistant Dietary Manager. The Assistant Dietary Manager was observed walking throughout the kitchen, into and out of the walk-in refrigerator, and preparing a dessert item with no hair covering. On 2/28/24 at 3:17 PM, an interview was conducted with the Dietary Manager (DM). The DM stated she did not require male kitchen staff to wear hair coverings if their hair was very short, and had not required staff who had a beard to wear hair coverings for their beards. The DM stated the Maintenance Manager came into the kitchen occasionally and did not wear hair coverings while in the kitchen. The DM stated kitchen staff with longer hair could wear a ball cap as a hair covering as long as they were clean shaven.

Based on observation and interview, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 2 out of 23 sampled residents, a staff member was observed to touch the resident's medications with their bare hand during medication administration. Resident identifiers: 62 and 70. Findings included: 1. On 2/28/24 at 8:34 AM, an observation was made of Licensed Practical Nurse (LPN) 1 during medication administration. LPN 1 was observed preparing medications for resident 70. LPN 1 was observed to dispense the medications from medication bottles. LPN 1 opened each bottle and shook the medication bottle until a tablet was near the edge of the bottle. LPN 1 took a bare finger and touched the medication, assisting the tablet into the bottle lid, and then placing the tablet into the medication cup. No hand hygiene was observed prior to touching cholecalciferol tablet 1000 units, famotidine tablet 40 milligrams (mg), and multivitamin with minerals tablet. LPN 1 was observed to administer the medications to resident 70. 2. On 2/28/24 at 8:40 AM, an observation was made of LPN 1 preparing medications for resident 62. LPN 1 was observed to dispense the medications from medication bottles. LPN 1 opened each bottle and shook the medication bottle until a tablet was near the edge of the bottle. LPN 1 took a bare finger and touched the medication, assisting the tablet into the bottle lid, and then placing the tablet into the medication cup. No hand hygiene was observed prior to touching acetaminophen 1000 mg, ascorbic acid 500 mg, cyanocobalamin 1000 micrograms, and senna docusate sodium 8.6-50 mg. LPN 1 was observed to administer the medications to resident 62. On 2/28/24 at 10:47 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that she would sanitize her hands prior to preparing resident medications and between resident medication preparations. RN 1 stated that she would sanitize her hands with alcohol based hand rub (ABHR) up to three times unless she touched the resident or administered insulin then she would wash her hands with soap and water. RN 1 stated that she would never bring other resident's medications in resident rooms or leave the medications anywhere. RN 1 stated if she needed to handle resident medication she would put gloves on. RN 1 stated she did not want to handle any resident medications with bare hands nor would she want any of her medications touched. On 2/28/24 at 10:55 AM, an interview was conducted with LPN 1. LPN 1 stated that she would wash her hands and use ABHR between residents. LPN 1 stated if a medication fell on the medication cart she would throw the medication away. LPN 1 stated she would try not to touch a resident's medications. LPN 1 stated if she needed to touch a resident's medications with her bare hand she would put on a glove I guess. On 2/28/24 at 11:00 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the staff used barriers like cups and paper towels to pass medications and not breach infection control. The DON stated that each resident had their own glucometer that the staff cleaned between each use. The DON stated that staff should not touch resident medications with their bare hands and hand sanitization should be done between each resident.

Based on observation and interview, it was determined, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, there were four chairs with missing seat cushions on the Memory Care Unit (MCU). Findings included: On 6/6/22 at 1:28 PM, an observation was made of four blue padded chairs without seat cushions. Two of the chairs were located in the MCU television room and the other two chairs were located in the MCU alcove. On 6/7/22 at 1:37 PM, an observation was made of the same four blue padded chairs on the MCU without seat cushions. On 6/7/22 at 1:44 PM, an interview was conducted with Registered Nurse (RN) 1 and Speech Therapist (ST) 1 on the MCU. RN 1 and ST 1 stated that the seat cushions from the four padded blue chairs on the MCU had been soiled and removed by housekeeping. RN 1 and ST 1 further stated that the seat cushions had been missing from the MCU for about a month. On 6/8/22 at 9:16 AM, an observation was made of the same four blue padded chairs on the MCU without seat cushions. On 6/8/22 at 11:33 AM, an interview was conducted with the Housekeeping Manager (HM). The HM stated that the four seat cushions from the MCU had become soiled and she had taken them to the laundry area to clean them. The HM stated she had removed the four seat cushions from the MCU about a week ago. The HM stated she was going to clean and return the seat cushions later today. On 6/8/22 at 12:47 PM, an interview was conducted with the Administrator. The Administrator stated she expected soiled furniture to be cleaned and returned within a day or two.

Based on interview and record review, it was determined, that the facility did not ensure that the Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of action to correct identified quality deficiencies. Specifically, the facility was found to be in non-compliance with F812 which was cited within the facility's 2017, 2018, and 2019 recertification survey. In addition, the facility was found to be in non-compliance with F584 which was cited within the facility's 2019 recertification survey. Findings included: An annual recertification survey was completed on 9/27/17. During the survey deficiency F371 (F812) was cited. An annual recertification survey was completed on 12/12/18. During the survey deficiencies F641, F697, F732, F756, F760, and F812 were cited. An annual recertification survey was completed on 12/19/19. During the survey deficiencies F554, F580, F584, F600, F609, F656, F676, F689, F695, F759, F760, F761, and F812 were cited. 1. Based on observation and interview, it was determined, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, there were four chairs with missing seat cushions on the Memory Care Unit. [Cross Reference F584] 2. Based on observation and interview, it was determined, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the walk-in freezer were open to air, and food items in the walk-in refrigerator were past the manufacturers use-by date. [Cross Reference F812] On 6/8/22 at 3:36 PM, an interview was conducted with the Administrator. The Administrator stated that all of the leadership team and both Certified Nursing Assistant coordinators attended the monthly QAA meeting. The Administrator stated that the Medical Director attended the QAA meeting monthly and the Pharmacist was invited. The Administrator stated that QAA concerns would come from the floor or the nursing department. The Administrator stated that what ever concerns were sent to her were sent to Quality Assurance and Performance Improvement. The Administrator stated that the kitchen had been discussed in the QAA meeting. The Administrator stated a Manager was responsible for assisting with serving all meals and eating a meal tray once a day. The Administrator stated a Manager would inspect the kitchen once a month. The Administrator stated a Manager was scheduled to be in the facility six days a week.

Based on observation and interview, it was determined, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the walk-in freezer were open to air, and food items in the walk-in refrigerator were past the manufacturers use-by date. Findings included: On 6/6/22 at 9:06 AM, an initial walk-through of the kitchen area was conducted. In the walk-in refrigerator, a container of sour cream with an open date of 5/10/22, and a use-by date of 5/24/22, was observed. A container of cottage cheese was also observed with a use-by date of 6/3/22. On 6/6/22 at 9:15 AM, an observation was made of the walk-in freezer. A box of frozen doughnut-holes were observed open to air. A box of pre-made omelets were also observed open to air. On 6/8/22 at 3:00 PM, a second walk-through was conducted of the kitchen. In the walk-in refrigerator, the sour cream container with a use by date of 5/24/22, and the cottage cheese container with a use by date of 6/3/22, were observed to still be in the refrigerator. In the walk-in freezer, an observation was made of the doughnut-holes open to air, the pre-made omelets open to air, and a box of ready to cook turkey breast open to air. On 6/8/22 at 3:11 PM, an interview was conducted with Dietary Aide (DA) 1. DA 1 stated when she would pull an item out of the refrigerator, she would check the date before using the item. DA 1 stated the open date and the use by date were supposed to be wrote on the food item. DA 1 stated food items needed to be covered with a lid, cling wrap, or in a sealed container. DA 1 stated she was not sure what to do with food items that were in boxes. DA 1 stated she would not feel comfortable using food items if they were past the use by date but would ask the Dietary Manager (DM) before throwing the food item away. On 6/8/22 at 3:15 PM, an interview was conducted with the DM. The DM stated she was the person who checked the dates of food items in the refrigerator and freezer. The DM stated she was especially watching the dates on salad dressings as they had been receiving items that were close to the expiration date. The DM stated she would refuse items that were delivered past their use by date or expired. The DM stated once a food item was opened a use by date of 7 days out from the open date was wrote on the food item container. The DM stated this was especially for dairy products. The DM stated if food items were expired or past the use by date, they did not use the food item. The DM stated an open date should be wrote on boxed food items also, and food items in the refrigerator and freezer should be closed or put in a zip-lock baggies for storage. The DM stated food items in boxes could also be taped back up to prevent contamination. The DM stated she went through the refrigerator every couple of days to ensure food items were not expired. The DM was shown the sour cream and cottage cheese in the walk-in refrigerator and acknowledged that they were past the use by and expiration dates and should have been thrown away. The DM removed the items from the walk-in refrigerator. The DM stated she would check the freezer to ensure the food items were all sealed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 1 of 28 sampled residents, that the facility did not determine if a resident was clinically appropriate to self-administer medications. Specifically, a resident was self-administering medication without being evaluated for safety. Resident identifier: 74. Findings include: Resident 74 was admitted to the facility on [DATE] with diagnoses which include hypertension, post-traumatic stress disorder, congestive heart failure, major depression, and type 1 diabetes. On 12/18/19, Licensed Practical Nurse (LPN) 1 was observed to prepare and administer medications to resident 74. LPN 1 stated that resident 74 kept at bedside and self-administered the Flonase medication. LPN 1 was observed to document on resident 74's Medication Administration Record that the Flonase was administered. LPN 1 stated that she would usually ask resident 74 if he had self-administered the Flonase medication. LPN 1 was observed and did not ask resident 74 about the administration of the Flonase medication. A record review for resident 74 was completed on 12/18/19. A self-administration of medication assessment dated [DATE], documented that resident 74 would like to self-administer medications. The form documented that resident 74 had no impairment in visual ability, was alert and oriented to person, place and time, and was physically able to self-administer medications. The form further documented that there was no other reason that resident 74 should not self-administer medications and resident 74 was capable of self-administration. A physician's order dated 9/27/18, documented Flonase Allergy Relief Suspension 2 sprays in both nostrils one time a day from allergies. [Note: The physician's order did not include a self-administration order for resident 74.] A care plan Focus dated 10/3/18, documented that Resident 74 had a physician's order for unsupervised self-administration of the following medications: lidocaine cream and Symbicot inhaler. The Goal was that Resident 74 would demonstrate the ability to take the medication at the correct dose, route, time frequency, and for the right reason. The Interventions developed was to assess resident 74's ability to safely self-administer medications specified on admission and re-admission, quarterly, with a change in medication orders, and with significant changes of condition. Discuss medications with each supervised administration. Demonstrate correct administrations as required. Review each medication as necessary with the client. [Note: The self-administration assessment was last completed on 4/23/19, which was over 7 months since the last assessment. This does not meet the quarterly requirement as specified in the care plan.] On 12/18/19 at 12:37 PM, an interview was conducted with LPN 1. LPN 1 stated that if a resident self-administered medications a physician's order to self-administer medications would be in the resident medical record. LPN 1 stated a nurse would assess the resident to determine safety for self-administration of medications. LPN 1 stated that she did not know how often the assessments were completed. On 12/18/19 at 1:07 PM, an interview was conducted with LPN 2. LPN 2 stated that if a resident requested to self-administer medications the facility did an assessment to ensure the resident was safe to self-administer medications. LPN 2 stated that if a resident was self-administering medications it would be located on the care plan. On 12/18/19 at 1:23 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that if a resident self-administered medications it would be located in the physician's orders and an assessment would have been documented. RN 1 stated that the assessment should be completed yearly or every 6 months, and that one of the supervisors completed the assessments. RN 1 stated if a resident was self-administering medications it would also be located on the care plan. On 12/18/19 at 3:11 PM, an interview was conducted with resident 74. Resident 74 stated that he did not self-administer any medications, and that staff gave him all his medications. Resident 74 stated that he did not have any medications at bedside. Resident 74 further stated that he had nasal spray at the bedside. Resident 74 stated the he did not take the nasal spray, but if the staff asked he would just lie and tell them that he had taken it. On 12/19/19 at 7:30 AM, an interview was conducted with Assistant Director of Nursing (ADON) 1. ADON 1 stated that she did not know if any residents self-administered medications. ADON 1 stated that she thought resident 74 might self-administer his medications but if he did he does not administer them alone, he does it with supervision and guidance of a nurse. ADON 1 stated that if a resident self-administered medications there must be a physician's order to self-administer, an assessment to determine if the resident was safe to self-administer medications, a care plan, and a consent form. ADON 1 stated she did not know how often a self-administration assessment should be completed, she thought it was either quarterly or annually. On 12/19/19 at 7:51 AM, an interview was conducted the Director of Nursing (DON). The DON stated that for a resident to self-administer medications an assessment should be completed. The DON stated that he believed the assessment should be updated every 6 months. The DON stated that there would be an order for self-administration in the resident physician's orders.

Based on observation, interview, and record review it was determined, for 4 of 28 sampled residents, that the facility did not provide a safe, clean, comfortable, and homelike environment. Specifically, resident wheelchairs were soiled and arm rests were cracked. Resident identifiers: 14, 22, 29, and 37. Findings include: 1. On 12/16/19 at approximately 9:00 AM, an observation was made of resident 37's wheelchair. Resident 37's wheelchair was observed to have a white and brown substance on the cushion, down the side of the wheelchair and on resident 37's shoe. On 12/19/19 at 10:29 AM, an observation was made of resident 37's wheelchair. Resident 37's wheelchair was observed to have a white and brown substance on the cushion, down the side of the wheelchair and on resident 37's shoe. 2. On 12/19/19 at 11:08 AM, an observation was made of resident 29's wheelchair. Resident 29's wheelchair was observed to have ripped arm rests. Resident 29 stated that he has had the wheelchair for 3 months with the ripped arm rests. 3. On 12/16/19 at 2:09 PM, an observation was made of resident 22's wheelchair. Resident 22's wheelchair was dirty, there was food on the cushions and the metal parts of the wheelchair. 4. On 12/17/19 at 7:43 AM, an observation was made of resident 14's wheelchair. Resident 14's wheelchair was observed to have ripped arm rests. On 12/19/19 at 10:30 AM, an interview was conducted with Certified Nursing Assistant (CNA) 7. CNA 7 stated that wheelchairs were cleaned during the afternoon shift and if the wheelchairs were not cleaned then it was passed onto the next shift. On 12/19/19 at 10:40 AM, an interview was conducted with CNA 2. CNA 2 stated that wheelchairs were cleaned during the graveyard shift. CNA 2 stated she was not sure how often wheelchairs were cleaned. CNA 2 stated that if wheelchairs are soiled during other shifts then the CNAs were to clean them immediately. On 12/19/19 at 10:54 AM, an interview was conducted with the CNA coordinator. The CNA coordinator stated that wheelchairs were cleaned weekly. The CNA coordinator stated the staff cleaned wheelchairs during the graveyard shift. The CNA coordinator stated that resident 37's wheelchair should have been cleaned on 12/18/19, according to the schedule. The CNA coordinator was observed to look at resident 37's wheelchair and stated the wheelchair was soiled. The CNA coordinator stated that staff filled out a work order for the maintenance director to be notified if a wheelchair needed to be repaired. The CNA coordinator stated that if the facility can not fix the wheelchair then the resident was provided a new wheelchair until it was repaired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 2 of 28 sampled residents, that the facility did not develop and implement a comprehensive person-centered care plan for each resident. Specifically, a resident that had a physician's order for oxygen did not have specific interventions developed and another resident's care plan was not updated with interventions after falls. Resident identifiers: 9 and 66. Findings include: 1. Resident 66 was admitted to the facility on [DATE] with diagnoses which included atherosclerotic heart disease, hypertension, gastro-esophageal reflux, anxiety disorder, dementia, and femur fracture. On 12/16/19 at 7:54 AM, a continual observation was made of resident 66. Resident 66 was observed in the dining room with the nasal cannula for the oxygen on the floor. Resident 66's oxygen tank had a dial that was on empty. At 8:56 AM, an observation was made of resident 66 wheeling himself in the hallway with his nasal cannula on the floor. Resident 66 was observed to wheel himself in his wheelchair to his room. Resident 66 was observed to ask Certified Nursing Assistant (CNA) 4 to help him get into bed. CNA 4 was observed to assist resident 66 into his bed. CNA 4 did not offer or apply resident 4's oxygen. CNA 4 was interviewed immediately. CNA 4 stated that she did not work on that hallway and did not know resident 66 and did not know if resident 66 needed oxygen. At 8:59 AM, CNA 5 was observed to check resident 66's pulse oxygen saturation level. Resident 66's pulse oxygen saturation level was 84% on room air. CNA 5 stated that resident 66's pulse oxygen saturation level was low and he needed oxygen at all times. CNA 5 stated that resident 66 needed 2 liters of oxygen. CNA 5 stated she did not know why he did not have his oxygen on. CNA 5 was observed to turn on the oxygen concentrator that was plugged into the wall and use the nasal cannula that was connected to the oxygen concentrator. CNA 5 confirmed that resident 66's portable oxygen tank on his wheelchair was empty. On 12/17/19 at 1:06 PM, an observation was made of resident 66 in the hallway. Resident 66 did not have a nasal cannula with oxygen on. Resident 66 was observed to propel himself in his wheelchair through the hallways asking staff to make his bed. Resident 66 was observed to ask CNA 6 if she would make his bed. CNA 6 was observed to tell resident 66 that CNA 7 would make his bed because CNA 6 told resident 66 she had to finish my work. Restorative Nursing Assistant (RNA) 1 was observed to be asked to help make resident 66's bed. RNA 1 was observed to go to resident 66's room and make his bed. At 1:27 PM, resident 66 was in his room with no oxygen. RNA 1 was observed to transfer resident 66 into his bed. RNA 1 was not observed to place oxygen on resident 66. At 2:17 PM, CNA 8 was observed to check resident 66's pulse oxygen saturation level. Resident 66's pulse oxygen saturation level was 84% on room air. Resident 66 was observed to ask CNA 8 why he did not have his oxygen on because he needed it. CNA 8 stated that resident 66 did not use oxygen at all times and only when he needed it. CNA 8 stated that she checked resident 66's pulse oxygen saturation level before she got him out of bed in the morning and before lunch. Resident 66's medical record was reviewed on 12/16/19. A significant change Minimum Data Set (MDS) assessment dated [DATE], revealed that resident 66 had shortness of breath with exertion and while lying flat. The MDS further revealed that resident 66 used oxygen while a resident at the facility. A care plan dated 6/21/18 and revised on 7/2/18, revealed [Resident 66] has had altered respiratory status/difficulty breathing requiring oxygen prn (as needed). The goal developed was, [Resident 66] will have no s/sx (signs and symptoms) of poor oxygen absorption through the review date. The intervention developed was, Position resident with proper body alignment for optimal breathing pattern. [Note: There was no information about monitoring oxygen pulse saturation levels or the amount of oxygen resident needed.] A physician's order dated 11/28/19, revealed Oxygen 1-4 liters per nasal canula (sic) to keep sats > 90%. Document O2 (oxygen) sats and liters per minute. every shift. Resident 66's vitals signs were reviewed and resident 66's pulse oxygen saturation levels were documented as the following: a. On 8/1/19 at 9:49 AM, 94.0 % on room air. b. On 9/22/19 at 9:36 PM, 94.0 % on room air. c. On 10/14/19 at 1:10 PM, 93.0 % on room air. d. On 11/24/19 at 1:59 PM, 90.0 % on room air. e. On 12/3/19 at 9:58 PM, 92.0 % on room air. f. On 12/16/19 at 8:27 AM, 95.0 % on room air. g. On 12/16/19 at 9:50 PM, 93.0 % on oxygen via nasal cannula. h. On 12/17/19 at 10:18 AM, 92.0 % on room air. The CNA documentation tasks section was reviewed. On 11/25/19, resident 66's oxygen was 90%. There were no other pulse oxygen saturation levels documented over the last 30 days. On 12/19/19 at 9:23 AM, an interview was conducted with Medical Director (MD) 1. MD 1 stated she was resident 66's physician. MD 1 stated that resident 66 refused oxygen at times and had taken it off in the past. MD 1 stated that if resident 66 was asking to have oxygen then the staff should test the pulse oxygen saturation level and place oxygen on him. On 12/19/19 at 10:42 AM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated that since resident 66 had fractured his femur he had required more oxygen. LPN 4 stated that staff checked resident 66's pulse oxygen saturations when he asked to have it done a few times a day. LPN 4 stated that when resident 66's pulse oxygen saturation was less than 90% the staff would put the oxygen on resident 66 and then recheck until it was above 90%. LPN 4 stated that resident 66 occasionally refused to have oxygen on but if his pulse oxygen saturations were low he allowed staff to place the oxygen. LPN 4 stated that if resident 66's pulse oxygen saturations was less than 90%, then staff placed resident 66 on 1 liter of oxygen. On 12/19/19 at 11:52 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the physician's order was for resident 66 to have 1 to 4 liters of oxygen at all times. The DON stated that the liters of oxygen and the pulse oxygen saturations were not documented. The DON stated if a pulse oxygen saturation level was lower than 90 he would expect staff to recheck and then document the original pulse oxygen saturation level and the follow up level. The DON stated that he would expect the CNAs to document the initial pulse oxygen saturation level. The DON stated he was not sure how staff were monitoring the amount of oxygen resident 66 required. 2. Resident 9 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, psychosis, chronic obstructive pulmonary disease, hypertension, and arthritis. On 12/16/19 at 2:17 PM, an interview was conducted with resident 9's family member. Resident 9's family member stated that resident 9 had experienced multiple falls. Resident 9's family member stated that resident 9 had a fall a few weeks ago that resulted in 2 black eyes and a laceration to the head. Resident 9's family member stated that resident 9 experienced a fall and her alarm was not on. Resident 9's medical record was reviewed on 12/18/19. A significant change MDS assessment dated [DATE], revealed that resident 9 had not experienced a fall since the last MDS was completed. A care plan dated 7/26/15 and updated on 12/2/19, revealed [Resident 9] is at high risk for falls r/t (related to) cognitive and visual deficits and alterations in physical mobility, she is legally blind and needs staff to walk with her, her gait can be unsteady, poor safety awareness. She often refuses to walk and uses w/c (wheelchair) most of the time. The goal developed was [Resident 9] will have no unaddressed injury related to falls through the next review period. The care plan interventions developed were the following: a. On 11/27/19, 42 (inch) bed to decrease chance of rolling out. b. On 2/3/16 Anticipate and meet [resident 9's] safety needs. c. On 12/11/19 Fall matt next to bed. d. On 11/2/17 and revised on 12/16/19, .Multiple safety precautions in place. [Resident 9] will continue to attempt self-transfers due to poor safety awareness. e. On 11/20/19, Intervention 11/16/19: Added dysom grip pad to wheelchair. f. On 4/25/18 and updated on 11/30/19, Replaced WC alarm: [Resident 9] uses an electronic alarm to wheelchair and bed. Bed/WC alarm is in place to alert staff that resident is trying to get out of bed/wheelchair and requires more assistance. The alarm does not hinder resident from getting out of bed/wheelchair. A progress note dated 11/7/19, revealed Res. (Resident) has crawled out of bed on to her bedside mat on her knees. She is quite talkative tonight and has been pleasant allowing staff to roll her back into bed. She replies 'no' when we ask her if she wants to get up. Water has been given she denies sh (sic) wants a snack. She is (sic) has been kept clean and dry with all her needs met. We have floated her right heel. A progress note dated 11/16/19 at 4:30 PM, revealed [Resident 9] was found in a fellow Resident's room, crouched down on her knees on the floor in front of the sink. She could not answer assessment questions intelligibly which isn't a variance from her baseline. Neuro assessments initiated per facility protocol as well as head to toe assessment: Right side of forehead hematoma, bilateral knees redness and light bruising. Supervisor informed hospice RN (registered nurse)/Physician. A progress note dated 11/30/19 at 11:10 AM, revealed Aide (CNA) found resident laying next to her wheelchair in her bedroom. She was laying on her left side with her knees bent up. She states that 'she was trying to change her clothes and slipped on the floor.' She was wearing slippers and attempted to get out of her wheelchair on her own. Aide and myself helped her back into her wheelchair and placed a fall alarm on. Vital signs WNL (within normal limits). No injuries noted and neuro checks were started. MD and family notified. Will continue to monitor. On 12/19/19 at 10:45 AM, an interview was conducted with LPN 2. LPN 2 stated that she was working when resident 9 fell on [DATE]. LPN 2 stated that resident 9 was in her room in her wheelchair and resident 9 stood up and fell down. LPN 2 stated that resident 9 did not have any injuries. LPN 2 stated that a CNA notified her that resident 9 had fallen. LPN 2 stated she was unable to remember what CNA notified her. LPN 2 stated that resident 9 did not have her alarm on when she fell. LPN 2 stated that the CNA who had assisted resident 9 out of bed that morning had forgot to place the alarm on her. LPN 2 stated that the alarm was functioning when she placed it on her after the fall. LPN 2 stated that resident 9 had an alarm because she was definitely a fall risk. LPN 2 stated that interventions developed to keep resident 9 from falling were to keep her in a main area, bed alarm, and shoes on. On 12/19/19 at approximately 12:30 PM, an interview was conducted with the DON and the Nurse Supervisor. The DON stated that the Nurse Supervisor updated resident care plans. The DON stated that after each fall a resident's care plan was updated. The DON stated that the Nurse Supervisor updated resident 9's care plan. The Nurse Supervisor stated that resident 9's alarm was not functioning and she updated the care plan. The Nurse Supervisor did not have additional information regarding resident 9's care plan being updated on 12/19/19, with the intervention that resident 9's alarm was not functioning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 11 was re-admitted to the facility on [DATE] with diagnoses which include depressive disorder, atypical atrial flutter, personal history of traumatic brain injury, and anxiety disorder. On 12/16/19 at 10:55 AM, an observation was made of resident 11. Resident 11 had long and jagged fingernails with debris underneath them. On 12/17/19 at 1:32 PM, resident 11 observed in hallway. Resident 11 was observed with long and jagged nails. On 12/18/19 at 12:37 PM, an interview was conducted with LPN 1. LPN 1 stated that the Certified Nursing Assistant (CNA) staff were to cut resident nails on scheduled shower days or when the resident nails were long. LPN 1 stated that sometimes the recreational therapist would do manicures for a resident activity. On 12/18/19 at 12:59 PM, an interview was conducted with CNA 2. CNA 2 stated that the CNA staff were to complete nail care on the resident's scheduled shower days. On 12/18/19 at 1:07 PM, an interview was conducted with LPN 2. LPN 2 stated that the CNA staff would cut resident fingernails when they gave the resident a shower or on Sundays. LPN 2 stated that sometimes if she noticed the resident's nails were long than she would cut them. On 12/18/19 at 1:23 PM, an interview was conducted with RN 1. RN1 stated that if a resident was not diabetic the CNA staff could cut resident fingernails. RN 1 stated that if a resident was diabetic then the nurse had to clip the nails, and usually the night nurse would do it. On 12/19/19 at 7:30 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that the CNA staff or nurses cut resident fingernails. The ADON stated that CNA staff were trained to clean and cut finger nails every Sunday. On 12/19/19 at 7:51 AM, an interview was conducted with DON. The DON stated that CNA staff and the activities staff cut resident nails. The DON stated that CNA staff cut resident nails on Sundays. Based on observation, interview, and record review it was determined, for 2 of 28 sampled residents, that the facility did not provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. Specifically, residents nails were long and soiled. Resident identifiers: 9 and 11. Findings include: 1. Resident 9 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, psychosis, chronic obstructive pulmonary disease, hypertension, and macular degeneration. On 12/16/19 at 2:19 PM, an interview was conducted with resident 9 and a family member. Resident 9 was observed to have a red substance on her pants, wheelchair, and on the floor. Resident 9 stated that she was getting her nails clipped and the staff member cut her. Resident 9 and family member stated that the red substance was blood. Resident 9 stated that her fingernails were really long and she wanted them cut and cleaned. Resident 9's family member stated that resident 9 was getting her fingernails clipped when staff cut her pinky finger with the fingernail clippers. Resident 9's family member stated that resident 9 liked her fingernails clipped and clean. Resident 9's family member stated that resident 9's fingernails were very long and staff had not cut her fingernails for over 2 weeks. Resident 9's fingernails were long with a yellow brown colored substance under her fingernails. On 12/16/19 at 2:38 PM, Licensed Practical Nurse (LPN) 1 was interviewed. LPN 1 stated that she was clipping resident 9's fingernails and didn't do it according to what the daughter wanted so I got into trouble. LPN 1 stated that she clipped resident 9's pinky finger when she was clipping the fingernails. LPN 1 stated that she placed a Band-Aid on resident 9's pinky finger. Resident 9's medical record was reviewed on 12/17/19. A significant change Minimum Data Set assessment dated [DATE], revealed that resident 9 was a 1 person extensive assistance with personal hygiene. A care plan created on 7/26/15 and updated on 10/7/19, revealed [Resident 9] has an ADL (activities of daily living) self-care performance deficit r/t (related to) loss of muscle mass, tone, and strength associated with prolonged disuse and inadequate nutritional status. The goal developed was [Resident 9] will participate in her current level of function in dressing self by participating in dressing with cuing and assistance from staff through the review date. The interventions developed did not address personal hygiene. Some of the interventions developed were, Eating: [resident 9]requires limited to extensive assist of (1) staff for eating and drinking. She may fall asleep during meals or is confused as to what to do. Her abilities fluctuate daily.Dressing: [Resident 9] requires extensive one staff to dress putting on her night gown and to assist her with putting on and off her brief. She now needs staff to assist her to do all her dressing, make up and put on her accessories which are important to her. Allow her to do what she can and offer assistance. A progress note dated 12/16/19 at 2:39 PM, revealed Right pinky finger tip cut during nail care. Resident's daughter here during incident. Area cleansed and dressed. MD (Medical Doctor) aware. On 12/19/19 at 11:32 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 9 probably wiggled when she was getting her fingernails clipped. RN 1 stated that she usually cut resident 9's fingernails when she was sleeping at night. RN 1 stated she did not document when she cut resident 9's fingernails. On 12/19/19 at 12:10 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 9 liked to have her nails really short. The DON stated he did not have a place to document nail care completed. The DON stated that nail care was completed when residents were showered. The DON stated residents should not be cut when getting fingernails clipped. The DON stated he did not know that resident 9 had been clipped. The DON stated he did not have additional information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 2 of 28 sampled residents, that the facility did not ensure that the resident's environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, the facility did not provide adequate supervision to prevent falls from occurring and interventions were not implemented after each fall. Resident identifiers: 9 and 68. Findings include: 1. Resident 68 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, essential hypertension, and dementia with behavioral disturbance. Resident 68's medical record was reviewed on 12/19/19. An Annual Minimum Data Set (MDS) assessment dated [DATE], documented resident 68 with a Brief Interview for Mental Status (BIMS) score of 00. [Note: A resident that was severely impaired cognitively would have a BIMS score of 00 to 07.] In addition, the staff documented resident 68 as requiring limited assistance of one person for walk in room and walk in corridor. A Care Plan dated 2/7/18 and revised on 11/22/19, documented a Focus area of [Resident 68] is at risk for falls Gait/balance problems, Incontinence, Psychoactive drug use, Vision/hearing problems. [Resident 68's] BIMS score is 00. Multiple interventions are in place for safety. The Goal developed was The resident will have no unaddressed falls through the review date. The interventions developed were: a. On 2/3/18, Encourage/remind resident to use mobility aides (walker) when ambulating/transferring to aide with fall prevention. Initiated on 2/7/18. b. On 3/7/18, Anticipate and meet resident's needs. Initiated on 3/8/18. c. On 7/4/18, Be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Initiated on 7/4/18. d. On 9/27/18, Staff to ensure that the resident was wearing appropriate footwear prior to transfers or ambulating. Initiated on 10/3/18. e. On 11/13/18, The resident needs a safe environment with even floors free from spills and/or clutter. Initiated on 11/15/18. f. On 1/24/19, Resident has always been an early riser. Night staff to offer and assist resident to get up at 5:00 AM for the day as this was his preference. Initiated on 1/25/19. g. On 2/5/19, Visual checks for safety, monitor resident while ambulating and ensure pathways are clear and assist as needed. Also ensure that resident was wearing his eyeglasses. Initiated on 2/6/19. h. On 5/6/19, Staff to place resident's stuffed [NAME] on the walker to encourage use of walker. Initiated on 5/9/19. i. On 9/15/19, Resident ambulates independently with his walker and will continue to fall related to his independence, gait imbalance, and poor safety awareness despite multiple interventions in place. Initiated on 9/18/19. A Fall Risk Evaluation dated 9/18/19, documented resident 68 at risk with a score of 19. [Note: A score of 10 or more indicates higher risk for falls and must be care planned.] An Incident Report dated 9/26/19, documented an Incident Description: The Certified Nursing Assistant (CNA) was changing the resident. Resident 68 moved and tried to sit on a folding chair in his room during the process. Resident 68 missed the chair and fell hitting his right elbow causing multiple skin tears. The resident was assisted to the couch where he likes to sleep as he kept getting up from his bed. A Care Plan dated 2/7/18 and revised on 11/22/19, documented the following interventions: a. On 9/27/19, Folding chairs removed from room. Initiated on 9/27/19. b. On 9/27/19, 10/26/19, 10/30/19, 11/2/19, and 11/5/19, Multiple fall interventions in place. Resident will continue to fall related to his independence and poor safety awareness. Initiated on 9/27/19 and revised on 11/6/19. A Fall Risk Evaluation dated 9/26/19, documented resident 68 at risk with a score of 19. An Incident Report dated 10/26/19, documented an Incident Description: Resident 68 got up from the couch and fell landing on his right side. A Care Plan dated 2/7/18 and revised on 11/22/19, documented the following intervention. On 9/27/19, 10/26/19, 10/30/19, 11/2/19, and 11/5/19, Multiple fall interventions in place. Resident will continue to fall related to his independence and poor safety awareness. Initiated on 9/27/19 and revised on 11/6/19. [Note: No new interventions were implemented.] A Fall Risk Evaluation dated 10/27/19, documented resident 68 at risk with a score of 16. An incident Report dated 10/30/19, documented an Incident Description: The CNA viewed the resident as he went to sit in a chair in front of the television. Resident 68 missed the chair and tried to grip the chair as he was falling with his right arm sustaining a shearing injury skin tear to the right forearm and distal portion of the right upper arm. A Care Plan dated 2/7/18 and revised on 11/22/19, documented the following intervention. On 9/27/19, 10/26/19, 10/30/19, 11/2/19, and 11/5/19, Multiple fall interventions in place. Resident will continue to fall related to his independence and poor safety awareness. Initiated on 9/27/19 and revised on 11/6/19. [Note: No new interventions were implemented.] A Fall Risk Evaluation dated 10/30/19, documented resident 68 at risk with a score of 14. An incident report dated 11/2/19, documented an Incident Description: Resident had both hands on the arms of the chair trying to stand. Resident 68's arm gave out and the resident slid down to the floor rubbing his back against the seat of the chair and landing on his buttocks. Resident 68 had two abrasions on the lower right side of his shoulder and the middle of his back. A Care Plan dated 2/7/18 and revised on 11/22/19, documented the following intervention. On 9/27/19, 10/26/19, 10/30/19, 11/2/19, and 11/5/19, Multiple fall interventions in place. Resident will continue to fall related to his independence and poor safety awareness. Initiated on 9/27/19 and revised on 11/6/19. [Note: No new interventions were implemented.] An incident report dated 11/5/19, documented an Incident Description: Resident 68 was walking past a residents wheelchair in front of the nurses desk and bumped into the wheel of the chair. Resident 68 fell backwards landing on his buttocks. A Care Plan dated 2/7/18 and revised on 11/22/19, documented the following intervention. On 9/27/19, 10/26/19, 10/30/19, 11/2/19, and 11/5/19, Multiple fall interventions in place. Resident will continue to fall related to his independence and poor safety awareness. Initiated on 9/27/19 and revised on 11/6/19. [Note: No new interventions were implemented.] A Fall Risk Evaluation dated 11/5/19, documented resident 68 at risk with a score of 16. A Physician/Practitioner Note dated 11/8/19, documented . Falls - has had multiple falls in the past month, several with resulting skin tears. Generally occurring with transfers and ambulation without his walker. Nursing notes he has poor judgement and insight, trying to transfer without assistance or use of assistive devices. See nursing notes regarding falls for detail, in short, has fallen when getting up out of a chair and when sitting into chair, missing the chair entirely. Once after a fall, SBP (systolic blood pressure) was 90, though not documented . A Fall Risk Evaluation dated 11/15/19, documented resident 68 at risk with a score of 16. An incident report dated 11/16/19, documented an Incident Description: Resident 68 was found on the floor crawling to pull himself up by the bed. Blood was noticed on the left upper sleeve of resident's shirt. Resident 68 had a small skin tear on his left upper arm. No new interventions were implemented. An incident report dated 12/10/19, documented an Incident Description: Resident 68 was found on the floor on his right side in the dining room. Resident 68's legs were out straight and his arms were at his side. A Care Plan dated 2/7/18 and revised on 11/22/19, documented the following intervention. On 12/10/19, Staff to monitor and assist resident into/up from dining chairs for safety. Initiated on 12/10/19. A Fall Risk Evaluation dated 12/10/19, documented resident 68 at risk with a score of 19. On 12/19/19 at 10:25 AM, an interview was conducted with CNA 1. CNA 1 stated that resident 68 required extensive assistance with all cares including showers, oral care, and dressing. CNA 1 stated that resident 68 required total assistance with hygiene. CNA 1 stated that resident 68 was able to walk on his own but required standby assistance. CNA 1 stated that he would always walk with resident 68 and would use a gait belt if required. CNA 1 stated that resident 68 was suppose to use a walker. CNA 1 stated that resident 68 was found on the ground recently relaxing. CNA 1 stated that resident 68 would sit down on the ground frequently and would get aggressive when staff tried to help him. On 12/19/19 at 10:49 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that resident 68 was very mobile and was suppose to use a walker but resident 68 would not use the walker. LPN 3 stated that if the walker was put in front of resident 68 he would drag the walker behind him. LPN 3 stated that resident 68 required standby assistance when he would first get up to ambulate. LPN 3 stated that resident 68 required contact guard assistance with standing and verbal cues. LPN 3 stated that contact guard assistance was guiding the resident with one hand on their lower back. LPN 3 stated that resident 68 had a very hard time transferring. LPN 3 stated that resident 68 would sit down where ever he wanted to sit and would not be able to get back up on his own. LPN 3 stated that resident 68 required assistance with transfers. LPN 3 stated that most of resident 68's falls were due to transfers from the couch. LPN 3 stated that resident 68 had a visual deficit and he would miss the edge of the couch. LPN 3 stated that resident 68 had no depth perception without his glasses. LPN 3 stated that resident 68 would sit his glasses down and the staff would be unable to find the glasses or resident 68 would switch glasses with other residents. LPN 3 stated that the fall committee would update the resident care plans and set interventions. LPN 3 stated that the nursing staff would fill out the fall scene investigation, update fall risk assessments, and list if the resident had a change recently in medications etc. LPN 3 stated that she would inform the doctor or the fall committee if there was an intervention that she felt would help the resident. On 12/19/19 at 11:11 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the process regarding resident falls was changed approximately a month ago. The DON stated that a Fall Scene Investigation Tool was implemented. The DON stated that the staff would investigate the possible root cause of the resident fall, the staff would have a huddle meeting, and interventions would be developed. 2. Resident 9 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, psychosis, chronic obstructive pulmonary disease, hypertension, and arthritis. On 12/16/19 at 2:17 PM, an interview was conducted with resident 9's family member. Resident 9's family member stated that resident 9 had experienced multiple falls. Resident 9's family member stated that resident 9 had a fall a few weeks ago that resulted in 2 black eyes and a laceration to the head. Resident 9's family member stated that resident 9 experienced a fall and her alarm was not on. Resident 9's medical record was reviewed on 12/18/19. A significant change MDS assessment dated [DATE], revealed that resident 9 had not experienced a fall since the last MDS was completed. A care plan dated 7/26/15 and updated on 12/2/19, revealed [Resident 9] is at high risk for falls r/t (related to) cognitive and visual deficits and alterations in physical mobility, she is legally blind and needs staff to walk with her, her gait can be unsteady, poor safety awareness. She often refuses to walk and uses w/c (wheelchair) most of the time. The goal developed was [Resident 9] will have no unaddressed injury related to falls through the next review period. The care plan interventions developed were the following: a. On 11/27/19, 42 (inch) bed to decrease chance of rolling out. b. On 2/3/16 Anticipate and meet [resident 9's] safety needs. c. On 12/11/19 Fall matt next to bed. d. On 11/2/17 and revised on 12/16/19, .Multiple safety precautions in place. [Resident 9] will continue to attempt self-transfers due to poor safety awareness. e. On 11/20/19, Intervention 11/16/19: Added dysom grip pad to wheelchair. f. On 4/25/18 and updated on 11/30/19, Replaced WC alarm: [Resident 9] uses an electronic alarm to wheelchair and bed. Bed/WC alarm is in place to alert staff that resident is trying to get out of bed/wheelchair and requires more assistance. The alarm does not hinder resident from getting out of bed/wheelchair. A progress note dated 11/7/19, revealed Res. (Resident) has crawled out of bed on to her bedside mat on her knees. She is quite talkative tonight and has been pleasant allowing staff to roll her back into bed. She replies 'no' when we ask her if she wants to get up. Water has been given she denies sh (sic) wants a snack. She is (sic) has been kept clean and dry with all her needs met. We have floated her right heel. A progress note dated 11/16/19 at 4:30 PM, revealed [Resident 9] was found in a fellow Resident's room, crouched down on her knees on the floor in front of the sink. She could not answer assessment questions intelligibly which isn't a variance from her baseline. Neuro assessments initiated per facility protocol as well as head to toe assessment: Right side of forehead hematoma, bilateral knees redness and light bruising. Supervisor informed hospice RN (registered nurse)/Physician. A progress note dated 11/30/19 at 11:10 AM, revealed Aide (CNA) found resident laying next to her wheelchair in her bedroom. She was laying on her left side with her knees bent up. She states that 'she was trying to change her clothes and slipped on the floor.' She was wearing slippers and attempted to get out of her wheelchair on her own. Aide and myself helped her back into her wheelchair and placed a fall alarm on. Vital signs WNL (within normal limits). No injuries noted and neuro checks were started. MD (Medical Doctor) and family notified. Will continue to monitor. On 12/19/19 at 10:45 AM, an interview was conducted with LPN 2. LPN 2 stated that she was working when resident 9 fell on [DATE]. LPN 2 stated that resident 9 was in her room in her wheelchair and resident 9 stood up and fell down. LPN 2 stated that resident 9 did not have any injuries. LPN 2 stated that a CNA notified her that resident 9 had fallen. LPN 2 stated she was unable to remember what CNA notified her. LPN 2 stated that resident 9 did not have her alarm on when she fell. LPN 2 stated that the CNA who had assisted resident 9 out of bed that morning had forgot to place the alarm on her. LPN 2 stated that the alarm was functioning when she placed it on her after the fall. LPN 2 stated that resident 9 had an alarm because she was definitely a fall risk. LPN 2 stated that interventions developed to keep resident 9 from falling were to keep her in a main area, bed alarm, and shoes on.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 1 of 28 samples residents, that the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice. Specifically, a resident with an order for oxygen was observed to be without oxygen and had a low pulse oxygen saturation level. Resident identifier: 66. Findings include: Resident 66 was admitted to the facility on [DATE] with diagnoses which included atherosclerotic heart disease, hypertension, gastro-esophageal reflux, anxiety disorder, dementia, and femur fracture. On 12/16/19 at 7:54 AM, a continual observation was made of resident 66. Resident 66 was observed in the dining room with the nasal cannula for the oxygen on the floor. Resident 66's oxygen tank had a dial that was on empty. At 8:56 AM, an observation was made of resident 66 wheeling himself in the hallway with his nasal cannula on the floor. Resident 66 was observed to wheel himself in his wheelchair to his room. Resident 66 was observed to ask Certified Nursing Assistant (CNA) 4 to help him get into bed. CNA 4 was observed to assist resident 66 into his bed. CNA 4 did not offer or apply resident 4's oxygen. CNA 4 was interviewed immediately. CNA 4 stated that she did not work on that hallway and did not know resident 66 and did not know if resident 66 needed oxygen. At 8:59 AM, CNA 5 was observed to check resident 66's pulse oxygen saturation level. Resident 66's pulse oxygen saturation level was 84% on room air. CNA 5 stated that resident 66's pulse oxygen saturation level was low and he needed oxygen at all times. CNA 5 stated that resident 66 needed 2 liters of oxygen. CNA 5 stated she did not know why he did not have his oxygen on. CNA 5 was observed to turn on the oxygen concentrator that was plugged into the wall and use the nasal cannula that was connected to the oxygen concentrator. CNA 5 confirmed that resident 66's portable oxygen tank on his wheelchair was empty. On 12/17/19 at 1:06 PM, an observation was made of resident 66 in the hallway. Resident 66 did not have a nasal cannula with oxygen on. Resident 66 was observed to propel himself in his wheelchair through the hallways asking staff to make his bed. Resident 66 was observed to ask CNA 6 if she would make his bed. CNA 6 was observed to tell resident 66 that CNA 7 would make his bed because CNA 6 told resident 66 she had to finish my work. Restorative Nursing Assistant (RNA) 1 was observed to be asked to help make resident 66's bed. RNA 1 was observed to go to resident 66's room and make his bed. At 1:27 PM, resident 66 was in his room with no oxygen. RNA 1 was observed to transfer resident 66 into his bed. RNA 1 was not observed to place oxygen on resident 66. At 2:17 PM, CNA 8 was observed to check resident 66's pulse oxygen saturation level. Resident 66's pulse oxygen saturation level was 84% on room air. Resident 66 was observed to ask CNA 8 why he did not have his oxygen on because he needed it. CNA 8 stated that resident 66 did not use oxygen at all times and only when he needed it. CNA 8 stated that she checked resident 66's pulse oxygen saturation level before she got him out of bed in the morning and before lunch. Resident 66's medical record was reviewed on 12/16/19. A significant change Minimum Data Set (MDS) assessment dated [DATE], revealed that resident 66 had shortness of breath with exertion and while lying flat. The MDS further revealed that resident 66 used oxygen while a resident at the facility. A care plan dated 6/21/18 and revised on 7/2/18, revealed [Resident 66] has had altered respiratory status/difficulty breathing requiring oxygen prn (as needed). The goal developed was, [Resident 66] will have no s/sx (signs and symptoms) of poor oxygen absorption through the review date. The intervention developed was, Position resident with proper body alignment for optimal breathing pattern. A physician's order dated 11/28/19, revealed Oxygen 1-4 liters per nasal canula (sic) to keep sats > 90%. Document O2 (oxygen) sats and liters per minute. every shift. Resident 66's vitals signs were reviewed and resident 66's pulse oxygen saturation levels were documented as the following: a. On 8/1/19 at 9:49 AM, 94.0 % on room air. b. On 9/22/19 at 9:36 PM, 94.0 % on room air. c. On 10/14/19 at 1:10 PM, 93.0 % on room air. d. On 11/24/19 at 1:59 PM, 90.0 % on room air. e. On 12/3/19 at 9:58 PM, 92.0 % on room air. f. On 12/16/19 at 8:27 AM, 95.0 % on room air. g. On 12/16/19 at 9:50 PM, 93.0 % on oxygen via nasal cannula. h. On 12/17/19 at 10:18 AM, 92.0 % on room air. The CNA documentation tasks section was reviewed. On 11/25/19, resident 66's oxygen was 90%. There were no other pulse oxygen saturation levels documented over the last 30 days. On 12/19/19 at 9:23 AM, an interview was conducted with Medical Director (MD) 1. MD 1 stated she was resident 66's physician. MD 1 stated that resident 66 refused oxygen at times and had taken it off in the past. MD 1 stated that if resident 66 was asking to have oxygen then the staff should test the pulse oxygen saturation level and place oxygen on him. On 12/19/19 at 10:42 AM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated that since resident 66 had fractured his femur he had required more oxygen. LPN 4 stated that staff checked resident 66's pulse oxygen saturations when he asked to have it done a few times a day. LPN 4 stated that when resident 66's pulse oxygen saturation was less than 90% the staff would put the oxygen on resident 66 and then recheck until it was above 90%. LPN 4 stated that resident 66 occasionally refused to have oxygen on but if his pulse oxygen saturations were low he allowed staff to place the oxygen. LPN 4 stated that if resident 66's pulse oxygen saturations was less than 90%, then staff placed resident 66 on 1 liter of oxygen. On 12/19/19 at 11:52 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the physician's order was for resident 66 to have 1 to 4 liters of oxygen at all times. The DON stated that the liters of oxygen and the pulse oxygen saturations were not documented. The DON stated if a pulse oxygen saturation level was lower than 90 he would expect staff to recheck and then document the original pulse oxygen saturation level and the follow up level. The DON stated that he would expect the CNAs to document the initial pulse oxygen saturation level. The DON stated he was not sure how staff were monitoring the amount of oxygen resident 66 required.

Based on observation, interview, and record review it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, staff were in the kitchen without hairnets, dietary staff were not changing their gloves after touching soiled items, domes used to cover plates were re-used, and there was cross contamination in the dining room. Findings include: 1. On 12/16/19 at 7:50 AM, a tour of the kitchen was conducted. The following was observed: a. The Minimum Data Set (MDS) coordinator was observed in the kitchen without a hair restraint. The MDS coordinator was observed to be in the the food preparation area. b. The shelf above the steam table was observed to be soiled under the shelf which was over the ready to eat food. c. The floor was observed to be soiled. There was substance and debris behind the ovens and fryer. 2. On 12/16/19, the following observations were made during the breakfast meal in the dining room: a. At 8:08 AM, a dietary staff (DS) member of the kitchen was observed wiping his nose and touching his nose with gloved hands. The DS member did not change gloves and continued to serve resident meals. b. At 8:12 AM, a DS member was seen leaving the kitchen 2 times with gloved hands. The DS member was touching things outside of the kitchen including the door to the kitchen with gloved hands. The DS member did not change gloves and continued to serve resident meals. c. At 8:14 AM, DS members were observed taking plates with plate domes to resident tables in the dining room, then returning the plate domes to the kitchen through the serving window. The plate domes were being touched by staff with bare hands on the inside and then handed back to kitchen staff for re-use without being cleaned. d. At 8:17 AM, a DS member in the kitchen was observed touching his clothing with gloved hands. The DS member did not change gloves and continued to serve resident meals. e. At 8:25 AM, a DS member dropped a plate dome, the DS member picked the plate dome up off the floor with gloved hands and handed it to another DS member. The DS member who picked the plate dome off the floor did not change gloves and continued to serve resident meals. 3. On 12/18/19, the following observations were made during the lunch meal in the dining room: a. At 12:19 PM, DS members were observed taking plates with plate domes to resident tables in the dining room, then returning the plate domes to the kitchen through the serving window. The plate domes were being touched by staff with bare hands on the inside and then handed back to kitchen staff for re-use without being cleaned. b. At 12:22 PM, a DS member in the dining room was observed with a dessert plate being held up against her scrub top while being carried to the resident. c. At 12:26 PM, a DS member in the kitchen was observed touching his hat with gloved hands and then continued to serve resident meals without changing gloves. d. At 12:30 PM, a DS member was observed bringing a used coffee dispenser from the dining room through the kitchen. The DS member refilled the coffee dispenser on the clean side of the kitchen and then transported it back out to the dining room. 4. On 12/19/19 at 10:25 AM, a follow up observation was made of the facility kitchen. The shelf above the steam table was observed to be soiled. The floors were observed to be soiled. There was substance and debris behind the ovens and fryer. An interview was immediately conducted with the Dietary Manager (DM). The DM stated that all staff should have their hair restrained when in the kitchen. The DM stated that the floors were cleaned by a professional company every 3 months. The DM stated that the floors were cleaned after each shift. The DM stated that the plate domes used for the plates in the dining room were reused when they were passed back into the kitchen after being served to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 3 of 28 sampled residents, that the facility did not consult with the residents physician when there was a need to alter treatment significantly. Specifically, the physician was not notified when 1 resident's insulin was held, 1 resident refused insulin, one resident's blood pressure was elevated, and medication was substituted for another medication without Medical Doctor (MD) notification. Resident identifiers: 29, 40, and 41. Findings include: 1. Resident 41 was admitted to the facility on [DATE] with the diagnoses which included Parkinson's disease, hypertension, major depressive disorder, and type 1 diabetes mellitus. On 12/18/19, Registered Nurse (RN) 1 was observed to prepare and administer medications to resident 41. RN 1 stated that resident 41 would always refuse the Humalog insulin. RN 1 was observed to document a refusal on the Medication Administration Record (MAR). Resident 41 was observed at the medication cart and RN 1 asked resident 41 if he only wanted to receive the long acting insulin. Resident 41 stated yes just the Lantus at this time. A record review for resident 41 was completed on 12/18/19. A Physician's order for Humalog Solution inject 13 units subcutaneously one time a date related to Type 1 Diabetes Mellitus. A start date of 2/28/19 to be administered at 7:30 AM. A review of the October, November, and December 2019 MAR documented that resident 41 refused the Humalog dose 7 times in October, 6 times in November, and 13 times in December. No documentation could be located in the medical record of MD notification of refusals. A Physician's order for Humalog Solution inject 6 unit subcutaneously one time a day. A start date of 2/28/19 to be administered at 11:30 AM. A review of the October, November, and December 2019 MAR documented that resident 41 had refused the above Humalog dose 7 times in October, 9 times in November, and 10 times in December. No documentation could be located in the medical record of MD notification of refusals. A Physician's order for Humalog Solution inject 14 unit subcutaneously in the evening. A start date of 2/27/19 to be administered at 4:30 PM. A review of the October, November, and December 2019 MAR documented that resident 41 had refused the above Humalog dose 1 time in October, 14 times in November, and 7 times in December. No documentation could be located in the medical record of MD notification of refusals. A Physician's order for Humalog Solution inject per sliding scale. If 0-59 give juice and notify MD, 60-149 give 0, 100-250 give 1, 251-300 give 2, 301-350 give 3, 351-400 give 4, and 401-999 give 5 and call MD subcutaneously 4 times a day for diabetes mellitus. No nightly sliding scale insulin unless above 250 give 1 unit for every 50 above 250. Administer insulin after eating with a start date of 11/2/19. A review of the October, November, and December 2019 MAR documented that resident 41 had refused the above Humalog dose 19 times in October, 14 times in November, and 22 times in December. In addition, resident 41's blood glucose was above 508 on 12/3/19. No documentation could be located in the medical record of MD notification of refusals. 2. Resident 40 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, congestive heart failure, major depressive disorder, hypertension, and type 2 diabetes mellitus. A record review for resident 40 was completed on 12/18/19. A physician's order for Insulin Aspart solution inject 10 units subcutaneously before meals for Diabetes Mellitus. Notify MD if blood glucose was below 70 or above 350. With a start date of 10/18/2019. A review of the October, November, and December 2019 MAR documented that resident 40's Insulin Aspart was held 3 times in October, 10 times in November, and 6 times in December. No documentation could be located in the medical record of MD notification when the insulin was held. 3. Resident 29 was admitted to the facility on [DATE] with diagnoses which included atrial flutter, congestive heart failure, hypertension, spinal stenosis, low back pain, and depressive disorder. A. On 12/18/19, RN 1 was observed to prepare and administer medications to resident 29. RN 1 was observed to use a battery operated wrist blood pressure cuff to obtain resident 29's blood pressure and pulse. RN 1 stated she was obtaining these vital signs to determine if resident 29's metoprolol should be administered. Resident 29's blood pressure was 181/93 and a pulse of 44. RN 1 was observed to not administer the metoprolol to resident 29. A record review for resident 29 was completed on 12/18/19. A review of physician's orders documented the following entries: i. Metoprolol Succinate extended release (ER) tablet 25 milligrams (mg). Give 12.5 mg by mouth one time a day related to essential (primary) hypertension. Hold for Systolic blood pressure (SBP) <100 and/or Apical pulse of <50. Apical pulse per MD order needs to be counted for a minimum of 30 seconds. Notify MD if pulse <35. A start date of 12/18/19. ii. Metoprolol Succinate ER tablet 25 mg. Give 12.5 mg by mouth one time a day related to essential (primary) hypertension. Hold for SBP <100 and/or Apical pulse of <50. Apical pulse per MD order needs to be counted for a minimum of 30 seconds. A start date of 11/21/19 and an end date of 12/17/19. A review of the December 2019 MAR documented that resident 29 refused the metoprolol 4 times in December and the metoprolol was held for a pulse out of parameters 11 times in December. [Note: Resident 29's blood pressures were hypertensive all 15 days they were recorded in the month of December. The SBP ranged from 136 to 181 and the diastolic blood pressure ranged from 72 to 98. No documentation could be located in the medical record of MD notification when the metoprolol was held, or for elevated blood pressures.] On 12/18/19 at 12:37 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she would only hold insulin after speaking to a supervisor and a physician with her reasoning. On 12/18/19 at 1:07 PM, an interview was conducted with LPN 2 . LPN 2 stated some medications have parameters to hold. LPN 2 stated that if a medication did not have parameters to hold she would not hold the medication on her own and would notify the MD for permission to hold. LPN 2 stated that she would notify the MD if a medication was refused 2 or 3 times and would ask the MD to review the medication for readjustment. LPN 2 further stated that if insulin was refused she would notify the MD. LPN 2 stated that if a resident was having hypertension frequently she would notify the MD and have the MD reevaluate the residents medications. On 12/18/19 at 1:23 PM, an interview was conducted with RN 1. RN 1 stated that a physician would be notified if a resident refused medications more than a couple of times. On 12/19/19 at 7:30 AM, an interview was conducted with Assistant Director of Nursing (ADON) 1. ADON 1 stated that the MD should be notified if a medication needed to be held without parameters. ADON 1 stated that medication should not be held unless there was an order to hold it based on the vital signs. On 12/19/19 at 7:51 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that medication with parameters were located in the physician's orders. The DON stated that if insulin needed to be held without parameters the MD should be notified. The DON stated that if a blood pressure was really high, or out of range, the physician should definitely be notified. On 12/19/19 at 9:01 AM, an interview was conducted with MD 1. MD 1 stated that her expectation would to be notified if insulin had been held or refused. MD 1 stated that she would expect to be notified of hypertension, and if she would have been notified of resident 29's elevated blood pressure on 12/18/19, and the trend of elevated blood pressures she would have reviewed his medications. B. On 12/16/19 at 11:41 AM, an interview was conducted with resident 29. Resident 29 stated he had pain in his lower back because he had 7 operations with a tumor on his sacrum. Resident 29 stated that his C2 and C7 were fused, 3 Lumbar's were fused, and L3 had been fractured. Resident 29 stated that he also had scoliosis. Resident 29 stated that he had surgery on a pinched nerve in his neck. Resident 29 stated that his pain was usually a 7 to 8 and down to a 0 if he was sitting still after taking pain medications. [Note: The pain scale was 0 no pain and 10 excruciating pain.] On 12/17/19 at approximately 2:00 PM, an observation was made of resident 29 telling RN 1 that he was having pain in his neck. RN 1 asked resident 29 if he wanted his cream rubbed on his neck. Resident 29 stated he wanted the cream rubbed on his neck. RN 1 was observed to pump cream from a large container labeled biofreeze and rubbed it into resident 29's neck using a gloved hand. Resident 29 was observed to thank RN 1 and stated his neck felt better. Resident 29's medical record was reviewed on 12/18/19. A physician's order dated 8/11/19, revealed Lidocaine Cream 4 % Apply to Mid back topically three times a day for Pain On 12/18/19 at 9:10 AM, an interview was conducted with RN 1. RN 1 stated that she applied biofreeze to resident 29's neck on 12/17/19. RN 1 stated that resident 29 had a physician's order for biofreeze. RN 1 was observed to look for Lidocaine Cream for resident 29 and stated there was no Lidocaine Cream available in the medication cart. On 12/18/19 at 10:40 AM, an interview was conducted with LPN 4. LPN 4 stated that resident 29 requested Biofreeze on his neck. LPN 4 stated that resident 29 received Biofreeze as he requested it. LPN 4 stated that she rubbed Biofreeze into his neck this morning. LPN 4 stated that she was not aware that the order was for Lidocaine Cream. LPN 4 stated that she had not reported that resident 29 was requesting Biofreeze instead of Lidocaine Cream. LPN 4 was observed to look for the Lidocaine Cream for resident 29. LPN 4 stated she did not have Lidocaine Cream available for application. On 12/18/19 at 12:14 PM, an interview was conducted with Pharmacist 1. Pharmacist 1 stated that Biofreeze and Lidocaine cream were very different medications. Pharmacist 1 stated that the Lidocaine 4% would last longer for pain relief. Pharmacist 1 stated the the two creams had different active ingredients for pain relief. On 12/18/19 at 12:20 PM, an interview was conducted with Pharmacy Technician (PT) 1. PT 1 stated that the pharmacy did not have a history of delivering Lidocaine 4% cream for resident 29. PT 1 stated that a 5% Lidocaine patch was delivered on 9/11/17. PT 1 stated that Lidocaine cream was specific for resident's so an individual tube with the resident's name would be delivered to the facility. On 12/18/19 at 2:24 PM, an interview was conducted with the DON. The DON stated that biofreeze and lidocaine were different medications. The DON stated that he had not contacted the Nurse Practitioner regarding interchanging the creams. On 12/19/19 at 9:23 AM, an interview was conducted with MD 1. MD 1 stated that she had not been notified that resident 29 was receiving Biofreeze instead of Lidocaine cream. MD 1 stated that staff should notify her if the resident requested a change in creams or if the resident was experiencing pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review it was determined, for 7 of 28 sampled residents, that the facility did not ensure that the residents were free from abuse and neglect. Specifically, the facility did not provide services to prevent one resident from having multiple resident to resident altercations that included physical contact with other residents. Resident identifiers: 4, 9, 11, 12, 21, 37, and 61. Findings include: Resident 11 was re-admitted to the facility on [DATE] with diagnoses which included depressive disorder, atypical atrial flutter, personal history of traumatic brain injury, and anxiety disorder. On 12/16/19 at 10:37 AM, an observation was made of resident 11 in the activity/TV room watching television. At 11:05 AM, resident 11 was observed to self-propel out of the TV room. Resident 11 encountered another resident. Resident 11 kept self-propelling towards the resident trying to get past, with wheelchair wheels in path and right next to another residents feet, hitting his wheelchair wheels into the other residents wheelchair wheel. The other resident then propelled his wheelchair back enough for resident 11 to pass. There was no staff present in the activity room during the 28 minute observation, or during the resident to resident interaction. Resident 11 was also observed in the activity/TV room with other residents and no staff present the following days and times: 12/16/19 at 12:20 PM, 12/16/19 at 1:15 PM, 12/18/19 at 9:35 AM, and 12/18/19 at 1:21 PM. Resident 11's medical record was reviewed on 12/18/19. The following resident to resident incidents were documented: a. On 1/8/19, resident 11 started swearing and struck resident 4 in the chest, resident 4 struck resident 11 back in the arm. b. On 1/12/19, resident 11 hit resident 9 several times in the back as witnessed by a staff member in the restorative dining room. c. On 1/24/19, resident 11 hit resident 37 2 times in the arm while in the activity room. d. On 3/31/19, resident 11 hit resident 12 two times in his right shoulder blade in the hallway. e. On 4/5/19, resident 11 ran over resident 61's toes while self-propelling during a musical performance activity. Resident 11 then started swinging at resident 61, resident 61 then held resident 11's hands down on wheelchair. f. On 5/8/19, resident 11 told resident 9 to shut up and swung to hit her. Resident 9 denied being hit. g. On 5/29/19, resident 11 was in his wheelchair in the hallway when resident 61 walked past. Resident 11 then started yelling profanities and struck resident 61 in the arm 3 times. h. On 8/10/19, resident 11 hit a resident in her left bicep while in the TV room in front of the bird's cage. i. On 9/27/19, resident 11 was observed in the activity/TV room swearing and kicking resident 21. A review of resident 11's progress notes revealed the following progress notes of additional aggressions towards other residents. a. On 9/24/19 at 8:22 PM, a progress note documented, continues to have verbally aggressive behaviors towards staff and other residents, he uses foul language and obscene gestures. NO physically aggressive behavior noted at this time. b. On 9/28/19 at 12:42 PM, a progress note documented, has had several outbursts today. Attempting to hit a resident, swatting at people walking by and shouting out cuss words. c. On 10/18/19 at 11:34 AM, a progress note documented, Behaviors today: This am [resident 11] .when he got close to the other resident, nurse pushed [resident 11] wheelchair away, and he yelled 'son of a bitch, I hate him', trying to swing at he (sic) other resident, but he was not close enough and didn't touch the other resident. d. On 11/3/19 at 10:06 AM, a progress note documented, [Resident 11] was rolling his wheelchair down the hall and one of the residents was sitting on the middle, facing the opposite side of him when [name removed] started yelling at the resident 'f you, f you, I hate you' while pushing his wheelchair towards the resident. Nurse interviewed before he hit the other residents. e. On 11/3/19 at 4:40 PM, a progress note documented, Behaviors: wife was called and she came. She stayed with him for a while. When she left [resident 11] was showing signs of aggression again towards any resident ahead of him Nurse removed him 2 times right before he punched another resident that was not looking at him. Resident had to be removed from the common area. MD (Medical Doctor) and family notified. A care plan Focus initiated on 2/23/16 and revised on 8/30/18, documented [Resident 11] uses anti-anxiety medications related to Anxiety disorder, and antidepressants for his tearfulness. He has verbally and physically aggressive behavioral symptoms attributed to his TBI (traumatic brain injury). The Goal initiated on 2/23/16 and revised on 10/2/19, documented [resident 11] will be free from discomfort or adverse reactions related to anti-anxiety therapy and antidepressants through the review date. He will not have an increase in verbal or physical aggression towards others through next review. [resident 11] will not have an increase in banging on furnishings during the nighttime. Resident to Resident: 2/24/16, 3/7/16, 3/29/18, 5/16,18, 5/23/18, 7/22/18, 11/1/18, 12/9/18, 1/8/19, 1/12/19, 1/24/19, 3/31/19, 4/5/19, 5/8/19, 5/29/19, 8/10/19, 9/27/19. The Interventions developed were: a. Assist [resident 11] when he appears 'trapped' in common areas to prevent verbal or physical aggression towards others. He has cursed, yelled and hit others whom he observes as obstacles in his path. Date initiated 10/3/19. b. Assist [resident 11] with navigating the hallways as he will allow to prevent him from bumping into others and diffuse conflicts that arise. Date initiated 1/14/19. c. Calm Reassurance. Date initiated 5/23/19. d. Care partners will monitor [resident 11] and provide redirection as necessary to assist him with navigating his wheelchair safely in an effort to prevent conflict with others. Date initiated 4/12/19. e. Care partners will redirect [resident 11] away from others he has shown aggression toward in an effort to prevent further incidents. [Resident 11] has expressed dislike for another individual whom he dines in the same area with. Date initiated 1/17/19. f. Help create a clear path for [resident 11] to exit the therapy gym as he self-propels his wheelchair. Provide physical space between [resident 11] and other residents whom he has previously had physical aggression towards. Date initiated 5/23/18. g. Intervene and separate [resident 11] from others if he is showing verbal and/or physical aggression toward others to promote safety. Date initiated 12/13/18 and revised on 5/23/19. h. [Resident 11] cursing and verbal outburst may be distressing to others. Care partners will redirect him from common areas when he is visibly upset to prevent conflict with others. Date initiated 1/29/19. i. Maintenance of daily routine and caregivers as possible. Date initiated 5/23/17. j. Quarterly review with IDT (interdisciplinary) team. Date initiated 5/23/16. k. Quiet environment. Date initiated 5/23/17. l. Redirect [resident 11] from others when he is expressing frustration or imposing on their personal space or interfering with their dining experience. Helping him to his room to calm down may be effective. Date initiated 5/25/18. m. Separate [resident 11] from others if an argument occurs to prevent escalation as he may swear and threaten others. Date initiated 4/5/18. On 12/18/19 at 12:59 PM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated that resident 11 will go to bingo but was often agitated, and that he liked to watch football in the tv room. CNA 2 stated that resident 11 was aggressive with other residents. CNA 2 stated she did not know any preventative measures in place for resident 11 to prevent resident to resident altercations. CNA 2 stated that resident 11 behaviors just come out of nowhere, one second he is fine and the next swearing and yelling. On 12/18/19 at 1:01 PM, an interview was conducted with CNA 3. CNA 3 stated that resident 11 attended music programs and watched music on tv in the tv room. CNA 3 stated that resident 11 had a history of outbursts, cussing, and resident to resident altercations. CNA 3 stated that if resident 11 was trying to leave a room and someone was in the way resident 11 would just continue to keep running into other residents. CNA 3 stated that if resident 11 was doing this type of behavior he was taken to the nurse to sit one on one with him, and if an altercation was witnessed the nurse, and a supervisor was notified. On 12/18/19 at 1:07 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that resident 11 had been combative in the past, but that he was doing better on his new medications. LPN 2 stated that resident 11 was sometimes agitated when he was constipated or in pain. LPN 2 stated that preventative measures for resident 11 to prevent resident to resident altercations was to be aware of who he is around, and if he was in the tv room it was best if someone was in there to watch, and keep him away from someone who triggers him. LPN 2 stated that mostly CNA staff and nurses knew where resident 11 was, and when he was getting agitated he would start swearing and the staff would intervene. LPN 2 stated that if a resident to resident occurred she removed residents, notified the family, MD, and supervisors. On 12/19/19 at 7:51 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that if a resident to resident altercation occurred the process was to dive in to see what the resident to resident was. The DON stated if there was any mental anguish or physical contact, then he would report to the state and come up with a solution to limit the altercation from happening again. The DON stated that it was a struggle with resident 11 because resident 11's wife would not let the staff use medication on resident 11. The DON stated that when the staff were able to get resident 11 on medication the resident to resident altercations had resolved. The DON stated that for resident 11 it required anticipation, and they usually put him close to have eyes on him so that he can be removed quickly. The DON stated that the supervisors usually had eyes on resident 11 or they would put resident 11 in an activities. The DON stated that often resident 11 would use the ipad or watch television. On 12/19/19 at 10:22 AM, an interview was conducted with the Administrator. The Administrator stated that the facility staff all watch resident 11 and removed resident 11 if he was getting agitated but the staff could not always catch resident 11. The Administrator stated that the facility tried some medication adjustments but the wife would always want the orders changed. The Administrator stated that she had spoke to resident 11's wife on several occasions about transferring resident 11 but the wife wanted nothing to do with it. The Administrator stated that during the last meeting with resident 11's wife and son she spoke to them about paying for a one on one staff member to sit with resident 11. The Administrator stated that the family did not want to pay for a one on one so the family agreed to let the staff adjust resident 11's medications. The Administrator stated that when stretching the facility to stay staffed it would be difficult to staff a one on one with a resident. The Administrator stated that staffing a one on one with resident 11 even if it were for 16 hours a day would not be logical, staffing with certified nursing assistants right now is so hard. The Administrator stated that if there had been an injury resulting from one of resident 11's resident to resident altercations that resident 11 would have been transferred out to a psych (psychiatric) facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 11 was re-admitted to the facility on [DATE] with diagnoses which include depressive disorder, atypical atrial flutter, personal history of traumatic brain injury, and anxiety disorder. Resident 11's medical record was reviewed on 12/16/19. A review of the incident reports revealed the following incidents, and the following date and times reported to the applicable agencies. a. On 1/8/19, resident 11 started swearing and struck resident 4 in the chest, resident 4 struck resident 11 back in the arm. This event occurred on 1/8/19 at 6:15 PM. i. Notification to the State Survey Agency occurred on 1/8/19 at 7:30 PM. ii. Notification to APS occurred on 1/9/19 at 12:30 PM. [Note: The APS reporting occurred more than 2 hours after the incident initially occurred and was reported to the facility administrator.] b. On 1/12/19, resident 11 hit resident 9 several times in the back as witnessed by a staff member in the restorative dining room. This even occurred on 1/12/19 at 6:15 AM. i. Notification to the State Survey Agency occurred on 1/12/19 at 9:14 AM. [Note: The State Survey Agency reporting occurred more than 2 hours after the incident initially occurred and was reported to the facility administrator.] ii. Notification to APS occurred on 1/14/19 at 12:00 PM. [Note: The APS reporting occurred more than 2 hours after incident initially occurred and was reported to the facility administrator.] c. On 1/24/19, resident 11 hit resident 37 2 times in the arm while in the activity room. This event occurred on 1/24/19 at 4:40 PM. i. Notification to the State Survey Agency occurred on 1/24/19 at 4:40 PM. ii. Notification to APS occurred on 1/25/19 at 10:30 AM. [Note: The APS reporting occurred more than 2 hours after incident initially occurred and was reported to the facility administrator. d. On 3/31/19, resident 11 hit resident 12 two times in his right shoulder blade in the hallway. This event occurred on 3/31/19 at 1:00 PM. i. Notification to the State Survey Agency occurred on 3/31/19 at 2:51 PM. ii. Notification to APS occurred on 4/1/19 at 11:40 AM. [Note: The APS reporting occurred more than 2 hours after incident initially occurred and was reported to the facility administrator. e. On 4/5/19, resident 11 ran over resident 61's toes while self-propelling during a musical performance activity. Resident 11 then started swinging at resident 61, resident 61 then held resident 11's hands down on wheelchair. This event occurred on 4/5/19 at 7:08 PM. i. Notification to the State Survey Agency occurred on 4/5/19. ii. Notification to APS occurred on 4/8/19 at 10:10 AM. [Note: The APS reporting occurred more than 2 hours after incident initially occurred and was reported to the facility administrator. f. On 5/8/19, resident 11 told resident 9 to shut up and swung to hit her. Resident 9 denied being hit. This event occurred on 5/8/19 at 4:25 PM. i. Notification to the State Survey Agency occurred on 5/8/19 at 5:49 PM. ii. Notification to APS occurred on 5/9/19 at 4:54 PM. [Note: The APS reporting occurred more than 2 hours after incident initially occurred and was reported to the facility administrator.] g. On 5/29/19, resident 11 was in his wheelchair in the hallway when resident 61 walked past. Resident 11 then started yelling profanities and struck resident 61 in the arm 3 times. This event occurred on 5/29/19 at 7:01 PM. i. Notification to the State Survey Agency occurred on 5/29/19 at 7:07 PM. ii. Notification to APS occurred on 5/30/19 at 2:05 PM. [Note: The APS reporting occurred more than 2 hours after incident initially occurred and was reported to the facility administrator. h. On 8/10/19, resident 11 hit a resident in her left bicep while in the TV room in front of the bird's cage. This event occurred on 8/10/19 at 10:15 AM. i. Notification to the State Survey Agency occurred on 8/10/19 at 5:45 PM. [Note: The State Survey Agency reporting occurred more than 2 hours after the incident initially occurred and was reported to the facility administrator.] ii. Notification to APS occurred on 8/12/19 at 9:00 AM. [Note: The APS reporting occurred more than 2 hours after incident initially occurred and was reported to the facility administrator. i. On 9/27/19, resident 11 was observed in the activity/TV room swearing and kicking resident 21. This event occurred on 9/27/19 at 10:00 AM. i. Notification the State Survey Agency occurred on 9/27/19 at 11:41 AM. ii. Notification to APS occurred on 9/24/19 at 12:57 PM. [Note: The APS reporting occurred more than 2 hours after incident initially occurred and was reported to the facility administrator. ] On 12/19/19 at 11:07 AM, an interview was conducted with the Administrator. The Administrator stated that the state agency was notified of potential abuse allegations by herself, the Director of Nursing, or the charge nurses at night. The administrator stated that the social worker notified APS and the Ombudsman of potential allegations of abuse the next time she was at the facility, and that APS had not been notified on off hours, but that they can change that process. Based on interview and record review it was determined, for 8 out of 28 sampled residents, that the facility did not ensure that the violations involving abuse including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury. Specifically, an injury of unknown origin was initially reported to the State Survey Agency 7 hours and 30 minutes after the incident was reported to the Administrator. In addition, resident to resident altercations were not reported timely to the State Survey Agency and Adult Protective Services (APS). Resident identifiers: 4, 9, 11, 12, 21, 37, 51, and 61. Findings include: 1. Resident 51 was admitted to the facility on [DATE] with diagnoses which included dementia without behavioral disturbance, pathological fracture of left ankle, disorders of bone density and structure, pain in joint, fracture of shaft of right ulna, essential hypertension, chronic atrial fibrillation, atypical atrial flutter, gout, muscle weakness, history of falling, and age related osteoporosis without current pathological fracture. On 12/16/19 at 11:24 AM, resident 51 was observed in a wheelchair in the day room. Resident 51 was observed to have a splint on his left foot and a cast on his right arm. Resident 51's medical record was reviewed on 12/17/19. A review of the Progress Notes documented the following entries: a. On 10/30/19 at 3:23 PM, Resident has complaints that his right forearm is hurting. There is no bruising or redness noted. MD (Medical Doctor) notified. b. On 10/30/19 at 5:25 PM, New order per [Name of MD]: x-ray 2 views of the right elbow and of the right radius and ulna. c. On 10/30/19 at 8:50 PM, a Nursing Progress Situation, Background, Assessment, Recommendations (SABR) Note documented, [Resident 51] reports c/o (complaints of) Guarding his right arm, cries out in pain if it is moved. XRAY tech (technician) came-angle fx (fracture) is visible to nurse who in (sic) not trained in reading xrays. There is actually a corresponding bump on his arm, that began on 10/30/2019 12:00 AM and have (sic) gotten worse since the onset. Moving make (sic) the symptoms worse, while Not moving improve the symptoms. These symptoms have not occurred before. Severe Osteopenia was dx (diagnosis). last fx. d. On 10/30/19 at 9:40 PM, [Family member name] was contacted about FX in Rt (right). Ulna and that he would probably go to [Hospital name] ER (emergency room) for treatment. e. On 10/31/19 at 12:18 AM, Finally got xray report. Mildly angulated, comminuted fx. of the mid-distal right ulna with medical angulation of the distal fragment relative to the proximal fragments. [MD name] notified. Order to send to ER to manage pain-cast/splint. Nurse called [transportation company name] r/t (related to) displaced fx. and risks for displacing fx. further with transport. EMT's (emergency medical technicians) had a splint they formed to his arm, and placed in sling. HE tolerated transport well. He had been given his nightly tylenol and and oxycodone as ordered. Plus we had pillow splinted for comfort while he was in bed. Res. (residents) bones fragile. f. On 10/31/19 at 1:39 AM, ER called they have placed a 'sugar toned (sic) splint' they are sending resident back by ambulance d/t (due to) fragility. He will have an f/u (follow up) appt. (appointment) with ortho (orthopedics). g. On 10/31/19 at 8:07 AM, a Geriatric Nurse Practitioner (GNP) Medical Necessity/focus Visit Note documented . Yesterday he seemed to indicate pain at the right elbow area. Mechanism of injury is not known. Symptoms: immediate pain, delayed swelling, inability to use arm directly after injury. Symptoms have been waxing and waning since that time. Prior history of related problems: no prior problems with this area in the past. h. On 11/1/19 at 6:31 PM, a Physician/Practitioner Note documented . Right ulnar fragility fracture: per staff report that I have knowledge of and the radiology reading of a spiral fracture I suspect this may have occurred while he was grabbing something (bar or door or aid's ((Certified Nursing Assistants)) arm are all possible) as aides were trying to bathe/shower him. He has known severe osteoporosis with several previous fragility fractures. In the setting of his dementia goals of care have been to focus on palliative approach with treatment focused on management of pain and prioritizing comfort. An Incident Report for Injury of Known Cause dated 10/29/19 at 7:30 AM, documented Nursing Description: Aide reported to nurse that Resident was agitated, trying to hit the aide and refused his shower. Aide also reported that while trying to go into the shower room, the resident had grabbed the doorway and clung on to it as he tried to go through. So he took the resident back to his room and laid him down. [NAME] continued to try to hit the aide and yelled at the aide so he reported to the nurse. A review of the facility reported incident investigation documented the following entries: a. On 10/31/19 at 9:30 AM, the Administrator was notified. b. On 10/31/19 at 5:00 PM. the State Survey Agency was notified. On 12/18/19 at 12:14 PM, an interview was conducted with the Social Services Assistant (SSA). The SSA stated that the Administrator was the abuse coordinator. The SSA stated that she would complete the investigation and the documentation. The SSA stated that she would notify Adult Protective Services and start the process of the Investigation Checklist. The SSA stated that she would review the nursing documentation and interview anyone that might have knowledge of the incident. The SSA stated that as soon as the incident was reported to her, she would investigate the incident, and the final document was reported to the State Department of Health within 5 working days. The SSA further stated that the Administrator notified the State Department of Health and that was how she would get the complaint number for the investigation. On 12/18/19 at 12:22 PM, an interview was conducted with the Administrator. The Administrator stated that the notification to the State Department of Health regarding the incident with resident 51 was reported late. The Administrator stated that the staff were unsure if the incident with resident 51 was abuse. The Administrator stated that resident 51 was very brittle and she did not think the incident was abuse. The Administrator stated that the incident was reported late and there were no excuses. The Administrator stated that the incident was an injury of unknown origin and it should have been reported timely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 2 of 28 sampled residents, that the facility did not ensure that it was free of medication error rates of five percent or greater. Observations of 46 medication opportunities on 12/18/19, revealed 5 medication errors which results in a 10.87 % medication error rate. Specifically, one resident was given the wrong dose of medication, one resident was given a substitute medication, one resident was given the wrong medication, and one residents physician's order for administration was not followed. Resident identifiers: 41 and 29. 1. Resident 41 was admitted to the facility on [DATE] with the diagnoses which included Parkinson's disease, hypertension, major depressive disorder, and type 1 diabetes mellitus. On 12/18/19 at 8:08 AM, Registered Nurse (RN) 1 was observed to prepare and administer medications to resident 41. RN 1 administered one 5 milligram (mg) tablet of memantine to resident 41. Resident 41's medical record was reviewed for the reconciliation of medications on 12/18/19. According to the Physician's order, resident 41 was to receive Memantine 5 mg, give 10 mg. 2. Resident 29 was admitted to the facility on [DATE] with diagnoses which included atrial flutter, congestive heart failure, hypertension, spinal stenosis, low back pain, and depressive disorder. On 12/18/19 at 8:27 AM, RN 1 was observed to prepare and administer medications to resident 29. The following observations were observed: a. Lidocaine cream 4% was marked refused on the Medication Administration Record and RN 1 administered biofreeze. According to the Physician's order, resident 29 was to receive Lidocaine cream 4%. No physician's order for Biofreeze could be located in resident 29's medical record. On 12/18/19 at 8:43 AM, an interview was conducted with resident 29. Resident 29 stated that he did not refuse his lidocaine cream, and that he did want it. b. Metamucil 2 plastic spoons of Metamucil, mixed in 4 ounces of water with Miralax. According to the physician's order, resident 29 was to receive Metamucil Fiber Packet (Psyllium) Give 1 packet by mouth one time a day for constipation. c. Metoprolol Succinate 12.5 mg was not administered and was held for a pulse of 44. RN 1 obtained resident 29's blood pressure and pulse with an electronic wrist blood pressure cuff. According to the physician's order, resident 29 was to receive Metoprolol Succinate Extended Release Tablet 25 mg. Give 12.5 mg by mouth one time a day related to Essential (primary) Hypertension. Hold for Systolic Blood Pressure <100 and/or Apical pulse of <50. Apical pulse per physician's order needs to be counted for a minimum of 30 seconds. Notify Medical Doctor if pulse <35. d. Prosight one tablet was administered. According to the physician's order, Resident 29 was to receive Ocuvite-Lutein Capsule (multivitamin- minerals) Give 1 capsule by mouth two times a day for eye vitamins. On 12/18/18 at 10:33 AM, an interview was conducted with Pharmacist 1. Pharmacist 1 stated that there were several manufactures that produce eye vitamins with Lutein. Pharmacist 1 stated that if the Prosight medication had Lutein in it, it would be a suitable substitute for the Ocuvite-Lutein. On 12/18/19 at approximately 11:00 AM, an observation was made. The Prosight vitamin that was administered to resident 29 was observed to have the following active ingredients which included Vitamin A, Vitamin C, Vitamin E, Calcium, Phosphorus, Zinc, Selenium, and Copper. The Prosight Vitamin did not include any Lutein in the ingredient list. On 12/19/19 at 9:01 AM, an interview was conducted with Medical Director (MD) 1. MD 1 stated that resident 29's pulse should be checked with an apical pulse as the order reads for administration of the Metoprolol. MD 1 stated that when a blood pressure and pulse was taken with a blood pressure cuff it can give an artificial low pulse if a resident has atrial fibrillation, and that was why resident 29 required an apical pulse for medication administration. On 12/19/19 at 9:51 AM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated that she had obtained the pulse for resident 29 prior to the medication administration. LPN 4 stated that she obtained resident 29's blood pressure and pulse with a blood pressure cuff. LPN 4 stated that the physician's order for resident 29's Metoprolol had not stated to take an apical pulse. LPN 4 stated that an apical pulse would be obtained with a stethoscope listening to the resident's chest.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 3 of 28 sampled residents, that the facility did not ensure residents were free of any significant medication errors. Specifically, 2 residents with diabetes were not administered insulin per the physician's order and a resident's apical pulse was not taken per physician's order for administration of medication. Resident identifiers: 29, 40, and 41. Findings include. 1. Resident 40 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, congestive heart failure, major depressive disorder, hypertension, and type 2 diabetes mellitus. Resident 40's medical record was reviewed on 12/18/19. A physician's order for Insulin Aspart Solution inject 10 units subcutaneously before meals for Diabetes. Notify Medical Doctor (MD) if blood glucose below 70 or above 350. A start date of 10/18/19. [Note: Resident 40's Insulin Aspart Solution did not include parameters to hold.] A review of the October, November, and December 2019 Medication Administration Record (MAR) documented the following entries: a. On 10/20/19 at 7:30 AM, insulin was held for vitals out of parameters. Blood glucose 89. b. On 10/20/19 at 11:40 AM, insulin was held for vitals out of parameters. Blood glucose 100. [Note: Resident 40's subsequent blood glucose was 284.] c. On 10/26/19 at 7:30 AM, insulin was held for vitals out of parameters. Blood glucose 91. [Note: Resident 40's subsequent blood glucose was 209.] d. On 11/2/19 at 4:30 PM, insulin was held for vitals out of parameters. Blood glucose 74. [Note: Resident 40's subsequent blood glucose was 332.] e. On 11/15/19 at 11:30 AM, insulin was held, with a code of 5 hold see nurse notes. Blood glucose 72. f. On 11/16/19 at 7:30 AM, insulin was held for vitals out of parameters. Blood glucose 100. g. On 11/17/19 at 7:30 AM, insulin was held for vitals out of parameters. Blood glucose 98. h. On 11/23/19 at 7:30 AM, insulin was held for vitals out of parameters. Blood glucose 78. i. On 11/24/19 at 7:30 AM, insulin was held for vitals out of parameters. Blood glucose 90. [Note: Resident 40's subsequent blood glucose was 230.] j. On 11/27/19, insulin was held with a code of 5 hold see nurse notes. Blood glucose 78. k. On 11/28/19, insulin was held with a code of 5 hold see nurse notes. Blood glucose 84. [Note: Resident 40's subsequent blood glucose was 232.] l. On 11/30/19 at 4:30 PM, insulin was held for vitals out of parameters. Blood glucose 100. [Note: Resident 40's subsequent blood glucose was 348.] m. On 12/1/19 at 4:30 PM, insulin was held for vitals out of parameters. Blood glucose 92. n. On 12/5/19 at 7:30 AM, insulin was held with a code of 5 hold see nurse notes. Blood glucose 84. [Note: Resident 40's subsequent blood glucose was 235.] o. On 12/6/19 at 7:30 AM, insulin was held with a code of 5 hold see nurse notes. Blood glucose 72. [Note: Resident 40's subsequent blood glucose of 268.] p. On 12/7/19 at 4:30 PM, insulin was held for vitals out of parameters. Blood glucose 78. [Note: Resident 40's subsequent blood glucose was 212.] q. On 12/8/19 at 7:30 AM, insulin was held for vitals out of parameters. Blood glucose 87. 2. Resident 41 was admitted to the facility on [DATE] with the diagnoses which included Parkinson's disease, hypertension, major depressive disorder, and type 1 diabetes mellitus. A record review for resident 41 was completed on 12/18/19. A physician's order for Humalog Solution inject 13 units subcutaneously one time a date related to Type 1 Diabetes Mellitus. A start date of 2/28/19 to be administered at 7:30 AM. A physician's order for Humalog Solution inject 6 units subcutaneously one time a day. A start date of 2/28/19 to be administered at 11:30 AM. A review of the December 2019 MAR documented the following entries: a. On 12/6/19, resident 41 received a partial dose of 4 units. b. On 12/13/19, resident 41 received a partial dose of 4 units. A physician's order for Humalog Solution inject 14 unit subcutaneously in the evening. A start date of 2/27/19 at to be administered at 4:30 PM. A review of the December 2019 MAR documented on 12/6/19, resident 41 received 6 units. A physician's order for Humalog Solution inject per sliding scale. If 0-59 give juice and notify MD, 60-149 give 0, 200-250 give 1, 251-300 give 2, 301-350 give 3, 351-400 give 4, and 401-999 give 5 and call MD subcutaneously 4 times a day for diabetes mellitus. No nightly sliding scale insulin unless above 250 give 1 unit for every 50 above 250. Administer insulin after eating with a start date of 11/2/19. [Note: There was no sliding scale for a blood glucose between 150 and 199.] A review of the November and December 2019 MAR documented the following entries: a. On 11/4/19 with the administration time of 6:00- 10:00 PM, resident 41 received 1 unit of insulin for a blood glucose of 238. [Note: Resident 41 should not have received insulin per the order for the nightly sliding scale.] b. On 11/7/19 with the administration time of 6:00-10:00 PM, resident 41 received 1 unit of insulin for a blood glucose of 204. [Note: Resident 41 should have not received insulin per the order for the nightly sliding scale.] c. On 11/10/19 with the administration time of 6:00-10:00 PM, resident 41 received 3 units of insulin for a blood glucose of 347. [Note: Resident 41 should have received 2 units per the order for nightly sliding scale.] d. On 11/11/19 with the administration time of 6:00-10:00 PM, resident 41 received 2 units for a blood glucose of 272. [Note: Resident 41 should have received 1 unit per the orders for nightly sliding scale.] e. On 11/20/19 with the administration time of 6:00 PM- 10:00 PM, resident 41 received 3 units of insulin for a blood glucose of 311. [Note: Resident 41 should have received 2 units per the orders for nightly sliding scale.] f. On 11/23/19 with the administration time of 6:00-10:00 PM, resident 41 received 2 units for a blood glucose of 258. [Note: Resident 41 should have received 1 unit per the orders for nightly sliding scale.] g. On 11/26/19 with the administration time of 6:00-10:00 PM, resident 41 received 4 units of insulin for a blood glucose of 370. [Note: Resident 41 should have received 3 units per the orders for nightly sliding scale.] h. On 11/27/19 with the administration time of 6:00-10:00 PM, resident 41 received 1 unit of insulin for a blood glucose of 212. [Note: Resident 41 should not have received any insulin per the order for nightly sliding scale.] i. On 12/1/19 with the administration time of 6:00 PM- 10:00 PM, resident 41 received 1 unit for a blood glucose of 221. [Note: The resident should have not received insulin per the order for nightly sliding scale.] j. On 12/8/19 with the administration time of 6:00 PM-10:00 PM, resident 41 received 1 unit of insulin for a blood glucose of 231. [Note: The resident should have not received insulin per the order for nightly sliding scale.] k. On 12/9/19 with the administration time of 6:00 PM-10:00 PM, resident 41 received 2 units of insulin for a blood glucose of 257. [Note: The resident should have received 1 unit for every 50 above 250 per the order for nightly dose of sliding scale.] l. On 12/13/19 with the administration time of 6:00 PM-10:00 PM, resident 41 received 1 unit of insulin with a blood glucose of 245. [Note: The resident should have not received insulin per the order for nightly sliding scale.] 3. Resident 29 was admitted to the facility on [DATE] with diagnoses which included; atrial flutter, congestive heart failure, hypertension, spinal stenosis, low back pain, and depressive disorder. On 12/18/19 at 8:27 AM, Registered Nurse (RN) 1 was observed to prepare and administer medications to resident 29. Resident 29's Metoprolol Succinate 12.5 milligrams (mg) was not administered and was held for a pulse of 44. RN 1 obtained resident 29's blood pressure and pulse with an electronic wrist blood pressure cuff. A record review for resident 41 was completed on 12/18/19. A physician's order documented, Metoprolol Succinate Extended Release Tablet 24 hour 25 milligram, give 12.5mg by mouth one time a day related to Essential (primary) Hypertension. Hold for Systolic Blood Pressure <100 and/or Apical pulse of <50. Apical pulse per Dr. (doctor) order needs to be counted for a minimum of 30 seconds. Notify MD if pulse is <35. Start date of 11/21/19. On 12/18/19 at 12:37 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she would only hold insulin after speaking to a supervisor and a physician with her reasoning. On 12/18/19 at 1:07 PM, an interview was conducted with LPN 2. LPN 2 stated that some medications have parameters to hold. LPN 2 stated that if a medication did not have parameters to hold she would not hold the medication on her own and would notify the MD for permission to hold. LPN 2 stated that she would notify the MD if a medication was refused 2 or 3 times and would ask the MD to review medication for re adjustment, but if it was insulin that was refused she would notify the MD. LPN 2 stated that if a resident was having hypertension frequently she would notify the physician, and that the physician would re-evaluate the residents medications. On 12/19/19 at 7:30 AM, an interview was conducted with Assistant Director of Nursing (ADON) 1. ADON 1 stated that the MD should be notified if a medication needs to be held without parameters. ADON 1 stated that medication should not be held unless there was an order to hold it based on the vital signs. On 12/19/19 at 7:51 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that a medication with parameters was located in the physician's orders. The DON stated that if insulin needed to be held without parameters the MD should be notified. On 12/19/19 at 9:01 AM, an interview was conducted with MD1. MD 1 stated that her expectation would to be notified if insulin had been held or refused. MD 1 stated that she would expect to be notified of hypertension. MD 1 stated if she would have been notified of resident 29's elevated blood pressure on 12/18/19, and the trend of elevated blood pressures she would have reviewed his medications. MD 1 stated that resident 29's pulse should be checked with an apical pulse as the order reads for administration of the Metoprolol. MD 1 stated that when a blood pressure and pulse was taken with a blood pressure cuff it could give an artificial low pulse if a resident had atrial fibrillation, and that was why resident 29 required an apical pulse for medication administration. On 12/19/19 at 9:51 AM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated that she had obtained the pulse for resident 29 prior to the medication administration. LPN 4 stated that she obtained resident 29's blood pressure and pulse with a blood pressure cuff. LPN 4 stated that the physician's order for resident 29's Metoprolol had not stated to take an apical pulse. LPN 4 stated that an apical pulse would be obtained with a stethoscope listening to the resident's chest.

Based on observation and interview it was determined that the facility did not ensure safe and secure storage of drugs and biologicals in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration dates on the medication. Specifically, drugs were not labled correctly and one resident was administered expired medication. Resident Identifier: 9. Findings include: On 12/18/19 at approximately 10:00 AM, the medication cart for the west hall was inspected, the following items were discovered: a. A clear cup with no labeling, contained 2 white pills, and was located in the top of the medication cart. An immediate interview was conducted with Registered Nurse (RN) 1. RN 1 stated that the pills were metformin, and it was not supposed to be in there so she was going to through it away. b. A bottle of Morphine 100 milligrams/5 milliliters was in the narcotic drawer of the medication cart. The bottle of Morphine did not have a Pharmacy label and a resident name was written on the bottle in black marker. c. An insulin pen with the medication Lantus was in the top drawer of the medication cart. There was no open date or use by date located on the insulin pen. d. A bag with 12 syringes of Ativan, Benadryl, and Haldol (ABH) cream with an expiration date of 12/14/19, for resident 9. A record review of Resident 9's controlled substance record was completed on 12/18/19. The controlled drug record documented that the expired ABH cream was administered to resident 9 on 12/16/19 at 3:00 PM and 12/17/19 at 3:00 PM. On 12/19/19 at 7:51 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the medication room and medication carts were checked weekly for expired medications by the graveyard supervisors. The DON stated that expired medications should not be administered to residents. The DON stated that insulin should be labeled with a use by or open date and should be used or discarded within 28 days. The DON stated that all medications other than over the counter (OTC) medications in the OTC bottles should have a label.