Based on resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide written notice, including the reason for the change, prior to a room transfer for three of five residents reviewed, Resident #1, Resident #3 and Resident #4. The findings include: 1. For Resident #1 (R1), the facility staff failed to provide written notice of room transfer including the reason for room change, prior to the room change on 2/15/2024. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 5/30/2024, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were cognitively intact for making daily decisions. The admission record for R1 documented the resident being their own responsible party. The census list for R1 documented a room change for R1 on 2/15/2024 from the North unit to the South unit. On 6/17/2024 at 11:35 a.m., an interview was conducted with R1 in their room. R1 stated that they had moved to their current on 2/15/2024 and had been forced to move to the other unit. R1 stated that no one provided a written notice stating why they had to change rooms before the move and they had been told a few days before they wanted them to move all the long term residents on the other unit and they refused to move and then they told them that the heater was broken and they had to move for it to be repaired. R1 stated that they did not trust the staff at the facility because they only told them what they wanted to hear and they felt that they had lied about the heater to get them to move. When asked if they still wanted to go back to their old room or were unhappy on the new unit, R1 did not answer and began to talk about another topic. The clinical record for R1 failed to evidence documentation that a written notice of room transfer including the reason for room change was provided to the resident prior to the change on 2/15/2024. A facility concern form dated 3/22/2024 for R1 documented in part, . [Name of facility administrator] did not give her in writing the reason why her room was changed. Requesting a copy of the moving situation document to keep for her records . Under Resolution of Concern it documented in part, .Resident provided letter stating she was moved due to broken ptac (heating/air conditioning) unit that could not be repaired. Written by [Name of facility administrator] given to [Name of R1] by [Name of business office manager] . The concern form was observed to be dated as resolved on 3/28/2024. On 6/18/2024 at 10:00 a.m., an interview was conducted with OSM (other staff member) #7, the director of social services. OSM #7 stated that normally they were notified by nursing staff when a room change was needed. She stated that her responsibility was to contact the responsible party to notify them of the room change and notify the resident of the room change. She stated that she also completed a room change assessment in the medical record and completed a progress note prior to the room change. She stated that she did not provide a written notice of room change to the resident or the responsible party prior to room changes and thought that maybe the admissions director did. She stated that R1's room had to be changed due to the heater being broken and it could not be repaired immediately. On 6/18/2024 at 10:06 a.m., an interview was conducted with OSM #8, the admissions director. OSM #8 stated that their role in room changes was limited to running the bed board. She stated that when a room change was required, the staff contacted her to ensure that a room was open and not being held for a new admission or hospitalized resident. She stated that she did not provide any written notice to the resident or the responsible party prior to a room change. She stated that for R1, she had played a larger role in the room change because she had a better relationship with the resident. She stated that she had spoken with R1 a few days prior to the move regarding moving to the other room for the fact that they were attempting to have most of the long term care residents on that unit for an attempt to create a more homelike environment over there. She stated that on that unit they were trying to create a more long term setting with the same residents, same staff and consistent schedules rather than the consistent changeover on the skilled unit. She stated that R1 had refused the room change that day and it was their right to refuse. She stated that a couple of days later the heater was broken and could not be repaired so they had been able to move them to the same room because it was still open and it was the only private room open at the time. On 6/18/2024 at 10:45 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that they were notified of room changes by social services putting a notice up at the nurses station telling them the date and location of the room change. She stated that she thought that they spoke to the resident and the responsible party regarding the room change and nursing did not provide any written notice of room change to the resident or the responsible party prior to the move. On 6/18/2024 at 12:20 p.m., ASM (administrative staff member) #1, the administrator stated that they did not have evidence that R1 was provided a written notice of transfer with reason for room change prior to the move on 2/15/2024. The facility policy, Room Change/Roommate Assignment dated May 2017 documented in part, .Advance notice of a roommate change will include why the change is being made and any information that will assist the roommate in becoming acquainted with his or her new roommate . On 6/18/2024 at 12:28 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the vice president of clinical services were made aware of the concern. No further information was presented prior to exit. 2. For Resident #3 (R3), the facility staff failed to provide written notice of room transfer including the reason for room change, prior to the room change on 2/20/2024. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/27/2024, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were cognitively intact for making daily decisions. The admission record for R3 documented the resident being their own responsible party. The census list for R3 documented a room change for R3 on 2/20/2024 from the South unit to the North unit. On 6/17/2024 at 2:10 p.m., an interview was conducted with R3. R3 stated that they had moved to the other unit for a while because they told them that other residents had COVID-19 and they needed the room for them. R3 stated that they did not give them anything in writing but they had moved them back to the room after a few weeks so they were satisfied. The clinical record for R3 failed to evidence documentation that a written notice of room transfer including the reason for room change was provided to the resident prior to the change on 2/20/2024. On 6/18/2024 at 10:00 a.m., an interview was conducted with OSM (other staff member) #7, the director of social services. OSM #7 stated that normally they were notified by nursing staff when a room change was needed. She stated that her responsibility was to contact the responsible party to notify them of the room change and notify the resident of the room change. She stated that she also completed a room change assessment in the medical record and completed a progress note prior to the room change. She stated that she did not provide a written notice of room change to the resident or the responsible party prior to room changes and thought that maybe the admissions director did. She stated that she thought that R3's room had to be changed due to nursing reasons. On 6/18/2024 at 10:06 a.m., an interview was conducted with OSM #8, the admissions director. OSM #8 stated that their role in room changes was limited to running the bed board. She stated that when a room change was required, the staff contacted her to ensure that a room was open and not being held for a new admission or hospitalized resident. She stated that she did not provide any written notice to the resident or the responsible party prior to a room change. On 6/18/2024 at 10:45 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that they were notified of room changes by social services putting a notice up at the nurses station telling them the date and location of the room change. She stated that she thought that they spoke to the resident and the responsible party regarding the room change and nursing did not provide any written notice of room change to the resident or the responsible party prior to the move. On 6/18/2024 at 12:28 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the vice president of clinical services were made aware of the concern. No further information was presented prior to exit. 3. For Resident #4 (R4), the facility staff failed to provide written notice of room transfer including the reason for room change, prior to the room change on 4/4/2024. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/10/2024, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were cognitively intact for making daily decisions. The admission record for R4 documented the resident being their own responsible party. The census list for R4 documented a room change for R4 on 4/4/2024 from the North unit to the South unit. On 6/18/2024 at approximately 8:22 a.m., an interview was conducted with R4. When asked about their room change to the South unit, R4 nodded that they remembered the move. When asked if they were told the reason for the move, R4 nodded, No. When asked if they received a written notice with reason for room change prior to the move, R4 nodded, No. When asked if they liked their current room and roommate, R4 nodded, Yes. The clinical record for R4 failed to evidence documentation that a written notice of room transfer including the reason for room change was provided to the resident prior to the change on 4/4/2024. On 6/18/2024 at 10:00 a.m., an interview was conducted with OSM (other staff member) #7, the director of social services. OSM #7 stated that normally they were notified by nursing staff when a room change was needed. She stated that her responsibility was to contact the responsible party to notify them of the room change and notify the resident of the room change. She stated that she also completed a room change assessment in the medical record and completed a progress note prior to the room change. She stated that she did not provide a written notice of room change to the resident or the responsible party prior to room changes and thought that maybe the admissions director did. She stated that she thought that R4's room had to be changed due to nursing reasons. On 6/18/2024 at 10:06 a.m., an interview was conducted with OSM #8, the admissions director. OSM #8 stated that their role in room changes was limited to running the bed board. She stated that when a room change was required, the staff contacted her to ensure that a room was open and not being held for a new admission or hospitalized resident. She stated that she did not provide any written notice to the resident or the responsible party prior to a room change. On 6/18/2024 at 10:45 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that they were notified of room changes by social services putting a notice up at the nurses station telling them the date and location of the room change. She stated that she thought that they spoke to the resident and the responsible party regarding the room change and nursing did not provide any written notice of room change to the resident or the responsible party prior to the move. On 6/18/2024 at 12:28 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the vice president of clinical services were made aware of the concern. No further information was presented prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide a dignified dining experience for one of 42 residents in the survey sample, Resident #16. The findings include: For Resident #16 (R16), the facility staff failed to provide lunch in a dignified manner on 11/13/23. R16 was served a meal on a Styrofoam plate and given plastic utensils. A review of R16's clinical record failed to reveal documentation that R16 should be served meals on a Styrofoam plate or given plastic utensils (the resident was not on isolation and did not present with dangerous behaviors). On 11/13/23 at 1:20 p.m., R16 was observed sitting up in bed and eating lunch. The resident's meal was on a Styrofoam plate and the resident was eating with plastic utensils. On 11/14/23 at 2:50 p.m., an interview was conducted with OSM (other staff member) #5 (the dietary director). OSM #5 stated that when she began employment 45 days ago, a lot of plates did not match, and she did not have enough plates. OSM #5 stated she requested four cases (each case containing 36 plates) of plates and had only received two cases. OSM #5 stated there was also a shortage of utensils and she had ordered multiple boxes of utensils because they get thrown in the trash or stockpiled in resident rooms. OSM #5 stated dining with a Styrofoam plate and plastic utensils is not dignified. On 11/14/23 at 4:57 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. ASM #1 stated four cases of plates had been ordered but two cases had not yet been received. The facility policy titled, Dignity documented, 5. When assisting with care, residents are supported in exercising their rights. For example, residents are: e. provided with a dignified dining experience .

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to evidence the required clinical documents were sent to the hospital for a facility-initiated transfer for three of 42 residents in the survey sample, Residents #82, #32, and #5. The findings include: 1. For Resident #82 (R82), the facility staff failed to evidence what documents were sent to the hospital with the resident on 8/10/2023. The nurse's notes 8/10/2024 at 8:10 p.m. documented in part, I was called to resident room by assigned CNA (certified nursing assistant) of this resident. When I arrived in the resident room, he was noted laying on this left side, on the L (left) side of his bed, noted his left arm under him. Resident was noted with his left side of his face to the floor. Resident was wearing his eyeglasses at the time of the fall; Resident eyeglasses was noted broken on the floor beside him. When assessed, Resident was noted with swelling to his L. eye/L side of face, (2) Lacerations to L. Side temple/hair line area, L. eye red and swollen, C/O (complained of) L. shoulder/arm pain, Laceration to L. side of mouth .On call contacted and gave verbal order to send (R82) to hospital E.R (emergency room) for further evaluation and treatment. (Name of town) EMS (emergency medical services) contacted and transported (R82) to (Name of Hospital), R.P. (responsible party) made aware (name of RP) (Name of nurse practitioner) made aware and gave verbal order. A copy of evidence of what documents were sent to the hospital for the transfer of 8/10/2023 was requested on 11/14/2023 at 11:37 a.m. however no documents were received. An interview was conducted with LPN (licensed practical nurse) #5 on 11/14/2023 at 4:16 p.m. When asked what documents are sent to the hospital when a resident is sent out, LPN #5 stated they send the face sheet, any pertinent laboratory test results, doctor's notes, nurse's notes, if the resident is a DNR (do not resuscitation), send that form, care plan, bed hold notice and medication list. LPN #5 was asked where it is documented that those documents are sent to the hospital, LPN #5 stated there should be documentation in the nurse's notes. A copy of the policy regarding documentation related to a hospital transfer was requested on 11/15/2023 at 8:40 a.m. The policy presented, Transfer and Discharge Notice, did not address the required documents to be sent with a resident at the time of a facility-initiated transfer. ASM (administrative staff member) #1, ASM #2, the director of nursing and ASM #3, the vice president of clinical operations, were made aware of the above concern on 11/14/2023 at 5:04 p.m. No further information was provided prior to exit. 2. For Resident #32, the facility staff failed to evidence what documents were sent to the hospital with the resident on 10/30/2023. The nurse practitioner (NP) note dated, 10/30/2023 documents in part, Patient's labs showed significant anemia, no signs of bleeding but given patient history and her feeling unwell send to ER (emergency room) to rule out bleed. Patient has a risk of decompensation. The nurse's note dated, 10/30/2023 at 10:00 a.m. documented, NP aware of sending out. The nurse's note dated, 10/30/2023 at 11:19 a.m., Squad picked up to send to ED (emergency department) for evaluation. There was no documentation of what was sent to the ED with the resident. A copy of evidence of what documents were sent to the hospital for the transfer of 10/30/2023 was requested on 11/14/2023 at 11:37 a.m. The SNF/NF to Hospital Transfer Form dated 10/30/2023 failed to evidence what documents were sent with the resident. The Acute Care Transfer Document Checklist dated 10/30/2023 was blank. The form didn't have a check off for the comprehensive care plan goals to be sent with the resident. An interview was conducted with LPN (licensed practical nurse) #5 on 11/14/2023 at 4:16 p.m. When asked what documents are sent to the hospital when a resident is sent out, LPN #5 stated they send the face sheet, any pertinent laboratory test results, doctor's notes, nurse's notes, if the resident is a DNR (do not resuscitation), send that form, care plan, bed hold notice and medication list. LPN #5 was asked where it is documented that those documents are sent to the hospital, LPN #5 stated there should be documentation in the nurse's notes. ASM (administrative staff member) #1, ASM #2, the director of nursing and ASM #3, the vice president of clinical operations, were made aware of the above concern on 11/14/2023 at 5:04 p.m. No further information was provided prior to exit. 3. For Resident #5, the facility staff failed to evidence what documents were sent to the hospital with the resident on 11/12/2023. The nurse's note dated, 11/12/2023 at 9:58 p.m. documented, Notified MD (medical doctor) about a ground level fall that happened when she tried to go to the bathroom. Notified the on-call doctor that she is complaining of pain at 8 out of 10 in her neck. No other injury noted. MD said since she had neck pain to send her out to the hospital to be evaluated. Primary nurse notified RP about the fall and sending her out to the hospital. 911 called an ambulance crew is on the way to take her to the nearest hospital to be evaluated. The nurses' note dated, 11/12/2023 at 10:22 p.m. documented, Ambulance crew here to pick up patient and transport her to the nearest hospital. Information packet given to squad members. A copy of evidence of what documents were sent to the hospital for the transfer of 11/12/2023 was requested on 11/14/2023 at 11:37 a.m. however no further documents were provided. An interview was conducted with LPN (licensed practical nurse) #5 on 11/14/2023 at 4:16 p.m. When asked what documents are sent to the hospital when a resident is sent out, LPN #5 stated they send the face sheet, any pertinent laboratory test results, doctor's notes, nurse's notes, if the resident is a DNR (do not resuscitation), send that form, care plan, bed hold notice and medication list. LPN #5 was asked where it is documented that those documents are sent to the hospital, LPN #5 stated there should be documentation in the nurse's notes. ASM (administrative staff member) #1, ASM #2, the director of nursing and ASM #3, the vice president of clinical operations, were made aware of the above concern on 11/14/2023 at 5:04 p.m. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to notify the State Long-Term Care Ombudsman of a facility initiated transfer for one of 42 residents in the survey sample, Resident #82. The findings include: For Resident #82 (R82), the facility staff failed to notify the ombudsman of a facility-initiated transfer on 8/10/2023. The nurse's notes 8/10/2024 at 8:10 p.m. documented in part, .Resident was noted with his left side of his face to the floor .When assessed, Resident was noted with swelling to his L. eye/L side of face, (2) Lacerations to L. Side temple/hair line area, L. eye red and swollen, C/O (complained of) L. shoulder/arm pain, Laceration to L. side of mouth .On call contacted and gave verbal order to send (R82) to hospital E.R (emergency room) for further evaluation and treatment. (Name of town) EMS (emergency medical services) contacted and transported (R82) to (Name of Hospital), R.P. (responsible party) made aware (name of RP) (Name of nurse practitioner) made aware and gave verbal order. A copy of the notice to the ombudsman for the transfer of 8/10/2023 was requested on 11/14/2023 at 11:37 a.m. A copy of the notice sent to the ombudsman for all of August 2023 facility-initiated transfers were reviewed. R82 was not on the list. An interview was conducted with OSM (other staff member) #1, the director of social services, on 11/14/2023 at 3:56 p.m. The notification documents sent to the ombudsman for transfers in August 2023 were reviewed with OSM #1. OSM #1 didn't know why it didn't populate (R82), she stated she just didn't know why. OSM #1 returned on 11/14/2023 at 4:43 p.m. and stated, R82 had a bed hold. OSM #1 further stated the resident wouldn't be considered a transfer in PCC (point click care-charting system) as he was holding the room. OSM #1 stated when she ran the report on 9/1/2023 he didn't show up because the room was reserved. When asked if a resident does a bed hold, then are you accurately reporting the discharged and transfers to the ombudsman, OSM #1 stated, she guesses not, there had to be a [NAME] in the computer system. The facility policy, Transfer and Discharge Notice documented in part, 6. A copy of the notice is sent to the Office of the State Long -Term Care Ombudsman at the same time as the transfer or discharge is provided to the resident and representative. ASM (administrative staff member) #1, ASM #2, the director of nursing and ASM #3, the vice president of clinical operations, were made aware of the above concern on 11/14/2023 at 5:04 p.m. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review it was determined that the facility staff failed to ensure an accurate MDS (minimum data set) assessment for one of 42 residents in the survey sample, Resident #98. The findings include: For Resident #98 (R98), the facility staff failed to accurately code the discharge MDS assessment with the ARD (assessment reference date) of 10/25/2023, with the correct discharge location. R98's most recent MDS, a discharge assessment with an ARD of 10/25/2023, coded R98 as having a planned discharge on [DATE] to a short term general hospital with a return to the facility not anticipated. The progress notes documented in part, - 10/17/2023 14:14 (2:14 p.m.) Note Text : SS (social services) and DT (director of therapy) spoke with Pt (patient) and Son about LCD (last covered day) of 10/24/2023 with a D/C (discharge) date of 10/25/2023. Pt and Son agreed, Son stated he would pick up Pt to take her home SS will set up home health PT has no preference. SS has sent referral to (Name of home health agency). - 10/25/2023 11:00 (11:00 a.m.) Note Text : Pt stable for discharge home and has departed the facility. On 11/15/2023 at 8:47 a.m., an interview was conducted with RN (registered nurse) #2, MDS coordinator. RN #2 stated that they followed the RAI (resident assessment instrument) manual when completing the MDS resident assessments. She stated that when completing the discharge assessments for residents she reviewed the medical record documentation, used the information provided in the morning meetings, 24 hour report and communication from the nursing staff. RN #2 reviewed the discharge MDS for R98 with the ARD of 10/25/2023 and the progress notes and stated that the MDS stated the resident was discharged to the hospital and it looked like the progress notes documented the resident being discharged home. She stated that she would further review her notes and follow up. On 11/15/2023 at 9:10 a.m., RN #2 stated that they had reviewed R98's notes and MDS and felt that it was a data entry error. She stated that she had corrected the MDS to reflect the correct discharge location and provided a printed copy of the corrected MDS at that time. According to the RAI Manual, Version 1.16, dated October 2018, section A2100 documented in the steps for assessment to review the medical record including the discharge plan and discharge orders for documentation of discharge location and to select the two digit code that corresponds to the resident's discharge status. On 11/15/2023 at 9:37 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the vice president of clinical operations were made aware of the findings. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide adequate respiratory care and services for three of 42 residents in the survey sample, Residents #77, #71, and #62. The findings include: 1. For Resident #77 (R77), the facility staff failed to store the resident's incentive spirometer (1) in a sanitary manner. A review of R77's clinical record revealed a physician's order dated 10/24/23 for an incentive spirometer. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 10/30/23, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 11/13/23 at 1:04 p.m., R77 was observed lying in bed. An uncovered incentive spirometer with the mouthpiece exposed to air was observed on the resident's overbed table. R77 stated the facility staff had not offered a cover for the incentive spirometer. On 11/14/23 at 8:22 a.m., the incentive spirometer remained uncovered and on the overbed table. On 11/14/23 at 4:05 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated incentive spirometers should be stored in a bag because germs can get on them. On 11/14/23 at 4:57 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility staff did not provide a specific policy regarding incentive spirometers. Reference: (1) The spirometer is a device used to help you keep your lungs healthy. Using the incentive spirometer teaches you how to take slow deep breaths. This information was obtained from: https://medlineplus.gov/ency/patientinstructions/000451.htm 2. For Resident #71 (R71), the facility staff failed to store the resident's nebulizer mask in a sanitary manner. A review of R71's clinical record revealed a physician's order dated 5/10/23 for albuterol sulfate (1) nebulization solution (1) 2.5 milligrams/3 milliliters 0.083%- one vial via nebulizer every six hours for wheezing and shortness of breath. On 11/13/23 at 1:25 p.m. and 3:56 p.m., R71 was observed lying in bed. An uncovered nebulizer mask was observed on the resident's nightstand. On 11/14/23 at 4:05 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated nebulizer masks should be stored in a bag because germs can get on them. On 11/14/23 at 4:57 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Departmental (Respiratory Therapy)- Prevention of Infection documented, Store the circuit in plastic bag, marked with date and resident's name, between uses. Reference: (1) Albuterol sulfate is used to treat wheezing and shortness of breath. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682145.html 3. For Resident #62 (R62), the facility staff failed to administer oxygen at the physician prescribed rate of 3 LPM (liters per minute). Observation was made of R62 on 11/13/2023 at approximately 1:30 p.m. The resident was sitting in her bed with her oxygen on via a nasal cannula (NC). The oxygen was set at 2.5 LPM. A second observation was made on 11/14/2023 9:10 a.m., the oxygen was in use by the resident and the setting was at 2.5 LPM. The physician order dated, 5/10/2023, documented, O2 (oxygen) at 3LPM via NC continuously. On 11/14/2023 at 12:41 p.m. an observation was made of R62 with LPN (licensed practical nurse) #5. R62 had her oxygen in use. When asked to read the setting of the oxygen, LPN #5 stated it was set at 2.5 LPM. When asked what the prescribed rate was for R62, LPN #5 stated, the resident is supposed to be on 3 LPM. LPN #5 was asked how often should the oxygen setting be checked by the nurse, LPN #5 stated at least once a shift. The comprehensive care plan dated, 4/9/2021, documented, Focus: Resident has altered respiratory status or is at risk for breathing difficulty r/t (related to): COPD (chronic obstructive pulmonary disease), dependence on supplemental oxygen. The Interventions documented in part, OXYGEN THERAPY: OXYGEN SETTINGS: O2 as ordered. The facility policy, Oxygen Administration documented in part, 7. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered .14. Monitor oxygen per MD order. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the vice president of clinical operations, were made aware of the above concern on 11/14/2023 at 3:31 p.m. No further information was provided prior to ext.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure a resident was free from unnecessary psychotropic medications for one of 42 residents in the survey sample, Resident #71. The findings include: For Resident #71 (R71), the facility staff failed to attempt GDRs (gradual dose reductions) for the resident's use of Seroquel (1) and Cymbalta (2). R71 was admitted to the facility on [DATE]. A review of R71's clinical record revealed the following physician's orders: 9/21/22- Seroquel 25 mg (milligrams)- two tablets every morning and at bedtime for depression. 11/21/22- Seroquel 25 mg- two tablets every morning and at bedtime for dementia with behavioral disturbance. 5/10/23- Seroquel 25 mg- two tablets in the morning and three tablets at bedtime for hallucinations. 9/21/22- Cymbalta 30 mg- one capsule in the evening for depression. 11/21/22- Cymbalta 60 mg- one capsule every morning for major depression disorder. 12/14/22- Cymbalta 60 mg in the morning and 30 mg in the evening for major depressive disorder. 2/6/23- Cymbalta 60 mg in the morning and 60 mg in the evening for major depressive disorder. A consultant pharmacist recommendation to the physician dated 5/16/23 documented, Federal guidelines state antipsychotic drugs should have an attempt at a gradual dose reduction (GDR) twice per year for the first year in 2 different quarters with at least 1 month between attempts, then annually thereafter. This resident has been taking SEROQUEL 50 MG QAM (every morning) and SEROQUEL 75 MG QHS (every bedtime) since 11/21/22 without a GDR. Could we attempt a dose reduction at this time to SEROQUEL 50 MG BID (twice a day) to verify this resident is on the lowest possible dose? If not, please indicate response below. The physician's response was a check mark beside, Use in accordance with relevant current standards of practice for psychiatric disorder. A consultant pharmacist recommendation to the physician dated 9/29/23 documented, Federal guidelines state antipsychotic drugs should have an attempt at a gradual dose reduction (GDR) twice per year for the first year in 2 different quarters with at least 1 month between attempts, then annually thereafter, when used to manage behavior, stabilize mood or treat psych disorder. This resident has been taking DULOXETINE (Cymbalta) 60 MG BID since 12/14/22 without a GDR. Could we attempt a dose reduction at this time to verify this resident is on the lowest possible dose? If not, please indicate response below. The physician's response was a check mark beside, Continue this antidepressant therapy; dose reduction contraindicated due to: (blank space). Further review of R71's clinical record failed to reveal a GDR was attempted for the resident's use of Seroquel and Cymbalta, and failed to reveal a documented clinical rational why a GDR was contraindicated for the resident. The nurse practitioners who signed the above pharmacy recommendations were no longer employed at the facility. On 11/14/23 at 4:53 p.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated a GDR for antipsychotic medications and antidepressants should be attempted twice per year for the first year in two different quarters with one month in between, then annually after that. ASM #2 stated that if the physicians or nurse practitioners decide to not attempt a GDR, then they need to document and address why it isn't being attempted. On 11/15/23 at 9:38 a.m., ASM #1 (the administrator) and ASM #2 were made aware of the above concern. The facility policy titled, Antipsychotic Medication Use documented, Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. References: (1) Seroquel is used to treat schizophrenia and bipolar disorder. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a698019.html (2) Cymbalta is used to treat depression. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a604030.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to follow infection control procedures during medication administration for two of four residents in the survey sample, Residents #60 and #88. The findings include: 1. For Resident #60 (R60), the facility staff failed to prepare medications in a sanitary manner during medication administration observation on 11/14/2023. On 11/14/2023 at 8:35 a.m., an observation was made of LPN (licensed practical nurse) #8 preparing medications for R60. LPN #8 was observed to prepare the following medications in a medication cup prior to taking them into R60's room for administration : - Norvasc 2.5mg (milligram) 1 tablet. - Buspar 15mg 1 tablet. - Celexa 40mg 1 tablet. - Lasix 20mg 1 tablet. - Risperidone 0.5mg 1 tablet. LPN #8 was observed to use her ungloved fingers to remove the Buspar 15mg, Celexa 40mg, Lasix 20mg and Risperidone 0.5mg tablets from their packaging and place them into the medication cup. On 11/14/2023 at 8:55 a.m., an interview was conducted with LPN #8. When asked about handling of tablets, LPN #8 stated that they should have put the pills directly into the medication cup from the packaging rather than handling them with their bare hands. She stated that it was a habit they had and they should not handle them to keep them clean. A review of the facility policy, Administering Medications revised April 2019, documented in part, .Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable . According to Fundamentals of Nursing, 5th edition, [NAME], [NAME] & [NAME], page 568, Administering Oral Medications: Procedure - 1. Wash hands. Rationale - Reduces transfer of microorganisms from hands to medication .Prepare selected medications .c. Medications from a bingo card: Snap the bubble containing the correct medication directly over the medication cup. Do not touch the medication. On 11/14/2023 at 3:32 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the vice president of clinical operations were made aware of the findings. No further information was provided prior to exit. 2. For Resident #88 (R88), the facility staff failed to prepare medications in a sanitary manner during medication administration observation on 11/14/2023. On 11/14/2023 at 8:43 a.m., an observation was made of LPN (licensed practical nurse) #8 preparing medications for R88. LPN #8 was observed to prepare the following medications in a medication cup prior to taking them into R88's room for administration: - Levetiracetam 1000mg (milligram) 1 tablet. - Novolog 15U (units) via insulin syringe. - Bumetanide 1mg 1/2 tablet. - Escitalopram 10mg 1 tablet. - Stool softener 100mg 1 tablet. LPN #8 was observed to use her ungloved fingers to remove the Bumetanide 1mg 1/2 tablet, Escitalopram 10mg and Stool softener 100mg tablets from their packaging and place them into the medication cup. On 11/14/2023 at 8:55 a.m., an interview was conducted with LPN #8. When asked about handling of tablets, LPN #8 stated that they should have put the pills directly into the medication cup from the packaging rather than handling them with their bare hands. She stated that it was a habit they had and they should not handle them to keep them clean. On 11/14/2023 at 3:32 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the vice president of clinical operations were made aware of the findings. No further information was provided prior to exit.

Based on observation, staff interview, and facility document review, the facility staff failed to conduct regular bed inspections for two of 42 residents in the survey sample, Residents #16 and #32. The findings include: 1. For Resident #16 (R16), the facility staff failed to conduct a regular bed inspection. A copy of the bed inspections was requesting during the entrance conference on 11/13/2023 at 11:20 a.m. On 11/13/23 at 1:20 p.m. and 11/14/23 at 8:28 a.m., R16 was observed in bed. On 11/15/23 at 9:17 a.m., an interview was conducted with OSM (other staff member) #6, the director of maintenance. OSM #6 stated the maintenance department has not completed bed inspections since before the pandemic. On 11/15/23 at 9:38 a.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Bed Safety documented, To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks . 2. For Resident #32, the facility staff failed to conduct regular bed inspections. Observation was made of Resident #32 (R32) on 11/13/2023 at approximately 1:20 p.m. R32 was in bed with bilateral side rails in place. A copy of the bed inspections was requesting during the entrance conference on 11/13/2023 at 11:20 a.m. A second request was made on 11/14/2023 at 3:31 p.m. A third request was made on 11/14/2023 at 5:04 p.m. and again on 11/16/2023 at 8:00 a.m. On 11/15/2023 at 9:17 a.m., an interview was conducted with OSM (other staff member) #6, the director of maintenance. OSM #6 stated the maintenance department has not completed bed inspections since before the pandemic. Administrative staff member (ASM) #1, the administrator, ASM #2, the director of nursing and ASM #3, the vice president of clinical operations was made aware of the above findings on 11/15/2023 at 9:36 a.m. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to notify the physician of a potential need to alter treatment for one of 42 residents in the survey sample, Resident #20. The findings include: For Resident #20 (R20), the facility staff failed to notify the physician when the resident's medication Gemtesa (1) was not available for administration on multiple dates in September 2023. A review of R20's clinical record revealed a physician's order dated 7/10/23 for Gemtesa 75 mg (milligrams)- one tablet by mouth in the morning for overactive bladder. A review of R20's September 2023 MAR (medication administration record) revealed the same physician's order for Gemtesa. On 9/4/23, 9/5/23, 9/6/23, 9/7/23 and 9/9/23, the MAR documented the code, 9= Other/ See Progress Notes. A nurse's note dated 9/4/23 documented, Medication pending pharmacy. A nurse's note dated 9/5/23 documented, Waiting on delivery from pharmacy. A nurse's note dated 9/6/23 documented, Awaiting pharmacy delivery. A nurse's note dated 9/7/23 documented, Waiting to be delivered by pharmacy. A nurse's note dated 9/9/23 documented, Waiting for pharmacy to deliver. Further review of R20's clinical record failed to reveal the resident's physician was notified and made aware the medication was not available for administration. On 11/14/23 at 4:05 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated nurses should notify the physician when a resident's medication is not available for administration because the doctor gave the order to give the medication for a reason, so the doctor needs to know if the medication is missed. On 11/14/23 at 4:57 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Notification of Change documented, 1. The nurse will notify the resident's Attending Physician / practitioner or physician on call when there has been a(an): e. Need to alter the resident's medical treatment significantly . Reference: (1) Gemtesa is used to treat overactive bladder. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a621015.html

6. For Resident #20 (R20), the facility staff failed to implement the resident's comprehensive care plan for medication administration to treat overactive bladder. A review of R20's clinical record revealed a physician's order dated 7/10/23 for Gemtesa (1) 75 mg (milligrams)- one tablet by mouth in the morning for overactive bladder. R20's comprehensive care plan dated 7/24/23 documented, The resident has alteration or potential for alteration in renal function r/t (related to) BPH (benign prostatic hyperplasia), Diuretics, Kidney disease, Prostate enlargement, Overactive bladder. Interventions: Administer medications and treatments as ordered . A review of R20's September 2023 MAR (medication administration record) revealed the same physician's order for Gemtesa. On 9/4/23, 9/5/23, 9/6/23, 9/7/23 and 9/9/23, the MAR documented the code, 9= Other/ See Progress Notes. A nurse's note dated 9/4/23 documented, Medication pending pharmacy. A nurse's note dated 9/5/23 documented, Waiting on delivery from pharmacy. A nurse's note dated 9/6/23 documented, Awaiting pharmacy delivery. A nurse's note dated 9/7/23 documented, Waiting to be delivered by pharmacy. A nurse's note dated 9/9/23 documented, Waiting for pharmacy to deliver. On 11/14/23 at 4:05 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated, I know the care plan is there for us to check. Orders are put in, the care plan is updated, and everything is there for us to check to know how to take care of that person and everything that person needs. LPN #5 stated the nurses usually try to order medications six or seven days before they run out. LPN #5 stated that if a medication is not available for administration, the nurses should see if the medication is in the facility backup medication supply and if it is not, the nurses should notify the physician, possibly put a hold on the medication until it arrives from the pharmacy and let the pharmacy know they need the medication. On 11/14/23 at 4:57 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. Reference: (1) Gemtesa is used to treat overactive bladder. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a621015.htmlBased on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for eight of 42 residents in the survey sample; Residents #12, #78, #90, #17, #73, #20, #5, and #62. The findings include: 1. For Resident #12, the facility staff failed to follow the comprehensive care plan to obtain weekly weights as ordered by the physician. The facility policy, Care Plans, Comprehensive Person-Centered was reviewed. This policy documented, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident A review of the comprehensive care plan revealed one dated 1/20/23 for The resident has alteration or potential for alteration in renal function . This care plan included an intervention dated 1/20/23 for Obtain weights per orders. Use same scale and preferably same time of day wearing same amount of clothing when obtaining weights. Report significant gain or loss to MD (Medical Doctor). A review of the clinical record revealed a physician's order dated 5/10/23 for Obtain weight weekly. Further review of the clinical record revealed that there were no weights obtained during the following weeks (below dates run a Sunday through Saturday time frame): Week of May 14 through May 20, 2023. Week of May 21 through May 27, 2023. Week of May 28 through June 3, 2023. Week of June 4 through June 10, 2023. Week of June 18 through June 24, 2023. Week of July 2 through July 8, 2023. Week of July 9 through July 15, 2023. Week of July 16 through July 22, 2023. Week of July 23 through July 29, 2023. Week of July 30 through August 5, 2023. Week of August 6 through August 12, 2023. Week of August 27 through September 2, 2023. Week of September 10 through September 16, 2023. Week of September 17 through September 23, 2023. Week of September 24 through September 30, 2023. Week of October 1 through October 7, 2023. Week of October 8 through October 14, 2023. Week of October 15 through October 21, 2023. Week of October 22 through October 28, 2023. Week of October 29 through November 4, 2023. There was no evidence the resident refused to be weighed the above weeks. On 11/15/23 at 9:11 AM, an interview was conducted with LPN #7 (Licensed Practical Nurse). She stated that if there is an order to obtain weights weekly or monthly, then it is expected that they are obtained unless the resident refuses. She stated that if it is not documented, then it was not done. She stated that if it was care planned and not done, then the care plan was not followed. She stated that the purpose of the care plan is everything you are supposed to do for the resident, their individualized needs. On 11/14/23 at 3:30 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the [NAME] President of Clinical Operations were made aware of the findings. No further information was provided by the end of the survey. 2. For Resident #78, the facility staff failed to follow the comprehensive care plan to obtain weekly weights as ordered by the physician. The facility policy, Care Plans, Comprehensive Person-Centered was reviewed. This policy documented, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident A review of the comprehensive care plan revealed one dated 11/21/22 for The resident has alteration or potential for alteration in renal function . This care plan included an intervention dated 11/21/22 for Obtain weights per orders. Use same scale and preferably same time of day wearing same amount of clothing when obtaining weights. Report significant gain or loss to MD (Medical Doctor). A review of the clinical record revealed a physician's order dated 6/19/23 for Obtain weekly weight every evening shift every Monday. Further review of the clinical record revealed that there were no weights obtained on the Monday or any other day during the following weeks (below dates run a Sunday through Saturday time frame): Week of July 2 through July 8, 2023. Week of September 3 through September 9, 2023. Week of September 17 through September 23, 2023. Week of September 24 through September 30, 2023. Week of October 1 through October 7, 2023. Week of October 8 through October 14, 2023. There was no evidence the resident refused to be weighed the above weeks. On 11/15/23 at 9:11 AM, an interview was conducted with LPN #7 (Licensed Practical Nurse). She stated that if there is an order to obtain weights weekly or monthly, then it is expected that they are obtained unless the resident refuses. She stated that if it is not documented, then it was not done. She stated that if it was care planned and not done, then the care plan was not followed. She stated that the purpose of the care plan is everything you are supposed to do for the resident, their individualized needs. On 11/14/23 at 3:30 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the [NAME] President of Clinical Operations were made aware of the findings. No further information was provided by the end of the survey. 3. For Resident #90, the facility staff failed to follow the comprehensive care plan to obtain weekly weights as ordered by the physician. The facility policy, Care Plans, Comprehensive Person-Centered was reviewed. This policy documented, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident A review of the comprehensive care plan revealed one dated 12/5/22 for The resident has alteration or potential for alteration in renal function . This care plan included an intervention dated 12/5/22 for Obtain weights per orders. Use same scale and preferably same time of day wearing same amount of clothing when obtaining weights. Report significant gain or loss to MD (Medical Doctor). A review of the clinical record revealed an order 6/7/23 for Obtain weekly weight every night shift every Thursday for monitoring. Further review of the clinical record revealed that there were no weights obtained on the Thursday or any other day during the following weeks (below dates run a Sunday through Saturday time frame): Week of July 23 through July 29, 2023. Week of October 22 through October 28, 2023. Week of October 29 through November 4, 2023. There was no evidence the resident refused to be weighed the above weeks. On 11/15/23 at 9:11 AM, an interview was conducted with LPN #7 (Licensed Practical Nurse). She stated that if there is an order to obtain weights weekly or monthly, then it is expected that they are obtained unless the resident refuses. She stated that if it is not documented, then it was not done. She stated that if it was care planned and not done, then the care plan was not followed. She stated that the purpose of the care plan is everything you are supposed to do for the resident, their individualized needs. On 11/14/23 at 3:30 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the [NAME] President of Clinical Operations were made aware of the findings. No further information was provided by the end of the survey. 4. For Resident #17, the facility staff failed to follow the comprehensive care plan to obtain weekly weights as ordered by the physician. The facility policy, Care Plans, Comprehensive Person-Centered was reviewed. This policy documented, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident A review of the comprehensive care plan revealed one dated 1/20/22 for The resident has alteration or potential for alteration in renal function . This care plan included an intervention dated 1/20/22 for Obtain weights per orders. Use same scale and preferably same time of day wearing same amount of clothing when obtaining weights. Report significant gain or loss to MD (Medical Doctor). A review of the clinical record revealed a physician's order dated 6/1/23 for Weight every day shift every Wednesday. Further review of the clinical record revealed that there were no weights obtained on the Wednesday or any other day during the following weeks (below dates run a Sunday through Saturday time frame): Week of July 23 through July 29, 2023. There was no evidence the resident refused to be weighed the above week. On 11/15/23 at 9:11 AM, an interview was conducted with LPN #7 (Licensed Practical Nurse). She stated that if there is an order to obtain weights weekly or monthly, then it is expected that they are obtained unless the resident refuses. She stated that if it is not documented, then it was not done. She stated that if it was care planned and not done, then the care plan was not followed. She stated that the purpose of the care plan is everything you are supposed to do for the resident, their individualized needs. On 11/14/23 at 3:30 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the [NAME] President of Clinical Operations were made aware of the findings. No further information was provided by the end of the survey. 5. For Resident #73, the facility staff failed to follow the comprehensive care plan to obtain monthly weights as ordered by the physician. The facility policy, Care Plans, Comprehensive Person-Centered was reviewed. This policy documented, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident A review of the comprehensive care plan revealed one dated 6/4/22 for The resident has alteration or potential for alteration in renal function . This care plan included an intervention dated 6/4/22 for Obtain weights per orders. Use same scale and preferably same time of day wearing same amount of clothing when obtaining weights. Report significant gain or loss to MD (Medical Doctor). A review of the clinical record revealed a physician's order dated 5/10/23 for Obtain weight monthly. Further review of the clinical record failed to reveal any weights obtained for the month of June 2023. There was no evidence the resident refused the weight for June 2023. On 11/15/23 at 9:11 AM, an interview was conducted with LPN #7 (Licensed Practical Nurse). She stated that if there is an order to obtain weights weekly or monthly, then it is expected that they are obtained unless the resident refuses. She stated that if it is not documented, then it was not done. She stated that if it was care planned and not done, then the care plan was not followed. She stated that the purpose of the care plan is everything you are supposed to do for the resident, their individualized needs. On 11/14/23 at 3:30 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the [NAME] President of Clinical Operations were made aware of the findings. No further information was provided by the end of the survey. 7. For Resident #5, the facility staff failed to implement the comprehensive care plan for obtaining weights per the physician orders. The comprehensive care plan dated, 4/3/2023, documented in part, Focus: The resident has compromised cardiovascular conditions or is at risk for compromise r/t (related to) CHF (congestive heart failure), Diabetes, Hypertension (high blood pressure). The Interventions documented in part, Monitor weight .per routine/prn (as needed)/orders. The physician order dated, 6/19/2023, documented, Weight every evening shift, every Wed (Wednesday). Review of the clinical record failed to evidence documentation of the weights on the following Wednesdays: 7/5/2023 8/30/2023 9/13/2023 10/25/2023 11/1/2023. On 11/14/2023, ASM (administrative staff member) #2, the director of nursing stated there were weights that were not obtained per the orders. An interview was conducted with LPN (licensed practical nurse) #5, on 11/14/2023 at 4:15 p.m. When asked the purpose of the care plan, LPN #4 stated, the staff can look at it to see what is going on and what the patient needs. LPN #5 was asked if the care plan documents to get weights as ordered and the weights are not obtained as ordered, is that following the care plan, LPN #5 stated, no. ASM #1, the administrator, ASM #2, and ASM #3, the vice president of clinical operations, were made aware of the above concern on 11/14/2023 at 5:04 p.m. No further information was obtained prior to exit. 8. For Resident #62 (R62), the facility staff failed to implement the comprehensive care plan to administer oxygen per the physician orders. The comprehensive care plan dated, 4/9/2021, documented, Focus: Resident has altered respiratory status or is at risk for breathing difficulty r/t (related to): COPD (chronic obstructive pulmonary disease), dependence on supplemental oxygen. The Interventions documented in part, OXYGEN THERAPY: OXYGEN SETTINGS: O2 as ordered. Observation was made of R62 on 11/13/2023 at approximately 1:30 p.m. The resident was sitting in her bed with her oxygen on via a nasal cannula (NC). The oxygen was set at 2.5 LPM (liters per minute). A second observation was made on 11/14/2023 9:10 a.m., the oxygen was in use by the resident and the setting was at 2.5 LPM. The physician order dated, 5/10/2023, documented, O2 (oxygen) at 3LPM via NC continuously. On 11/14/2023 at 12:41 p.m. an observation was made of R62 with LPN (licensed practical nurse) #5. R62 had her oxygen in use. When asked to read the setting of the oxygen, LPN #5 stated it was set at 2.5 LPM. When asked what the prescribed rate was for R62, LPN #5 stated, the resident is supposed to be on 3 LPM. LPN #5 was asked how often should the oxygen setting be checked by the nurse, LPN #5 stated at least once a shift. When asked the purpose of the care plan, LPN #4 stated, the staff can look at it to see what is going on and what the patient needs. LPN #5 was asked if the care plan documents to administer oxygen per the physician order and it's not at the prescribed rate, is that following the care plan, LPN #5 stated, no. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the vice president of clinical operations, were made aware of the above concern on 11/14/2023 at 3:31 p.m. No further information was provided prior to ext.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to monitor residents weights per physician's orders for six of 42 residents in the survey sample; Residents #12, #78, #90, #17, #73, and #5. The findings include: 1. For Resident #12, the facility staff failed to obtain weekly weights as ordered by the physician. A review of the clinical record revealed a physician's order dated 5/10/23 for Obtain weight weekly. Further review of the clinical record revealed that there were no weights obtained during the following weeks (below dates run a Sunday through Saturday time frame): Week of May 14 through May 20, 2023. Week of May 21 through May 27, 2023. Week of May 28 through June 3, 2023. Week of June 4 through June 10, 2023. Week of June 18 through June 24, 2023. Week of July 2 through July 8, 2023. Week of July 9 through July 15, 2023. Week of July 16 through July 22, 2023. Week of July 23 through July 29, 2023. Week of July 30 through August 5, 2023. Week of August 6 through August 12, 2023. Week of August 27 through September 2, 2023. Week of September 10 through September 16, 2023. Week of September 17 through September 23, 2023. Week of September 24 through September 30, 2023. Week of October 1 through October 7, 2023. Week of October 8 through October 14, 2023. Week of October 15 through October 21, 2023. Week of October 22 through October 28, 2023. Week of October 29 through November 4, 2023. There was no evidence the resident refused to be weighed the above weeks. On 11/15/23 at 9:11 AM, an interview was conducted with LPN #7 (Licensed Practical Nurse). She stated that if there is an order to obtain weights weekly or monthly, then it is expected that they are obtained unless the resident refuses. She stated that if it is not documented, then it was not done. A review of the comprehensive care plan revealed one dated 1/20/23 for The resident has alteration or potential for alteration in renal function . This care plan included an intervention dated 1/20/23 for Obtain weights per orders. Use same scale and preferably same time of day wearing same amount of clothing when obtaining weights. Report significant gain or loss to MD (Medical Doctor). The facility policy, Weight Assessment and Intervention was reviewed. This policy documented, 1. The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter . The policy did not address obtaining weights per physician's orders, that may have a different frequency than the facility protocol of a monthly weight. On 11/14/23 at 3:30 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the [NAME] President of Clinical Operations were made aware of the findings. No further information was provided by the end of the survey. 2. For Resident #78, the facility staff failed to obtain weekly weights as ordered by the physician. A review of the clinical record revealed a physician's order dated 6/19/23 for Obtain weekly weight every evening shift every Monday. Further review of the clinical record revealed that there were no weights obtained on the Monday or any other day during the following weeks (below dates run a Sunday through Saturday time frame): Week of July 2 through July 8, 2023. Week of September 3 through September 9, 2023. Week of September 17 through September 23, 2023. Week of September 24 through September 30, 2023. Week of October 1 through October 7, 2023. Week of October 8 through October 14, 2023. There was no evidence the resident refused to be weighed the above weeks. On 11/15/23 at 9:11 AM, an interview was conducted with LPN #7 (Licensed Practical Nurse). She stated that if there is an order to obtain weights weekly or monthly, then it is expected that they are obtained unless the resident refuses. She stated that if it is not documented, then it was not done. A review of the comprehensive care plan revealed one dated 11/21/22 for The resident has alteration or potential for alteration in renal function . This care plan included an intervention dated 11/21/22 for Obtain weights per orders. Use same scale and preferably same time of day wearing same amount of clothing when obtaining weights. Report significant gain or loss to MD (Medical Doctor). The facility policy, Weight Assessment and Intervention was reviewed. This policy documented, 1. The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter . The policy did not address obtaining weights per physician's orders, that may have a different frequency than the facility protocol of a monthly weight. On 11/14/23 at 3:30 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the [NAME] President of Clinical Operations were made aware of the findings. No further information was provided by the end of the survey. 3. For Resident #90, the facility staff failed to obtain weekly weights as ordered by the physician. A review of the clinical record revealed an order 6/7/23 for Obtain weekly weight every night shift every Thursday for monitoring. Further review of the clinical record revealed that there were no weights obtained on the Thursday or any other day during the following weeks (below dates run a Sunday through Saturday time frame): Week of July 23 through July 29, 2023. Week of October 22 through October 28, 2023. Week of October 29 through November 4, 2023. There was no evidence the resident refused to be weighed the above weeks. On 11/15/23 at 9:11 AM, an interview was conducted with LPN #7 (Licensed Practical Nurse). She stated that if there is an order to obtain weights weekly or monthly, then it is expected that they are obtained unless the resident refuses. She stated that if it is not documented, then it was not done. A review of the comprehensive care plan revealed one dated 12/5/22 for The resident has alteration or potential for alteration in renal function . This care plan included an intervention dated 12/5/22 for Obtain weights per orders. Use same scale and preferably same time of day wearing same amount of clothing when obtaining weights. Report significant gain or loss to MD (Medical Doctor). The facility policy, Weight Assessment and Intervention was reviewed. This policy documented, 1. The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter . The policy did not address obtaining weights per physician's orders, that may have a different frequency than the facility protocol of a monthly weight. On 11/14/23 at 3:30 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the [NAME] President of Clinical Operations were made aware of the findings. No further information was provided by the end of the survey. 4. For Resident #17, the facility staff failed to obtain weekly weights as ordered by the physician. A review of the clinical record revealed a physician's order dated 6/1/23 for Weight every day shift every Wednesday. Further review of the clinical record revealed that there were no weights obtained on the Wednesday or any other day during the following weeks (below dates run a Sunday through Saturday time frame): Week of July 23 through July 29, 2023. There was no evidence the resident refused to be weighed the above week. On 11/15/23 at 9:11 AM, an interview was conducted with LPN #7 (Licensed Practical Nurse). She stated that if there is an order to obtain weights weekly or monthly, then it is expected that they are obtained unless the resident refuses. She stated that if it is not documented, then it was not done. A review of the comprehensive care plan revealed one dated 1/20/22 for The resident has alteration or potential for alteration in renal function . This care plan included an intervention dated 1/20/22 for Obtain weights per orders. Use same scale and preferably same time of day wearing same amount of clothing when obtaining weights. Report significant gain or loss to MD (Medical Doctor). The facility policy, Weight Assessment and Intervention was reviewed. This policy documented, 1. The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter . The policy did not address obtaining weights per physician's orders, that may have a different frequency than the facility protocol of a monthly weight. On 11/14/23 at 3:30 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the [NAME] President of Clinical Operations were made aware of the findings. No further information was provided by the end of the survey. 5. For Resident #73, the facility staff failed to obtain monthly weights as ordered by the physician. A review of the clinical record revealed a physician's order dated 5/10/23 for Obtain weight monthly. Further review of the clinical record failed to reveal any weights obtained for the month of June 2023. There was no evidence the resident refused the weight for June 2023. On 11/15/23 at 9:11 AM, an interview was conducted with LPN #7 (Licensed Practical Nurse). She stated that if there is an order to obtain weights weekly or monthly, then it is expected that they are obtained unless the resident refuses. She stated that if it is not documented, then it was not done. A review of the comprehensive care plan revealed one dated 6/4/22 for The resident has alteration or potential for alteration in renal function . This care plan included an intervention dated 6/4/22 for Obtain weights per orders. Use same scale and preferably same time of day wearing same amount of clothing when obtaining weights. Report significant gain or loss to MD (Medical Doctor). The facility policy, Weight Assessment and Intervention was reviewed. This policy documented, 1. The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter . The policy did not address obtaining weights per physician's orders, that may have a different frequency than the facility protocol of a monthly weight. On 11/14/23 at 3:30 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the [NAME] President of Clinical Operations were made aware of the findings. No further information was provided by the end of the survey. 6. For Resident #5, the facility staff failed to obtain physician ordered weekly weights. The physician order dated, 6/19/2023, documented, Weight every evening shift, every Wed (Wednesday). Review of the clinical record failed to evidence documentation of the weights on the following Wednesdays: 7/5/2023 8/30/2023 9/13/2023 10/25/2023 11/1/2023. On 11/14/2023, ASM (administrative staff member) #2, the director of nursing, presented some of the weights that were previously missing and stated, yes, there were weights that were not obtained per the orders. An interview was conducted with LPN (licensed practical nurse) #5 on 11/14/2023 at 4:16 p.m. When asked if there is a physician order for weekly weights, what actions should the nurse take, LPN #5 stated, the weights should be obtained per the physician order. The comprehensive care plan dated, 4/3/2023, documented in part, Focus: The resident has compromised cardiovascular conditions or is at risk for compromise r/t (related to) CHF (congestive heart failure), Diabetes, Hypertension (high blood pressure). The Interventions documented in part, Monitor weight .per routine/prn (as needed)/orders. ASM #1, the administrator, ASM #2, and ASM #3, the vice president of clinical operations, were made aware of the above concern on 11/14/2023 at 5:04 p.m. No further information was obtained prior to exit.

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to evidence communication with the dialysis center for one of one residents receiving dialysis services, Resident #82. The findings include: For Resident #82, the facility staff failed to ensure there was communication with the dialysis center each visit. The physician orders dated, 8/18/2023, documented, Hemodialysis at (name of dialysis center) M, W, F (Monday, Wednesday, Friday) and time to be picked up 0900 (9:00 a.m.). Review of the clinical record revealed the facility staff did not have the communication form, or the forms were missing communication information from either party (nursing facility or dialysis center) as follows: 9/4/2023 - no communication form 9/6/2023 - no communication documented from dialysis center on form. 9/8/2023 - no communication documented from dialysis center on form. 9/11/2023 - no communication documented from dialysis center on form. 9/13/2023 through 9/29/2023 - there was no communication forms. 10/13/2023 - no communication documented from dialysis center on form. 10/16/2023 - no communication documented from dialysis center on form. 10/18/2023 - no communication documented from dialysis center on form. 10/20/2023 - no communication documented from dialysis center on form. 10/23/2023 - no communication documented from dialysis center on form. 10/25/2023 - no communication documented from dialysis center on form. 10/27/2023 - no communication documented from dialysis center on form. 10/30/2023 - no communication documented from dialysis center on form. 11/1/2023 - there was no communication form. 11/6/2023 - no communication documented from dialysis center on form. 11/10/2023 - there was no communication form. The comprehensive care plan dated, 8/18/2023, documented in part, Focus: The resident has alteration or potential for alteration in renal function .needs hemo (hemodialysis). The Interventions documented in part, Hemodialysis at (name of dialysis center) in (town of facility) on M, W, F at 9:30 a.m. to be picked up by (name of transport company) at 9:00 a.m. An interview was conducted with LPN (licensed practical nurse) #5, on 11/14/2023 at 1:22 p.m. When asked what steps a nurse takes to send a resident out to a dialysis center, LPN #5 stated the staff get vital signs, and put them on the communication sheet and send the sheet with the resident. LPN #5 was asked when the resident returns, what do they do, LPN #5 stated they get a set of vital signs and review the communication form. LPN #5 stated many times the communication form is not filled in by the dialysis center. An interview was conducted with RN (registered nurse) #3 on 11/14/2023 at 1:34 p.m. When asked the purpose of the communication form sent with the resident to dialysis, RN #3 stated it to let the dialysis center know the stability of the resident upon discharge from the facility and the dialysis center is to let us know how the resident did at dialysis. The facility policy, Dialysis Communication documented in part, Nursing facility and dialysis centers will have effective communication and collaboration related to resident care. 1. Any changes in condition of resident will be communicated to the dialysis center by facility staff. Any changes in condition that occurs during time at dialysis center will be communicated by telephone or communication form. 2. Any changes in physician/treatment orders or lab (laboratory) values will be communicated to dialysis center by facility staff by communication form or telephone. Any changes made my nephrologist/dialysis center or changes in lab values will be made by telephone or communication form. ASM (administrative staff member) #1, ASM #2, the director of nursing and ASM #3, the vice president of clinical operations, were made aware of the above concern on 11/14/2023 at 5:04 p.m. No further information was provided prior to exit. (1) Hemodialysis filters your blood to rid your body of harmful wastes, extra salt, and water. This information was obtained from the following website: https://medlineplus.gov/dialysis.html.

Based on staff interview, facility document review and clinical record review, the facility staff failed to provide pharmacy services for one of 42 residents in the survey sample, Resident #20. The findings include: For Resident #20 (R20), the facility staff failed to ensure the medication Gemtesa (1) was available for administration on multiple dates in September 2023. A review of R20's clinical record revealed a physician's order dated 7/10/23 for Gemtesa 75 mg (milligrams)- one tablet by mouth in the morning for overactive bladder. A review of R20's September 2023 MAR (medication administration record) revealed the same physician's order for Gemtesa. On 9/4/23, 9/5/23, 9/6/23, 9/7/23 and 9/9/23, the MAR documented the code, 9= Other/ See Progress Notes. A nurse's note dated 9/4/23 documented, Medication pending pharmacy. A nurse's note dated 9/5/23 documented, Waiting on delivery from pharmacy. A nurse's note dated 9/6/23 documented, Awaiting pharmacy delivery. A nurse's note dated 9/7/23 documented, Waiting to be delivered by pharmacy. A nurse's note dated 9/9/23 documented, Waiting for pharmacy to deliver. A review of the facility backup medication supply list revealed the medication Gemtesa was not available in the supply. On 11/14/23 at 4:05 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated the nurses usually try to order medications six or seven days before they run out. LPN #5 stated that if a medication is not available for administration, the nurses should see if the medication is in the facility backup medication supply and if it is not, the nurses should notify the physician, possibly put a hold on the medication until it arrives from the pharmacy and let the pharmacy know they need the medication. On 11/14/23 at 4:57 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Medication and Treatment Orders documented, 11. Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available. Reference: (1) Gemtesa is used to treat overactive bladder. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a621015.html

Based on observation, staff interview, and facility document review, it was determined that the facility staff failed to store food in a sanitary manner in one of one facility kitchens. The findings include: On 11/13/23 at 11:30 AM, the kitchen was inspected with OSM #5 (Other Staff Member) the Director of Dietary Services. The following items were noted: 1. A box of individual packages of animal crackers was on the floor in dry storage area. The box was open. 2. A baseball cap was on top of a box of thickened apple juice. 3. A large storage bin on wheels of thickener powder was left open with the bag of thickener also left open and exposed. There was no staff at the bin utilizing it. This bin was near the kitchen sink. 4. The stand mixer, which was clean and ready for use, and was covered, was stored next to meat slicer. The meat slicer was recently used for this day's lunch meal that was being prepared. It had been used to slice roast beef. A piece of roast beef (identified as such by OSM #5) was noted inside the mixing bowl of the stand mixer. On 11/14/23 at 2:47 PM, an interview was conducted with OSM #5 who stated that the animal crackers should not be on the floor. She stated that she addressed the ball cap that was on the thickened apple juice with the staff member, and that it should not be stored on top of food products. She further stated that personal items should not be in the kitchen area. Regarding the storage bin of thickener, she stated that staff took the lid off to wash it but it should not have been left open. Regarding the roast beef that was inside the mixing bowl of the stand mixer that was ready for use, she stated that she did not know how it got in the bowl because it had a cover over it. The facility policy, Food Receiving and Storage was reviewed. This policy documented, Foods shall be received and stored in a manner that complies with safe food handling practices 1. Food Services, or other designated staff, will maintain clean food storage areas at all times 6. Food in designated dry storage areas shall be kept off the floor (at least 18 inches) and sprinkler heads, sewage/waste disposal pipes and vents The policy did not address the other identified concerns above. On 11/14/23 at 3:30 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the [NAME] President of Clinical Operations were made aware of the findings. No further information was provided by the end of the survey.

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide complete and accurate documentation for two of 42 residents in the survey sample, Resident #301 and Resident #45. The findings include: 1. For Resident #301, the facility staff failed to evidence complete and accurate documentation for incontinence care, bathing, and weights. A review of the ADL (activities of daily living) document for September 2023 and October 2023 revealed September Bathing documentation missing for three of twelve shifts: 9/21, 9/22, and 9/29/23; October Bathing documentation missing from five of nine shifts: 10/2, 10/2, 10/3, 10/4, and 10/5/23. A review of the ADL document for September 2023 revealed September incontinence documentation missing from three of twelve-day shifts 9/21, 9/22 and 9/29/23; two of twelve evening shifts 9/29 and 9/30/23, and four of twelve night shifts 9/22, 9/23, 9/24, and 9/26/23. A review of the ADL document for October 2023 revealed October incontinence documentation missing from five of nine-day shifts 10/1, 10/2, 10/3, 10/4 and 10/5/23, two of eight evening shifts 10/1 and 10/3/23, and two of eight night shifts 10/1 and 10/3/23. A review of the weights in the vital sign sheet and on the September TAR (treatment administration record) showed no missing weights. Weights were documented as done on the October TAR, with no evidence of the weight obtained either on the TAR or the vital sign sheet. Unable to locate manual/paper weight documentation. An interview was conducted on 11/13/23 at 3:10 PM with CNA (certified nursing assistant) #1. When asked the process for providing incontinence care and bathing for the residents, CNA #1 stated, we round every two hours and perform incontinence care. We bathe/shower residents twice a week. If they are incontinent or get sweaty/dirty then they are bathed more frequently. This is documented on the CNA form. When asked what it means if incontinence care or showers/baths are not documented, CNA #1 stated, it means it was not documented, not that it was not done. When asked if this is a complete and accurate medical record if there is missing documentation, CNA #1 stated, no, it is not a complete and accurate medical record. An interview was conducted on 11/14/23 at 8:30 AM with LPN (licensed practical nurse) #2, the unit manager. When asked about the missing documentation for Resident #301's bathing and incontinence care, LPN #2 stated they had a lot of agency aides at the time and the care was provided but not documented in PCC (point click care). LPN #2 stated they rounded on the residents and saw that care was being provided, the aides did not document it in PCC. An interview was conducted on 11/14/23 at 1:30 PM with LPN #4, when asked about Resident #301, and if her signature was on 10/4/23 weight line on the October 2023 TAR, LPN #4 stated, Yes, those are my initials. I do not why I did not put the weight in there. When asked the process for obtaining weights, LPN #4 stated, the CNAs write the weights on a sheet of paper and the nurses are to transcribe it into the medical record. She did not transcribe it. When asked if the medical record is complete and accurate, LPN #4 stated, no, there is no evidence of the weight. When asked if there are copies of the paper forms, LPN #4 stated, no. An interview was conducted on 11/14/23 at 8:15 AM with CNA #3. When asked the process for obtaining resident weights, CNA #3 stated, see this paper form, the nurse highlights in pink the residents that need weights and in yellow the residents that need vital signs. We document on this form and the nurses enter the information in PCC. On 11/14/23 at approximately 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the vice president of clinical operations was made aware of the findings. A review of the facility's Charting and Documentation policy revealed All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. No further information was provided prior to exit. 2. For Resident #45 (R45), the facility staff failed to maintain accurate ADL (activities of daily living) documentation for bathing/showers provided in August 2023 and October 2023. The ADL (activities of daily living) documentation for R45 dated 8/1/2023-8/31/2023 documented in part, ADL- Bathing (Prefers: Shower/Whirlpool). Review of the ADL documentation failed to evidence a shower/bath documented on 8/11/2023 and 8/22/2023. The areas for documentation on these dates were observed to be blank. The ADL documentation for R45 dated 10/1/2023-10/31/2023 documented in part, ADL- Bathing (Prefers: Shower/Whirlpool). Review of the ADL documentation failed to evidence a shower/bath documented on 10/17/2023 and 10/31/2023. The area for documentation on 10/17/2023 and 10/31/2023 was observed to be blank. On 11/14/2023 at 10:35 a.m., an interview was conducted with CNA (certified nursing assistant) #3. CNA #3 stated that personal hygiene and bathing were completed every shift. She stated that showers were given according to a schedule and were about every two days. She stated that R45 often refused their showers and preferred bed baths. She stated that when residents refused showers they offered them a second time later that day and then notified the unit manager and charge nurse if they still refused. She stated that they had shower caps that they used for residents who preferred bed baths to wash their hair. She stated that there was a shower aide employed by the facility Monday through Friday and they completed the scheduled showers. She stated that all care was documented every shift and there should not be any blanks in the ADL documentation. She stated that if there were blanks in the documentation the staff probably failed to document and they could not say that the care was not provided. On 11/14/2023 at 1:44 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that R45 refused care often and often refused to get out of bed, refused to allow staff to brush their hair and refused showers. She stated that she had showers were twice a week and they attempted to get R45 to take them but they mostly refused. On 11/14/2023 at 2:00 p.m., an interview was conducted with CNA #4. CNA #4 stated that they worked Monday through Friday as a shower aide and used a schedule for know which residents were scheduled for showers each day. She stated that R45 mostly refused to shower but would accept bed baths. She stated that baths and showers were documented in the computer in the ADL documentation by the assigned CNA and she documented the bath/shower on a paper shower sheet or resident list. On 11/15/2023 at 8:42 a.m., an interview was conducted with LPN #2. LPN #2 stated that she had reviewed the paper shower/bath sheets and ADL documentation for R45 and was unable to find evidence a shower/bath on 8/11/2023, 8/22/2023, 10/17/2023 or 10/31/2023. She stated that they had a lot of agency staff in the building during that time and the documentation was not completed. She stated that the medical record was not complete and there was no excuse for not documenting the care provided or refusal of the care. On 11/15/2023 at 9:37 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the vice president of clinical operations were made aware of the findings. No further information was provided prior to exit.

Based on staff interview and facility document review, it was determined the facility staff failed to develop a policy for monthly medication regimen reviews with times frames for the different steps in the process, including identifying the time frame in which the physician/nurse practitioner should respond to the recommendations from the consulting pharmacist for five of five residents included in the unnecessary medication reviews, Residents #71, #17, #22, #32, and #5. The findings include: Resident #71, #17, #22, #32, and #5's clinical records were reviewed for unnecessary medications. A review of the facility policy, Medication Regimen Reviews documented in part, 11. If the Physician does not provide a timely or adequate response, the Consultant Pharmacist identifies that no action has been taken, he/she contacts the Medical Director of (if Medical Director is the physician of record) the Administrator. The policy failed to include any documentation regarding the timeframe in which the physician must respond to the Consultant Pharmacist's recommendations. An interview was conducted with ASM (administrative staff member) #3, the vice president of clinical operations, on 11/14/2023 at 5:05 p.m. She presented a copy of the Medication Regimen Reviews policy and stated she added the words, within 30 days to the policy for the physician to respond. Administrative staff member (ASM) #1, the administrator, ASM #2, the director of nursing and ASM #3, the vice president of clinical operations was made aware of the above findings on 11/15/2023 at 9:36 a.m. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement the care plan for one of five residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to implement the care plan to monitor the urine output, on multiple days in September 2023. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 9/9/23, R1 was coded as having an indwelling urinary catheter. A review of R1's physician's orders revealed the following order dated 9/4/23: Foley catheter (1) 16 fr (French)/10 cc (cubic centimeters) monitor output q shift (every shift). A review of R1's clinical record revealed documentation of urinary out put on 9/7/23 at 3:26 p.m., 9/8/23 at 12:48 p.m., and 9/12/23 at 4:26 p.m. Other than these three entries in the nurses' notes, a review of R1's September 2023 MAR (medication administration record), TAR (treatment administration record), and nurses' notes revealed no evidence of urinary output documentation. A review of R1's care plan dated 9/13/23 revealed, in part: The resident has alteration or potential for alteration in renal (kidney) function r/t (related to) .Foley catheter .Monitor intake and output as per facility policy. A review of the facility policy, Catheter Care, Urinary, revealed, in part: General Guidelines .Input/Output .Monitor the resident's daily output. On 9/26/23 at 11:19 a.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. On 9/26/23 at 11:41 a.m., ASM #2 stated the care plan is developed by the nursing staff in response to an individual resident's particular needs. She stated the whole clinical team is responsible for implementing the resident's care plan. The purpose of the care plan is to provide individualized care to the resident in a way that makes sense for the resident and is relevant for the resident. A review of the facility policy, Care Plans, Comprehensive Person-Centered, revealed, in part: The interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. No further information was provided prior to exit. References (1) A urinary catheter (brand name Foley) is a tube placed in the body to drain and collect urine from the bladder. This information is taken from the website https://medlineplus.gov/ency/article/003981.htm.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to monitor a resident's urine output as ordered by the physician for one of five residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to monitor the urine output on multiple days in September 2023. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 9/9/23, Resident #1 as having an indwelling urinary catheter. A review of R1's physician's orders revealed the following order dated 9/4/23: Foley catheter (1) 16 fr (French)/10 cc (cubic centimeters) monitor output q shift (every shift). A review of R1's clinical record revealed documentation of urinary out put on 9/7/23 at 3:26 p.m., 9/8/23 at 12:48 p.m., and 9/12/23 at 4:26 p.m. Other than these three entries in the nurses' notes, a review of R1's September 2023 MAR (medication administration record), TAR (treatment administration record), and nurses' notes revealed no evidence of urinary output documentation. A review of R1's care plan dated 9/13/23 revealed, in part: The resident has alteration or potential for alteration in renal (kidney) function r/t (related to) .Foley catheter .Monitor intake and output as per facility policy. On 9/26/23 at 8:39 a.m., LPN #1 was interviewed. She stated if a resident has an order for urine output, the nurse should record the total amount of urine in the urinary collection bag at the end of every shift. She stated this is important to make sure the resident is not retaining urine, as this could result in a urinary tract infection or other more serious concerns. On 9/26/23 at 8:56 a.m., LPN #2 was interviewed. She stated if a resident has an order to monitor urinary output, she will monitor the catheter throughout her shift to make sure urine is flowing with no obstructions. She stated she will check the total amount of urine at the end of the shift, and record it on the TAR (treatment administration record). She stated: We need to know how much they are putting out. If it's a small amount, we know something is wrong. On 9/26/23 at 9:11 a.m., LPN #3 was interviewed. She stated an order to monitor a resident's output requires her to check the urine collection bag at the end of the shift and to record the amount either in the progress notes or on the TAR. She stated: We want to make sure they are urinating enough. On 9/26/23 at 9:30 a.m., ASM #4 was interviewed. He stated monitoring a resident's urinary output if the resident has an indwelling catheter is important to prevent urinary tract infections and to assess for some type of urinary obstruction. On 9/26/23 at 9:42 a.m., RN (registered nurse) #1, the unit manager, was interviewed. She stated urinary output should be calculated on all three shifts for any resident who has an indwelling catheter. She added: We do not want a ruptured bladder. On 9/26/23 at 11:19 a.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. On 9/26/23 at 11:41 a.m., ASM #2 stated: We can't see the total output without a number, so we can make sure they have adequate output. She stated a potential danger of a lack of output is a resident's ruptured bladder. A review of the facility policy, Catheter Care, Urinary, revealed, in part: General Guidelines .Input/Output .Monitor the resident's daily output. No further information was provided prior to exit. References (1) A urinary catheter (brand name Foley) is a tube placed in the body to drain and collect urine from the bladder. This information is taken from the website https://medlineplus.gov/ency/article/003981.htm.

Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to implement policies for the reporting of abuse for one of five residents in the survey sample; Resident #3. The findings include: Resident #3 made an allegation of abuse on 6/12/23. The nurse documented it in a nurse's note but did not follow facility policies to report the allegation of abuse to administrative staff. Therefore, the facility also did not report the allegation to the required State Agency as of the survey on 7/12/23. The facility policy, Abuse Prevention Program documented, 3. Develop and Implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements. The facility policy, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating documented, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown sources is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law A review of the admission MDS (Minimum Data Set) dated 4/16/23 coded Resident #3 as being severely cognitively impaired, scoring a 4 out of a possible 15 on the BIMS (Brief Interview for Mental Status) exam. A review of the clinical record revealed a nurse's note dated 6/12/23 that documented, .At 1800 (6:00 PM), while resident was in the dayroom, staff observed bruising and mild swelling of left eye. Resident stated that she was hit earlier. Denies pain/discomfort. Call placed to DON (Director of Nursing) and notified. Call placed to (name of), NP (nurse practitioner) and updated. New order to activate standing Tylenol (1) order and Ice PRN (as needed) for discomfort and swelling . The State Agency had not received a report of this allegation as of the survey date of 7/12/23. On 7/11/23 at 3:21 PM, an interview was conducted with ASM #2 (Administrative Staff Member) the DON. She stated that she never got this allegation of abuse and that this conversation was the first time she heard of this. She stated that she was called about the eye appearing bruised and swollen by the nurse that wrote the above note (LPN #1 - Licensed Practical Nurse), and she called another nurse (LPN #2) and requested that LPN #2 go and assess the resident to see what was going on with the eye. She stated that LPN #2 reported to her that LPN #2 did not see anything going on with the eye and that the resident was asked if anyone had hit her in the eye and the resident stated that no one had hit her. ASM #2 then stated that upon her arrival to the facility she also assessed the resident's eye and did not see anything going on with it and she also asked the resident if anyone had hit her and the resident did not respond to her. When asked if she had previously read the above nurse's note in the clinical record, she stated that she had not. No further information was provided by the end of the survey. References: (1) Tylenol is used for mild to moderate pain. Information obtained from https://medlineplus.gov/druginfo/meds/a681004.html

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to report an allegation of abuse to the facility management, and to the required State Agency, for one of five residents in the survey sample; Resident #3. The findings include: Resident #3 made an allegation of abuse on 6/12/23. The nurse documented it in a nurse's note but did not report the allegation of abuse to administrative staff, therefore, the facility also did not report the allegation to the required State Agency. A review of the admission MDS (Minimum Data Set) dated 4/16/23 coded Resident #3 as being severely cognitively impaired, scoring a 4 out of a possible 15 on the BIMS (Brief Interview for Mental Status) exam. A review of the clinical record revealed a nurse's note dated 6/12/23 that documented, .At 1800 (6:00 PM), while resident was in the dayroom, staff observed bruising and mild swelling of left eye. Resident stated that she was hit earlier. Denies pain/discomfort. Call placed to DON (Director of Nursing) and notified. Call placed to (name of), NP (nurse practitioner) and updated. New order to activate standing Tylenol order and Ice PRN (as needed) for discomfort and swelling . The State Agency had not received a report of this allegation as of the survey date of 7/12/23. On 7/11/23 at 3:21 PM, an interview was conducted with ASM #2 (Administrative Staff Member) the DON. She stated that she never got this allegation of abuse and that this conversation was the first time she heard of this. She stated that she was called about the eye appearing bruised and swollen by the nurse that wrote the above note (LPN #1 - Licensed Practical Nurse), and she called another nurse (LPN #2) and requested that LPN #2 go and assess the resident to see what was going on with the eye. She stated that LPN #2 reported to her that LPN #2 did not see anything going on with the eye and that the resident was asked if anyone had hit her in the eye and the resident stated that no one had hit her. ASM #2 then stated that upon her arrival to the facility she also assessed the resident's eye and did not see anything going on with it and she also asked the resident if anyone had hit her and the resident did not respond to her. When asked if she ever read the above nurse's note in the clinical record, she stated that she had not. The facility policy, Abuse Prevention Program documented, 3. Develop and Implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements. The facility policy, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating documented, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown sources is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law No further information was provided by the end of the survey.

Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to ensure a complete and accurate clinical record for one of five residents in the survey sample; Resident #3. The findings include: For Resident #3, facility staff failed to document a resident assessment on 6/12/23. A review of the admission MDS (Minimum Data Set) dated 4/16/23 coded Resident #3 as being severely cognitively impaired, scoring a 4 out of a possible 15 on the BIMS (Brief Interview for Mental Status) exam. A review of the clinical record revealed a nurse's note dated 6/12/23 that documented, .At 1800 (6:00 PM), while resident was in the dayroom, staff observed bruising and mild swelling of left eye. Resident stated that she was hit earlier. Denies pain/discomfort. Call placed to DON (Director of Nursing) and notified. Call placed to (name of), NP (nurse practitioner) and updated. New order to activate standing Tylenol (1) order and Ice PRN (as needed) for discomfort and swelling . On 7/11/23 at 3:21 PM, an interview was conducted with ASM #2 (Administrative Staff Member) the DON. She stated that she never got this allegation of abuse and that this conversation was the first time she heard of this. She stated that she was called about the eye appearing bruised and swollen by the nurse that wrote the above note (LPN #1 - Licensed Practical Nurse), and she called another nurse (LPN #2) and requested that LPN #2 go and assess the resident to see what was going on with the eye. She stated that LPN #2 reported to her that LPN #2 did not see anything going on with the eye and that the resident was asked if anyone had hit her in the eye and the resident stated that no one had hit her. ASM #2 then stated that upon her arrival to the facility she also assessed the resident's eye and did not see anything going on with it and she also asked the resident if anyone had hit her and the resident did not respond to her. When asked if she ever read the above nurse's note in the clinical record, she stated that she had not. On 7/12/23 at 10:43 AM, an interview was conducted with LPN #2. She stated that she received a call from the DON to assess Resident #3's eye and did not see anything going on with the eye. She stated that she asked Resident #3 if she had been hit in her eye or anything, and the resident denied being hit. Further review of the clinical record failed to reveal any documentation by LPN #2 related to the above interview regarding her assessment of the resident and the resident statement that she was not hit. In a follow up interview with LPN #2 on 7/12/23 at at 1:53 PM, when asked if she documented her assessment of the resident's eye and the resident statement that she had not been hit, she stated she did not. When asked if she should have documented her assessment of the resident, she stated that she should have. LPN #2 stated that she was a new nurse and thought the DON was documenting it upon her report to the DON of her assessment. The facility policy, Charting and Documentation documented, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care 2. The following information is to be documented in the resident medical record: a. Objective observations .9. Documentation of procedures and treatments will include care-specific details, including: .c. the assessment data No further information was provided by the end of the survey. References: (1) Tylenol is used for mild to moderate pain. Information obtained from https://medlineplus.gov/druginfo/meds/a681004.html

Based on observation, staff interview and facility document review, it was determined the facility staff failed to maintain the confidentiality of resident information on one of two medication carts on the south unit, cart A. The findings include: Observation was made of the south unit, medication cart A on 5/9/2023 at 12:19 p.m. RN (registered nurse) #2 was in a resident's room. The medication cart was outside the door. The drawers of the medication cart were facing away from the door. The computer was open with the screen visible and displaying resident information. There was a report sheet on top of the cart facing up, that contained each resident's name on the hall, room numbers, and documented vital signs. A second observation was made of RN #2 administering medications on 5/9/2023 at 1:24 p.m. There was an open box for the medication, Trelegy (1), with the resident's name and instructions on how to take the medications on the prescription label. There was also the report sheet face up on the medication cart with residents names and information visible. The computer screen was again open and displayed resident names and information. RN #2 was in a resident's room with her back to the door/medication cart. An interview was conducted with RN #2 on 5/9/2023 at 1:28 p.m. When asked if the residents names should be displayed on the computer screen while she was in a resident room, with her back to the medication cart, and should her report sheet be face up with resident information in view for anyone to read, RN#2 stated, no, she shouldn't have left the computer screen up with resident names, she forgot. An interview was conducted with LPN (licensed practical nurse) #1 on 5/10/2023 at 8:42 a.m. When asked what a nurse should do before leaving her medication cart, LPN #2 stated, first you put the privacy screen on the computer and lock it. LPN #2 stated there should be no papers visible with resident information on it, it should be flipped over. The facility policy, Confidentiality of Information and Personal Privacy documented in part, Policy Statement:Our facility will protect and safeguard resident confidentiality and personal privacy. Policy Interpretation and Implementation:1.The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. 2.The facility will strive to protect the resident's privacy regarding his or her: b. medical treatment. 4.Access to resident personal and medical records will be limited to authorized staff and business associates. ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing were made aware of the above findings on 5/9/2023 at 4:45 p.m. No further information was obtained prior to exit. (1) Trelegy is used to control wheezing, shortness of breath, coughing, and chest tightness caused by chronic obstructive pulmonary (COPD; a group of diseases that affect the lungs and airways, that includes chronic bronchitis and emphysema). It is also used in adults to control wheezing, shortness of breath, coughing, and chest tightness caused by asthma. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a618017.html

Based on observation, staff interview and facility document review, it was determined the facility staff failed to secure medications on one of two medication carts on the south unit, cart A. The findings include: Observation was made on 5/9/2023 at 12:19 p.m. of cart A on the south unit. There were five plastic bottles of over-the-counter medications on the top of the cart. The cart drawers were facing away from the resident room that the nurse was in, and her back was to the medication cart. The computer screen was up and blocking the view from the back of the cart where the nurse was. An interview was conducted with RN (registered nurse) #2, on 5/9/2023 at 1:28 p.m. The above observation was shared with RN #2. RN #2 concurred that the medications should not be left on the medication cart if she was in the resident's room with her back to her medication cart. The facility policy, Storage of Medications documented in part, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications.3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above findings on 5/9/2023 at 4:45 p.m. No further information was obtained prior to exit.

Based on observation, resident interview, and staff interview, the facility staff failed to serve palatable food for one of seven residents in the survey sample, Resident #1, and failed to prepare puree food in a palatable manner. The findings include: 1. For Resident #1 (R1), the facility staff failed to serve grilled cheese at an appetizing temperature. On the most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 2/2/2023, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. An interview was conducted with R1 on 5/9/2023 at 12:21 p.m. The resident stated the food is served cold for many meals. R1 stated they got a hamburger that was cold and the cheese on it wasn't even melted. During the interview, the resident's lunch tray was served. The tray contained a hot plate with a dome lid on it. The plate under the lid had a grilled cheese sandwich. The resident felt the sandwich and stated, See this is cold. This surveyor put on a glove and felt the sandwich, it was cold, there was no warmth to the sandwich. R1 requested a CNA (certified nursing assistant) to come to their room so they could ask for a hot sandwich. An interview was conducted with OSM (other staff member) #4, the dietary director, on 5/9/2023 at 4:13 p.m. The above observation was shared with OSM #4. When asked the process for a grilled cheese sandwich to get to the resident, OSM #4 stated they are pre-made and kept on the tray line. When asked if the grilled cheese sandwich should be hot when the resident gets it, OSM #4 stated, yes. A policy on maintaining the temperature of food was requested. ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing were made aware of the above findings on 5/9/2023 at 4:45 p.m. 2. The puree pork was not served at a palatable taste. A test tray was requested and presented to the survey team on 5/9/2023 at 12:00 p.m. The plates consisted of pork chop with gravy, spinach, steak fries, peas and carrots, mashed potatoes, puree spinach, puree bread and puree pork with a beef gravy on top. All food was tasted by OSM #4 and the survey team. The puree pork did not taste like pork, the portion tasted like more thickener than pork. All three agreed to this observation. OSM #4 stated he would have the staff add more pork to the puree pork before serving it today. ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above findings on 5/9/2023 at 4:45 p.m. No further information was obtained prior to exit.

Based observation, resident interview, and facility staff interview, the facility staff failed to honor food preferences for one of seven residents in the survey sample, Resident #1. The finding include: The facility staff failed to serve soup to Resident #1 (R1) for lunch on 5/9/2023. An interview was conducted with R1 on 5/9/2023 at 12:21 p.m. R1 stated they do not get what they've ordered most of the time. During the interview, R1's lunch tray was served. R1 stated they had ordered a grilled cheese sandwich and tomato soup for lunch. There was no soup on the tray. An interview was conducted with OSM (other staff member) #4 on 5/9/2023 at 4:13 p.m. When asked why R1 did not get soup on his lunch tray, OSM #4 looked at the resident work sheets, that documented on 5/9/2023 R1 had requested a grilled cheese with a bowl of soup. A second worksheet with all resident names on it documented for 5/9/2023 that R1 had requested grilled cheese with a bowl of soup. When asked if the resident's preferences were honored, OSM #4 stated, no, but they were given a cup of soup after the kitchen was made aware of it not being on the tray. A request for a policy on honoring resident preferences for food was requested. ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above findings on 5/9/2023 at 4:45 p.m. No further information was obtained prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement infection control practices for one of seven residents in the survey sample, Resident #3. The findings include: For Resident #3 (R3), the facility staff failed to sanitize their hands between dirty and clean portions of wound care on 5/10/23. On 5/10/23 at 9:30 a.m., R3 was observed sitting up in bed. RN (registered nurse) #1, the wound care nurse, was observed providing care to R3's right heel pressure ulcer/injury (1). RN #1 removed the dirty dressing from the resident's right heel then changed gloves without sanitizing her hands. After applying clean gloves, she cleansed the wound with wound cleanser and gauze, discarded the dirty gauze, removed her gloves, and put on a new pair of gloves without sanitizing her hands. She applied the clean dressing and removed her gloves. On 5/10/23 at 9:48 a.m., RN #1 was interviewed. When asked if she remembered what she did after she removed the resident's dirty wound dressing, she stated she put on clean gloves. She added: Oh no, I forgot to sanitize my hands. She stated she should have sanitized her hands between the dirty and clean portions of the procedure, both after removing the old dressing and discarding the gauze she had used to clean the wound. On 5/10/23 at 10:30 a.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Handwashing/Hand Hygiene, revealed, in part: This facility considers hand hygiene the primary means to prevent the spread of infections .Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .Before handling clean or soiled dressings, gauze pads, etc .After handling used dressings, contaminated equipment, etc. No further information was provided prior to exit. NOTES (1) A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. This information is taken from the website https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf.

Based on observation, staff interview, and facility document review, the facility staff failed to maintain a homelike environment in four of seven resident rooms in the survey sample, Residents #3, #4, #6, and #7. The findings include: 1. For Resident #3 (R3), the facility staff failed to maintain a homelike environment on the walls of the resident's room. On 5/10/23 at 9:30 a.m., R3 was observed sitting up in bed. The long wall closest to the foot of the resident's bed had multiple areas of chipped paint and bare drywall. This wall also contained multiple black friction marks. The wall behind the resident's head contained multiple areas of chipped paint and bare drywall. On 5/10/23 at 9:20 a.m., OSM (other staff member) #1, the maintenance director, was interviewed. He stated he goes through some, but not all, resident rooms each morning to look for items that need repair. He stated he also has work orders in a maintenance software program. He stated the staff can put information in the software about items they have noticed. He stated he gets through the items as quickly as possible, triaging the most important tasks first. OSM #1 accompanied the survey team to R3's room. When shown the walls, he stated: No, that's not homelike. He stated he would not want that disrepair in his own home. On 5/10/23 at 10:30 a.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. ASM #1 stated the facility staff perform room rounds daily, and the staff members enter any repair tasks into the facility's maintenance software program. She stated OSM #1 and OSM #2, the environmental services director, each have a list of daily work, based on the software system's data. She added that the facility is missing a maintenance staff member, and it is taking extra time to complete repairs. A review of the facility policy, Quality of Life - Homelike Environment, revealed, in part: Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible .Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment; b. Comfortable (minimum glare) yet adequate (suitable to the task) lighting; c. Inviting colors and décor; d. Personalized furniture and room arrangements. No further information was provided prior to exit. 2. For Resident #4 (R4), the facility staff failed to maintain a homelike environment on the floor and chest of drawers in the resident's room. On 5/9/23 at 1:38 p.m., R4 was observed sitting up in bed. The tiles in the area at the foot of the resident's bed (both under the bed and not under the bed) contained approximately 20 dark brown circles. Each circle was between a quarter and fifty cent piece in diameter. R4's chest of drawers contained multiple scarred areas on the wood veneer on each of the drawers. One of the drawers was without a handle. On 5/10/23 at 9:20 a.m., OSM (other staff member) #1, the maintenance director, was interviewed. He stated he goes through some, but not all, resident rooms each morning to look for items that need repair. He stated he also has work orders in a maintenance software program. He stated the staff can put information in the software about items they have noticed. He stated he gets through the items as quickly as possible, triaging the most important tasks first. OSM #1 accompanied the survey team to R3's room. When shown the floor and chest of drawers, he stated: No, that's not homelike. He stated he would not want the stained tiles or the scarred chest of drawers in his own home. On 5/10/23 at 10:04 a.m., OSM #2, the environmental services director, was interviewed. She stated she tries to go in and catch a couple of rooms each day for extra cleaning needs. She stated she particularly looks at walls and floors. She stated if she identifies something that needs extra cleaning, she tries to schedule an extra staff person in the next few days to address the need. She stated the brown circular areas on the tiles are grease stains from new beds. She stated attempts have been made to clean and strip the stained tiles, but these efforts have not been successful. She stated the rooms need new tiles, and she could provide the survey team with evidence the facility had these repairs in process. On 5/10/23 at 10:30 a.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. ASM #1 stated the facility staff perform room rounds daily, and the staff members enter any repair tasks into the facility's maintenance software program. She stated OSM #1 and OSM #2, the environmental services director, each have a list of daily work, based on the software system's data. She added that the facility is missing a maintenance staff member, and it is taking extra time to complete repairs. No further information was provided prior to exit. 3. For Resident #6 (R6), the facility staff failed to maintain a homelike environment on the floor and door, and under the sink in the resident's room. On 5/9/23 at 1:38 p.m., R6 was observed sitting up in bed. The resident's door had multiple areas of chipped wood. The tiles in the area at the foot of the resident's bed (both under the bed and not under the bed) contained approximately 20 dark brown circles. Each circle was between a quarter and fifty cent piece in diameter. The area under the sink had multiple areas of chipped paint and bare drywall, as well as multiple black friction marks. On 5/10/23 at 9:20 a.m., OSM (other staff member) #1, the maintenance director, was interviewed. He stated he goes through some, but not all, resident rooms each morning to look for items that need repair. He stated he also has work orders in a maintenance software program. He stated the staff can put information in the software about items they have noticed. He stated he gets through the items as quickly as possible, triaging the most important tasks first. OSM #1 accompanied the survey team to R3's room. When shown the door, floor, and area under R6's sink, he stated: No, that's not homelike. He stated he would not want this kind of disrepair in his own home. On 5/10/23 at 10:04 a.m., OSM #2, the environmental services director, was interviewed. She stated she tries to go in and catch a couple of rooms each day for extra cleaning needs. She stated she particularly looks at walls and floors. She stated if she identifies something that needs extra cleaning, she tries to schedule an extra staff person in the next few days to address the need. She stated the brown circular areas on the tiles are grease stains from new beds. She stated attempts have been made to clean and strip the stained tiles, but these efforts have not been successful. She stated the rooms need new tiles, and she could provide the survey team with evidence the facility had these repairs in process. On 5/10/23 at 10:30 a.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. ASM #1 stated the facility staff perform room rounds daily, and the staff members enter any repair tasks into the facility's maintenance software program. She stated OSM #1 and OSM #2 each has a list of daily work, based on the software system's data. She added that the facility is missing a maintenance staff member, and it is taking extra time to complete repairs. No further information was provided prior to exit. 4. For Resident #7, the facility staff failed to maintain a homelike environment. Observation was made of Resident #7's room on 5/9/2023 at approximately 1:30 p.m. The wall behind the bed had two large areas of plaster, with no paint. The door had multiple areas of gouged wood, including an area that had crumbling wood filler. On 5/10/23 at 9:20 a.m., OSM (other staff member) #1, the maintenance director, was interviewed. He stated he goes through some, not all, resident rooms each morning to look for items that need repair. He stated he also has work orders in a maintenance software program. He stated the staff can put information in the software about items they have noticed. He stated he gets through the items as quickly as possible, triaging the most important tasks first. OSM #1 accompanied the survey team to R7's room. When shown the wall and door, he stated: No, that's not homelike. He stated he would not want that kind of disrepair in his home. On 5/10/23 at 10:30 a.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. ASM #1 stated the facility staff perform room rounds daily, and the staff members enter any repair tasks into the facility's maintenance software program. She stated OSM #1 and OSM #2, the environmental services director, each have a list of daily work, based on the software system's data. She added that the facility is missing a maintenance staff member, and it is taking extra time to complete repairs. No further information was obtained prior to exit.

Based on observation, resident interview and staff interview, the facility staff failed to provide a homelike environment for one of 36 residents in the survey sample, Resident # 64. The facility staff failed to clean a black substance on the floor around the base of the sink and the wall behind and to the right of the sink and failed to repair a hole in the wall behind R64's head-of the-bed. The findings include: On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 03/04/2022, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. On 04/05/22 at approximately 1:51 p.m., R64 was interviewed and expressed concerns about a black substance around the base of the pedestal sink and the base of the wall behind and to the right of the sink. The pedestal sink was and the base of the wall behind and to the right of the sink was observed and confirmed R64's statement. R64 also expressed concerns about about insects in the corner of the room behind the head of the bed. An observation failed to evidence insects; however, the wall behind the head of the bed revealed a hole in the wall approximately four inches long and two-and-a- half inches wide. On 04/05/22 at approximately 4:05 p.m., an observation of R64's room revealed a black substance around the base of the pedestal sink and the base of the wall behind and to the right of the sink and the hole in the wall behind the head of the bed. On 04/06/22 at approximately 8:15 a.m an observation of R64's room revealed a black substance around the base of the pedestal sink and the base of the wall behind and to the right of the sink and the hole in the wall behind the head of the bed. On 04/06/2022 at approximately 11:30 a.m., an interview and observation of R64's room was conducted with OSM (other staff member) # 4, director of environmental services. When asked to describe the procedure for cleaning a resident's room OSM # 4 stated that they change out the trash, clean the over-the-bed tables, clean the bathroom, clean and disinfect all the door handles, dust, sweep and mop the floor and check the supply of soap, paper towels and toilet paper. When asked how often a resident's room is cleaned OSM # 4 stated that it is done once a day. When asked about the floors in the resident's rooms OSM # 4 stated that they expect the housekeepers to make sure the floors are clean and free of dirt and debris. When asked to describe the procedure when there is substances on the floor that the housekeeper may not be able to clean OSM # 4 stated that they should let them know and they would the room on a schedule to have the floor stripped and waxed. After observing the floor around the base of the sink and the base of the wall behind the sink and to the right of the sink OSM # 4 stated that it was not clean and that they were not made aware of the concern. On 04/06/2022 at approximately 11:35 a.m., an interview and observation of (R64's) room was conducted with OSM # 3, director of maintenance. When asked to describe to procedure they follow for checking for repairs OSM # 3 stated that each department head is assigned a number of resident rooms that they check every morning for anything that is in need of repair and if anything is found it is put in tels (computerized work order). OSM # 3 also stated that they rely on the housekeepers to identify any problems in the resident's room. After being shown the hole in the wall behind the head of the bed in (R64's) room, OSM # 3 stated that they were not aware of it. Using a standardized measuring tape OSM # X was asked to measure the size of the hole. OSM # 3 stated it was approximately five-and-a-half inches high and approximately two-and-a-half inches wide. The facility's policy Maintenance Services documented in part, 2. Functions of maintenance personnel include, but are not limited to: b. maintaining the building in good repair and free from hazards. On 04/06/2022 at approximately 5:00 p.m., ASM (administrative staff member) # 1, administrator, and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to provide respiratory care and services for 1 of 36 residents in the survey sample, Resident #191. The facility staff failed to administer oxygen to Resident #191 (R191) per the physician prescribed rate of two liters per minute. The findings include: R191's diagnoses included but were not limited to shortness of breath. R191's admission minimum data set assessment was not complete. R191's admission nursing assessment dated [DATE] documented the resident was alert but not oriented to person, place, time or situation. A review of R191's clinical record revealed a baseline care plan dated 3/28/22 that documented, Pulmonary management. Provide treatments per orders . R191's April 2022 physician's order sheet documented a physician's order dated 4/1/22 for oxygen at two liters per minute as needed for shortness of breath or an oxygen saturation level below 90%. On 4/5/22 at 11:45 a.m., 4/5/22 at 4:10 p.m. and 4/6/22 at 7:59 a.m., R191 was observed in bed, receiving oxygen at one and a half liters per minute. On 4/6/22 at 2:00 p.m., an interview was conducted with RN (registered nurse) #3. RN #3 stated nurses should look at residents' physician's orders to verify oxygen orders. RN #3 stated the two liter line in the oxygen concentrator flowmeter should run through the middle of the ball in the flowmeter if the physician's order is for two liters. On 4/6/22 at 5:07 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. On 4/7/22 at 8:32 a.m., ASM #2 stated she thought something was wrong with R191's oxygen concentrator and it was taken out of service. ASM #2 stated nurses should check residents' oxygen concentrators every shift. The oxygen concentrator manufacturer's instructions documented, NOTE: To properly read the flowmeter, locate the prescribed flowrate line on the flowmeter. Next, turn the flow knob until the ball rises to the line. Now, center the ball on the L/min (liter per minute) line prescribed. The facility policy titled, Oxygen Administration documented, 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, the facility staff failed to evidence written documentation to the Resident or RP (responsible party) upon transfer for six out of 36 residents in the survey sample who were transferred to the hospital; Residents #18, #71, #69, #81, #17 and #36. The findings include: 1. Resident #18 was admitted to the facility with diagnoses that included but were not limited to: cerebrovascular accident with right hemiparesis and diabetes mellitus. Resident #18's most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 1/21/22, coded the resident as scoring 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the nursing progress note dated 11/30/21 at 4:20 PM, revealed the following, Resident aware of need for transfer, reason, RP aware of new order for transfer and reason. RP aware of bed hold policy and agreement being sent with resident to the emergency room. Face sheet, history/physical, physician progress notes, labs and x-ray results, care plan sent with resident. Director of nursing and administrator aware of transfer out. On 4/5/22 at approximately 5:00 PM a request was made for the evidence of written notification to the RP and ombudsman when Resident #18 was transferred to the hospital on [DATE]. On 4/6/22 at approximately 8:30 AM, an interview was conducted with LPN (licensed practical nurse) #3. When asked who provides the written notification to the RP and ombudsman when a resident is transferred to the hospital, LPN #3 stated, We call the RP and notify them, I do not know who does the written notification to the RP or the ombudsman. On 4/6/22 at 11:55 AM, an interview was conducted with ASM (administrative staff member) #2, the director of nursing. When asked for the evidence of written notification to the RP, ASM #2 stated, We're checking on the RP written notification. We changed social workers and they also moved offices. I called the previous social worker and she told me where to look but we cannot find it. The ombudsman is helping us look for their notification. On 4/6/22 at 1:40 PM, an interview was conducted with OSM (other staff member) #9, the social services director. When asked do you play a part in written notification to the RP or ombudsman, OSM #9stated, I would think social services does but I have not taken that on. On 4/6/22/22 at 5:00 PM, ASM #1, the administrator and ASM #2, the director of nursing, were informed of the above concern. No further information was provided prior to exit. 2. Resident #69 was admitted to the facility with diagnoses that included but were not limited to: encephalopathy, neurogenic bladder and diabetes mellitus. Resident #69's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 3/8/22, coded the resident as scoring 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the nursing progress note dated 2/25/22 at 9:40 AM, revealed the following, Resident noted with increased voluntary movements, increased confusion with yelling out, 'I've got to get out of here!', attempting to get out of bed continuously despite redirection. NP (nurse practitioner) in to evaluate, new order noted to transfer to emergency room for evaluation for AMS. Resident notified of transfer order and reason, first contact phoned and notified of above, transfer to emergency room (ER) order and reason. Aware that bed hold agreement is sent to ER with resident. Given copies of pertinent information, recent labs, face sheet, care plan. Director of nursing and administrator aware of transfer. On 4/5/22 at approximately 5:00 PM a request was made for the evidence of written notification to the RP and ombudsman when Resident #18 was transferred to the hospital on [DATE]. On 4/6/22 at approximately 8:30 AM, an interview was conducted with LPN (licensed practical nurse) #3, when asked who provides the written notification to the RP and ombudsman when a resident is transferred to the hospital, LPN #3 stated, We call the RP and notify them, I do not know who does the written notification to the RP or the ombudsman. On 4/6/22 at 11:55 AM, an interview was conducted with ASM (administrative staff member) #2, the director of nursing. When asked for the evidence of written notification to the RP, ASM #2 stated, We're checking on the RP written notification. We changed social workers and they also moved offices. I called the previous social worker and she told me where to look but we cannot find it. The ombudsman is helping us look for their notification. On 4/6/22 at 1:40 PM, an interview was conducted with OSM (other staff member) #9, the social services director. When asked do you play a part in written notification to the RP or ombudsman, OSM #9stated, I would think social services does but I have not taken that on. On 4/6/22/22 at 5:00 PM, ASM #1, the administrator and ASM #2, the director of nursing, were informed of the above concern. No further information was provided prior to exit. 3. Resident #71 was admitted to the facility with diagnoses that included but were not limited to: cerebral infarction, congestive heart failure and dementia. Resident #71's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 3/9/22, coded the resident as scoring 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the nursing progress note dated 2/19/22 at 3:09 PM, revealed the following, CNA (certified nursing assistant) asked for writer to come look at resident. CNA reported resident was reluctant to receiving care, complained of pain to his all over, and crying out. Writer into assess resident and resident refused for writer to assess resident. Resident stated to writer, 'No baby I'm hurting too bad'. Writer spoke with charge nurse who stated no abnormal reports were given to her from previous shift. Writer asked for labs to be faxed, writer received labs. Writer called NP (nurse practitioner), and expressed the above to NP who gave orders to send resident to the ER (emergency room) for evaluation. Writer called RP and left message. Called for transport, charge nurse aware. RP notified of bed hold policy. On 4/5/22 at approximately 5:00 PM a request was made for the evidence of written notification to the RP and ombudsman when Resident #18 was transferred to the hospital on [DATE]. On 4/6/22 at approximately 8:30 AM, an interview was conducted with LPN (licensed practical nurse) #3, when asked who provides the written notification to the RP and ombudsman when a resident is transferred to the hospital, LPN #3 stated, We call the RP and notify them, I do not know who does the written notification to the RP or the ombudsman. On 4/6/22 at 11:55 AM, an interview was conducted with ASM (administrative staff member) #2, the director of nursing. When asked for the evidence of written notification to the RP, ASM #2 stated, We're checking on the RP written notification. We changed social workers and they also moved offices. I called the previous social worker and she told me where to look but we cannot find it. The ombudsman is helping us look for their notification. On 4/6/22 at 1:40 PM, an interview was conducted with OSM (other staff member) #9, the social services director. When asked do you play a part in written notification to the RP or ombudsman, OSM #9stated, I would think social services does but I have not taken that on. On 4/6/22/22 at 5:00 PM, ASM #1, the administrator and ASM #2, the director of nursing, were informed of the above concern. No further information was provided prior to exit. 4. On the most recent MDS (minimum data set), a five-day assessment with an ARD (assessment reference date) of 3/14/2022, the resident scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident is not cognitively impaired for making daily decisions. The progress notes for R81 documented in part: 2/16/2022 17:14 (5:14 p.m.) Resident called writer to room, resident noted SOB (short of breath) with O2 (oxygen) on, widespread crackles heard throughout bilateral upper and lower lung fields, vitals checked. N.P. (nurse practitioner) (Name of nurse practitioner) called, vitals recorded, N.P. (Name of nurse practitioner) gave orders to bump O2 up high as it goes, and call 911, writer staying in room with resident and communicating with staff to assist, 911 called, O2 increased to 6 liters, O2 came up to 80 percent, 911 on way, writer R.P (responsible party) (Name of responsible party) called and notified of the resident condition, and orders to send resident to the ER (emergency room), and gave permission as well to do this, emergency services here and resident is being taken to the hospital. Per EMT's (emergency medical technicians) going to take to (Name of hospital). R.P. (Name of responsible party) called and made aware of this. 2/17/2022 08:24 (8:24 a.m.) Per hospital receptionist resident admitted to (Name of hospital) ICU (intensive care unit). Unable to reach nurse. No known dx (diagnosis) at this time. NP (Name of nurse practitioner) aware. The clinical record failed to evidence documentation of written notification provided to the responsible party for the transfer on 2/16/2022 for R81. On 4/6/2022 at approximately 10:00 a.m., a request was made by written list to ASM (administrative staff member) #1, the administrator for evidence of written notification provided to the responsible party for the transfer on 2/16/2022 for R81. On 4/6/2022 at 11:53 a.m., ASM #2, the director of nursing provided a copy of the transfer to hospital checklist for R81 dated 2/16/2022 and the progress notes documented above. The transfer to hospital checklist failed to evidence written notification provided to the responsible party for the transfer on 2/16/2022. On 4/6/2022 at 11:55 a.m., an interview was conducted with ASM #2, the director of nursing. ASM #2 stated that they had changed social workers, offices and that they had called the previous social worker but were not able to find any evidence of written notification provided to the responsible party. On 4/06/2022 at 1:40 p.m., an interview was conducted with OSM (other staff member) #9, the social services director. OSM #9 stated that they were new to the facility and had not taken over sending the written notification to the responsible party at that time. OSM #9 stated that in their previous experience at other facilities, the social services department had been responsible for sending out a notice of transfer/discharge to the responsible party and the ombudsman with hospital transfers. On 4/6/2022 at approximately 5:00 p.m., ASM #1, the administrator and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. 5. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/20/2022, the resident scored 11 out of 15 on the BIMS (brief interview for mental status), indicating the resident is moderately impaired for making daily decisions. The progress notes for R17 documented in part: 3/26/2022 16:45 (4:45 p.m.) Resident sent to ER (emergency room) with paper work, pertinent information, face sheet, H&P (history and physical), most recent MD (medical doctor) progress noted (sic), MD orders, pertinent lab and diagnostic reports, care plan and care plan goals, bed hold agreement, R.P. (responsible party) and resident notified of the bed hold notice, E.R. called and given report of the resident and is aware of the resident coming, resident is OOF (out of facility) to the E.R. 3/29/2022 13:25 (1:25 p.m.) Writer called (Name of hospital) and spoke with (Name of staff member) who stated resident was admitted for dx (diagnosis) Encephalopathy. The clinical record failed to evidence documentation of written notification provided to the responsible party for the transfer on 3/26/2022 for R17. On 4/6/2022 at approximately 10:00 a.m., a request was made by written list to ASM (administrative staff member) #1, the administrator for evidence of written notification provided to the responsible party for the transfer on 3/26/2022 for R17. On 4/6/2022 at 11:53 a.m., ASM #2, the director of nursing provided a copy of the transfer to hospital checklist for R17 dated 3/26/2022. The transfer to hospital checklist failed to evidence written notification provided to the responsible party for the transfer on 3/26/2022. On 4/6/2022 at 11:55 a.m., an interview was conducted with ASM #2, the director of nursing. ASM #2 stated that they had changed social workers, offices and that they had called the previous social worker but were not able to find any evidence of written notification provided to the responsible party. On 4/06/2022 at 1:40 p.m., an interview was conducted with OSM (other staff member) #9, the social services director. OSM #9 stated that they were new to the facility and had not taken over sending the written notification to the responsible party at that time. OSM #9 stated that in their previous experience at other facilities, the social services department had been responsible for sending out a notice of transfer/discharge to the responsible party and the ombudsman with hospital transfers. On 4/6/2022 at approximately 5:00 p.m., ASM #1, the administrator and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. 6. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/7/22, the resident scored 3 out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely cognitively impaired for making daily decisions. A review of R36's clinical record revealed a nurse's note dated 1/19/22 that documented the resident was transferred to the hospital for abnormal lab results. Further review of R36's clinical record failed to reveal evidence that written notice of the transfer was provided to R36'a representative. On 4/6/22 at 11:55 a.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated the facility changed social workers and moved offices. ASM #2 stated she would check on written resident representative notification for hospital transfers. On 4/6/22 at 5:07 p.m., ASM #1 (the administrator) and ASM #2 were made aware of the above concern. According to the facility's Transfer or Discharge Notice policy, dated 3/21, which reveals, Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge: An immediate transfer or discharge is required by the resident's urgent medical needs. The resident and representative are notified in writing of the following information: specific reason for the transfer or discharge, location to which the resident is being transferred or discharged and effective date of the transfer or discharge. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #20 was admitted to the facility with diagnoses that included but were not limited to: metabolic encephalopathy, dementia and cerebral ischemia. Resident #20's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 1/18/22, coded the resident as scoring 02 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of Resident #20's clinical record failed to reveal evidence of completion of a Level 1 PASARR either prior to or on admission on [DATE]. An interview was conducted on 4/6/22 at 1:40 PM, with OSM (other staff member) #9, the director of social services. When asked how long she had been employed at the facility, OSM #9 stated, I started here last Monday, 3/28/22. When asked what process she used to complete the PASARR, OSM #9 stated, at my previous facility, I would do the level I PASARR for residents admitted . I have not done any here yet. I believe the previous person is still doing them. I did every level I PASARR at my last facility. When asked if a level I PASAAR is to be done for every person admitted to the facility, OSM #9 stated, Yes, regardless of payer source. On 4/6/22 at 2:19 PM OSM #9 stated, I verified the PASARR information with my administrator (ASM #1), I told you the way I did it before was from my prior facility. At this facility, the patients who are Medicaid or Medicaid pending will have not the level 1 PASARR completed. On 4/6/2022 at 2:46 p.m., an interview was conducted with ASM (administrative staff member) #1, the administrator. ASM #1 stated that the level 1 PASARR was completed by the hospital, social services or admissions for Medicaid or Medicaid pending residents. ASM #1 stated that residents who were admitted as skilled care or managed care would not have a PASARR completed. On 4/6/22/22 at 5:00 PM, ASM #1, the administrator and ASM #2, the director of nursing, were informed of the above concern. According to the facility's admission Criteria policy dated 3/19, which reveals, All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. The facility conducts a Level 1 PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD. No further information was provided prior to exit.Based on clinical record review and staff interview, the facility staff failed to evidence completion of a level 1 PASRR (preadmission screening and resident review) for 5 of 36 residents in the survey sample, Residents #11, #90, #81, #20, and #64. The findings include: 1. Resident #11 (R11) was admitted to the facility with diagnoses that included but were not limited to traumatic brain injury, post traumatic stress disorder, and schizoaffective disorder. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 1/10/2022, the resident scored 11 out of 15 on the BIMS (brief interview for mental status), indicating the resident is moderately impaired for making daily decisions. Review of R11's clinical record failed to evidence a level 1 PASRR. On 4/6/2022 at approximately 10:00 a.m., a request was made to ASM (administrative staff member) #1, the administrator for the Level 1 PASRR for R11. On 4/6/2022 at 1:21 p.m., ASM #1 stated that they did not have a PASRR for R11 because they followed the rule that anyone admitted prior to 7/1/2019 did not need to have a PASRR completed. On 4/6/2022 at 1:40 p.m., an interview was conducted with OSM (other staff member) #9, the social services director. OSM #9 stated that they were new to the facility and had not started completing PASRR assessments in the facility at this time. OSM #9 stated that in their previous experience at other facilities they would complete the Level 1 PASRR for every resident admitted regardless of their payer source. OSM #9 stated that they were not sure how long the Level 1 PASRR assessment was a requirement and was not sure if there was a date that exempted residents from screening. OSM #9 stated that most residents arrived from the hospital with the Level 1 PASRR completed but at times they did it at the facility. OSM #9 stated that they would review Resident #11's record to see if they were able to locate a Level 1 PASRR. On 4/6/2022 at 2:19 p.m., OSM #9 stated that they had verified their process with ASM #1, the administrator and had spoken previously about the process from their former facility. OSM #9 stated that at this facility, the only residents who had Level 1 PASRR were Medicaid or Medicaid pending residents. On 4/6/2022 at 2:46 p.m., an interview was conducted with ASM #1, the administrator. ASM #1 stated that the level 1 PASRR was completed by the hospital, social services or admissions for Medicaid or Medicaid pending residents only. ASM #1 stated that residents who were admitted as skilled care or managed care would not have a PASRR completed. ASM #1 stated that they had a form that they completed which documented the effective date of 7/1/2019 and showed that R11 was exempted due to being admitted in 2011 and would provide that. On 4/6/2022 at 3:37 p.m., an interview was conducted with OSM #1, the business office manager. OSM #1 stated that R11 did not have a Level 1 PASRR because it was not required for anyone admitted prior to 7/1/2019. OSM #1 provided a copy of Virginia Department of Medical Assistance Services Nursing Facility Admission, Discharge or Level of Care Change (DMAS-80) dated 1/7/2021 for Resident #11. It documented regulatory special circumstance for residents admitted prior to July 1, 2019 for review of a completed Medicaid LTSS (Long-term Services and Supports) Screening Package that indicates the individual met Level of Care Criteria and was authorized for LTSS services. The document failed to evidence documentation that a PASRR Level 1 screening was not required for R11. According to Virginia's Medicaid Program document Required Screening for Nursing Facility Placement and Use of the LTC (long term care) Portal dated 6/20/2019 it documented in part, .Handling Special Circumstances .Be sure to complete Level 1 if special circumstance is met. NF (nursing facility) completes the DMAS-80 form and submit a copy to the plan Both Plan and NF retains a record to document the special circumstances .The Level one PASRR should have been completed upon admission by the NF for all Special Circumstances . This information was obtained from the website: https://www.dmas.virginia.gov/media/1153/required-screening-for-nursing-facility-placement-and-use-of-the-ltc-portal.pdf The facility policy admission Criteria dated revised March 2019 documented in part, .The facility conducts a Level 1 PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD (mental disorder), ID (intellectual disability), or RD (related disorders) . On 4/6/2022 at approximately 5:00 p.m., ASM #1, the administrator and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. 2. Resident #90 (R90) was admitted to the facility with diagnoses that included but were not limited to bipolar disorder and schizoaffective disorder. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/21/2022, the resident scored 8 out of 15 on the BIMS (brief interview for mental status), indicating the resident is moderately impaired for making daily decisions. Review of R90's clinical record failed to evidence a level 1 PASRR. On 4/6/2022 at approximately 10:00 a.m., a request was made to ASM (administrative staff member) #1, the administrator for the Level 1 PASRR for R90. On 4/6/2022 at 1:21 p.m., ASM #1 provided a UAI (uniform assessment instrument) for R90 dated 8/27/2019. The document failed to evidence documentation of a Level 1 PASRR screening. On 4/6/2022 at 1:40 p.m., an interview was conducted with OSM (other staff member) #9, the social services director. OSM #9 stated that they were new to the facility and had not started completing PASRR assessments at this time. OSM #9 stated that in their previous experience at other facilities they would complete the Level 1 PASRR for every resident admitted regardless of their payer source. OSM #9 stated that they were not sure how long the Level 1 PASRR assessment was a requirement and was not sure if there was a date that exempted residents from screening. OSM #9 stated that most residents arrived from the hospital with the Level 1 PASRR completed but at times they did it. OSM #9 reviewed the UAI dated 8/27/2019 for R90 and stated that they did not see any documentation of a Level 1 PASRR in the document. On 4/6/2022 at 2:19 p.m., OSM #9 stated that they had verified their process with ASM #1, the administrator and had spoken previously about the process from their former facility. OSM #9 stated that at this facility, the only residents who had Level 1 PASRR were Medicaid or Medicaid pending residents. On 4/6/2022 at 2:46 p.m., an interview was conducted with ASM #1, the administrator. ASM #1 stated that the level 1 PASRR was completed by the hospital, social services or admissions for Medicaid or Medicaid pending residents. ASM #1 stated that residents who were admitted as skilled care or managed care would not have a PASRR completed. ASM #1 stated that they would check for another PASRR for R90. On 4/6/2022 at approximately 5:00 p.m., ASM #1, the administrator and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. 3. Resident #81 (R81) was admitted to the facility with diagnoses that included but were not limited to schizoaffective disorder, anxiety disorder and major depressive disorder. On the most recent MDS (minimum data set), a five-day assessment with an ARD (assessment reference date) of 3/14/2022, the resident scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident is not cognitively impaired for making daily decisions. Review of R81's clinical record failed to evidence a level 1 PASRR. On 4/6/2022 at approximately 10:00 a.m., a request was made to ASM (administrative staff member) #1, the administrator for the Level 1 PASRR for R81. On 4/6/2022 at 1:21 p.m., ASM #1 stated that they did not have a PASRR for R81 because they were were a Medicare resident and they did not complete them for those residents. On 4/6/2022 at 1:40 p.m., an interview was conducted with OSM (other staff member) #9, the social services director. OSM #9 stated that they were new to the facility and had not started completing PASRR assessments at this time. OSM #9 stated that in their previous experience at other facilities they would complete the Level 1 PASRR for every resident admitted regardless of their payer source. OSM #9 stated that they were not sure how long the Level 1 PASRR assessment was a requirement and was not sure if there was a date that exempted residents from screening. OSM #9 stated that most residents arrived from the hospital with the Level 1 PASRR completed but at times they did it. On 4/6/2022 at 2:19 p.m., OSM #9 stated that they had verified their process with ASM #1, the administrator and had spoken previously about the process from their former facility. OSM #9 stated that at this facility, the only residents who had Level 1 PASRR were Medicaid or Medicaid pending residents. On 4/6/2022 at 2:46 p.m., an interview was conducted with ASM #1, the administrator. ASM #1 stated that the level 1 PASRR was completed by the hospital, social services or admissions for Medicaid or Medicaid pending residents. ASM #1 stated that residents who were admitted as skilled care or managed care would not have a PASRR completed. ASM #1 stated that Resident #81 was admitted under Medicare and would not have been screened. On 4/6/2022 at approximately 5:00 p.m., ASM #1, the administrator and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. 5. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 03/04/2022, Resident #64 scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. A review of (R64's) clinical record revealed they were admitted under Medicare. Further review of the clinical record failed to evidence a level 1 (one) PASARR was completed prior to admission on [DATE]. On 04/06/2022 at approximately 1:50 p.m., an interview was conducted with OSM (other staff member) # 1, business office manager. When asked about a level 1 PASARR for (R64) OSM # 1 stated that when (R64) was originally admitted to the facility it was for short term care but had a change in their level of care and a level 1 PASARR was not completed because it wasn't required. On 4/6/2022 at 2:46 p.m., an interview was conducted with ASM (administrative staff member) #1, the administrator. ASM #1 stated that the level 1 PASARR was completed by the hospital, social services or admissions for Medicaid or Medicaid pending residents. ASM #1 stated that residents who were admitted as skilled care or managed care would not have a PASRR completed. On 04/06/2022 at approximately 5:00 p.m., ASM (administrative staff member) # 1, administrator, and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit.

Based on resident interview, resident representative interview, staff interview, facility document review, clinical record review and in the course of a complaint investigation, the facility staff failed to provide adequate bathing for 2 of 36 residents in the survey sample, Residents #57 and #29. The findings include: 1. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/29/22, Resident #57 (R57) scored 3 out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely cognitively impaired for making daily decisions. Section G coded R57 as requiring one person physical assistance with bathing. R57's comprehensive care plan dated 4/20/21 documented, The resident has an ADL (activities of daily living) Performance Deficit .Provide the resident with a sponge bath when a full bath or shower cannot be tolerated. On 4/5/22 at 2:06 p.m., a telephone interview was conducted with R57's representative. The representative stated sometimes staff does not provide R57 with regular showers like they should but then the representative reminds them and they provide a shower. A review of R57's clinical record (including shower sheets, ADL records and nurses' notes for February 2022) failed to reveal documentation that R57 was offered or provided any type of bathing (including showers, a tub bath or a bed bath/sponge bath) on the following dates: 2/1/22, 2/3/22, 2/6/22, 2/8/22, 2/9/22, 2/10/22, 2/12/22, 2/13/22, 2/15/22, 2/17/22, 2/19/22, 2/20/22, 2/22/22, 2/24/22, 2/26/22 and 2/27/22. Further review of these documents failed to reveal documentation that R57 refused bathing on these dates. On 4/6/22 at 2:00 p.m., an interview was conducted with RN (registered nurse) #3, regarding resident bathing. RN #3 stated the CNAs (certified nursing assistants) provide showers according to a shower schedule but she was not sure how the schedule goes. On 4/6/22 at 2:19 p.m., an interview was conducted with CNA #6. CNA #6 stated residents are supposed to receive a shower or whirlpool tub bath twice a week and receive a bed bath on all other days. On 4/7/22 at 8:02 a.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Bath, Shower/Tub documented, The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The policy did not document how often residents should receive bathing. No further information was presented prior to exit. COMPLAINT DEFICIENCY2. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 01/03/2022, Resident # 29 scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section G0120 coded (R29) as requiring Physical help in part of bathing activity of one staff member. Section G0400 Functional Limitation in Range of Motion' coded (R29) as having impairment one side of upper and lower extremities requiring a walker or wheelchair. On 04/05/22 at approximately 1:31 p.m., during an interview with R29 they stated that they had not received a bath in three weeks. When asked how often they were to receive a bath or shower, R29 stated they were to get a bath or shower twice a week. The comprehensive care plan for R29 documented in part, Focus: The resident has an ADL Self Care Performance Deficit r/t Decreased mobility, function, and weakness, Impaired balance . Date Initiated: 01/06/2022. Under interventions it documented in part, Provide the resident with a sponge bath when a full bath or shower cannot be tolerated. Date Initiated: 01/06/2022 The facility's document entitled Documentation Survey Report V2 for ADLs (activities of daily living) dated 03/01/2022 through 03/31/2022 documented in part, ADL - Shower or whirlpool. Review of the form revealed R29 received a bed bath on 03/05/2022, 03/16/2022 and on 03/23/2022. Further review failed to evidence of documentation that R29 received a shower or whirlpool bath from 03/01/2022 through 03/31/2022. The progress notes for (R29) dated 03/01/2022 through 03/31/2022 failed to evidence that R29 received a shower or whirlpool bath from 03/01/2022 through 03/31/2022. Further review of the progress notes failed to evidence documentation that R29 refused a shower or whirlpool from 03/01/2022 through 03/31/2022. Review of the facility's resident's shower sheets from 03/01/2022 through 03/31/2022 failed to evidence that R29 refused or was offered a shower or whirlpool. On 04/06/2022 at approximately 1:50 p.m., an interview was conducted with LPN (licensed practical nurse) # 1. When asked how often a resident is provided a shower or bath LPN # 1 stated that a resident is scheduled for a bath or shower twice a week unless they refuse and that they are offered a bed bath. After reviewing the ADL sheet and the bath/shower sheets for (R29) LPN # 1 stated that (R29) received three bed baths and was not offered or given a shower or bath during March 2022. When asked why (R29) was not offered or received a bath or shower during March LPN # 1 stated that it may have been due to not having enough staff for shower aides. On 04/06/2022 at approximately 5:00 p.m., ASM (administrative staff member) # 1, administrator, and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, the facility staff failed to provide care and service for a complete dialysis program for one of 36 residents in the survey sample, Resident # 59 (R59). The facility staff failed to provide dialysis communication forms for R59 and the dialysis center on 03/02/2022, 03/04/2022, 03/07/2022, 03/09/2022, 03/11/2022, 03/14/2022, 03/16/2022, 03/18/2022 and on 03/21/2022. The findings include: R59 was admitted to the facility with diagnoses included but were not limited to: end stage renal disease. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/24/2022, the resident scored 3 out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely impaired of cognition intact for making daily decisions. Section O Special Treatments, Procedures and Programs coded R59 for Dialysis while a resident. The physician's order for R59 documented in part, (Name of Dialysis Center with Name of Physician and Phone Number) on MON-WED-FRI (Monday, Tuesday and Friday). Order Date: 12/29/2021. On 04/06/2022 at approximately 10:02 a.m., ASM (administrative staff member) # 2, director of nursing, provided copies of the facility's dialysis communication forms for R59 dated 03/23/2022, 03/25/2022, 03/28/2022, 03/30/2022, 04/01/2022 and 04/04/2022. When asked about the dialysis communication forms for 03/02/2022, 03/04/2022, 03/07/2022, 03/09/2022, 03/11/2022, 03/14/2022, 03/16/2022, 03/18/2022 and on 03/21/2022, ASM # 2 stated they recognized that the dialysis communication form were not being completed and that they put a plan of correction (POC) in place. The facility's POC for dialysis communication forms documented, 1) No communication forms to be sent with resident to dialysis for treatments. Identified on 3/15/2022. 2) Dialysis communication form implemented on 3/22/2022. 3) Nurses updated on use of new sheets. New forms placed in communication book. 4) Communication sheets/handoff from dialysis center monitored once return from dialysis. 5) Day of Compliance 4/1/2022. On 04/06/2022 at approximately 5:00 p.m., ASM (administrative staff member) # 1, administrator, and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. Past Noncompliance

Based on observation, staff interview, and facility document review, the facility staff failed to store and prepare food in a sanitary manner in one of one facility kitchens, and on one nursing unit. The findings include: On 04/05/2022 at approximately 10:50 a.m., an observation of the facility's kitchen was conducted with OSM (other staff member) # 2, a cook. Observation of the meat slicer located in the facility's kitchen on a food preparation table was conducted with OSM # 2. When asked if the meat slicer was cleaned and ready for use OSM # 2 stated yes. An observation of the meat slicer revealed food debris on the surface of the base under the gauge plate and on the knife cover. When asked if the mixer was clean OSM # 2 stated no. When asked how often the meat slicer is cleaned OSM # 2 stated that it should be cleaned after every use. An observation of the inside of the facility's walk-in refrigerator revealed a three quart container with approximately 12 slices of ham with a use-by-date of 04/01/2022, available for use. When asked if the ham should be available for use OSM # 2 stated no and immediately removed the container from the walk-in refrigerator and discarded the ham. On 04/06/2022 at approximately 9:25 a.m., an observation of the south unit refrigerator/ freezer revealed a half bottle of salad dressing without a name or date in the refrigerator. Further observation revealed one frozen pot pie and two half gallons of ice cream without a name or date in the freezer. On 04/06/2022 at approximately 9:28 a.m., an observation of the north unit refrigerator/ freezer revealed two frozen dinners without a name or date. On 04/06/2022 at approximately 1:40 p.m., an interview and observation of the refrigerators and freezers on the north and south units with OSM # 8, cook. When asked to describe the procedure for the use of the unit refrigerator/freezers OSM # 8 stated that they were used for the residents food and that their name should be on the items and the date when it was put in the refrigerator or freezer. When asked who was responsible for checking them and how often it was done OSM # 8 stated that the kitchen staff on the night shift was responsible for checking them every night. After observing the two frozen dinners in the north unit freezer OSM # 8 stated that they did not have a name of a resident or a date of when they were placed in the freezer and immediately discarded the items. After observing the two half gallons of ice cream, frozen pot pie in the freezer and the bottle of salad dressing in the refrigerator on the south unit, OSM # 8 stated that they did not have a name of a resident or a date of when they were placed in the refrigerator or the freezer and immediately discarded the items. The facility's policy Food Receiving and Storage documented in part, 14. Food items and snacks kept on the nursing units must be maintained as indicated below: .b. All foods belonging to residents must be labeled with the resident's name, the item and the use-by date. The facility's policy Food Preparation and Service documented in part, Food Preparation Area. 4d. Cleaning and sanitizing work services (including cutting boards) and food-contact equipment between uses, following food code guidelines. On 04/06/2022 at approximately 5:00 p.m., ASM (administrative staff member) # 1, administrator, and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to ensure accommodation of resident needs and preferences for one of 47 residents in the survey sample, Resident #64. The air mattress box located on the footboard of Resident #64's prevented Resident #64 from independently accessing her nightstand and bathroom. The findings include: Resident #64 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: high blood pressure, anxiety disorder, peripheral vascular disease [any abnormal condition, including atherosclerosis, affecting blood vessels outside the heart (1)], and depression. The most recent MDS (minimum data set) assessment, a Medicare 30 day assessment, with an assessment reference date of 3/2/19, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating she was capable of making daily cognitive decisions. The resident was coded as requiring extensive assistance of one or more staff members for most of her activities of daily living. The resident was coded as needing only supervision for locomotion on the unit and off the unit. A resident interview was conducted with Resident #64 on 4/2/19 at 2:51 p.m. Resident #64 was asked if her room was set up so that she could function in the room. Resident #64 stated, I can't get past the end of the bed to get to the bathroom to wash my hands when I want. I also can't get to my things on my night stand on that side of the bed. Two bibles and a music device were observed on the resident's nightstand. Observation of Resident #64's room revealed, the head of the bed was placed against the left wall. Behind the bed, attached to the wall, appeared to be handicapped rails placed approximately 1 foot apart. The rails prevented the bed from being flush up against the wall. The dresser was placed on the wall to the left as you enter the room. The nightstand was located on the far side of the bed, against the left wall. The bathroom door was on the right wall of the room, near the window. A box that controlled the air mattress, on the resident's bed, was observed on the footboard of the bed. The distance from the end of the footboard, not including the air mattress box, was two and approximately 1/3 of a square tile length (each tile is 12 inches square) from the wall. The average width of a wheelchair is 24.5 inches. (2) An interview was conducted with CNA (certified nursing assistant) #4 on 4/3/19 at 2:12 p.m. CNA #4 was shown Resident #64's room. When asked how the resident reached the bathroom or her side of the room where the nightstand was located with her Bible or music device, CNA #4 stated, She asks us to move the box on the end of the bed and then she can squeeze through. At this time, CNA #4 shoved the bed up against the handicap handrails attached to the wall and there was a little more room but the air mattress box still had to be removed from the foot of the bed to allow the resident to pass in a wheelchair. CNA #4 stated that Resident #64 likes to be independent. Observation of Resident #64 prior to this interview revealed the resident self-propelling her wheelchair in the hallway. Resident #64 demonstrated how she goes through the space, once she removes the box for the air mattress from the footboard of the bed. Resident #64 barely had enough room to get through the space to reach her nightstand and bathroom. On 4/3/19 at 2:26 p.m., an interview was conducted with administrative staff member (ASM) #1, the administrator. ASM #1 was shown Resident #64's room. The resident told ASM #1 at this time that she can't get to the other side of her room to reach her Bible and can't get to the bathroom to wash her hands. She informed the ASM #1 that she has to pick up the box, on the footboard of the bed, and place it on the bed, to get by and that is still tight for her. When asked if this was okay, ASM #1 stated the resident should have access to her things. ASM #1, ASM #2, the director of nursing, and ASM #3, the vice president of clinical services, were made aware of the above concern on 4/3/19 at 6:02 p.m. On 4/5/19 at 1:05 p.m., a request for the facility policy on accommodation of resident needs for the resident's room was made to ASM #3. At 3:13 p.m., ASM #3 informed the survey team that the facility did not have a policy on the accommodation of needs for the resident's room. No further information was obtained prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 447 (2) This information was obtained from the following website: thoroughlyreviewed.com/health-beauty/best-wheel-chair/

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to protect Resident #73's private information during medication administration. LPN (licensed practical nurse) #1 left a box of medication on the top of the medication cart unattended with Resident #73's name on the label, visible to anyone who may have passed by the medication cart. Resident #73 was admitted to the facility on [DATE] with the diagnoses of but not limited to stroke, heart failure chronic obstructive pulmonary disease (1), respiratory failure, and type 2 diabetes mellitus. Resident #73's Minimum Data Set (MDS) an admission assessment with an Assessment Reference Date (ARD) of 1/18/19 coded Resident #73 as having no cognitive impairment in her ability to make daily life decisions. The resident was coded as requiring setup assistance for eating; limited assistance for hygiene; extensive assistance for dressing, transfers, and toileting; total care for bathing; and as occasionally incontinent of bladder and continent of bowel. On 4/3/19 at 8:05 a.m., to 8:16 a.m., an observation of medication administration was performed. LPN (Licensed Practical Nurse) #1 was observed administering medications during this time to one resident. On 4/3/19 at 8:05 a.m., LPN #1 was observed leaving a box of Resident #73's Anoro Ellipta (2) medication on the cart with the label facing outward. The label contained Resident #73's name was visible and easily to read by this surveyor when walking by the medication cart. LPN #1 was observed walking away from the cart in the hallway to administer Resident #73's medication in her room. However, the Anora Ellipta medication remained on the top of the medication cart unattended with Resident #73's name on the label visible to anyone who may have passed by the medication cart. No one was observed to walking past the medication cart at this time. On 4/4/19 at 12:25 p.m., an interview was conducted with LPN #1. LPN #1 was asked about the process for administering medication. LPN #1 stated, I pop the pills, check the orders in the eMAR (electronic mediation administration record). I don't check them off yet, in case the resident does not take them. Then I close the computer down so you can't see the screen and lock the cart. I knock on the door and greet them. I stay with them while they take their medication. I then wash my hands as I leave or use sanitizer. When asked about not closing or lowering a computer screen on the medication cart, LPN#1 stated, It would be a HIPAA (Health Insurance Portability and Accountability Act) violation if I did that. When asked about leaving items on the top of the medication cart, LPN#1 stated, You should have the top cleared off so no one can see any resident information, and keep the cart locked. When asked about leaving a medication box with patient label visible to anyone walking by LPN#1 stated, It should not be left on the cart. A review of the facility's policy Confidentiality of Information documented in part, Our facility shall treat all resident information confidentially .1. The facility will safeguard all resident records .to protect the confidentiality of the information. A review of the facility's policy Administration of Medications documented in part, All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in diagnosis .Wash hands before and after each administration of medication or hand sanitizer as appropriate .Medication cart is not to be left open and unattended. Computer screen is not to be up with the Resident information when the cart is unattended. On 4/4/19 at 4:15 PM, ASM (Administrated Staff Member) #1, the administrator, and ASM #2, the DON (Director of Nursing) were made aware of the findings. No further information was provided by the end of the survey. (1) Chronic Obstructive Pulmonary Disease makes it hard for you to breathe. The two main types are chronic bronchitis and emphysema. The main cause of COPD is long-term exposure to substances that irritate and damage the lungs. This is usually cigarette smoke. Air pollution, chemical fumes, or dust can also cause it. This information was obtained from the website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=copd&_ga=2.160000441.566140716.1522143307-139120270.1477942321 (2) Anoro Ellipta: used long term to treat chronic obstructive pulmonary disease (COPD), including chronic bronchitis, emphysema, or both, for better breathing. ANORO is not used to treat sudden COPD symptoms and won't replace a rescue inhaler. ANORO is not for asthma. This information was obtained from the website: https://www.anoro.com/ 3. The facility staff failed to protect Resident #23's private information during medication administration. LPN #2 was observed leaving the computer screen on the medication cart open with Resident #23's information exposed to the hallway, visible to the surveyor and easily read when walking by the medication cart. Resident #23 was admitted to the facility on [DATE] with the diagnoses of but not limited to chronic obstructive pulmonary disease (1), high blood pressure, solidary pulmonary nodule (2) and gastro-esophageal reflux disease. Resident #23's Minimum Data Set (MDS), an admission assessment with an Assessment Reference Date (ARD) of 1/11/19, coded Resident #23 as having no cognitive impairment in his ability to make daily life decisions. On 4/3/19 at 8:21to 8:40 a.m., an observation of medication administration was performed. LPN (Licensed Practical Nurse) #2 was observed administering medications during this time to one resident. On 4/3/19 at 8:21 a.m., LPN #2 was observed leaving the computer screen on the medication cart open with Resident #23's information exposed to the hallway, visible to the surveyor and easily read when walking by the medication cart. LPN #2 was observed walking away from the cart in the hallway to administer Resident #23's medication in her room. However, the computer screen with Resident #23's information remained visible to anyone who may have walked past the medication cart. No one was observed to walking past the medication cart at this time. On 4/4/19 at12:38 p.m., an interview was conducted with LPN #2 about the process for administering medication. LPN #2 stated, I do the rights: time, route, resident, dosage, you know all five. I ensure privacy and knock before I enter a resident's room. I introduce myself. I state why I am there. I check all identifiers; armband, room, and the resident's picture on the computer screen. When asked about not closing or lowering a computer screen on the medication cart, LPN #2 stated, When I leave the cart, my screen is down and the cart is locked. Everything is turned over so no one could see. When informed of the above observation and asked if it was a problem to leave the computer screen open, LPN #2 stated, Oh yes! HIPAA (Health Insurance Portability and Accountability Act). People could see the resident's name. I should not have left the screen up. On 4/4/19 at 4:15 PM, ASM (Administrated Staff Member) #1, the administrator, and ASM #2, the DON (Director of Nursing) were made aware of the findings. No further information was provided by the end of the survey. (1) Chronic Obstructive Pulmonary Disease makes it hard for you to breathe. The two main types are chronic bronchitis and emphysema. The main cause of COPD is long-term exposure to substances that irritate and damage the lungs. This is usually cigarette smoke. Air pollution, chemical fumes, or dust can also cause it. This information was obtained from the website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=copd&_ga=2.160000441.566140716.1522143307-139120270.1477942321 (2) Solidary Pulmonary Nodule: is an isolated, single lesion in a round or oval shape with a diameter of ?3 cm (centimeters) in lung parenchyma (the portion of the lung involved in gas transfer), surrounded entirely by gas-containing lung tissue. This information was obtained from the website: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3886703/ Based on resident interview, staff interview and facility document review it was determined that the facility staff failed to provide prompt delivery of the resident's postal mail and the facility staff failed to protect the resident's private information for two of six residents in the medication observation, Resident #73 and Resident #23. 1. The facility staff failed to maintain postal mail delivery for the residents on Saturdays. During the Group Resident meeting, residents stated they did not receive mail on Saturdays. 2. The facility staff failed to protect Resident #73's private information during medication administration. LPN (licensed practical nurse) #1 left a box of medication on the top of the medication cart unattended with Resident #73's name on the label, visible to anyone who may have passed by the medication cart. 3. The facility staff failed to protect Resident #23's private information during medication administration. LPN #2 was observed leaving the computer screen on the medication cart open with Resident #23's information exposed to the hallway, visible to the surveyor and easily read when walking by the medication cart. The findings include: 1. A group interview was conducted with four residents, who were cognitively intact, on 4/3/19 at 2:30 p.m. When asked if they received mail on Saturdays, the residents stated that they only get mail Monday through Friday because there is not enough office help to hand it out on Saturdays. An interview as conducted on 4/3/19 at 3:16 p.m., with other staff member (OSM) #5, the business office assistant. OSM #5 was asked when mail is delivered to the residents. OSM #5 stated the mail comes Monday through Friday around 11:00 a.m. The mail is received in the front office and then put in the boxes (mailboxes) for the staff members. The resident's mail is put in the activities box and they separate it and distribute it to the residents. An interview was conducted on 4/3/19 at 3:20 p.m. with OSM #6, the business office manager. When asked about the process for mail delivery to residents', OSM #6 stated that the mail is received from the post office and anything with a resident's name on it goes into the activities box. They then distribute it to the residents. When asked about mail delivery to residents' on Saturdays, OSM #6 stated, We don't get mail on Saturday and Sundays. It's been set up that way for a long time. We don't have an actual mail box outside. When asked if the residents had access to receive mail on Saturdays, OSM #6 stated, No, Ma'am. An interview was conducted with administrative staff member (ASM) #1, the administrator, on 4/3/19 at 3:25 p.m. regarding residents receiving mail at the facility. ASM #1 stated would have to get back with this surveyor. ASM #1 was asked at this time for a policy on mail delivery to residents. On 4/4/19 at 9:34 a.m., ASM #1 stated the facility did not have a written policy on mail delivery. ASM #1 stated, After talking to my staff, based on a history of 15 -20 years ago, they requested the post office not to deliver mail on Saturdays, because it was in those big plastic bins and it was available for everyone to see. There is no one in the admissions office to receive it. Any mail collected on the weekends is brought to the facility on Monday mornings. When asked if this is following the regulations, ASM #1 stated, I'd have to check the regulations. ASM #1 was made aware of the above concern for no delivery of mail to residents on Saturdays. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review ad clinical record review, it was determined the facility staff failed investigate an allegation of abuse and failed to protect residents during an investigation for three of 47 residents in the survey sample, Residents #63, #146 and #53. 1. The facility staff failed to ensure Resident #63 and other residents were protected during the investigation of Resident #63's allegation of abuse. The employee, LPN (licensed practical nurse) #11 named in the allegation was not suspend, and worked on 12/31/18, during the investigation. 2. The facility staff failed to investigate an allegation of abuse between Resident #146 and Resident #53. The findings include: 1. The facility staff failed to ensure Resident #63 and other residents were protected during the investigation of Resident #63's allegation of abuse. The employee, LPN (licensed practical nurse) #11 named in the allegation was not suspend, and worked on 12/31/18, during the investigation. Resident #63 was admitted to the facility to the facility on 1/12/18, with a recent readmission on [DATE] with diagnoses that included but were not limited to: morbid obesity, diabetes, high blood pressure, and congestive heart failure [abnormal condition characterized by circulatory congestion and retention of salt and water by the kidneys (1)]. The most recent MDS (minimum data set) assessment, a Medicare 30 day assessment, with an assessment reference date of 3/1/19, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact to make daily decisions. Resident #63 was coded as having rejected care daily during the look back period. The resident was coded as requiring extensive assistance of two staff members for most of her activities of daily living, including transfers. The resident was coded as being able to feed herself once set up assistance was provided. A Facility Reported Incident (FRI) dated 1/2/19, documented, Report date: 1/2/19. Incident Date 12/12/18. The report further documented, Resident noted on 12/12/18 to have a fall. On 12/28/18, Resident reported to have arm and wrist pain and stated that the injury occurred when resident was helped up off of floor. Investigation initiated. The name of an employee was documented under Name of Employee involved. The Final Report dated, 1/7/19, documented, On 1/2/19 you were contacted regarding an injury for Resident (#63). Resident reported that she did not injure her left arm when she fell but that the nurse (LPN - licensed practical nurse- #11) pulled on her arm to get her off the floor. This nurse was not informed of this until 12/28/18 when the resident came to express her concern. Under, If applicable, date notification provided to: Responsible party - 12/12/2018; Physician - 12/12/18. There was no documented notification to APS (adult protective services), DHP (department of health professionals) or Law Enforcement. This FRI was completed by ASM #2. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, the one who completed the FRI reporting, on 4/4/19 at 3:33 p.m. When asked why she waited to report the FRI on 1/2/19 when she had knowledge of the allegation on 12/28/18, ASM #2 stated, At my last facility, I thought we had five days to get it in. Since then I've been told the requirements for reporting within two hours. ASM #2 was asked about the requirements for reporting suspected abuse, neglect or misappropriation of resident property according to the facility policy, ASM #2 stated, We need to send it to the ombudsman, (state agency), department of social services and depending on the outcome, to the board of nursing. When asked who is responsible for reporting to the state agency, ASM #2 stated, Either (Name of administrator) or myself. If we are not here, the nurse on the floor is responsible to send it in the two hour time frame. ASM #2 was asked to check to see if LPN #11 was suspended during the investigation. An interview was conducted with ASM #1, the administrator, on 4/4/19 at 3:45 p.m. When asked the process for reporting allegations of abuse or mistreatment, ASM #1 stated as soon as it is reported to any staff in the building, it is to be reported to myself or (Name of ASM #2). Once we determine that it should be reported we have a two hour window. If it's involving a staff member, it should be reported to all entities. For the final report I have five working days to get it completed. When asked if an action plan was initiated for this, ASM #1 stated, No, I gave (ASM #2) a copy of the fax cover sheets for all four entities so she would have them for future use. She and I talked about the two hour window. The facility policy, Abuse documented in part, 6. Protection: a. In the event of an allegation or observation of abuse, the facility will immediately assess the resident, notify the physician and resident representative and protect the resident and other residents from further harm or incident. d. When specific staff is identified as being allegedly involved in the abuse allegation, the staff may be re-assigned or suspended during the investigation. Administrative staff member (ASM) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional vice president of clinical services, were made aware of the above concern on 4/4/19 at 6:48 p.m. On 4/4/19 at 7:09 p.m. ASM #2 informed this surveyor that the LPN #11 worked on 12/31/18, during the investigation, but was not assigned to Resident #63. No further information was provided prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 138. 2. The facility staff failed to investigate an allegation of abuse between Resident #146 and Resident #53. Resident #146 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: dementia, depression and insomnia [a condition characterized by difficulty falling asleep or staying asleep (1)]. The most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 1/3/19, coded the resident as scoring a 3 on the BIMS (brief interview for mental status) score, indicating she was severely impaired to make daily cognitive decisions. The resident was coded as requiring extensive assistance to being totally dependent upon staff for her activities of daily living. Resident #53 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: high blood pressure, kidney stones, and intellectually disabled [persons whose general intelligence is significantly below average, and they have difficulty adapting to their environment (2)]. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 2/8/19, coded the resident as having both short and long-term memory difficulties and being severely impaired to make daily cognitive decisions. The resident was coded as requiring extensive assistance of one staff member for most of her activities of daily living. The FRI (facility reported incident) dated 10/26/18, documented in part, Date of report 10/26/18. Incident date: 10/26/18. Describe Incident: (Resident #53) was kicked in left shin by (Resident #146). No injury assessed. Residents separated. Employee action initiated or taken: Resident separated and 1:1 (one to one) provided. An interview was conducted with ASM (administrative staff member) #1, the administrator, on 4/4/19 at 3:45 p.m., regarding the process for reporting allegations of abuse or mistreatment. ASM #1 stated as soon as it is reported to any staff in the building, it is to be reported to myself or (Name of ASM #2, the director of nursing). Once we determine that it should be reported we have a two-hour window. If it's involving a staff member, it should be reported to all entities. For the final report, I have five working days to get it completed. A copy of the facilities internal investigation of the 10/26/18 incident between Resident #53 and Resident #146 was requested on 4/3/19 at approximately 5:00 p.m. At 5:32 p.m. on 4/4/19, ASM (administrative staff member) #1, the administrator, informed this surveyor he could not locate an investigation on this FRI and stated there was no final report submitted to his knowledge. Administrative staff member (ASM) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional vice president of clinical services, were made aware of the above concern on 4/4/19 at 6:48 p.m. No further information was provided prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 300. (2) This information was obtained from the following website: https://www.healthychildren.org/English/health-issues/conditions/developmental-disabilities/Pages/Outlook-for-Children-with-Intellectual-Disabilities.aspx

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to provide written notification to the ombudsman of a facility initiated transfer for one of 47 residents in the survey sample, Residents # 3. The facility staff failed to notify the ombudsman when Resident # 3 was transferred to the hospital on [DATE]. The findings include: Resident # 3 was admitted to the facility on [DATE] with diagnoses that included but were not limited to respiratory failure (1), bipolar disorder (2), and spondylolysis (3). Resident # 3's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/19/18, coded Resident # 3 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. The nurse's Progress Notes, dated 12/21/2018 for Resident # 3 documented, 3:01 PM (p.m.) Staff notified that resident found in bedroom around 230pm (2:30 p.m.) with bloody drainage on right side of shoulder and floor from fall. Resident is A&Ox3 (alert and oriented times three, person place and time), T (temperature) 98.3, BP (blood pressure 156/78 (one hundred fifty-six over seventy-eight), p (pulse) 86, RR (respiration) 20, O2 (oxygen) 69% (percent) RA (on room air), c/o (complaint of) pain to head,. Resident noted with small lump near back of R (right) side of head with skin tear in center. Moderate amount of bright red blood stabilized with gauze and compression gauze. ROM (range of motion) wnl (within normal limits), prn (as needed) Tylenol; 650 mg (milligram) po (by mouth) at 246pm (2:46 p.m.). No shoes or socks to feet. Resident was able to reach out and use call bell to notify staff, Supervisor, RP (responsible party), MD (medical doctor) notified. Resident has been sent to (Name of Hospital) ER (emergency room) for treatment. Left with EMT (emergency medical technician) out the facility via (by) stretcher at 256pm (2:56 p.m.). RP stated he would not hold bed if resident admitted to hospital. On 04/03/19 at 5:15 p.m., an interview was conducted with OSM (other staff member) #2, the social worker and admissions director. When asked to describe the procedure to notify the ombudsman of a facility initiated transfer for a resident, OSM # 2 stated, We fax a list to the ombudsman at the beginning of each month. OSM # 2 was asked to provide evidence that the ombudsman was notified of Resident # 3's transfer to the hospital on [DATE]. On 04/04/19 at 8:00 a.m., an interview was conducted with OSM # 2, social worker and admissions director. When asked about the notification to the ombudsman for Resident # 3's transfer to the hospital on [DATE], OSM # 2 stated, When asked, went out the admissions and business was not notified she went out and returned therefore the ombudsman was not notified. On 04/04/19 at approximately 6:45 p.m. ASM (administrative staff member) # 1, the administrator, ASM # 2, director of nursing and ASM # 3, vice president of clinical services, were made aware of the findings. No further information was provided prior to exit. References: (1) When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html. (2) A brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks. This information was obtained from the website: https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml. (3) A condition in which a bone (vertebra) in the spine moves forward out of the proper position onto the bone below it. This information was obtained from the website: https://medlineplus.gov/ency/article/001260.htm. (4) A common respiratory virus that usually causes mild, cold-like symptoms. Most people recover in a week or two, but RSV can be serious, especially for infants and older adults. In fact, RSV is the most common cause of bronchiolitis (inflammation of the small airways in the lung) and pneumonia (infection of the lungs) in children younger than 1 year of age in the United States. It is also a significant cause of respiratory illness in older adults. This information was obtained from the website: https://www.cdc.gov/rsv/index.html.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record, it was determined that the facility staff failed to maintain an accurate MDS (minimum data set) assessment for one of 47 residents in the survey sample, Resident # 34. The facility staff failed to accurately code Resident # 34's 14-Day MDS (minimum data set), assessment with an ARD (assessment reference date) of 03/23/19, for a pressure ulcer. The findings include: Resident # 34 was admitted to the facility on [DATE] with diagnoses that included but were not limited to respiratory failure (1), diabetes mellitus (2), and major depressive disorder (3). Resident # 34's most recent MDS (minimum data set), a 14-day assessment with an ARD (assessment reference date) of 03/23/19, coded Resident # 34 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Resident # 34 was coded as requiring extensive assistance of one staff member for activities of daily living and independent with eating. Section M0210 Unhealed Pressure Ulcers/Injuries. Does the resident have one or more unhealed pressure ulcers/injuries? coded Resident # 34 as zero, No. The facility's Progress Notes for Resident # 34 dated 03/14/19 documented, 5:31 p.m. Area on bottom 0.5 x 0.75 (0.5 by 0.75 centimeters) on sacrum [4]. Existing order for triad (5). MD (medical doctor) aware. RP (responsible party) called and awaiting phone call back. The facility's Pressure Injury Investigation for Resident # 34 dated 3/14/19 documented, Location of Ulcer: Sacrum. Stage and/or description of ulcer at time of discovery 0.5 x 0.75 open area. The comprehensive care plan for Resident # 34 dated 03/09/19 documented, Problem. Category: Pressure Ulcer. 3/14/19 Sacrum open area. 3/26/19 resolved. On 04/05/19 at 10:27 a.m., an interview was conducted with LPN (licensed practical nurse) # 7, MDS coordinator. After LPN #7 was asked to review section M of the MDS for Resident # 34 with the ARD of 03/23/19, the progress note dated 03/14/19 and the Pressure Injury Investigation dated 03/14/19 . After the review, LPN # 7 stated that the MDS should have coded Resident # 34 with a pressure ulcer. When asked to describe the process for coding the MDS for a pressure ulcer, LPN # 7 stated, I look at documentation, nurse's notes, wound doctor notes and communicate with the nurses. LPN # 7 further stated that they follow the RAI (resident assessment instrument) manual. Review of CMS's (Centers for Medicare/Medicaid) RAI (Resident Assessment Instrument) Version 3.0 Manual CH (chapter) 3: MDS Item M0210: Unhealed Pressure Ulcers/Injuries documented, Steps for Assessment 1. Review the medical record, including skin care flow sheets or other skin tracking forms. 2. Speak with direct care staff and the treatment nurse to confirm conclusions from the medical record review. 3. Examine the resident and determine whether any skin ulcers/injuries are present. Key areas for pressure ulcer/injury development include the sacrum, coccyx, trochanters, ischial tuberosities, and heels. Other areas, such as bony deformities, skin under braces, and skin subjected to excess pressure, shear, or friction, are also at risk for pressure ulcers/injuries. Without a full body skin assessment, a pressure ulcer/injury can be missed. Examine the resident in a well-lit room. Adequate lighting is important for detecting skin changes. For any pressure ulcers/injuries identified, measure and record the deepest anatomical stage. 4. Identify any known or likely unstageable pressure ulcers/injuries. On 04/05/19 at approximately 6:45 p.m. ASM (administrative staff member) # 1, the administrator, ASM # 2, director of nursing and ASM # 3, vice president of clinical services, were made aware of the findings. No further information was provided prior to exit. References: (1) When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html. (2) A chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/001214.htm. (3) Depression may be described as feeling sad, blue, unhappy, miserable, or down in the dumps. Most of us feel this way at one time or another for short periods. Clinical depression is a mood disorder in which feelings of sadness, loss, anger, or frustration interfere with everyday life for weeks or more. This information was obtained from the website: https://medlineplus.gov/ency/article/003213.htm. (4) A shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis. The sacrum forms the posterior pelvic wall and strengthens and stabilizes the pelvis. Joined at the very end of the sacrum are two to four tiny, partially fused vertebrae known as the coccyx or tail bone. The coccyx provides slight support for the pelvic organs but actually is a bone of little use. This information was obtained from the website: https://medlineplus.gov/ency/imagepages/19464.htm (5) A hydrophilic paste that contains zinc-oxide. It is usually used for managing light-to-moderate levels of wound exudates. Coloplast triad paste absorbs excess exudate and it gently sticks to moist wound beds. Coloplast Triad Dressing provides an optimal wound healing environment that facilitates natural autolytic debridement. This information was obtained from the website: https://www.healthproductsforyou.com/p-coloplast-triad-hydrophilic-dressing.html?gclid=EAIaIQobChMIl9X8yIXB4QIVD8DICh2u7QrSEAAYASAAEgIh1PD_BwE

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The facility staff failed to implement Resident # 83's comprehensive care plan for the administration of oxygen to the resident as ordered. Resident # 83 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: pneumonia (1), chronic obstructive pulmonary disease (2), and acute respiratory failure (3) with hypoxia (4). Resident # 83's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 03/27/2019, coded Resident # 83 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 being no cognitive impairment for making daily decisions. Resident # 83 was coded as requiring extensive assistance of one staff member for activities of daily living and supervision of one staff member for eating. Under section O. Special Treatment, Procedures and Programs, Resident # 83 was coded for C. Oxygen therapy. On 04/02/19 at 12:16 p.m., an observation of Resident # 83 revealed she was sitting up in her wheelchair at the dining table waiting for her meal. Resident # 83 appeared to be drowsy and occasionally nodding off. Further observation revealed Resident # 83 was wearing a nasal cannula connected to a portable oxygen tank. Observation of the oxygen flow meter on the oxygen tank revealed the oxygen flow rate knob was set on the off position. At 12: 33 p.m., approximately 17 minutes later, RN # 3 was observed setting Resident # 83's oxygen flow rate at two liters per minute. The POS (physician's order sheet) for Resident # 83 dated 03/13/2019 documented, O2 (oxygen) at 2 L (two liters) via (by) NC (nasal cannula) continuously, [chronic obstructive pulmonary disease]. Every shift; day shift, evening shift, night shift] Order Date: 03/13/2019. The comprehensive care plan for Resident # 83 dated 03/22/2019 documented under goals, Resident will not exhibit signs of hypoxia (cyanosis (5), tachypnea(6), dyspnea (7), confusion, restlessness, nasal flaring (8), elevated blood pressure, increased respirations, and increased pulse). Under approach it documented, Oxygen via (by) N/C (nasal cannula) as ordered. Start Date: 03/22/2019. On 04/04/19 at 1:23 p.m., an interview was conducted with LPN (licensed practical nurse) # 1. When asked to look at the Resident # 83's care plan and determine if the care plan was followed, LPN # 1 stated, No, the care plan was not followed. A review of the facility policy titled, Oxygen Administration documented as follows: 1. Oxygen is administer to the resident only upon written order of a licensed physician. According to Lippincott Manual of Nursing Practice, Seventh Edition: by [NAME] & [NAME], pg. 276 read: The plan of nursing care (patient care plan) is the written guide that directs the efforts of the nursing team as nurses work with patients to meet their health goals .Is responsive to the individual characteristics and needs of the patient. On 04/04/19 at approximately 4:52 p.m., ASM (administrative staff member) # 1, administrator, was made aware of the findings. No further information was provided prior to exit. Reference: 1. An infection in one or both of the lungs. Many germs, such as bacteria, viruses, and fungi, can cause pneumonia. You can also get pneumonia by inhaling a liquid or chemical. This information was obtained from the website: https://medlineplus.gov/pneumonia.html. 2. Disease that makes it difficult to breath that can lead to shortness of breath). The two main types are chronic bronchitis and emphysema. The main cause of COPD is long-term exposure to substances that irritate and damage the lungs. This is usually cigarette smoke. Air pollution, chemical fumes, or dust can also cause it. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. 3. A condition in which not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html. 4. Deficiency of oxygen reaching the tissues of the body. This information was obtained from the website: https://www.merriam-webster.com/dictionary/hypoxia. 5. A bluish color to the skin or mucous membrane is usually due to a lack of oxygen in the blood. The medical term is cyanosis. This information was obtained from: ttps://medlineplus.gov/ency/article/003215.htm 6. Breathing - rapid and shallow; Fast shallow breathing. https://medlineplus.gov/ency/article/007198.htm - Medical Encyclopedia 7. When you're short of breath, it's hard or uncomfortable for you to take in the oxygen your body needs. You may feel as if you're not getting enough air. Sometimes you can have mild breathing problems because of a stuffy nose or intense exercise. But shortness of breath can also be a sign of a serious disease. This information was obtained from the website: https://medlineplus.gov/breathingproblems.html. 8. Occurs when the nostrils widen while breathing. It is often a sign of trouble breathing. This information was obtained from the website: https://medlineplus.gov/ency/article/003055.htm - Medical Encyclopedia Based on observation, staff interview, and facility record review, it was determined the facility staff failed to develop and/or implement the comprehensive care plan for three of 47 residents in the survey sample, Residents #2, #60, #45, and #83. 1. The facility staff failed to implement the comprehensive care plan for a physician ordered treatment for Resident #60. 2. The facility staff failed to implement the care plan for when a resident has behaviors for Resident #45. On 12/8/18 the facility staff only attempted the intervention of redirection and failed to implement other intervention identified on the care plan for her behaviors 3. The facility staff failed to implement Resident # 83's comprehensive care plan for the administration of oxygen to the resident as ordered. The findings include: 1. The facility staff failed to implement the comprehensive care plan for a physician ordered treatment for Resident #60. Resident #60 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: stroke, diabetes, and peripheral vascular disease [any abnormal condition, including atherosclerosis, affecting blood vessels outside the heart (1)]. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 3/1/19, coded the resident as scoring a 13 on the BIMS (brief interview for mental status) score, indicating she is capable of making daily cognitive decisions. Resident #60 was coded as requiring limited to extensive assistance of one staff member for most of her activities of daily living. Observation was made of Resident #60 on 4/2/19 at 4:03 p.m. the resident was sitting in her wheelchair in her room. There was noted to be a dressing on her left lower leg on the shin and handwritten on the dressing, 3/31/19. The comprehensive care plan dated, 3/5/19, documented in part, Tx (treatment) to area on L (left) LE (lower extremity) per orders; see eTAR (skin tears). The Approach documented in part, Treatments as ordered; refer to wound DR (doctor) as indicated. The physician orders dated, 3/5/19, documented, Cleanse left lower leg with NS (normal saline) cover with dry dressing and Kerlix, once a day. Review of the eTAR (electronic treatment administration record) for April 2019 documented the above order. The treatment was scheduled for the 7:00 a.m. to 3:00 p.m. shift. On 4/1/19 it was initialed as being completed by RN (registered nurse) #4. Under the Comments section it was documented, Charted late. An interview was conducted with LPN (licensed practical nurse) #1 on 4/4/19 at 11:59 a.m. When asked the purpose of the care plan, LPN #1 stated, It gives you set goals and a way to get there. When asked if a physician ordered treatment is on the care plan and it's not completed, is that following the care plan, LPN #1 stated, No, Ma'am. An interview was conducted with RN (registered nurse) #4 on 4/4/19 at 5:06 p.m. When asked if the care plan documents that a treatment should be completed as ordered by the physician and it's not completed, is that following the care plan, RN #4 stated, No, Ma'am. Administrative staff member (ASM) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional vice president of clinical services, were made aware of the above concern. On 4/5/19 at 1:00 p.m., a request was made of ASM #3 for a policy related to following the comprehensive care plan. At 3:13 p.m. ASM #3 informed the survey team the facility didn't have a policy on following the care plan that it is a standard of practice. When asked which standard of practice the facility follows, ASM #3 stated, [NAME]. According to Fundamentals of Nursing [NAME] and [NAME] 2007 pages 65-77 documented, A written care plan serves as a communication tool among health care team members that helps ensure continuity of care .The nursing care plan is a vital source of information about the patient's problems, needs, and goals. It contains detailed instructions for achieving the goals established for the patient and is used to direct care .expect to review, revise and update the care plan regularly, when there are changes in condition, treatments, and with new orders. No further information was provided prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 447. 2. The facility staff failed to implement the care plan for when a resident has behaviors for Resident #45. On 12/8/18 the facility staff only attempted the intervention of redirection and failed to implement other intervention identified on the care plan for her behaviors Resident #45 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: anxiety disorder, dementia, and high blood pressure. The most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 2/15/19, coded the resident as scoring a 6 on the BIMS (brief interview for mental status) score, indicating she was severely impaired to make daily cognitive decisions. The resident was coded as having disorganized thinking and physical behavior directed towards others on one-three days of the look back period. Resident #45 was coded as requiring extensive assistance of one or more staff members for most of her activities of daily living. In Section N - Medications, the resident was coded as receiving seven days of an antipsychotic and an antidepressant. The comprehensive care plan dated, 11/19/18, documented in part, Problem: Anxiety, received psychotropic daily. Seroquel (an antipsychotic medication used to treat schizophrenia, bipolar depression and in conjunction with other medication for depression) (1) d/c during review for GDR (gradual dose reduction); mood appears to remain stable most times. Can be combative and curse staff at times when performing care, continues to sleep in chair while up and doesn't like to be bothered likely associated with advancing dementia. Melatonin added for insomnia. Added on 12/8/18, Seroquel per orders d/t (due to) increased agitation. The Approaches documented in part, Attempt gradual dose reduction. monitor and record (Resident #45)'s behavior when combative to determine the need for medication adjustments. Monitor (Resident #45) for increased anxiety during care and attempt to redirect behavior by talking to her, providing music or leaving her alone and coming back later to try again. Offer snack before bedtime or when resident awakens during night. Provide comfortable environment to promote sleep (e.g., clean bedding, comfortable bed clothing, incontinence care, comfortable temperature, ventilation). When resident awakens during the night, provide comfort measures (e.g., back rub, repositioning, incontinence care, snack). The nurse's note in December 2018 documented, 12/8/18 at 2:41 a.m. - Res (Resident)awake at beginning of shift, noted with increased confusion, stating 'I need to call my husband and let him know where I am,' 1:1 given with positive effect. 12/8/18 at 6:10 a.m. - Res awake all shift talking outloud (sic) to self. Res up in dayroom at this time, stating 'I have to go home,' 1:1 ineffective. There were no further notes for 12/8/18. The next note related to behavior was on 12/12/18 at 8:17 a.m. - No behavior issues noted through the night. An interview was conducted with AMS (administrative staff member ) #2, the director of nursing, on 4/5/19 at 12:44 p.m. The nurses' notes and the care plan were reviewed with ASM #2. When asked if the staff were implementing the care plan on 12/8/18, ASM #2 stated, No, they only attempted redirection where there were other things on the care plan to try for her behaviors. ASM #2 was made aware of the above concern at this time. No further information was provided prior to exit. (1) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a698019.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, it was determined that facility staff failed to review or revise the care plan for one of 47 residents in the survey sample, Resident # 3. The facility staff failed to update Resident # 3's comprehensive care plan concerning a fall on 03/08/19. The findings include: The facility staff failed to update Resident # 3's comprehensive care plan concerning a fall on 03/08/19. Resident # 3 was admitted to the facility on [DATE] with diagnoses that included but were not limited to respiratory failure (1), bipolar disorder (2), and spondylolysis (3). Resident # 3's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/19/18, coded Resident # 3 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. The facility's Progress Notes dated 03/08/2019 for Resident # 3 documented, Resident was found on the floor in her bathroom @ (at) 930pm (9:30 p.m.) unable to explain how she fell on the floor. Range of motion and assessment done denies pain no injury @ this time RP (responsible party) daughter [sic] inlaw notified and MD (medical doctor (Name of Doctor) made aware will continue to monitor. The comprehensive care plan dated 12/26/18 with a target date of 03/26/19 for Resident # 3 was reviewed. Under Need it documented, Category: Falls. (Resident # 3) is at a low risk for falling r/t (related to) psychotropic meds (medications), incontinence and generalized muscle weakness, balance issues, alert and oriented X (times 0) 3 (three) and available and able to make needs known. Further review of the care plan failed to evidence documentation that the comprehensive care plan was reviewed or revised following Resident # 3's fall on 03/08/19. On 04/04/19 at 1:46 p.m., an interview was conducted with LPN (licensed practical nurse) # 7, MDS assistant coordinator about updating or revising the care plan for Resident # 3's fall on 3/8/19. After reviewing the care plan for Resident # 3 dated 12/26/18 with a target date of 03/26/19, LPN # 7 stated, It was not on the care plan because it was not reported me. When asked to describe the process: for updating the care plan LPN # 7 stated, They are updated on a daily basis by the MDS office if there is a change or issue. The nurse's on the floor can always add to care plan when there is a change because the plans are on the floor at the nurse's station. LPN # 7 stated, We are notified during our morning meeting, by pulling up the facility report on the computer which is every 24 hours and/or communication with the unit manager or the nurses on the floor. The RAI (Resident Assessment Instrument) 3.0 User's Manual Version 1.16 dated October 2018 documented, 4.7 The RAI and Care Planning As required at 42 CFR 483.21(b), the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care. On 04/04/19 at approximately 6:45 p.m. ASM (administrative staff member) # 1, the administrator, ASM # 2, director of nursing and ASM # 3, vice president of clinical services, were made aware of the findings. No further information was provided prior to exit. References: (1) When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html. (2) A brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks. This information was obtained from the website: https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml. (3) A condition in which a bone (vertebra) in the spine moves forward out of the proper position onto the bone below it. This information was obtained from the website: https://medlineplus.gov/ency/article/001260.htm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure one resident (Resident #60) of 47 sampled residents, received the care and services in accordance with professional standards and the comprehensive care plan. The facility staff failed to administer a treatment to Resident #60 per the physician orders. The findings include: Resident #60 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: stroke, diabetes, and peripheral vascular disease [any abnormal condition, including atherosclerosis, affecting blood vessels outside the heart (1)]. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 3/1/19, coded the resident as scoring a 13 on the BIMS (brief interview for mental status) score, indicating she is capable of making daily cognitive decisions. Resident #60 was coded as requiring limited to extensive assistance of one staff member for most of her activities of daily living. Observation was made of Resident #60 on 4/2/19 at 4:03 p.m. the resident was sitting in her wheelchair in her room. A dressing was observed on her left lower leg, on the shin. The date 3/31/19 was handwritten on the dressing. The physician orders dated, 3/5/19, documented, Cleanse left lower leg with NS (normal saline) cover with dry dressing and Kerlix, once a day. Review of the eTAR (electronic treatment administration record) for April 2019 documented the above physician's order. The treatment was scheduled for the 7:00 a.m. to 3:00 p.m. shift. On 4/1/19, it was initialed as being completed by RN (registered nurse) #4. Under the Comments section, Charted late was documented. The comprehensive care plan dated, 3/5/19, documented in part, Tx (treatment) to area on L (left) LE (lower extremity) per orders; see eTAR (skin tears). The Approach documented in part, Treatments as ordered; refer to wound DR (doctor) as indicated. An interview was conducted with LPN (licensed practical nurse) #1 on 4/4/19 at 11:59 a.m. When asked if she was working on 4/1/19, LPN #1 stated she was off that day. When asked if she performed the dressing to Resident #60's left lower leg on 4/2/19, LPN #1 state yes. When asked what date she saw on the dressing on 4/2/19, LPN #1 stated, 3/31/19. When asked if the physician order is for a daily dressing change, LPN #1 stated, It's do be done no matter what. It's once a day so it really doesn't matter which shift but has to be completed once a day. If it is late, then you have to notify the doctor and chart in the record that it was late. When asked if staff followed the physician orders since the dressing wasn't completed on 4/1/19, LPN #1 stated, No. An interview was conducted with RN #4 on 4/4/19 at 5:06 p.m. The above information was reviewed with RN #4. When asked if he signed off the treatment on 4/1/19, RN #4 stated, Yes. When asked if he completed the dressing ordered by the physician to the resident left lower leg, RN #4 stated, No, the system keeps popping up a red window that it's not completed so I just signed it off. When asked if a physician order for a treatment, should be followed, RN #4 stated, Yes, Ma'am. Administrative staff member (ASM) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional vice president of clinical services, were made aware of the above concern. On 4/5/19 at 1:00 p.m., a request was made of ASM #3 for a policy related to following physician orders. On 4/5/19 at 3:13 p.m., ASM #3 informed the survey team the facility did not have a policy on following physician orders; it's a professional standard of practice. When asked which standard of practice they follow, ASM ## stated, Lippincott. The [NAME]-[NAME] Fundamentals of Nursing, 6th edition, was used as a reference related to documentation. In a table describing the Legal Guidelines for Recording, the following was noted; Chart only for yourself. Records need to reflect accountability during the time frame of the entry, which is best accomplished when nurses chart only their own observations and actions. No further information was provided prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 447.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review it was determined that the facility staff failed to provide the necessary treatment and services, consistent with professional standards of practice, to promote the healing pressure ulcers for one of 47 residents in the survey sample, Resident #83. The facility staff failed to ensure weekly measurements were completed to assess and monitor the healing of Resident #83's multiple pressure ulcers. The findings include: The facility staff failed to complete weekly assessments including measurements and wound description to determine wound healing or decline, to evaluate / monitor the healing of Resident #83's sore. Resident # 83 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: malignant neoplasm (1) of brain (2), epilepsy (3), and chronic obstructive pulmonary disease (4). Resident # 83's most recent MDS (minimum data set), a 14-day assessment with an ARD (assessment reference date) of 03/27/19, coded Resident # 83 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Resident # 83 was coded as requiring extensive assistance of one staff member for activities of daily living and independent with eating. Section M0210 Unhealed Pressure Ulcers/Injuries. Does the resident have one or more unhealed pressure ulcers/injuries? coded Resident # 34 as One, Yes. During the entrance conference on 04/02/19 at approximately 11:30 a.m., a request was made for a list of all residents who had pressure injuries. The facility's pressure ulcer list documented Resident # 83 with an acquired stage II pressure ulcer on her buttocks. The facility's Pressure Injury Investigation for Resident # 83 dated 3/15/19 documented, Location of Ulcer: Buttocks. Stage and/or description of ulcer at time of discovery: Stg (stage) 2 (two). Further review of the Pressure Injury Investigation failed to document any measurements. The facility's Weekly Skin Assessment for Resident # 83 dated 3/15/19 documented a picture outline of a human body with three short horizontal lines on the left buttocks and was labeled Open. The facility's Progress Notes for Resident # 83 dated 03/15/2019 documented in part, ADMITT (admission) (Name of Physician) in to see resident for admit and NNO (no new orders). MD (medical doctor) aware of open areas to resident's buttocks. Advised to continue current Tx (treatment) at this time . The comprehensive care plan for Resident # 83 dated 03/22/2019 documented, Category: Pressure Ulcer. Potential for skin breakdown. (Resident # 83) is a new admit (admission) with recent hospitalization for UTI (urinary tract infection)? sepsis. She has edema (swelling) to her BLE (bilateral [both sides] lower extremities). Had previous injury to LLE (left lower extremity) and was receiving wound care from (Name of Doctor). Resident has 2 (two) stage 2 (two) pressure ulcers on each of her buttocks that is being treated with triad paste. Under Approach, it documented several interventions and treatments for the pressure ulcer. Further review of the comprehensive care plan failed to evidence documentation of wound measurements. The facility's TAR (treatment administration record) for Resident # 83 dated 03/01/2019 - 03/31/2019 documented, Skin Assessment. Further review of the TAR revealed skin assessments conducted on 03/19/19 that documented, No new skin areas and on 03/26/19 that documented, No new abnormalities. The facility's TAR for Resident # 83 dated 04/01/2019 - 04/04/2019 documented, Skin Assessment. Further review of the TAR revealed staff initials on 04/02/19 at 3:00 p.m. - 11:00 p.m. indicating a skin assessment was completed. Under Results it documented, n/a (not applicable). The facility's Progress Notes for Resident # 83 dated 03/18/2019 documented, 5:30 p.m., Per discussion with RP (responsible party) on 3/15/19 when RP notified of order changes to resident's sacrum. RP advised that the blister / open area cycle has been an ongoing problem with resident that is why she has had A&D ointment in place. RP made aware of new order of Traid at that time. Thanked writer for updating. Further update given at this time of continuing tx. The facility's Progress Notes for Resident # 83 dated 03/26/2019 documented, 9:05 a.m. After observation of resident peri area and sacrum. Open area approximately 1/8 (one-eighth inch) x (by) 0.25 (one-fourth inch) with no drainage and pink wound bed noted on left buttocks with surrounding skin intact and [sic] non reddened. Right buttocks [sic] nonreddened and healing area of previous skin peeling noted. MD (medical doctor) aware. Attempted to contact RP, awaiting call back at this time. Further review of the facility's progress notes for Resident # 83 dated 03/15/19 through 03/25/04/19 and 03/27/19 through 04/04/19 failed to evidence assessment, measurements, tracking and monitoring of Resident # 83's pressure ulcer. On 4/4/19 at 6:50 p.m., during the end of day meeting with ASM #1, ASM #2, and ASM #3 (Administrative Staff Members; the Administrator, Director of Nursing, and Regional [NAME] President of Clinical Services) were made aware of the findings. At this time a request was made to observe Resident # 83's wound on 4/5/19. The facility staff did not provide this opportunity. On 04/05/19 at 11:17 a.m., an interview was conducted with RN (registered nurse) # 3. After reviewing the facility's Pressure Injury Investigation for Resident # 83 dated 3/15/19, RN # 3 agreed the wound was a stage II and was discovered on 0 3/15/19. RN #3 stated, she (Resident #83) had an order for A&D ointment and I followed the order. When asked if weekly skin assessment for Resident # 83 were completed, RN # 3 stated, Weekly skin assessments are completed for all residents. When asked if wound assessments including measurements are taken weekly for residents with pressure ulcers, RN # 3 stated, They should be. After reviewing Resident # 83's TARs dated for March and April 2019 and the progress notes, RN # 3 was asked if the assessments and measurements of Resident # 83's wound were being documented. RN # 3 stated, I don't see any. When asked if there was tracking and trending for Resident # 83's pressure ulcer, RN # 83 stated, Not done appropriately When asked why is was important to assess, measure, track and monitor a pressure ulcer, RN # 3 stated, We need to know the condition of the resident so we can treat appropriately. A review of the facility policy, Wound Protocol which was undated, documented: It is the intent of the facility to complete a weekly assessment of all wounds. Many of the wounds are assessed weekly by the wound care physician with documentation provided to facility and scanned into the clinical record. That physician also provides a weekly wound report of the status of each of the wounds he treats. This report is utilized by the facility as the weekly wound report. There are also wounds which that physician does not assess and treat on a weekly basis. The facility nurses are responsible for assessing and documenting the assessment in the clinical record. It is further the intent that the facility will be knowledgeable of the status / progress of each wound in facility. Process: 1. All wounds are to be treated daily by the nurse who is responsible for the care of that resident. 2. Each Thursday, the nurse will assess, measure and document on the status of each wound not being followed by the wound physician. 3. Documentation will be completed on the Weekly Pressure Ulcer and Non-Pressure Skin Condition forms. 4. The assessment will include the following: a. resident room number and name. b. identify if the wound is admitted and the date of admission. c. identify if the wound is in-house acquired and the date of onset. d. site of area of impairment. e. stage (if pressure). f. if not pressure, identify the type of wounds (venous, arterial, skin tear, etc.) g. measurements (length x width x depth). h. description of wound bed. i. peri wound tissue. j. exudate (type and amount). k. odor. l. drainage - type/amount. m. pain. n. status of the wound (improving/declining/no change); also include devices. 5. The nurse is to complete the assessment and document every Thursday. This will ensure all wounds existing in facility are assessed on the same day each week (wound physician in facility on Thursdays). 6. The wound documentation forms will be placed on the MD board on each unit for the unit manager on Friday morning. The unit manager will ensure notification to physician. 7. Unit manager will use information from the documentation to complete the wound report. 8. The wound report is to be completed by the unit manager each week and submitted to the DON by the end of the workday on Friday. While completing the report, the unit manager is validating that the assessment of the wounds has been completed and documented per protocol. 9. If wound physician does not come, then the facility nurse is responsible for documenting and reporting on each wound, including those the wound physician generally assesses and treats. 10. Identification of a new wound must be included on the shift 24-hour report form. 11. Nurse is expected to contact physician for new orders upon identification of a new wound. 12. Weekly report to be submitted to DON, ADON, Infection Control Nurse, MDS nurses, and Administrator. The Pressure Ulcer Treatment Quick Reference Guide by NPUAP (National Pressure Ulcer Advisory Panel) states on page 8 concerning pressure ulcer assessment, Asses the pressure ulcer initially and re-assess it at least weekly, documenting findings. On 04/04/19 at approximately 6:45 p.m. ASM (administrative staff member) # 1, the administrator, ASM # 2, director of nursing and ASM # 3, vice president of clinical services, were made aware of the findings. No further information was provided prior to exit. References: (1) The term malignancy refers to the presence of cancerous cells that have the ability to spread to other sites in the body (metastasize) or to invade nearby (locally) and destroy tissues. Malignant cells tend to have fast, uncontrolled growth and DO NOT die normally due to changes in their genetic makeup. Malignant cells that are resistant to treatment may return after all detectable traces of them have been removed or destroyed. This information was obtained from the website: https://medlineplus.gov/ency/article/002253.htm. (2) A brain tumor is a growth of abnormal cells in the tissues of the brain. Brain tumors can be benign, with no cancer cells, or malignant, with cancer cells that grow quickly. Some are primary brain tumors, which start in the brain. Others are metastatic, and they start somewhere else in the body and move to the brain. This information was obtained from the website: https: https://medlineplus.gov/braintumors.html. (3) A brain disorder that causes people to have recurring seizures. The seizures happen when clusters of nerve cells, or neurons, in the brain send out the wrong signals. People may have strange sensations and emotions or behave strangely. They may have violent muscle spasms or lose consciousness. This information was obtained from the website: https://medlineplus.gov/epilepsy.html. (4) Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility policies review, and clinical record review, it was determined that the facility staff failed to provide respiratory care and services consistent with professional standards of practice, and the comprehensive person-centered care plan for one of 47 residents in the survey sample, Resident # 83. The facility staff failed to administer Resident # 83's oxygen according to the physician's orders. The findings include: Resident # 83 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: pneumonia (1), chronic obstructive pulmonary disease (2), and acute respiratory failure (3) with hypoxia (4). Resident # 83's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 03/27/2019, coded Resident # 83 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 being no cognitive impairment for making daily decisions. Resident # 83 was coded as requiring extensive assistance of one staff member for activities of daily living and supervision of one staff member for eating. Under section O. Special Treatment, Procedures and Programs Resident # 83 was coded for C. Oxygen therapy. On 04/02/19 at 12:16 p.m., an observation of Resident # 83 revealed she was sitting up in her wheelchair at the dining table waiting for her meal. Resident # 83 appeared to be drowsy and occasionally nodding off. Further observation revealed Resident # 83 was wearing a nasal cannula connected to a portable oxygen tank. Observation of the oxygen flow meter on the oxygen tank revealed the oxygen flow- rate knob was set on the off position. At 12: 33 p.m., approximately 17 minutes later, RN # 3 was observed setting Resident # 83's oxygen flow rate at two litters per minute. On 04/03/19 at 9:27 a.m., an observation of Resident # 83 revealed she was lying in bed receiving oxygen by nasal cannula. Observation of the oxygen flow meter on the oxygen concentrator revealed the oxygen flow rate at two liters per minute. The POS (physician's order sheet) for Resident # 83 dated 03/13/2019, documented, O2 (oxygen) at 2 L (two liters) via (by) NC (nasal cannula) continuously, [chronic obstructive pulmonary disease]. Every shift; day shift, evening shift, night shift] Order Date: 03/13/2019. The comprehensive care plan for Resident # 83 dated 03/22/2019 documented under goals, Resident will not exhibit signs of hypoxia (cyanosis (5), tachypnea(6), dyspnea (7), confusion, restlessness, nasal flaring, elevated blood pressure, increased respirations, and increased pulse). Under approach it documented, Oxygen via (by) N/C (nasal cannula) as ordered. Start Date: 03/22/2019. On 04/04/19 at 1:23 p.m., an interview was conducted with LPN (licensed practical nurse) # 1. When asked how staff determine how much oxygen a resident is receiving, LPN # 1 stated, I check the physician's order and I check the resident pulse oximetry (8). When asked what the physician's order documented for Resident # 83's oxygen, LPN # 1 stated Two liters. When asked if the physician's order for oxygen is being followed, if Resident #83's oxygen flow- rate knob is turned to the off position. LPN # 1 stated, No, the physician's orders were not followed. A review of the facility policy titled, oxygen administration documented in part, 1. Oxygen is administered to the resident only upon written order of a licensed physician. On 04/04/19 at approximately 4:52 p.m., ASM (administrative staff member) # 1, the administrator, was made aware of the findings. No further information was provided prior to exit. Reference: 1. An infection in one or both of the lungs. Many germs, such as bacteria, viruses, and fungi, can cause pneumonia. You can also get pneumonia by inhaling a liquid or chemical. This information was obtained from the website: https://medlineplus.gov/pneumonia.html. 2. Disease that makes it difficult to breath that can lead to shortness of breath). The two main types are chronic bronchitis and emphysema. The main cause of COPD is long-term exposure to substances that irritate and damage the lungs. This is usually cigarette smoke. Air pollution, chemical fumes, or dust can also cause it. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. 3. A condition in which not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html. 4. Deficiency of oxygen reaching the tissues of the body. This information was obtained from the website: https://www.merriam-webster.com/dictionary/hypoxia. 5. A bluish color to the skin or mucous membrane is usually due to a lack of oxygen in the blood. The medical term is cyanosis. https://medlineplus.gov/ency/article/003215.htm 6. Breathing - rapid and shallow; Fast shallow breathing. https://medlineplus.gov/ency/article/007198.htm - Medical Encyclopedia 7. When you're short of breath, it's hard or uncomfortable for you to take in the oxygen your body needs. You may feel as if you're not getting enough air. Sometimes you can have mild breathing problems because of a stuffy nose or intense exercise. But shortness of breath can also be a sign of a serious disease. This information was obtained from the website: https://medlineplus.gov/breathingproblems.html. 8. Most people need an oxygen saturation level of at least 89% to keep their cells healthy. Having an oxygen level lower than this for a short time is not believed to cause damage. However, your cells can be strained or damaged if low oxygen levels happen many times. If your oxygen level is low on room air, you may be asked to use supplemental (extra) oxygen. The oximeter can be used to help see how much oxygen you need and when you may need it. This information was obtained from the website: file:///C:/Users/mth39879/Downloads/pulse-oximetry.pdf

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure one resident (Resident #45) of 47 sampled residents were free of unnecessary psychotropic medications. The facility staff restarted an antipsychotic medication without proper indications for Resident #45. The findings included: Resident #45 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: anxiety disorder, dementia, and high blood pressure. The most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 2/15/19, coded the resident as scoring a 6 on the BIMS (brief interview for mental status) score, indicating she was severely impaired to make daily cognitive decisions. The resident was coded as having disorganized thinking and physical behavior directed towards others on one-three days of the look back period. Resident #45 was coded as requiring extensive assistance of one or more staff members for most of her activities of daily living. In Section N - Medications, the resident was coded as receiving seven days of an antipsychotic and an antidepressant. The pharmacy Consultant Report dated, 9/13/18 documented in part, DC (discontinue) Seroquel [an antipsychotic medication used to treat schizophrenia, bipolar depression and in conjunction with other medication for depression) (1). Lexapro (used to treat depression and general anxiety disorder (2)] 5 mg (milligrams) daily. A physician telephone order dated, 12/8/18, documented, Seroquel 25 mg, amt (amount) 0.5 (half a tablet) tab (tablet) daily. This order was received by LPN (licensed practical nurse) #10. The physician progress note dated, 12/5/18, documented in part, a/p (approach/plan) - 4. dementia w/ (with) behaviors - severe - on Seroquel .6. Anxiety - on Lexapro. The physician progress note dated, 2/1/19, documented in part, a/p - 4. dementia w/ behaviors - severe - on Seroquel .6. Anxiety - on Lexapro. Review of the physician order summaries for October and November 2018 failed to evidence a physician order for Seroquel. The nurse's notes for September 2018 were reviewed. The following was documented: 9/1/18 at 6:49 a.m. - No behavior issues noted at this time: 9/2/18 at 11:02 a.m. - No behavior issues noted at this time: 9/4/18 at 6:34 a.m. - No behavior issues noted at this time: 9/4/18 at 12:56 p.m. - No behavior issues noted at this time: 9/5/18 at 6:00 a.m. - No behavior issues noted at this time: 9/6/18 at 6:19 a.m. - No behavior issues noted at this time: 9/6/18 at 1:28 p.m. - No behavior issues noted at this time: 9/7/18 ar 12:52 p.m. - No behavior issues noted at this time: 9/9/18 at 5:51 a.m. -No behavior issues noted at this time: 9/10/18 at 6:28 a.m. - No behavior issues noted at this time: 9/10/18 at 12:36 p.m. - No behavior issues noted at this time: 9/11/18 at 12:46 p.m. - No behavior issues noted at this time: 9/12/18 at 8:00 a.m. - No behavior issues noted at this time: 9/12/18 at 1:45 p.m. - No behavior issues noted at this time: 9/13/18 at 1:11 p.m. - No behavior issues noted at this time: 9/14/18 at 7:34 a.m. - No behavior issues noted at this time: 9/15/18 at 5:43 a.m. - No behavior issues noted at this time: 9/16/18 at 2:32 p.m. - No behavior issues noted at this time: 9/17/18 at 1:20 p.m. - No behavior issues noted at this time: 9/18/18 at 3:03 p.m. - No behavior issues noted at this time: 9/19/19 at 8:46 a.m. - No behavior issues noted at this time: 9/20/19 at 2:15 p.m. - No behavior issues noted at this time: 9/21/18 at 11:41 a.m. - No behavior issues noted at this time: 9/23/18 at 5:50 a.m. - No behavior issues noted at this time: 9/24/18 at 6:17 a.m. - No behavior issues noted at this time: 9/24/18 at 2:01 p.m. - No behavior issues noted at this time: 9/24/18 at 2:49 p.m. - New order noted by (name of doctor) to DC Seroquel and decrease Lexapro to 5 mg daily at this time. 9/27/18 at 2:26 p.m. - No behavior issues noted at this time: 9/28/18 at 6:23 a.m. - No behavior issues noted at this time: The October nurse's notes documented the following: 10/1/18 at 3:04 p.m. - resident combative towards aides during continence care, one on one given by writer and resident accepted. No further behavior issues noted at this time. 10/2/18 at 8:44 a.m. - No behavior issues noted at this time: 10/2/18 at 12:23 p.m. - No behavior issues noted at this time: 10/3/18 at 6:21 a.m. - No behavior issues noted at this time: 10/4/18 at 9:37 a.m. - No behavior issues noted through the night 10/4/18 at 12:26 p.m. - No behavior issues noted at this time: 10/5/18 at 4:28 a.m. - No behavior issues noted at this time: 10/7/18 at 12:07 p.m. - No behavior issues noted at this time: 10/8/18 at 6:54 a.m. - No behavior issues noted at this time: 10/8/18 at 3:32p.m. - No behavior issues noted throughout day shift. 10/9/18 at 12:35 p.m. - No behavior issues noted at this time: 10/11/18 at 2:33 p.m. - No behavior issues noted at this time: 10/13/18 at 6:03 a.m. - No behavior issues noted at this time: 10/16/18 at 7:01 a.m. - No behavior issues noted at this time: 10/16/18 at 8:27 a.m. - Res (resident) noted confused, thinks she is at home, 1:1 (one to one) given without effect. 10/17/18 at 6:13 a.m. - No behavior issues noted at this time: 10/18/18 at 8:02 a.m. - No behavior issues noted through the night 10/21/18 at 10:57 a.m. - Resident noted with confusion still this shift continually asking for help and having to be redirected multiple times which was noted somewhat effective altering behavior. 10/21/18 at 9:30 p.m. - Resident noted with increased confusion this shift aeb (as exhibited by) multiple attempts to exits seeking trying to find 'the care outside,' 1:1 rendered somewhat effective in altering behaviors. 10/23/18 at 3:12 p.m. - No behavior issues noted. 10/24/18 at 5:43 a.m. - No behavior issues noted at this time: 10/24/18 at 4:28 p.m. - No behavior issues noted throughout day shift. 10/25/18 at 7:44 a.m. - No behavior issues noted at this time: 10/25/18 at 3:06 p.m. - No behavior issues noted throughout day shift 10/26/18 at 5:30 a.m. - No behavior issues noted at this time: 10/27/18 at 5:37 a.m. - No behavior issues noted at this time: 10/27/18 at 12:59 p.m. - No behavior issues noted at this time: 10/28/18 at 2:24 p.m. - No behavior issues noted at this time: 10/29/18 at 11:40 a.m. - No behavior issues noted at this time: 10/30/18 at 6:49 a.m. - No behavior issues noted at this time: 10/30/18 at 10:33 a.m. - Resident resistive & (and) combative during am (morning) care, writer given one to one encouragement and resident accepted redirection easily No further behavior issues noted at this time. 10/31/18 at 7:23 a.m. - No behavior issues noted through the night The November nurses notes documented the following: 11/1/18 at 5:25 a.m. - Res with increased confusion, thinking she was at home, noted awake most of the shift talking outloud (sic). 11/1/18 at 2:39 p.m. - No behavior issues noted at this time: 11/2/18 at 6:08 a.m. - No behavior issues noted at this time: 11/4/18 at 6:10 a.m. - No behavior issues noted this shift 11/5/18 at 10:16 a.m. - No behavior issues noted through the night 11/6/18 at 4:25 p.m. - No behavior issues noted throughout day shift 11/8/18 at 6:40 a.m. - No behavior issues noted at this time: 11/10/18 at 5:50 a.m. - No behavior issues noted at this time: 11/13/18 at 6:35 a.m. - No behavior issues noted at this time: 11/15/18 at 6:01 a.m. - No behavior issues noted at this time: 11/19/18 at 6:58 a.m. - No behavior issues noted at this time: 11/19/18 at 10:42 a.m. - resident combative during adl (activities of daily living), one on one given and resident accepted redirection, no further behavior issues noted at this time. 11/21/18 at 5:59 a.m. - No behavior issues noted at this time: 11/22/18 at 6:04 a.m. - No behavior issues noted at this time: 11/24/18 at 6:07 a.m. - No behavior issues noted at this time: 11/27/18 at 6:47 a.m. - No behavior issues noted at this time: 11/28/18 at 7:37 a.m. - No behavior issues noted at this time: 11/30/18 at 5:36 a.m. - No behavior issues noted at this time: 11/30/18 at 5:46 p.m. - Often times, resident requests staff to call daughters and husband to come take her home. The December 2018 nurse's notes documented the following: 12/2/18 at 6:10 a.m. - No behavior issues noted at this time: 12/2/18 at 8:04 a.m. - Res refused nail care. 12/5/18 at 8:42 a.m. - No behavior issues noted through the night 12/6/18 at 7:28 a.m. - No behavior issues noted at this time: 12/7/18 at 8:23 a.m. - No behavior issues noted through the night 12/8/18 at 2:41 a.m. - Res awake at beginning of shift, noted with increased confusion, stating 'I need to call my husband and let him know where I am,' 1:1 given with positive effect. 12/8/18 at 6:10 a.m. - Res awake all shift talking outloud (sic) to self. Res up in dayroom at this time, stating 'I have to go home,' 1:1 ineffective. There were no further notes for 12/8/18. The next note related to behavior was on 12/12/18 at 8:17 a.m. - No behavior issues noted through the night. The comprehensive care plan dated, 11/19/18, documented in part, Problem: Anxiety, received psychotropic daily. Seroquel d/c during review for GDR (gradual dose reduction); mood appears to remain stable most times. Can be combative and curse staff at times when performing care, continues to sleep in chair while up and doesn't like to be bothered likely associated with advancing dementia. Melatonin added for insomnia. Added on 12/8/18, Seroquel per orders d/t (due to) increased agitation. The Approaches documented in part, Attempt gradual dose reduction. monitor and record (Resident #45)'s behavior when combative to determine the need for medication adjustments. Monitor (Resident #45) for increased anxiety during care and attempt to redirect behavior by talking to her, providing music or leaving her alone and coming back later to try again. Offer snack before bedtime or when resident awakens during night. Provide comfortable environment to promote sleep (e.g., clean bedding, comfortable bed clothing, incontinence care, comfortable temperature, ventilation). When resident awakens during the night, provide comfort measures (e.g., back rub, repositioning, incontinence care, snack). An interview was conducted with administrative staff member (ASM) # 4, the attending physician, on 4/5/19 at 11:52 a.m. The pharmacy consultant report of 9/13/18 was reviewed with ASM #4. The new physician order dated 12/8/18 was reviewed with ASM #4. ASM #4 was asked to review the nurse's notes of 12/8/18. When asked where about the location of his documentation regarding the reason why the Seroquel was restarted on 12/8/18, ASM #4 reviewed his progress notes and stated, I don't see any documentation as to why it was restarted. It had to be some reason, that's an omission on my part, it should be documented. An interview was conducted with RN (registered nurse) #3 on 4/5/18 at 12:16 p.m. When asked why Resident #45 was restarted on the Seroquel on 12/8/18, RN #3 stated, I know there was a note on `12/8/18 that she had behaviors. When asked if the resident had two documented behaviors in one shift, is that a reason to restart the Seroquel, RN #3 did not respond. A second interview was conducted with ASM #4 on 4/5/18 at 12:36 p.m. When asked if one episode of behavior on one shift was an appropriate reason to restart the Seroquel, ASM #4 stated, I would say no. When asked if the documentation revealed that she was a danger to herself or others, ASM #4 stated, No. It's my bad because I didn't document why it was restarted and if the behaviors were that bad, I would have expected the nurse to write a more descriptive note. An interview was conducted with ASM #2, the director of nursing; on 4/5/18 at 12:44 p.m., ASM #2 was asked to review the nurse's notes of 12/8/18. Once reviewed, ASM #2 was asked if the behaviors documented on the one shift on 12/8/18 would be reason to restart Seroquel, ASM #2 stated, No, I don't think so. ASM #2 was asked if the LPN who wrote the order for Seroquel was available for interview, ASM #2 stated that the employee was no longer employed at the facility. The facility policy, Psychotropic Drugs documented in part, Standard: The facility will develop and maintain a system for assuring proper use and monitoring of psychoactive agents. Psychoactive agents can only be used on receipt of physician's order to eliminate or reduce identified behavioral symptoms or to treat a specific diagnosis Procedure: 1. Initiation of Psychoactive drug therapy: a. The resident's chart must contain an appropriate diagnosis for the use and the diagnosis should also be entered onto the Physician's Order Sheet and on the Medication Administration Record. b. Non-Drug interventions have been attempted and documented as ineffective .2. Monitoring Routine Use of Psychoactive Drugs: 2. Define and document specific behavioral problems within the nursing notes. 3. Set reasonable and measurable objectives and reflect this in the resident's care plan .5. Charting of occurrence will be reflected as follows: Each occurrence, or lack of occurrence, will be noted for each day and shift. 6. Physician will routinely comment on progress of resident in medical progress notes. ASM (administrative staff member) #1, the administrator and ASM #3, the vice president of clinical services were made aware of the above concern on 4/5/19 at 1:45 p.m. (1) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a698019.html (2) This information was obtained from the following website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=lexapro

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff popped Resident #23's pills into a gloved hand that had just touched the medication cart and then administered the medication to Resident #23. Resident #23 was admitted to the facility on [DATE] with the diagnoses of but not limited to chronic obstructive pulmonary disease (1), high blood pressure, solidary pulmonary nodule (2) and gastro-esophageal reflux disease. Resident #23's Minimum Data Set (MDS) was an admission assessment with an Assessment Reference Date (ARD) of 1/11/19, coded Resident #23 as having no cognitive impairment in his ability to make daily life decisions. On 4/3/19 at 8:21 to 8:40 a.m., an observation of medication administration was observed. LPN (Licensed Practical Nurse) #2 was observed administering medications during this time to Resident #23. On 4/3/19 at 8:21 a.m., LPN #2 was observed washing her hands, opening the medication cart with her keys, and then putting gloves on her hands. LPN #2 then opened the medication cart drawer with her gloved hand. LPN #2 pulled out one of Resident #23's medication packets and pop the pill into her gloved hand and then place the pill into the medication cup. LPN #2 was observed pulling out another one of Resident #23's medication packets popping the pill into her gloved hand and then placing the pill into the medication cup. LPN #2 pulled out another one of Resident #23's medication packets, popped the pill into her gloved hand, and then place the pill into the medication cup. LPN #2 then locked the medication cart with her gloved hand, picked up the medication cup with her gloved hand and handed the cup to Resident #23. On 4/4/19 at 12:38 p.m., an interview was conducted with LPN (Licensed Practical Nurse) #2 regarding the process of infection control for medication administration. When asked about the process, LPN #2stated, I washed my hands first, sang the birthday song, and put on gloves. I administered his (Resident #23) meds (medications) per order. I opened the cart without having gloves on. I took out the bubble packs and removed the meds over a cup with the same gloves on as I identified the meds. One pill fell onto the cart and I disposed of it and got a new pill. When asked if any of the medications were placed into her gloved hand and then placed into the cup, LPN #2 stated, No. When LPN #2 was asked if she was adhering to infection control measures, she stated, I probably wasn't. No ma'am, I wasn't. When LPN #2 was asked what the issues with infection control during her medication administration were, LPN #2 stated, The issues were when I opened the cart drawer and the pill packets with the same gloves on. A review of the facility's policy Handwashing documented in part, To provide guidelines to employees for proper and appropriate handwashing that will aid in the prevention of infection. A review of the facility's policy Administration of Medications documented in part, All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in diagnosis .Wash hands before and after each administration of medication or hand sanitizer as appropriate. On 4/4/19 at 4:15 PM, ASM (Administrated Staff Member) #1, the administrator and ASM #2, the DON (Director of Nursing) were made aware of the findings. No further information was provided by the end of the survey. (1) Chronic Obstructive Pulmonary Disease makes it hard for you to breathe. The two main types are chronic bronchitis and emphysema. The main cause of COPD is long-term exposure to substances that irritate and damage the lungs. This is usually cigarette smoke. Air pollution, chemical fumes, or dust can also cause it. This information was obtained from the website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=copd&_ga=2.160000441.566140716.1522143307-139120270.1477942321 (2) Solidary Pulmonary Nodule: is an isolated, single lesion in a round or oval shape with a diameter of ?3 cm (centimeters) in lung parenchyma (the portion of the lung involved in gas transfer), surrounded entirely by gas-containing lung tissue. This information was obtained from the website: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3886703/ 3. The facility staff failed to serve food to the residents in a sanitary manner during a dining room observation. Staff were observed touching the food surface of plates that were then served to residents. On 4/2/19 between 12:12 and 1:15 p.m., an observation of the main dining room was conducted. OSM (Other Staff Member) #2 was observed lifting a packet of bread, and a butter packet, then placed them onto her left arm. OSM #2 then lifted a bowl of vegetables with her thumb above the top of the rim of the bowl and when she placed the bowl on the table, she touched the top of the rim of the bowl with her thumb. On 4/2/19 at 1:10 p.m., OSM #3 was observed bringing a saucer with grilled cheese sandwich to a resident and had her thumb on top of the rim of the saucer. OSM #3 then touched the top of the rim of the desert saucer as she was removing the wrapping and placed the desert saucer on the table. On 4/4/19 at 8:17 a.m., an interview was conducted with CNA #1. When CNA #1 was asked to demonstrate how to serve resident's plates, she demonstrated lifting the plate from the bottom. When CNA #1 was asked to demonstrate how to remove plastic wrap from a plate, she demonstrated removing the plastic wrap and then placed her thumb on the edge of the top of the rim of the plate. When CNA #1 was asked where she placed her thumb, she stated It was on the side. When the surveyor pointed out to CNA #1 that her thumb was on the edge of the top of the rim of the plate, CNA #1 stated, It should not be there. Your hands should not be where the resident's food is at. When CNA #1 was asked why bare fingers or thumbs should not touch the top of the rim of the plates, CNA #1 stated, Infection. You don't want your hands to touch their food. We had two meetings for the dining room to serve food in a more restaurant style and how to hold the plates. A review of the facility's policy Handwashing documented in part, To provide guidelines to employees for proper and appropriate handwashing that will aid in the prevention of infection. On 4/4/19 at 4:15 PM, ASM (Administrated Staff Member) #1, the administrator and ASM #2, the DON (Director of Nursing) were made aware of the findings. No further information was provided by the end of the survey. In Fundamentals of Nursing, [NAME] and [NAME] 2007 page 140-143 The hands are conduits for almost every transfer of potential pathogens from one patient to another, from a contaminated object to the patient, or from a staff member to the patient. Hand hygiene is the single most important procedure in preventing infection typically hands are washed with soap before coming on duty; before and after direct or indirect patient contact; .before preparing or administering medications Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to follow infection control practices for one of 47 residents in the survey sample and for one of six residents in the medication administration observation, (Resident #23), and in one of one facility dining rooms, (main dining room). 1. The facility staff failed to follow infection control practices during a wound are observation for Resident # 34. 2. The facility staff popped Resident #23's pills into a gloved hand that had just touched the medication cart and then administered the medication to Resident #23. 3. The facility staff failed to serve food to the residents in a sanitary manner during a dining room observation. Staff were observed touching the food surface of plates that were then served to residents. The findings include: 1. The facility staff failed to follow infection control practices during a wound care observation for Resident # 34. Resident # 34 was admitted to the facility on [DATE] with diagnoses that included but were not limited to respiratory failure, diabetes mellitus [a complex and chronic disorder of metabolism due either to partial or total lack of insulin secretion by the pancreas (1)], chronic kidney disease requiring hemodialysis [a procedure used in toxic conditions and renal [kidney] failure, in which wastes and impurities are removed from the blood by a special machine (2)], and depression. The most recent MDS (minimum data set) assessment, a Medicare 14 day assessment, with an assessment reference date of 3/23/19, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating she was cognitively intact to make daily cognitive decisions. Resident #34 was coded as requiring extensive assistance of one staff member for most of her activities of daily living. Observation was made on 4/5/19 at 7:50 a.m. of Resident #34's skin, accompanied by RN (registered nurse) #1. RN #1 proceeded to gather her supplies to take in the room. RN #1 was observed taking her computer into the resident's room and placing it on a stack of the resident belongings in the resident's chair. She also brought in a box of wound measuring plastic sheets and placed the box on the resident's bed, on top of the sheets. The resident's sheet and blanket were pulled back to the footboard of the bed. RN #1 took the box of wound measuring plastic sheets and placed them on the folded back sheets, placing it in the inside of the resident's bed. The observation was completed with no observed concerns with the resident's skin. Resident #34 asked RN #1 to put her blankets in her bag that she takes to dialysis. RN #1 picked up her computer and placed it on the resident's bed. Then proceeded to put the blankets in the bag as requested. RN #1 then washed her hands. She then picked up her computer and the box of wound measuring plastic sheets and placed them on top of the treatment cart outside the resident's room. RN #1 then used hand sanitizer and walked away from the treatment cart. An interview was conducted with RN #1 on 4/5/19 at 8:00 a.m. RN #1 was asked if it is acceptable to bring the computer into a residents room, place it on a resident's personal belongings, and then place it on the resident's bed. RN #1 stated, I guess not. When asked why the staff should not put the computer on someone's belongings or bed, RN #1 stated, I guess for infection control reasons. RN #1 was informed of the above observation of the wound measuring sheets on the resident's bed linens. When asked if this was following infection control practices, RN #1 stated, No, I guess not. I will have to throw out the whole box. An interview was conducted with administrative staff member (ASM) #2, the director of nursing, on 4/5/19 at 10:35 a.m. When asked if it is appropriate to take the computer, used on the treatment and medication administration carts, into the resident's room to do wound care, ASM #2 stated, No, they are to be left on the treatment cart. When asked if the computer should be placed on the resident's personal belongings and on the bed, ASM #2 stated, It shouldn't be in the room at all. ASM #2 was made aware of the above concern at this time. On 4/5/19 at 1:00 p.m., a request was made of ASM #3, the vice president of clinical services, for a policy related to taking equipment used throughout the facility into a resident's room and placing the equipment on a resident's personal belongings and the bed. At 3:13 p.m. ASM #3 stated the facility did not have a policy on the request made and stated, It's normal practice not to take that into the room when performing treatments. No further information was obtained prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 163. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 266.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility documentation review, it was determined that the facility staff failed to serve food in a dignified manner in two of one facility dining rooms, (main dinning room); and for three of 45 sampled residents, (Resident #501, #39 and #50). 1. During a meal observation in the main facility dining room on 4/2/19 residents were observed being served and eating the lunch meal on trays cafeteria style and not in a homelike dining manner. 2. The facility staff failed to ensure a dignified dining experience during the lunch meal on 4/2/19. Resident #501 was observed seated at a table waiting approximately eleven minutes for her lunch meal to be served, while her tablemate's and other residents were eating their lunch meal. 3. During a meal observation in the assisted dining room on 4/2/19, Resident #39, was not provided her meal and fed by CNA #7 (Certified Nursing Assistant) until 12:55 p.m., approximately 15 minutes after her tablemate began eating his meal. Resident #50's tablemate finished eating at 1:04 p.m., and approximately 31 minutes elapsed before staff attempted to feed Resident #50. Staff feeding residents were observed talking amongst themselves and not interacting with the residents they were assisting. The findings include: 1. On 4/2/19 at approximately 12:39 p.m., an observation was made of the first floor's main dining room. Eight residents sitting around four different tables located near the left side of the dining room were served their meals on plates placed on cafeteria style trays by OSM (other staff member) # 3. She then placed the trays on the table without removing the plates, cups, and utensils from the trays. The residents then ate their food from the trays cafeteria style and not in a homelike dining manner. Two out of eight resident had a BIMS (brief interview for mental status) score of 13 out of 15, 13 indicating that they were cognitively intact for daily decision making. These two residents didn't mind having their food served on the tray. However six of eight resident that were cognitively impaired (they were not interviewable) for daily decision making were not served in a dignified manner. On 04/04/19 8:17 a.m., an interview was conducted with CNA # 1. When asked about the process of serving food to the residents, CNA # 1 stated, We serve the resident from the big tray cart. Remove the plates from the tray before placing the food plate on the table in front of the residents. Each resident is served individually by their ticket number. When asked if residents should be served their food on food trays which are kept there throughout their dining experience, CNA # 1 stated, They shouldn't be served their food on the trays. We are supposed to remove the plates from the tray and place them on the table. When asked what should have been done, CNA # 1 stated, We received training from name of OSM [other staff member # 1, the facility dietary manager] how to serve all residents even if they are assisted dinners. On 4/4/19 at 03:19 p.m., an interview was conducted with OSM # 1, regarding the observations above. When asked if residents eating in the dining room should be served their food on the cafeteria style food trays, OSM # 1 stated, No, you are right, all residents should be served in the same manner, and food should be off the tray before serving it to the residents. When asked why this should have been done, OSM # 1 stated, We are working on providing residents a fine dining experience as all other residents. A review of the facility's policy on Privacy-Dignity documented as followed: 1. All residents shall be treated with dignity and respect at all times. 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. On 04/03/19 at approximately 6:01 p.m., ASM (administrative staff member) # 1, the administrator, ASM # 2, director of nursing, and ASM # 3, regional vice president of clinical services, were made aware of the findings. No further information was provided prior to exit. 2. The facility staff failed to ensure a dignified dining experience during the lunch meal on 4/2/19. Resident #501 was observed seated at a table waiting approximately eleven minutes for her lunch meal to be served, while her tablemate's and other residents were eating their lunch meal. Resident #501 was admitted to the facility on [DATE] with the diagnoses of but not limited to metabolic encephalopathy (1), Type 2 Diabetes Mellitus, high blood pressure, legal blindness, gastro-esophageal reflux disease, and osteoarthritis. Resident #501 Minimum Data Set (MDS) was an admission assessment with an Assessment Reference Date (ARD) of 12/26/18, coded Resident #501 as moderately cognitively impaired in her ability to make daily life decisions. The resident was coded as requiring setup assistance for eating. On 4/2/19 between 12:33 to 1:15 p.m., an observation was made of the main dining room. One resident, Resident #501 was sitting at a table with three other residents. On 4/2/19 at 1:06 p.m., it was observed that two people at the table with Resident #501 were served their food. At that time another resident was brought into the dining room and seated at another table behind the table Resident #501 was sitting at. The new resident received her food. On 4/2/19 at 1:14 p.m., it was observed the third resident at the table with Resident #501 was served their food. Another resident was brought into the dining room and seated at another table behind the table Resident #501 was sitting at. The new resident received her food. On 4/2/19 at 1:15 p.m., Resident #501 received her food. On 4/4/19, multiple attempts were made to interview Resident #501. However, Resident #501 was not available. On 4/4/19 at 8:17 a.m., an interview was conducted with CNA (certified nursing assistant) #1 regarding the process for serving residents seated at the same table, CNA #1 stated, You don't serve the food until the entire table's food is ready. When CNA #1 was asked if some of the residents at a table were served their food and some had not would you serve food to another table, CNA #1 stated, You should not serve the food until all are there and you should not have served another table until all are served at the first table. A review of the facility's policy Privacy - Dignity documented in part, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality .1. Residents shall be treated with dignity .at all times. 2. 'Treated with dignity' means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. On 4/4/19 at 4:15 p.m., ASM (Administrated Staff Member) #1, the administrator and ASM #2, the DON (Director of Nursing) were made aware of the findings. No further information was provided by the end of the survey. (1) Metabolic encephalopathy: Encephalopathy is a term for any diffuse disease of the brain that alters brain function or structure. This information was retrieved from https://www.ninds.nih.gov/Disorders/All-Disorders/Encephalopathy-Information-Page 3. During a meal observation in the assisted dining room on 4/2/19, Resident #39, was not provided her meal and fed by CNA #7 (Certified Nursing Assistant) until 12:55 p.m., approximately 15 minutes after her tablemate began eating his meal. Resident #50's tablemate finished eating at 1:04 p.m., and approximately 31 minutes elapsed before staff attempted to feed Resident #50. Staff feeding residents were observed talking amongst themselves and not interacting with the residents they were assisting. Resident #39 was admitted to the facility on [DATE] with the diagnoses of but not limited to dementia, high blood pressure, bipolar disorder, depression, and anxiety disorder. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 2/1/19. The resident was coded as severely cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for all areas of activities of daily living. Resident #50 was admitted to the facility on [DATE] with the diagnoses of but not limited to stroke, skin cancer, cardiomyopathy, dementia, congestive heart failure, glaucoma, atrial fibrillation, acute kidney failure, aphasia, and degenerative disease of the nervous system. The most recent MDS (Minimum Data Set) was an annual assessment with an ARD (Assessment Reference Date) of 2/5/19. The resident was coded as being severely impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing, hygiene, toileting, eating, dressing, and transfers. On 4/2/19 from 12:15 p.m. to 1:40 p.m., an observation was made of the assisted care dining room. At 12:30 p.m., a resident was observed being brought into the dining room by staff and seated at table 6 by himself. At 12:33 p.m., Resident #39 was brought into the dining room and seated at table 5. At 12:34 p.m., another resident was observed being brought into the dining room by staff and placed at table 5 with Resident #39. At 12:38 p.m., staff was observed brining Resident #50 into the dining room and placing the resident at table 4. At 12:40 p.m., another resident was brought in by staff and seated at table 4 with Resident #50. At table 5, the resident brought in at 12:34 p.m., was provided his tray at 12:40 p.m. Resident #39, who arrived to the dining room at 12:33 p.m., was not provided her meal and fed by CNA #7 (Certified Nursing Assistant) until 12:55 p.m This was approximately 15 minutes after her tablemate began eating his meal. At table 4, the resident seated at the table with Resident #50, was provided her meal at 12:44 p.m., and CNA (certified nursing assistant) #6 sat down to feed her. This resident was done with her meal at 1:04 p.m. CNA #6 then went to table 6 and began feeding the resident seated there at 1:05 p.m. The staff did not attempt to feed Resident #50 at this time. At 1:35 p.m., approximately 57 minutes after being brought to the dining room and approximately 31 minutes after her tablemate finished eating; CNA #7 was observed attempting to feed Resident #50. At this time, Resident #50 was observed in a deep sleep and was not aroused to by CNA #7 to be fed. CNA #7 closed Resident #50's uneaten tray, and was observed taking Resident #50 and the resident's meal tray out of the dining room. This was resident observed awake at times early during dining and could have been fed by a separate staff member while her tablemate was being fed. At 1:05 p.m., LPN #7 (Licensed Practical Nurse), the MDS nurse, came into the dining room and sat down in a chair near the window next to table 6 where a resident was being fed by CNA #6. LPN #7 sat there for the remainder of the lunch service (until at least 12:40 p.m.), talking to the staff who were feeding residents, and was not doing anything to assist residents who still needed to be fed. CNA #6 and CNA #7 were engaged in talking to LPN #7 and observed having minimal interaction with the residents they were feeding. On 4/3/19 at 11:07 a.m., an interview with LPN #7, she stated that she was there to monitor for choking. When informed it was noted that the residents who were in the dining room for supervision only were all seated on the opposite side of the dining room from where LPN #7 was sitting, LPN #7 had no comment. When asked if she, as an LPN was trained and able to assist with feeding residents, LPN #7 stated she could have. LPN #7 further stated, We need to be more mindful in how we place the residents at the tables, who needs to be fed and who is just supervision. Both residents at a given table should be fed at the same time. When asked about engaging the staff who were feeding residents in unrelated conversation rather than the staff engaging with the residents, LPN #7 stated she did not realize she was doing that. On 4/3/19 at 10:47 a.m., in an interview with CNA #7, she stated that residents at the same table should be fed at the same time, that it is a dignity issue. CAN #7 further stated that staff should be interacting with the residents and not each other; and that staff who are not assisting should not be hanging out in the dining room during the meal. On 4/4/19 at 8:24 a.m., in an interview with CNA #1, she stated that all the residents at the table should be served at the same time. CNA #1 stated that if there are two people at a table that require feeding, the residents should be fed at the same time by two different staff. CNA #1 stated that if one resident at the table eats independently or requires supervision only, and the other resident at the table requires feeding by staff, that staff should feed the resident that requires feeding at the same time the independent eater gets their meal. After feeding one at the table, then staff should feed the next one at the same table if no one else was available to feed them at the same time, before moving to another table. CNA #1 stated you should concentrate on the resident being fed and interact with them, not the other staff in the dining room. On 4/5/19 at 9:47 a.m., in an interview with CNA #6, when asked about the observation of feeding the resident seated at table 5 with Resident #50 and then leaving the table to feed the resident at table 6 without attempting to feed Resident #50, CNA #6 stated, That was wrong, I should have done the same table. I feel there should be 2 staff feeding both residents at the same time. CNA #6 further stated that if there is a table where one resident eats independently and one requires staff to feed them, the resident requiring staff to feed them should be fed at the same time as the independent eater. CNA #6 stated, There should be someone there to help her at the same time at the same table. It is a dignity and respect issue for the resident. When asked about interacting with other staff and not the residents being assisted with the meal, CNA #6 stated, Interacting with staff during resident meal, instead of the resident is not treating the resident with dignity. On 4/4/19 at 4:30 p.m., ASM #1 and ASM #2 (Administrative Staff Member - the Administrator and Director of Nursing, respectively) were made aware of the findings. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to implement the abuse policies for reporting allegations of abuse for four of 47 residents in the survey sample, Residents #63, #146, #53 and #16. 1. The facility staff failed to implement their policies for reporting Resident #63's allegation of abuse within 2 hours to the state agency and other required agencies. On 12/28/18, Resident #63 informed the facility staff of the allegation of abuse, and the facility staff failed to report the allegation to the state agency until 1/2/19. 2. The facility staff failed to implement their abuse policies and procedures for a resident-to-resident incident between Resident #146 and Resident #53. The facility staff submitted a FRI (facility reported incident) on 10/26/19 for the incident but failed to conduct an investigation and failed to submit a final report to the State Agency within five working days. 3. The facility staff failed to implement the policies for immediately reporting an allegation abuse to the administrator for Resident #16 that occurred on 10/21/18. An employee did not report the allegation to the administrator until 10/29/18, eight days after incident occurred. The findings include: 1. The facility staff failed to implement their policies for reporting Resident #63's allegation of abuse within 2 hours to the state agency and other required agencies. On 12/28/18, Resident #63 informed the facility staff of the allegation of abuse, and the facility staff failed to report the allegation to the state agency until 1/2/19. Resident #63 was admitted to the facility to the facility on 1/12/18, with a recent readmission on [DATE] with diagnoses that included but were not limited to: morbid obesity, diabetes, high blood pressure, and congestive heart failure [abnormal condition characterized by circulatory congestion and retention of salt and water by the kidneys (1)]. The most recent MDS (minimum data set) assessment, a Medicare 30 day assessment, with an assessment reference date of 3/1/19, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact to make daily decisions. Resident #63 was coded as having rejected care daily during the look back period. The resident was coded as requiring extensive assistance of two staff members for most of her activities of daily living, including transfers. The resident was coded as being able to feed herself once set up assistance was provided. A Facility Reported Incident (FRI) dated 1/2/19, documented, Report date: 1/2/19. Incident Date 12/12/18. The report further documented, Resident noted on 12/12/18 to have a fall. On 12/28/18, Resident reported to have arm and wrist pain and stated that the injury occurred when resident was helped up off of floor. Investigation initiated. The name of an employee was documented under Name of Employee involved. The Final Report dated, 1/7/19, documented, On 1/2/19 you were contacted regarding an injury for Resident (#63). Resident reported that she did not injure her left arm when she fell but that the nurse (LPN - licensed practical nurse- #11) pulled on her arm to get her off the floor. This nurse was not informed of this until 12/28/18 when the resident came to express her concern. Under, If applicable, date notification provided to: Responsible party - 12/12/2018; Physician - 12/12/18. There was no documented notification to APS (adult protective services), DHP (department of health professionals) or Law Enforcement. This FRI was completed by ASM #2. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, the one who completed the FRI reporting, on 4/4/19 at 3:33 p.m. When asked why she waited to report the FRI on 1/2/19 when she had knowledge of the allegation on 12/28/18, ASM #2 stated, At my last facility, I thought we had five days to get it in. Since then I've been told the requirements for reporting within two hours. ASM #2 was asked about the requirements for reporting suspected abuse, neglect or misappropriation of resident property according to the facility policy, ASM #2 stated, We need to send it to the ombudsman, (state agency), department of social services and depending on the outcome, to the board of nursing. When asked who is responsible for reporting to the state agency, ASM #2 stated, Either (Name of administrator) or myself. If we are not here, the nurse on the floor is responsible to send it in the two hour time frame. An interview was conducted with ASM #1, the administrator, on 4/4/19 at 3:45 p.m. When asked about the process for reporting allegations of abuse or mistreatment, ASM #1 stated as soon as it is reported to any staff in the building, it is to be reported to myself or (Name of ASM #2). Once we determine that it should be reported we have a two-hour window. If it's involving a staff member, it should be reported to all entities. For the final report, I have five working days to get it completed. When asked if an action plan was initiated for this, ASM #1 stated, No, I gave (ASM #2) a copy of the fax cover sheets for all four entities so she would have them for future use. She and I talked about the two hour window. The facility policy, Abuse documented in part, 4. Identification: b. Staff are encouraged to identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. Immediately following ensuring the resident's safety, staff are to report any allegation or observation of abuse to their supervisor, director of nursing, administrator or facility leadership member .5. Investigation: Designated staff will immediately review and investigate all allegations or observations of abuse. a. The results of all investigation are to be communicated to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 2 hours of the incident, and if the alleged violation is verified, appropriate corrective action must be taken. 6. Protection: a. In the event of an allegation or observation of abuse, the facility will immediately assess the resident, notify the physician and resident representative and protect the resident and other residents from further harm or incident. d. When specific staff is identified as being allegedly involved in the abuse allegation, the staff may be re-assigned or suspended during the investigation 7. Reporting: a. The organization will maintain systems to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made. Administrative staff member (ASM) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional vice president of clinical services, were made aware of the above concern on 4/4/19 at 6:48 p.m. No further information was provided prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 138. 2. The facility staff failed to implement their abuse policies and procedures for a resident-to-resident incident between Resident #146 and Resident #53. The facility staff submitted a FRI (facility reported incident) on 10/26/19 for the incident but failed to conduct an investigation and failed to submit a final report to the State Agency within five working days. Resident #146 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: dementia, depression and insomnia [a condition characterized by difficulty falling asleep or staying asleep (1)]. The most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 1/3/19, coded the resident as scoring a 3 on the BIMS (brief interview for mental status) score, indicating she was severely impaired to make daily cognitive decisions. The resident was coded as requiring extensive assistance to being totally dependent upon staff for her activities of daily living. Resident #53 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: high blood pressure, kidney stones, and intellectually disabled [persons whose general intelligence is significantly below average, and they have difficulty adapting to their environment (2)]. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 2/8/19, coded the resident as having both short and long term memory difficulties and being severely impaired to make daily cognitive decisions. The resident was coded as requiring extensive assistance of one staff member for most of her activities of daily living. The FRI (facility reported incident) dated 10/26/18, documented in part, Date of report 10/26/18. Incident date: 10/26/18. Describe Incident: (Resident #53) was kicked in left shin by (Resident #146). No injury assessed. Residents separated. Employee action initiated or taken: Resident separated and 1:1 (one to one) provided. An interview was conducted with ASM (administrative staff member) #1, the administrator, on 4/4/19 at 3:45 p.m., regarding the process for reporting allegations of abuse or mistreatment. ASM #1 stated as soon as it is reported to any staff in the building, it is to be reported to myself or (Name of ASM #2, the director of nursing). Once we determine that it should be reported we have a two-hour window. If it's involving a staff member, it should be reported to all entities. For the final report, I have five working days to get it completed. A copy of the facilities internal investigation of the 10/26/18 incident between Resident #53 and Resident #146 was requested on 4/3/19 at approximately 5:00 p.m. At 5:32 p.m. on 4/4/19, ASM (administrative staff member) #1, the administrator, informed this surveyor he could not locate an investigation on this FRI and stated there was no final report submitted to his knowledge. Administrative staff member (ASM) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional vice president of clinical services, were made aware of the above concern on 4/4/19 at 6:48 p.m. No further information was provided prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 300. (2) This information was obtained from the following website: https://www.healthychildren.org/English/health-issues/conditions/developmental-disabilities/Pages/Outlook-for-Children-with-Intellectual-Disabilities.aspx 3. The facility staff failed to implement the policies for immediately reporting an allegation abuse to the administrator for Resident #16 that occurred on 10/21/18. An employee did not report the allegation to the administrator until 10/29/18, eight days after incident occurred. Resident #16 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: high blood pressure, heart failure, atrial fibrillation [a condition characterized by rapid and random contraction of the atria of the heart causing irregular beats of the ventricles and resulting in decreased heart output and frequently clot formation in the atria (1)] and unspecified conduct disorder. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 1/10/19, coded the resident as scoring a 14 on the BIMS (brief interview for mental status) score, indicating he was capable of making daily cognitive decisions. The FRI (facility reported incident) documented, Report date: 29OCT2018. Incident Date: 21OCT2018. Describe the incident, including location and action taken: It was reported to Administrator on 29OCT2018 from dietary employee, name of [other staff member (OSM) #7] that dietary employee [Name of OSM #8, the dietary employee] intentionally did not take resident (Resident #16)'s meal order on Sunday 21[DATE] in the main dining room. It was reported that (OSM #8) took everyone else's order except for (Resident #16). Administrator (ASM - administrative staff member #1) was out on medical leave 22-26OCT2018, and this is why (OSM #7) decided to wait to report it to the Administrator. An interview was conducted with ASM #1, the administrator, on 4/4/19 at 3:45 p.m., regarding the process for reporting allegations of abuse or mistreatment. ASM #1 stated as soon as it is reported to any staff in the building, it is to be reported to myself or (Name of ASM #2). Once we determine that it should be reported we have a two-hour window. If it's involving a staff member, it should be reported to all entities. For the final report, I have five working days to get it completed. When asked if an action plan was initiated for this, ASM #1 stated, No, I gave (ASM #2) a copy of the fax cover sheets for all four entities so she would have them for future use. She and I talked about the two hour window. On 4/5/19 at 8:15 a.m., ASM #1 presented education on timely reporting documentation, dated 3/7/19. Review of the education revealed the documented signatures of the interdisciplinary team. When asked if the rest of the staff has been educated in timely reporting of abuse allegations, ASM #1 stated they have not taught them that as of this date. Administrative staff member (ASM) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional vice president of clinical services, were made aware of the above concern on 4/4/19 at 6:48 p.m. No further information was provided prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 55.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to report allegations of abuse immediately, but not later than 2 hours and/or failed to report to the state agency the final findings of an investigation for four residents in the survey sample, Residents #63, #146, #16, #53 and #2. 1. The facility staff failed to immediately (or within 2 hours) report, Resident #63's allegation of abuse to the state agency and to other officials in accordance with State law through established procedures. On 12/28/18, Resident #63 informed the facility staff of the allegation of abuse, and the facility staff failed to report the allegation to the state agency until 1/2/19. 2. The facility staff submitted a FRI (facility reported incident) on 10/26/19 for a resident-to-resident incident between Resident #146 and Resident #53, but failed to complete an investigation and report the results to the State Agency and to other officials within five working days. 3. The facility staff failed to report immediately an allegation abuse for Resident #16 that occurred on 10/21/18 to the state agency and to other officials in accordance with State law through established procedures. The allegation was not reported until 10/29/18 (eight days after the incident occurred) and was not reported to adult protective services. The findings include: 1. The facility staff failed to immediately (or within 2 hours) report, Resident #63's allegation of abuse to the state agency and to other officials in accordance with State law through established procedures. On 12/28/18, Resident #63 informed the facility staff of the allegation of abuse, and the facility staff failed to report the allegation to the state agency until 1/2/19. Resident #63 was admitted to the facility to the facility on 1/12/18, with a recent readmission on [DATE] with diagnoses that included but were not limited to: morbid obesity, diabetes, high blood pressure, and congestive heart failure [abnormal condition characterized by circulatory congestion and retention of salt and water by the kidneys (1)]. The most recent MDS (minimum data set) assessment, a Medicare 30 day assessment, with an assessment reference date of 3/1/19, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact to make daily decisions. Resident #63 was coded as having rejected care daily during the look back period. The resident was coded as requiring extensive assistance of two staff members for most of her activities of daily living, including transfers. The resident was coded as being able to feed herself once set up assistance was provided. A Facility Reported Incident (FRI) dated 1/2/19, documented, Report date: 1/2/19. Incident Date 12/12/18. The report further documented, Resident noted on 12/12/18 to have a fall. On 12/28/18, Resident reported to have arm and wrist pain and stated that the injury occurred when resident was helped up off of floor. Investigation initiated. The name of an employee was documented under Name of Employee involved. The Final Report dated, 1/7/19, documented, On 1/2/19 you were contacted regarding an injury for Resident (#63). Resident reported that she did not injure her left arm when she fell but that the nurse (LPN - licensed practical nurse- #11) pulled on her arm to get her off the floor. This nurse was not informed of this until 12/28/18 when the resident came to express her concern. Under, If applicable, date notification provided to: Responsible party - 12/12/2018; Physician - 12/12/18. There was no documented notification to APS (adult protective services), DHP (department of health professionals) or Law Enforcement. This FRI was completed by ASM #2. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, the one who completed the FRI reporting, on 4/4/19 at 3:33 p.m. When asked why she waited to report the FRI on 1/2/19 when she had knowledge of the allegation on 12/28/18, ASM #2 stated, At my last facility, I thought we had five days to get it in. Since then I've been told the requirements for reporting within two hours. ASM #2 was asked about the requirements for reporting suspected abuse, neglect or misappropriation of resident property according to the facility policy, ASM #2 stated, We need to send it to the ombudsman, (state agency), department of social services and depending on the outcome, to the board of nursing. When asked who is responsible for reporting to the state agency, ASM #2 stated, Either (Name of administrator) or myself. If we are not here, the nurse on the floor is responsible to send it in the two hour time frame. Administrative staff member (ASM) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional vice president of clinical services, were made aware of the above concern on 4/4/19 at 6:48 p.m. No further information was provided prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 138. 2. The facility staff submitted a FRI (facility reported incident) on 10/26/19 for a resident-to-resident incident between Resident #146 and Resident #53, but failed to complete an investigation and report the results to the State Agency and to other officials within five working days. Resident #146 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: dementia, depression and insomnia [a condition characterized by difficulty falling asleep or staying asleep (1)]. The most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 1/3/19, coded the resident as scoring a 3 on the BIMS (brief interview for mental status) score, indicating she was severely impaired to make daily cognitive decisions. The resident was coded as requiring extensive assistance to being totally dependent upon staff for her activities of daily living. Resident #53 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: high blood pressure, kidney stones, and intellectually disabled [persons whose general intelligence is significantly below average, and they have difficulty adapting to their environment (2)]. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 2/8/19, coded the resident as having both short and long-term memory difficulties and being severely impaired to make daily cognitive decisions. The resident was coded as requiring extensive assistance of one staff member for most of her activities of daily living. The FRI (facility reported incident) dated 10/26/18, documented in part, Date of report 10/26/18. Incident date: 10/26/18. Describe Incident: (Resident #53) was kicked in left shin by (Resident #146). No injury assessed. Residents separated. Employee action initiated or taken: Resident separated and 1:1 (one to one) provided. An interview was conducted with ASM (administrative staff member) #1, the administrator, on 4/4/19 at 3:45 p.m., regarding the process for reporting allegations of abuse or mistreatment. ASM #1 stated as soon as it is reported to any staff in the building, it is to be reported to myself or (Name of ASM #2, the director of nursing). Once we determine that it should be reported we have a two-hour window. If it's involving a staff member, it should be reported to all entities. For the final report, I have five working days to get it completed. A copy of the facilities internal investigation of the 10/26/18 incident between Resident #53 and Resident #146 was requested on 4/3/19 at approximately 5:00 p.m. At 5:32 p.m. on 4/4/19, ASM (administrative staff member) #1, the administrator, informed this surveyor he could not locate an investigation on this FRI and stated there was no final report submitted to his knowledge. Administrative staff member (ASM) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional vice president of clinical services, were made aware of the above concern on 4/4/19 at 6:48 p.m. No further information was provided prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 300. (2) This information was obtained from the following website: https://www.healthychildren.org/English/health-issues/conditions/developmental-disabilities/Pages/Outlook-for-Children-with-Intellectual-Disabilities.aspx 3. The facility staff failed to report immediately an allegation abuse for Resident #16 that occurred on 10/21/18 to the state agency and to other officials in accordance with State law through established procedures. The allegation was not reported until 10/29/18 (eight days after the incident occurred) and was not reported to adult protective services. Resident #16 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: high blood pressure, heart failure, atrial fibrillation [a condition characterized by rapid and random contraction of the atria of the heart causing irregular beats of the ventricles and resulting in decreased heart output and frequently clot formation in the atria (1)] and unspecified conduct disorder. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 1/10/19, coded the resident as scoring a 14 on the BIMS (brief interview for mental status) score, indicating he was capable of making daily cognitive decisions. The FRI (facility reported incident) documented, Report date: 29OCT2018. Incident Date: 21OCT2018. Describe the incident, including location and action taken: It was reported to Administrator on 29OCT2018 from dietary employee, name of [other staff member (OSM) #7] that dietary employee [Name of OSM #8, the dietary employee] intentionally did not take resident (Resident #16)'s meal order on Sunday 21[DATE] in the main dining room. It was reported that (OSM #8) took everyone else's order except for (Resident #16). Administrator (ASM - administrative staff member #1) was out on medical leave 22-26OCT2018, and this is why (OSM #7) decided to wait to report it to the Administrator. An interview was conducted with ASM #1, the administrator, on 4/4/19 at 3:45 p.m., regarding the process for reporting allegations of abuse or mistreatment. ASM #1 stated as soon as it is reported to any staff in the building, it is to be reported to myself or (Name of ASM #2). Once we determine that it should be reported we have a two-hour window. If it's involving a staff member, it should be reported to all entities. For the final report, I have five working days to get it completed. When asked if an action plan was initiated for this, ASM #1 stated, No, I gave (ASM #2) a copy of the fax cover sheets for all four entities so she would have them for future use. She and I talked about the two hour window. On 4/5/19 at 8:15 a.m., ASM #1 presented education on timely reporting documentation, dated 3/7/19. Review of the education revealed the documented signatures of the interdisciplinary team. When asked if the rest of the staff has been educated in timely reporting of abuse allegations, ASM #1 stated they have not taught them that as of this date. Administrative staff member (ASM) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional vice president of clinical services, were made aware of the above concern on 4/4/19 at 6:48 p.m. No further information was provided prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 55.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. The facility staff failed to evidence that Resident # 36's comprehensive care plan goals were sent with the resident to the hospital for the transfer dated 12/31/18. Resident # 36 was admitted to the facility on [DATE] with the most recent readmission date of 01/03/19. His diagnoses included but were not limited to acute bronchitis (1), hypertension (2), and umbilical (belly button area) hernia (3). Resident # 36's most recent Minimum Data Set (MDS) assessment was a Quarterly Assessment with an Assessment Reference Date (ARD) of 02/01/19. The Brief Interview for Mental Status (BIMS) coded Resident # 36 as scoring a 11 on BIMS of a score of 0 - 15, 11 - indicating moderately impaired for making daily decisions. A review of Resident # 36's clinical record was conducted on 04/04/19. A nurse's note dated 1/03/19 at 5:29 p.m., documented Resident # 36 had been sent to the hospital for surgical hernia repair. The nurse's note did not document if comprehensive care plan goals were sent along with the resident to the hospital. On 04/03/19 at 2:38 p.m., an interview was conducted with LPN (licensed practical nurse) # 3. LPN #3 was asked to describe the paperwork that is provided to the receiving facility at the time of a resident's transfer to a hospital. LPN # 3 stated, We send a copy of the facesheet, list of medications, progress notes (nurse's notes), recent laboratory and/or x-rays, copy of insurance card, the bed hold agreement paper and the resident's code status, contact information and notification to the responsible party and it is documented in the nurse's notes. When asked if they send a copy of the resident's comprehensive care plan goals at the time of transfer LPN # 3 stated, No. On 3/20/19 at approximately 5:30 p.m., ASM (administrative staff member) # 1, the Administrator, and ASM # 2, The Director of Nursing, and ASM # 3, regional vice president of clinical services, were made aware of the findings. No further information was provided. References: 1. Acute bronchitis is swelling and inflamed tissue in the main passages that carry air to the lungs. This information was obtained from the website: https://medlineplus.gov/ency/article/001087.htm - Medical Encyclopedia 2. High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html. 3. An umbilical hernia is an outward bulging (protrusion) of the lining of the abdomen or part of the abdominal organ(s) through the area around the belly button. This information was obtained from the website: https://medlineplus.gov/ency/article/000987.htm. 7. The facility staff failed to ensure the comprehensive care plan goals were provided to the receiving facility when Resident #67 was transferred to the hospital on 1/26/19, 1/28/19, 2/3/19, 2/5/19, 2/12/19, 2/28/19, and 3/2/19. Resident #67 was admitted to the facility on [DATE] with the diagnoses of but not limited to urinary tract infection, retention of urine, iron deficiency anemia, high blood pressure, heart failure, and chronic obstructive pulmonary disease. Resident #67's Minimum Data Set (MDS) was an admission assessment, with an Assessment Reference Date (ARD) of 2/5/19, coded Resident #67 as having no cognitive impairment in his ability to make daily life decisions. A review of the clinical record revealed physician orders dated 1/26/19 that documented, send to ER (emergency room) for evaluation of possible fx (fracture). A review of the clinical record revealed nurse's notes dated 1/26/19 at 3:41 p.m., that documented, left facility at 1540 (3:40 PM), via stretcher to (name of facility) ER (emergency room). Bed hold sent with him, RP (Responsible Person) aware. A review of the clinical record revealed physician orders dated 2/3/19 that documented, send resident hospital for evaluation due to critical labs [laboratory] severe anemia. A review of the clinical record revealed nurse's notes dated 2/3/19 at 1:07 p.m., that documented in part, received call from (name of lab) with critical lab results on resident at 11:15 a.m., .all results called to (name of physician) he gave new orders to send to ER for evaluation of severe anemia .Notified POA (power of attorney) will decide about bed hold policy if resident is admitted . A review of the clinical record revealed physician orders dated 2/12/19 that documented send resident out to (name of hospital) ER for evaluation. A review of the clinical record revealed nurse's notes dated 2/12/19 at 11:01 p.m., that documented, resident admitted to (name of hospital) with diagnosis of hypothermia, low blood pressure, and sepsis. A nurse's note dated 2/12/19 at 5:52 p.m., documented bed hold agreement sent with resident. A review of the clinical record revealed physician orders dated 2/28/19 that documented, send resident out to (name of hospital) ER for evaluation. A review of the clinical record revealed nurse's notes dated 2/28/19 at 9:38 p.m., that documented in part, Resident sent out to (name of hospital) ER for evaluation at 7:45 p.m., via 911 on stretcher .MD (medical doctor) and RP aware. No bed hold per family request. A review of the clinical record revealed nurse's notes dated 3/2/19 at 3:00 p.m., that documented in part, resident wheeled himself outside the front door .stating he was going to wheel himself to the ER, complaining of shortness of breath .information forwarded to MD and RP. 911 was called to transport resident to (name of hospital) ER for evaluation. Per RP resident is no bed hold. A review of the clinical record documented that written notice of the bed hold policy was mailed to the RP on the following dates: 1/26/19, 2/3/19, 2/12/19, 2/28/19, and 3/2/19. A review of the clinical record failed to reveal any evidence that care plan goals were sent with the resident upon transfer to the hospital on 1/26/19, 2/3/19, 2/12/19, 2/28/19, and 3/2/19. On 04/03/19 at 2:38 p.m., an interview was conducted with LPN (licensed practical nurse) # 3. LPN #3 was asked to describe the paperwork that is provided to the receiving facility at the time of a resident's transfer to a hospital. LPN # 3 stated, We send a copy of the facesheet, list of medications, progress notes (nurse's notes), recent laboratory and/or x-rays, copy of insurance card, the bed hold agreement paper and the resident's code status, contact information and notification to the responsible party and it is documented in the nurse's notes. When asked if they send a copy of the resident's comprehensive care plan goals at the time of transfer LPN # 3 stated, No. On 4/4/19 at 4:15 p.m., ASM (Administrated Staff Member) #1, the administrator, and ASM #2, the DON (Director of Nursing), were made aware of the findings. No further information was provided by the end of the survey. Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to ensure the required documentation was provided to the receiving facility at the time of a transfer for eleven of 47 residents in the survey sample, Resident's # 3, # 33, # 71, # 29, # 2, # 36, # 67, # 10, # 60 # 76 and # 63. 1. The facility staff failed to evidence Resident # 3's comprehensive care plan goals were sent with the resident to the hospital for the facility-initiated transfers to the hospital on [DATE] and 12/21/18. 2. The facility staff failed to provide the receiving facility with Resident # 33's comprehensive care plan goals upon a hospital transfer that occurred on 01/11/19. 3. The facility staff failed to evidence what, if any of the required documentation was provided to the hospital when Resident #71 was transferred to the hospital on 2/7/19. 4. The facility staff failed to evidence what, if any of the required documentation was provided to the hospital when Resident #29 was transferred to the hospital on [DATE]. 5. The facility staff failed to evidence what, if any of the required documentation was provided to the hospital when Resident #2 was transferred to the hospital on [DATE]. 6. The facility staff failed to evidence that Resident # 36's comprehensive care plan goals were sent with the resident to the hospital for the transfer dated 12/31/18. 7. The facility staff failed to ensure the comprehensive care plan goals were provided to the receiving facility when Resident #67 was transferred to the hospital on 1/26/19, 1/28/19, 2/3/19, 2/5/19, 2/12/19, 2/28/19, and 3/2/19. 8. The facility staff failed to evidence the documentation of the comprehensive care plan goals being sent to the receiving facility for a transfer of Resident #10 to the hospital on [DATE] and 3/27/19. 9. The facility staff failed to evidence the documentation of the comprehensive care plan goals being sent to the receiving facility for a transfer of Resident #76 to the hospital on 2/12/19 and 3/18/19. 10. The facility staff failed to evidence the comprehensive care plan goals were provided to the receiving facility for a transfer of Resident # 63 to the hospital on 1/17/19. 11. The facility staff failed to evidence the comprehensive care plan goals were provided to the receiving facility for a transfer of Resident # 64 to the hospital on 1/21/19 and 2/1/19. The findings include: 1. The facility staff failed to evidence Resident # 3's comprehensive care plan goals were sent with the resident to the hospital for the facility-initiated transfers to the hospital on [DATE] and 12/21/18. Resident # 3 was admitted to the facility on [DATE] with diagnoses that included but were not limited to respiratory failure (1), bipolar disorder (2), and spondylolysis (3). Resident # 3's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/19/18, coded Resident # 3 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. The nurse's Progress Notes, dated 12/08/2018 for Resident # 3 documented, 12:10 p.m., Late Entry: This RN (registered nurse) was notified by Staff [sic] by at 6:00 a.m., that the resident was non-compliant with staying in her room under isolation precautions for RSV (Respiratory syncytial (sin-SISH-[NAME]) virus) [4]. Resident refusing to go back to her room and even ate breakfast in the dining room. Resident not responding to staff. Patient to be ECO'd (emergency court ordered) due to noncompliance and possible infection of other residents. Lithium levels not known at this time. Sheriff's office was notified. Magister petitioned to have Resident removed from facility due to noncompliance. Facility unable to give adequate care. Resident removed from facility via (by) ambulance and taken to (Name of Hospital) to be evaluated at this time. The nurse's Progress Notes, dated 12/21/2018 for Resident # 3 documented, 3:01 PM (p.m.) Staff notified that resident found in bedroom around 230pm (2:30 p.m.) with bloody drainage on right side of shoulder and floor from fall. Resident is A&Ox3 (alert and oriented times three, person place and time), T (temperature) 98.3, BP (blood pressure 156/78 (one hundred fifty-six over seventy-eight), p (pulse) 86, RR (respiration) 20, O2 (oxygen) 69% (percent) RA (on room air), c/o (complaint of) pain to head. Resident noted with small lump near back of R (right) side of head with skin tear in center. Moderate amount of bright red blood stabilized with gauze and compression gauze. ROM (range of motion) wnl (within normal limits), prn (as needed) Tylenol; 650 mg (milligram) po (by mouth) at 246pm (2:46 p.m.). No shoes or socks to feet. Resident was able to reach out and use call bell to notify staff, Supervisor, RP (responsible party), MD (medical doctor) notified. Resident has been sent to (Name of Hospital) ER (emergency room) for treatment. Left with EMT (emergency medical technician) out the facility via (by) stretcher at 256pm (2:56 p.m.). RP stated he would not hold bed if resident admitted to hospital. Review of the facility's Transfer To Hospital Checklist form dated 12/08/18 and 12/21/18 for Resident # 3 failed evidence documentation that the comprehensive care plan goals were sent to (Name of Hospital) for the transfers of Resident # 3 to the hospital. On 04/03/19 at 2:38 p.m., an interview was conducted with LPN (licensed practical nurse) # 3. LPN #3 was asked to describe the paperwork that is provided to the receiving facility at the time of a resident's transfer to a hospital. LPN # 3 stated, We send a copy of the facesheet, list of medications, progress notes (nurse's notes), recent laboratory and/or x-rays, copy of insurance card, the bed hold agreement paper and the resident's code status, contact information and notification to the responsible party and it is documented in the nurse's notes. When asked if they send a copy of the resident's comprehensive care plan goals at the time of transfer LPN # 3 stated, No. On 04/03/19 at approximately 6:00 p.m. ASM (administrative staff member) # 1, the administrator, ASM # 2, director of nursing and ASM # 3, vice president of clinical services, were made aware of the findings. No further information was provided prior to exit. References: (1) When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html. (2) A brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks. This information was obtained from the website: https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml. (3) A condition in which a bone (vertebra) in the spine moves forward out of the proper position onto the bone below it. This information was obtained from the website: https://medlineplus.gov/ency/article/001260.htm. (4) A common respiratory virus that usually causes mild, cold-like symptoms. Most people recover in a week or two, but RSV can be serious, especially for infants and older adults. In fact, RSV is the most common cause of bronchiolitis (inflammation of the small airways in the lung) and pneumonia (infection of the lungs) in children younger than 1 year of age in the United States. It is also a significant cause of respiratory illness in older adults. This information was obtained from the website: https://www.cdc.gov/rsv/index.html. 2. The facility staff failed to provide the receiving facility with Resident # 33's comprehensive care plan goals upon a hospital transfer that occurred on 01/11/19. Resident # 33 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: heart failure (1), peripheral vascular disease (2), chronic kidney disease (3) and hypertension (4). Resident # 33's most recent MDS (minimum data set), a 5-day assessment with an ARD (assessment reference date) of 01/23/19, coded Resident # 33 as scoring a 6 (six) on the brief interview for mental status (BIMS) of a score of 0 - 15, 6 (six) - being severely impaired of cognition for making daily decisions. The nurse's Progress Notes, for Resident # 33 dated 01/11/19 at 3:21 p.m., documented the resident was transferred to a local hospital for evaluation after complaining of numbness and tingling in hands and legs. The note documented in part, Resident had to purplish lips, call MD (medical doctor) gave order to send out for evaluation at hospital call RP (responsible party) states he is not a bed hold will continue to monitor. Review of the facility's Transfer To Hospital Checklist form dated 01/11/19 for Resident # 33 failed evidence documentation that the comprehensive care plan goals were sent to (Name of Hospital) upon the transfers of Resident # 3. On 04/03/19 at 2:38 p.m., an interview was conducted with LPN (licensed practical nurse) # 3. LPN #3 was asked to describe the paperwork that is provided to the receiving facility at the time of a resident's transfer to a hospital. LPN # 3 stated, We send a copy of the facesheet, list of medications, progress notes (nurse's notes), recent laboratory and/or x-rays, copy of insurance card, the bed hold agreement paper and the resident's code status, contact information and notification to the responsible party and it is documented in the nurse's notes. When asked if they send a copy of the resident's comprehensive care plan goals at the time of transfer LPN # 3 stated, No. On 04/04/19 at approximately 6:45 p.m. ASM (administrative staff member) # 1, the administrator, ASM # 2, director of nursing and ASM # 3, vice president of clinical services, were made aware of the findings. No further information was provided prior to exit. References: (1) A condition in which the heart is no longer able to pump oxygen-rich blood to the rest of the body efficiently. This causes symptoms to occur throughout the body. This information was obtained from the website: https://medlineplus.gov/ency/article/000158.htm. (2) The vascular system is the body's network of blood vessels. It includes the arteries, veins and capillaries that carry blood to and from the heart. Arteries can become thick and stiff, a problem called atherosclerosis. Blood clots can clog vessels and block blood flow to the heart or brain. Weakened blood vessels can burst, causing bleeding inside the body.) This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/vasculardiseases.html. (3) Kidneys are damaged and can't filter blood as they should. This information was obtained from the website: https://medlineplus.gov/chronickidneydisease.html. (4) High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html. 3. The facility staff failed to evidence what, if any of the required documentation was provided to the hospital when Resident #71 was transferred to the hospital on 2/7/19. Resident #71 was admitted to the facility on [DATE] with the diagnoses of but not limited to osteoarthritis, heart failure, diabetes, high blood pressure, and chronic kidney disease. The most recent MDS (Minimum Data Set) was an admission/5-day assessment with an ARD (Assessment Reference Date) of 2/19/19. The resident was coded as being cognitively intact in ability to make daily life decisions. A review of the clinical record revealed a nurse's note dated 2/7/19 at 3:48 p.m., that documented Resident #71 was sent to a local hospital for evaluation due to wheezing in bilateral lungs and a fever. The note documented in part, .writer called to inform MD about change in status. MD states she had 2 neb [nebulizer] tx [treatments] and was not effective, then send her out for evaluation. RP (responsible party) is resident and also grandson was called and told of this change and he wanted her back in the hospital because he says she never be this bad with her breathing. Writer called 911 and EMT (emergency medical technician) arrived at 10:50 AM and got resident and she was taken to (name of hospital, name of town) will call to check on status . Further review of the clinical record failed to reveal any evidence of what, if any, required documentation was provided to the hospital for Resident #71's transfer to the hospital on 2/7/19. On 04/03/19 at 2:38 p.m., an interview was conducted with LPN (licensed practical nurse) # 3. LPN #3 was asked to describe the paperwork that is provided to the receiving facility at the time of a resident's transfer to a hospital. LPN # 3 stated, We send a copy of the facesheet, list of medications, progress notes (nurse's notes), recent laboratory and/or x-rays, copy of insurance card, the bed hold agreement paper and the resident's code status, contact information and notification to the responsible party and it is documented in the nurse's notes. When asked if they send a copy of the resident's comprehensive care plan goals at the time of transfer LPN # 3 stated, No. On 4/5/19 at 10:33 a.m., in an interview with RN (registered nurse) #1, a unit manager, she provided a blank copy of the transfer form. RN #1 stated, This is the form we typically use. Care plan goals is not on the form. What all is sent should be in the progress notes. We keep a copy of the form. When asked what it meant if there was no note documenting what was sent to the hospital, and there was no copy of the completed form / checklist of what was sent to the hospital, RN #1 stated, There is no evidence of what was sent to the hospital. On 4/5/19 at 9:30 a.m., ASM #1 (Administrative Staff Member, the Administrator stated) that the transfer form for this hospitalization of Resident #71 could not be located. No further information was provided. (1) Tylenol is used to relieve mild to moderate pain from headaches, muscle aches, menstrual periods, colds and sore throats, toothaches, backaches, and reactions to vaccinations (shots), and to reduce fever. Information obtained from https://medlineplus.gov/druginfo/meds/a681004.html 4. The facility staff failed to evidence what, if any of the required documentation was provided to the hospital when Resident #29 was transferred to the hospital on [DATE]. Resident #29 was admitted to the facility on [DATE] with the diagnoses of but not limited to pressure ulcer, depression, Herpes Zoster with post herpetic nervous system involvement, trigeminal neuralgia, and high blood pressure. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 1/23/19. The resident was coded as mildly impaired in ability to make daily life decisions. A review of the clinical record revealed a nurse's note dated 12/13/18 at 9:46 a.m., which documented, Resident alert to self, remains confused to place/time/environment and emotional by crying and calling out for her mother. Resident given first dose of ABT (antibiotic) for UTI (urinary tract infection) this AM PO (by mouth) .MD (medical doctor) notified with change of condition with VS (vital signs) T (temperature) 97.4, 143/84 (blood pressure), p (pulse) 80, RR (respiratory rate) 18, unlabored, 02 (oxygen) 94% RA (on room air). New order from MD to send to (name of hospital) per RP (responsible party) request. Report given to (name of hospital) and resident transported via stretcher by EMT (emergency medical technician) and left facility at 9:20 (AM). Further review of the clinical record failed to reveal any evidence of what, if any, required documentation was provided to the hospital for Resident #29's transfer on 12/13/18. On 04/03/19 at 2:38 p.m., an interview was conducted with LPN (licensed practical nurse) # 3. LPN #3 was asked to describe the paperwork that is provided to the receiving facility at the time of a resident's transfer to a hospital. LPN # 3 stated, We send a copy of the facesheet, list of medications, progress notes (nurse's notes), recent laboratory and/or x-rays, copy of insurance card, the bed hold agreement paper and the resident's code status, contact information and notification to the responsible party and it is documented in the nurse's notes. When asked if they send a copy of the resident's comprehensive care plan goals at the time of transfer LPN # 3 stated, No. On 4/5/19 at 10:33 a.m., in an interview with RN (registered nurse) #1, a unit manager, she provided a blank copy of the transfer form. RN #1 stated, This is the form we typically use. Care plan goals is not on the form. What all is sent should be in the progress notes. We keep a copy of the form. When asked what it meant if there was no note documenting what was sent to the hospital, and there was no copy of the completed form / checklist of what was sent to the hospital, RN #1 stated, There is no evidence of what was sent to the hospital. On 4/5/19 at 9:30 AM ASM #1 (Administrative Staff Member, the Administrator stated) that the transfer form for this hospitalization for this resident could not be located. No further information was provided. 5. The facility staff failed to evidence what, if any of the required documentation was provided to the hospital when Resident #2 was transferred to the hospital on [DATE]. Resident #2 was admitted to the facility on [DATE] with the diagnoses of but not limited to left above knee amputation, epilepsy, multiple sclerosis, gangrene of left amputation site, osteoporosis, acute respiratory failure, high blood pressure, aphasia, stroke, right femur fracture, and syphilitic heart involvement. The most recent MDS (Minimum Data Set) was a significant change assessment with an ARD (Assessment Reference Date) of 12/18/18. The resident was coded as severely cognitively impaired in ability to make daily life decisions. A review of the clinical record revealed a nurse's note date 12/26/18 at 7:47 AM that documented, 0655 (6:55 AM) CNA (certified nursing assistant) entered room and observed resident with seizure like activity. Magnet obtained and swiped over left chest VNS therapy system without improvement to seizure activity. Rectal Diazepam (1) administered as ordered at 0705 (7:05 AM) with no improvement. Multiple attempts to obtain Vitals unsuccessful d/t (due to) significant seizure activity. After Diazepam administered attempted VNS magnet swipe again without improvement. Call placed to (name of medical doctor) and updated. (Name of doctor) in facility and evaluated. Ordered to send to ER (emergency room) for evaluation and treatment. Call placed to 911 at 0715 (7:15 AM). While fellow LPN (licensed practical nurse) called Daughter and RP (responsible party) (name of daughter) as well as report called to (name of ER facility) (Name of county) rescue squad arrived, report given and resident transferred to stretcher as seizure activity continued Further review of the clinical record failed to reveal any evidence of what, if any, required documentation was provided to the hospital, when Resident #2 was transferred to the hospital on [DATE]. On 04/03/19 at 2:38 p.m., an interview was conducted with LPN (licensed practical nurse) # 3. LPN #3 was asked to describe the paperwork that is provided to the receiving facility at the time of a resident's transfer to a hospital. LPN # 3 stated, We send a copy of the facesheet, list of medications, progress notes (nurse's notes), recent laboratory and/or x-rays, copy of insurance card, the bed hold agreement paper and the resident's code status, contact information and notification to the responsible party and it is documented in the nurse's notes. When asked if they send a copy of the resident's comprehensive care plan goals at the time of transfer LPN # 3 stated, No. On 4/5/19 at 10:33 a.m., in an interview with RN (registered nurse) #1, a unit manager, she provided a blank copy of the transfer form. RN #1 stated, This is the form we typically use. Care plan goals is not on the form. What all is sent should be in the progress notes. We keep a copy of the form. When asked what it meant if there was no note documenting what was sent to the hospital, and there was no copy of the completed form / checklist of what was sent to the hospital, RN #1 stated, There is no evidence of what was sent to the hospital. On 4/5/19 at 9:30 AM ASM #1 (Administrative Staff Member, the Administrator stated) that the transfer form for this hospitalization for this resident could not be located. No further information was provided. (1) Diazepam rectal gel is used in emergency situations to stop cluster seizures (episodes of increased seizure activity) in people who are taking other medications to treat epilepsy (seizures). Information obtained from https://medlineplus.gov/druginfo/meds/a605033.html 8. The facility staff failed to evidence the documentation of the comprehensive care plan goals being sent to the receiving facility for a transfer of Resident #10 to the hospital on [DATE] and 3/27/19. Resident #10 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: stroke, diabetes, encephalopathy [any disease or disorder of the brain (1)], and pneumonitis [inflammation of the lung caused by virus or allergic reaction, or foreign material (2)]. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 1/8/19 coded the resident as being severely impaired to make daily cognitive decisions. A nurse's note dated, 12/27/18 at 11:15 p.m. documented in part, Resident sitting up in w/c (wheelchair) bedside bed, private sitter reported to staff that res (Resident) 'felt hot,' Temp (temperature) 102.7, writer observed that res had brownish phlegm during mouth care, prior to admin (administration) prn (as needed) Tylenol (used to treat fever and mild pain) for increased temp, res' residual feeding was 260 ml (milliliters), during care RP (responsible party), spouse in facility, writer telephoned MD (medical doctor) at 1645 (4:45 p.m.) and made aware of all findings, gave order to send to ER (emergency room), telephoned 911 (emergency medical services) .Out of facility via stretcher at 1715 (5:15 p.m.). A nurse's note dated, 3/27/19 at 9:55 a.m. documented in part, MD in house, observed resident to monitor, noted that resident coughed some thick green sputum up and is desaturating (sic) at times in the 84% range, MD ordered to send resident out to the hospital to be evaluated. The review of the clinical record failed to evidence documentation that the comprehensive care plan goals were sent with the resident to the hospital for each of the above transfers. On 04/03/19 at 2:38 p.m., an interview was conducted with LPN (licensed practical nurse) # 3. LPN #3 was asked to describe the paperwork that is provided to the receiving facility at the time of a resident's transfer to a hospital. LPN # 3 stated, We send a copy of the facesheet, list of medications, progress notes (nurse's notes), recent laboratory and/or x-rays, copy of insurance card, the bed hold agreement paper and the resident's code status, contact information and notification to the responsible party and it is documented in the nurse's notes. When asked if they send a copy of the resident's comprehensive care plan goals at the time of transfer LPN # 3 stated, No. Administrative staff member (ASM) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the vice president of clinical services were made aware of the above concern on 4/4/19 at 6:48 p.m. No further information was provided prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 192. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 464. 9. The facility staff failed to evidence the documentation of the comprehensive care plan goals being sent to the receiving facility for a transfer of Resident #76 to the hospital on 2/12/19 and 3/18/19. Resident #76 was admitted to the facility on [DATE] with a recent readmission on [DATE], with diagnoses that included but were not limited to: high blood pressure, diabetes, stroke and dementia. The most recent MDS (minimum data set) assessment, a Medicare five day assessment, with an assessment reference date of 3/12/19, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact to make daily decisions. A nurse's note dated, 2/12/19 at 1:15 a.m. documented in part, &quo[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and facility document review, it was determined that the facility staff failed to ensure expired medications were not available for use in two of two medication carts, (South Back Unit medication cart and the facility's North Front Unit medication cart). The facility staff failed to ensure four expired inhalers, three Advairs (1) and one Flovent (2) were not available for use on two of two medication carts. The findings include: On 04/05/19 at approximately 2:00 p.m., an observation of the facility's South Back Unit medication cart was conducted with LPN (licensed practical nurse) # 8. Observation of the bottom drawer of the medication cart revealed the following: Advair 100/50 mcg (microgram) with an open date documented on the inhaler of 12/16/18. One Advair 500/50 mcg, open without an open date documented on the Advair box or inhaler and Flovent 100 mcg open without an open date documented on the Flovent box or inhaler. On 04/05/19 at approximately 2:20 p.m., an interview was conducted with LPN # 8. When asked how long the Advair 100/50 mcg with the open dated of 12/16/18 was good for and how long the Advair 500/50 mcg and Flovent 100 mcg had been, opened, LPN # 8 stated that she did know. A review of the manufacturer's instructions and description of the Advair and Flovent with LPN # 8 failed to evidence documentation of how long the inhalers were good for after being opened. LPN # 8 stated she would call the pharmacist. LPN # 8 immediately telephoned the pharmacist in the presence of this surveyor. During the telephone conversation with the pharmacist, they stated that Advair and Flovent were expired after 30 days from the open date. A request was then made by LPN # 8 during the telephone conversation with the pharmacist in the presence of this surveyor to send the information regarding the inhalers by facsimile to the facility. LPN # 8 was asked about the Advair 11/50 mcg with the open date of 12/16/18. LPN # 8 stated, It's expired. When asked about the Advair 500/50 mcg and Flovent 100 mcg both without open dates LPN # 8 stated that without the open date she didn't know how long they had been opened and removed them from the medication cart. When asked to describe the procedure to ensure expired medication are not available for use, LPN # 8 stated, They should be checked before administering them. On 04/05/19 at approximately 2:25 p.m., an observation of the facility's North Front Unit medication cart was conducted with LPN (licensed practical nurse) # 9. Observation of the bottom drawer of the medication cart revealed the following: Advair 250/50 mcg with an open date documented on the inhaler of 02/22/19. LPN # 9 agreed that it was expired. When asked to describe the procedure to ensure expired medication are available for use LPN # 8 stated, They should be checked before administering them. The facility's policy 5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles documented, 4. Facility should ensure that medications and biologicals: 4.1 Have an expiration date on the label; 4.2 Have not been retained longer than recommended by manufacturer or supplier guidelines; or, 4.3 Have not been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. Discard ADVAIR DISKUS 1 month after opening the foil pouch or when the counter reads 0 (after all blisters have been used), whichever comes first. This information was obtained from the following website:https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=4eeb5f6a-593f-4a9e-9692-adefa2caf8fc Fluticasone Oral Inhalation (Flovent): What should I know about storage and disposal of this medication? Store your fluticasone aerosol inhaler with the mouthpiece pointing down. Store it out of reach of children, at room temperature and away from excess heat and moisture (not in the bathroom). If you are using the fluticasone powder for inhalation 100 mcg or 250 mcg, you must dispose of the inhaler 2 months after opening the foil pouch. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a601056.html On 04/05/19 at approximately 3:15 p.m. ASM (administrative staff member) # 3, the vice president of clinical services, was made aware of the findings. No further information was provided prior to exit. References: (1) The combination of fluticasone and salmeterol (Advair Diskus, Advair HFA) is used to treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by asthma. The combination of fluticasone and salmeterol (Advair Diskus) is also used to prevent and treat wheezing, shortness of breath, coughing, and chest tightness caused by chronic obstructive pulmonary disease (COPD; a group of lung diseases that includes chronic bronchitis and emphysema). The combination of fluticasone and salmeterol (Advair Diskus) is used in adults and children 4 years of age and older. The combination of fluticasone and salmeterol (Advair HFA) is used in children [AGE] years of age and older. Fluticasone is in a class of medications called steroids. It works by reducing swelling in the airways. Salmeterol is in a class of medications called long-acting beta-agonists ([NAME]). It works by relaxing and opening air passages in the lungs, making it easier to breathe. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a699063.html. (2) Fluticasone oral inhalation is used to prevent difficulty breathing, chest tightness, wheezing, and coughing caused by asthma in adults and children 4 years of age and older. It is in a class of medications called corticosteroids. Fluticasone works by decreasing swelling and irritation in the airways to allow for easier breathing. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a601056.html.

Based on observation, staff interview, and facility document review, it was determined that the facility staff failed to store and serve food in a sanitary manner in one of one facility kitchen. 1. An unopened three pound bag of an unlabeled item reported to be 'ginger liver' by OSM (other staff member) #1 was observed stored in the freezer without manufacturer expiration date, or use-by-date and no labeling of the contents on the bag. 2. The facility staff failed to maintain the food mixer in a sanitary manner in the facility kitchen. The findings include: On 04/02/19 at approximately 11:21 a.m., observation of the kitchen was conducted with OSM (other staff member) #1, dietary manager. Observation of the walk in freezer revealed an unopened three-pound bag of frozen item. OSM #1 stated the bag contained ginger liver. The ginger liver bag was missing any indication of when it was received in the facility, when it was stored in the freezer, the manufacturer expiration date, the use-by-date, and the name of the item in the bag. When OSM # 1 was asked how he knew when the item was put in storage and when it was going to expire, OSM # 1 stated, I have no idea when the item is going to expire and the item should have a label indicating the expiration date or the use-by-date. Observation of the food mixer revealed it assembled, sitting on the food preparation table and covered with a plastic bag. When asked if the food mixer was cleaned and ready for use, OSM # 1 stated, Yes. OSM # 1 then removed the bag covering the food mixer. Further observation of the food mixer revealed debris on the inside surface and on and around the handle area the of the food mixer. OSM # 1 was asked to observe the debris on the food mixer. When asked if the debris was food debris, OSM # 1 stated yes and agreed the food mixer was not clean. When asked how often the food mixer should be cleaned, OSM # 1 stated, After each use, with soap and water and rinse with warm water until all debris are gone. The facility policy CLEANING documented, [WARNING] unplug machine power cord before beginning any cleaning procedure. The mixer should be thoroughly cleaned daily. [DO NOT] use hose to clean mixer; it should washed with a clean, damp cloth. The facility staff was ask for the kitchen foods storage policies but no additional information was provided. On 04/03/19 at approximately 6:01 p.m., ASM (administrative staff member) # 1, the administrator, ASM # 2, director of nursing, and ASM # 3, clinical regional vice president, were made aware of the findings. No further information was provided prior to exit.