**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 report injuries of unknown origin to the state agency for one of 47 residents in the survey sample, Resident #107. On 3/9/22, the facility staff observed injuries of unknown origin (bruises) on Resident #107's face and left hand. The facility staff failed to report the injuries of unknown origin to the state agency. The findings include: Resident #107 was admitted to the facility on [DATE]. Resident #107's diagnoses included but were not limited to dementia and paralysis. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/22/22, the resident scored 1 out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely cognitively impaired for making daily decisions. Review of Resident #107's clinical record revealed a nurse's note dated 3/9/22 that documented, At exactly 0630 (6:30 a.m.), CNA (certified nursing assistant) informed this writer that she has observed some bruises to the left side of resident's face and left hand. This writer quickly went over to resident's room for further assessment. Head to toe assessment was done, findings from this writer's skin assessment confirmed the CNA's earlier report. When asked what happened, resident kept saying 'I am fine, leave me alone.' Alert and oriented, tolerated all scheduled medications and treatments well. Remains in stable condition, range of motion in all lower extremities. Vital signs obtained as follows- BP (blood pressure)-129/73/ Pulse-75, Temp (temperature)-97.4, Resp (respirations)-18, 02sat (oxygen level)-98% at Room Air. MD (medical doctor) notified, no new order given. Lung sound clear to auscultation bilaterally, no wheezing or rhonchi observed. Respiration even and unlabored. Abdomen soft, non tender, and non-distended. Bowel sounds present at all four quadrants. Head of bed elevated, call light bell and frequently used items placed within reach. In no acute distress, nursing staff will continue to monitor. Further review of Resident #107's clinical record failed to reveal documentation of the cause of the bruises and failed to reveal documentation that these injuries of unknown origin were reported to the state agency. On 3/16/22 at 2:53 p.m., an interview was conducted with LPN (licensed practical nurse) #4 (the nurse who documented the above note). LPN #4 stated he was about to leave when Resident #107's bruises were observed. LPN #4 stated he believed the previous shift could have seen Resident #107's bruises and could have done something about them. LPN #4 stated he reported the bruises to the oncoming nurse and the unit manager. LPN #4 stated he also asked the night shift staff and oncoming staff about the bruises and other staff stated they did not know about them. On 3/16/22 at 3:25 p.m., ASM (administrative staff member) #1 (the administrator) stated she did not have an investigation regarding Resident #107's bruises but the unit manager said he was working on one. ASM #1 stated the injuries of unknown origin were not reported to the state agency. On 3/16/22 at 2:55 p.m., ASM #2 (the director of nursing) presented a typed document that documented, [Resident #107] - STAFF STATEMENT ON 3/9/22 BY THE CHARGE NURSE- This writer quickly went over to resident's room for further assessment. Head to toe assessment was done, findings from this writer's skin assessment confirmed the CNA's earlier report. When asked what happened, resident kept saying 'I am fine, leave me alone.' Alert and oriented, tolerated all scheduled medications and treatments well. Remains in stable condition. Vital signs obtained as follows- BP (blood pressure)-129/73/ Pulse-75, Temp (temperature)-97.4, Resp (respirations)-18, 02sat (oxygen level)-98% at Room Air. MD (medical doctor) notified, no new order given. Lung sound clear to auscultation bilaterally, no wheezing or rhonchi observed. Respiration even and unlabored. Abdomen soft, non tender, and non-distended. Bowel sounds present at all four quadrants. Head of bed elevated, call light bell and frequently used items placed within reach. The documented was signed by RN (registered nurse) #1 (unit manager). On 3/16/22 at 3:37 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated he was made aware of Resident #107's bruises during the early morning on 3/9/22. RN #1 stated he reported the bruises to the administrator and the director of nursing that same morning during the morning meeting. On 3/16/22 at 4:39 p.m., an interview was conducted with ASM #1 and ASM #2. ASM #1 stated an injury of unknown origin is an injury that staff cannot identify the root cause of and includes bruises. ASM #1 stated staff is supposed to immediately report injuries of unknown origin to the department head who is supposed to immediately report to her. ASM #1 stated she is supposed to report injuries of unknown origin to the state agency within two hours then complete an investigation. ASM #1 stated she was not aware of Resident #107's injuries of unknown origin that were identified on 3/9/22. On 3/16/22 at approximately 5:50 p.m., ASM #1and ASM #2 were made aware of the above concern. The facility policy titled, Prohibition of Abuse failed to document information regarding injuries of unknown origin. The facility grievance policy documented, 6. The following grievances are reported to Department of Health (DOH): Abuse and neglect, Misappropriation of items, Injury of Unknown Origin. No further information was presented 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, it was determined that the facility staff failed to investigate injuries of unknown origin for one of 47 residents in the survey sample, Resident #107. On 3/9/22, the facility staff observed injuries of unknown origin (bruises) on Resident #107's face and left hand. The facility staff failed to investigate these injuries of unknown origin. The findings include: Resident #107 was admitted to the facility on [DATE]. Resident #107's diagnoses included but were not limited to dementia and paralysis. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/22/22, the resident scored 1 out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely cognitively impaired for making daily decisions. Review of Resident #107's clinical record revealed a nurse's note dated 3/9/22 that documented, At exactly 0630 (6:30 a.m.), CNA (certified nursing assistant) informed this writer that she has observed some bruises to the left side of resident's face and left hand. This writer quickly went over to resident's room for further assessment. Head to toe assessment was done, findings from this writer's skin assessment confirmed the CNA's earlier report. When asked what happened, resident kept saying 'I am fine, leave me alone.' Alert and oriented, tolerated all scheduled medications and treatments well. Remains in stable condition, range of motion in all lower extremities. Vital signs obtained as follows- BP (blood pressure)-129/73/ Pulse-75, Temp (temperature)-97.4, Resp (respirations)-18, 02sat (oxygen level)-98% at Room Air. MD (medical doctor) notified, no new order given. Lung sound clear to auscultation bilaterally, no wheezing or rhonchi observed. Respiration even and unlabored. Abdomen soft, non tender, and non-distended. Bowel sounds present at all four quadrants. Head of bed elevated, call light bell and frequently used items placed within reach. In no acute distress, nursing staff will continue to monitor. Further review of Resident #107's clinical record failed to reveal documentation of the cause of the bruises and failed to reveal documentation that these injuries of unknown origin were reported to the state agency. On 3/16/22 at 2:53 p.m., an interview was conducted with LPN (licensed practical nurse) #4 (the nurse who documented the above note). LPN #4 stated he was about to leave when Resident #107's bruises were observed. LPN #4 stated he believed the previous shift could have seen Resident #107's bruises and could have done something about them. LPN #4 stated he reported the bruises to the oncoming nurse and the unit manager. LPN #4 stated he also asked the night shift staff and oncoming staff about the bruises and other staff stated they did not know about them. On 3/16/22 at 3:25 p.m., ASM (administrative staff member) #1 (the administrator) stated she did not have an investigation regarding Resident #107's bruises but the unit manager said he was working on one. On 3/16/22 at 2:55 p.m., ASM #2 (the director of nursing) presented a typed document that documented, [Resident #107] - STAFF STATEMENT ON 3/9/22 BY THE CHARGE NURSE- This writer quickly went over to resident's room for further assessment. Head to toe assessment was done, findings from this writer's skin assessment confirmed the CNA's earlier report. When asked what happened, resident kept saying 'I am fine, leave me alone.' Alert and oriented, tolerated all scheduled medications and treatments well. Remains in stable condition. Vital signs obtained as follows- BP (blood pressure)-129/73/ Pulse-75, Temp (temperature)-97.4, Resp (respirations)-18, 02sat (oxygen level)-98% at Room Air. MD (medical doctor) notified, no new order given. Lung sound clear to auscultation bilaterally, no wheezing or rhonchi observed. Respiration even and unlabored. Abdomen soft, non tender, and non-distended. Bowel sounds present at all four quadrants. Head of bed elevated, call light bell and frequently used items placed within reach. The documented was signed by RN (registered nurse) #1 (unit manager). On 3/16/22 at 3:37 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated he was made aware of Resident #107's bruises during the early morning on 3/9/22. RN #1 stated he reported this to the administrator and the director of nursing that same morning during the morning meeting. RN #1 stated an injury of unknown origin investigation should consist of talking to staff who cared for the resident during multiple previous shifts, if possible interviewing the resident, completing an incident report and reporting the injury to the director of nursing and administrator so they can complete their own investigation. RN #1 stated he did not personally complete an investigation regarding Resident #107's bruises and did not know the cause. RN #1 stated the above document, signed by him was completed on this day. On 3/16/22 at 4:39 p.m., an interview was conducted with ASM #1 and ASM #2. ASM #1 stated an injury of unknown origin is an injury that staff cannot identify the root cause of and includes bruises. ASM #1 stated an injury of unknown origin investigation should consist of a body audit, witness statements from other residents and interviews with staff. ASM #1 stated she was not aware of Resident #107's injuries of unknown origin that were identified on 3/9/22. On 3/16/22 at approximately 5:50 p.m., ASM #1and ASM #2 were made aware of the above concern. The facility policy titled, Prohibition of Abuse failed to document information regarding injuries of unknown origin. The facility grievance policy documented, 6. The following grievances are reported to Department of Health (DOH): Abuse and neglect, Misappropriation of items, Injury of Unknown Origin. 7. The facility must ensure that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions . No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to maintain an accurate MDS (minimum data set) for the use of oxygen for Resident #2. Resident #2 was admitted to the facility with diagnoses that included but were not limited to acute respiratory failure with hypoxia and heart failure. On the most recent MDS, a quarterly assessment with an ARD (assessment reference date) of 2/23/2022, the resident scored a 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact. Section O of the assessment failed to evidence the use of oxygen while a resident. On 3/15/2022 at 12:19 p.m., an observation was made of Resident #2 in their room. Resident #2 was observed receiving oxygen via a nasal cannula attached to an oxygen concentrator. At this time an interview was conducted with Resident #2, who stated that they wore the oxygen all the time and had used oxygen for a long time. The physician orders for Resident #2 documented in part, Oxygen at 1 liter per min (minute) via nasal cannula to maintain sats (saturations) above 92%. Order Date: 8/16/2021. The comprehensive care plan failed to evidence documentation for the use of oxygen. The eTAR (electronic treatment administration record) for Resident #2 dated 2/1/2022-2/28/2022 and 3/1/2022-3/31/2022 documented Resident #2 receiving oxygen at 1 liter per minute via nasal cannula every shift. On 3/16/2022 at approximately 2:20 p.m., an interview was conducted with LPN (licensed practical nurse) #3, MDS coordinator. LPN #3 stated that they followed the RAI (resident assessment instrument) when completing the MDS assessments. On 3/17/2022 at 9:00 a.m., an interview was conducted with LPN #3. LPN #3 stated that they reviewed the physician orders, MARs (medication administration record) and TARs (treatment administration record) when completing the MDS. LPN #3 stated that they would look at Resident #2's quarterly MDS with the ARD of 2/23/2022 to see if oxygen was coded. On 3/17/2022 at approximately 9:15 a.m., LPN #3 stated that they had reviewed Resident #2's record and they did receive oxygen during the look back period. LPN #3 stated that oxygen was not coded on the quarterly MDS with the ARD of 2/23/2022, and it should have been on there. According to the RAI manual, Section O0100: Special Treatments, Procedures, and Programs, it documented in part, .O0100C, Oxygen therapy, Code continuous or intermittent oxygen administered via mask, cannula, etc., delivered to a resident to relieve hypoxia in this item . The facility policy Clinical Documentation/Accuracy of Documentation & Coding documented in part, .The clinical record facilitates .Accurate coding of MDS to promote adequate plan of care interventions . On 3/17/2022 at 9:30 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, administrator of a sister facility and RN (registered nurse) #3, staff development were notified of the findings. No further information was provided prior to exit. Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure a complete and accurate MDS assessment for 2 of 47 residents in the survey sample, Residents #83 and #2. The findings include: 1. For Resident #83 the 2/7/22 quarterly MDS assessment was coded incorrectly for weight, weight loss, and weight gain. The resident was coded as having significant weight loss and significant weight gain, based on a weight obtained approximately one year prior to the MDS. The resident had no weights obtained in approximately a year. Resident #83 was admitted to the facility on [DATE] and had the diagnoses of but not limited to cerebral vascular disease, high blood pressure and Alzheimer's disease. On the most recent MDS (Minimum Data Set), a quarterly assessment with an ARD (Assessment Reference Date) of 2/7/22, the resident scored a 0 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely cognitively impaired for making daily decisions. A review of the clinical record revealed the resident's weights. The last weight obtained was on 3/25/21 at 78 pounds. A review of the above MDS dated [DATE] documented the following in Section K Swallowing and Nutritional Status: Section K0200 Height and Weight B. Weight (in pounds). Base weight on most recent measure in last 30 days The documented weight was 78 pounds. This weight should not have been documented, as this weight was obtained approximately a year prior to the above MDS, and did not meet the parameters of base weight on most recent measure in last 30 days. Section K0300 Weight Loss: Loss of 5% or more in the last month or loss of 10% or more in last 6 months. 0. No or unknown. 1. Yes, on physician-prescribed weight-loss regimen. 2. Yes, not on physician-prescribed weight-loss regimen. This section was marked with a 2 in the box, indicating the resident had a significant weight loss, according to the above documented parameters. Section K0400 Weight Gain: Gain of 5% or more in the last month or gain of 10% or more in last 6 months. 0. No or unknown. 1. Yes, on physician-prescribed weight-gain regimen. 2. Yes, not on physician-prescribed weight-gain regimen. This section was marked with a 2 in the box, indicating the resident had a significant weight gain, according to the above documented parameters. The resident had not had any weights obtained in approximately a year, hence the above parameters of weight loss or gain of 5% or more in the last month or 10% or more in last 6 months would not apply. On 3/16/22 at 2:20 PM an interview was conducted with LPN #3 (Licensed Practical Nurse) the MDS nurse. When asked if a resident has not had any weights obtained, how the MDS should be coded regarding weight loss / gain. She stated she would follow up on that. When asked what resource is used to complete the MDS, she stated the RAI manual (Resident Assessment Instrument). On 3/16/22 04:25 PM a follow up interview was conducted with LPN #3. She stated that if there has not been any weights to determine if there had been a weight loss or gain, the MDS should be coded as a 0 (for No or Unknown for significant weight loss or gain) because you don't know. On 3/16/22 at 5:06 PM another follow up interview was conducted with LPN #3. She stated the MDS was miscoded. She stated the weight from a year ago should not have been used. On 3/16/22 at 5:19 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, ASM #3 the Assistant Director of Nursing, ASM #4 Administrator of sister facility, and RN #3 (Registered Nurse) Staff Development, were made aware of the findings. No further information was provided by the end of the survey. According to the RAI Manual 3.0 dated October 2019: Steps for Assessment for K0200B, Weight 1. Base weight on the most recent measure in the last 30 days. 2. Measure weight consistently over time in accordance with facility policy and procedure, which should reflect current standards of practice (shoes off, etc.). 3. For subsequent assessments, check the medical record and enter the weight taken within 30 days of the ARD of this assessment. 4. If the last recorded weight was taken more than 30 days prior to the ARD of this assessment or previous weight is not available, weigh the resident again. 5. If the resident's weight was taken more than once during the preceding month, record the most recent weight. If a resident cannot be weighed, for example because of extreme pain, immobility, or risk of pathological fractures, use the standard no-information code (-) and document rationale on the resident's medical record. K0300 Weight Loss . Coding Instructions: Code 0, no or unknown: if the resident has not experienced weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days or if information about prior weight is not available. · Code 1, yes on physician-prescribed weight-loss regimen: if the resident has experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight loss was planned and pursuant to a physician ' s order. In cases where a resident has a weight loss of 5% or more in 30 days or 10% or more in 180 days as a result of any physician ordered diet plan or expected weight loss due to loss of fluid with physician orders for diuretics, K0300 can be coded as 1. Code 2, yes, not on physician-prescribed weight-loss regimen: if the resident has experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight loss was not planned and prescribed by a physician. K0310 Weight Gain . Coding Instructions: Code 0, no or unknown: if the resident has not experienced weight gain of 5% or more in the past 30 days or 10% or more in the last 180 days or if information about prior weight is not available. · Code 1, yes on physician-prescribed weight-gain regimen: if the resident has experienced a weight gain of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight gain was planned and pursuant to a physician ' s order. In cases where a resident has a weight gain of 5% or more in 30 days or 10% or more in 180 days as a result of any physician ordered diet plan, K0310 can be coded as 1. · Code 2, yes, not on physician-prescribed weight-gain regimen: if the resident has experienced a weight gain of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight gain was not planned and prescribed by a physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview it was determined that the facility staff failed to evidence completion of a level 1 PASRR (preadmission screening and resident review) for 1 of 47 residents in the survey sample, Resident #30. The facility staff failed to complete a level 1 PASRR for Resident #30 who was admitted to the facility on [DATE]. The findings include: Resident #30 was admitted to the facility on [DATE] with diagnoses that included delusional disorders, hallucinations and unspecified dementia with behavioral disturbance. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/26/2021, the resident scored 10 out of 15 on the BIMS (brief interview for mental status), indicating the resident is moderately impaired for making daily decisions. Review of Resident #30's clinical record failed to evidence a level 1 PASRR. On 3/16/2022 at approximately 9:26 a.m., a request was made to ASM (administrative staff member) #1, the administrator for the Level 1 PASRR for Resident #30. On 3/16/2022 at approximately 2:30 p.m., ASM #1 provided a Level 1 PASRR for Resident #30 with a completion date of 3/16/2022. On 3/17/2022 at 8:00 a.m., an interview was conducted with OSM (other staff member) #5, the director of social services. OSM #5 stated that the level 1 PASRR normally came with the admission documents for residents. OSM #5 stated that when they began working at the facility their expectation was that all of the residents at the facility at that time already had a Level 1 PASRR. OSM #5 stated that they did not realize that Resident #30 did not have a Level 1 PASRR until the request was made on 3/15/2022. OSM #5 stated that they had completed the level 1 PASRR on 3/16/2022 and that one should have been done prior to this date. The facility policy, Preadmission Screening and Annual Resident Review (PASRR) Policy documented in part, .As part of the preadmission process, the facility participates in the Preadmission Screening and Resident Review (PASRR) screening process (Level I) for all new and readmissions per requirement to determine if the individual meets the criterion for mental disorder (SMI/SMD), intellectual disability (ID) or related condition. Based upon the Level I screen, the facility will not admit an individual with a mental disorder or intellectual disability until the Level II screening process has been completed and the recommendations allow for a nursing facility admission and the facility's ability to provide the specialized services determined in the Level II screen. If a provisional admission to the facility is approved via the Level II screen process, the facility will coordinate with the State PASRR representative related to the individual needs of the resident as indicated . The document, COVID-19 Emergency Declaration Waivers updated 11/29/2021, documented in part on page 16, Waive Pre-admission Screening and Annual Resident Review (PASARR). CMS (Centers for Medicare and Medicaid Services) is waiving 42CFR 483.20(k), allowing nursing homes to admit new residents who have not received Level 1 or Level 2 Preadmission Screening. Level 1 assessments may be performed post-admission. On or before the 30th day of admission, new patients admitted to nursing homes with a mental illness (MI) or intellectual disability (ID) should be referred promptly by the nursing home to State PASARR program for Level 2 Resident Review . This information was obtained from the website: https://www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdf On 3/17/2022 at 9:30 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, the administrator at sister facility and RN (registered nurse) #3, staff development were made aware of the 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 that the facility staff failed to develop a complete baseline care plan for 1 of 47 residents in the survey sample, Resident #315. The facility staff failed to develop Resident #315's baseline care plan to include the use of an incentive spirometer. The findings include: Resident #315 was admitted to the facility on [DATE]. Resident #315's diagnosis included but was not limited to a heart attack. Resident #315's admission minimum data set was not completed. An admission assessment dated [DATE] documented Resident #315 was alert and oriented to person, place, time and situation. A review of Resident #315's March 2022 physician's orders failed to reveal a physician's order for an incentive spirometer. A review of Resident #315's baseline care plan initiated on 3/7/22 failed to reveal documentation regarding an incentive spirometer. On 3/15/22 at 1:15 p.m. and 3/16/22 at 8:34 a.m., Resident #315 was observed sitting in a chair in the bedroom. An incentive spirometer was on the resident's over bed table. At this time, an interview was conducted with the resident. Resident #315 stated, They told me to inhale 10 times. The resident did not specify who they were. On 3/16/22 at 2:20 p.m., an interview was conducted with LPN (licensed practical nurse) #3 (the minimum data set coordinator). LPN #3 stated the purpose of the care plan is to coordinate resident care and work out a plan of care for that resident. LPN #3 stated an incentive spirometer is a respiratory device used for the lungs and has to be on the baseline care plan so staff can monitor it. On 3/16/22 at approximately 5:50 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, Care Plan/Care Plan Meeting/Baseline Care Plan documented, The facility must develop and implement a baseline person-centered care plan within 48 hours for each patient that includes the instructions needed to provide effective and person-centered care that meet professional standards of quality of care. No further information was presented prior to exit.

Based on observation, clinical record review, staff interview and facility document review, it was determined that the facility staff failed to meet professional standards of practice in providing care and services to one of 47 residents in the survey sample, Resident #71. The facility staff failed to completely transcribe a physician order for Resident #71 to include the type of enteral feeding to be administered. The findings include: On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 2/9/2022, the resident was assessed as being severely impaired for making daily decisions. Section K documented Resident #71 as having a feeding tube and receiving 51% or more of their total calories through tube feeding. On 3/15/2022 at approximately 12:45 p.m., an observation of Resident #71 was made in their room. Resident #71 was observed in bed receiving Glucerna tube feeding at 45 ml/hr (milliliters per hour) via pump. The physician orders for Resident #71 documented in part, Enteral Feed Order every shift for Nutritional Support Administer 45ml per hr via G-tube (gastrostomy) continuously via pump. Due to dysphagia. Order Date: 03/07/2022. The physician orders failed to evidence the type of enteral feeding to be administered. The comprehensive care plan for Resident #71 documented in part, The resident requires tube feeding r/t (related to) dysphagia. Date Initiated: 09/03/2020. On 3/16/2022 at 12:15 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that when transcribing orders they verified the frequency, the patient, the medication, the duration and the time. LPN #5 stated that tube feeding orders required the name of the feeding that was ordered to be included. LPN #5 reviewed Resident #71's orders and stated that the order needed to be clarified. LPN #5 stated that the rate of the Glucerna had recently been increased and the feeding type had not changed, however the order should reflect the name of the feeding to be administered. The facility policy Physician Medication Orders/Transcription documented in part, .7. Orders for medications must include: a. Name and strength of the drug; The policy further documented, .10. Resident orders must be transcribed accurately as ordered by the prescriber. On 3/16/2022 at 5:20 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, administrator of a sister facility and RN (registered nurse) #3, staff development were notified of the findings. No further information was provided prior to exit.

2. The facility staff failed to implement care and services for a documented pressure injury for Resident #2. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/23/2022, the resident scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section M documented Resident #2 having one Stage 3 pressure ulcer. On 3/15/2022 at 12:19 p.m., an observation was made of Resident #2 in their room. Resident #2 was observed in bed with her feel elevated on pillows covered with blankets. Resident #2 was observed to have an air mattress in place. The wound evaluation note dated 3/2/2022 documented in part, Left lateral leg, Length: 1.36 cm (centimeter), Width: 0.80 cm, Depth: 0.00 cm .Date Wound Acquired: 3/2/22; Nonblanchable erythema (redness) surrounding a subcentimeter site of desquamation. Zinc oxide paste to wound and peri-wound Q (every) shift. Wound status: New; Acquired in house? Yes; Etiology: Pressure Ulcer- Stage 2 . The progress notes for Resident #2 documented in part, 3/2/2022 12:14 (12:14 p.m.) Skin/Wound Note.Chief Complaint: comprehensive skin and wound evaluation .Wound plan of care: Recurrent stage 3 pressure injury to sacrum and stage 2 pressure injury to lateral left lower leg. Please see TA (tissue analytics) for detailed description and treatment recommendations .Wound rounds completed and reconciled with wound nurse today . The physician orders for Resident #2 failed to evidence orders for treatment to the left lateral leg. The eTAR (electronic treatment administration record) and eMAR (electronic medication administration record) for Resident #2 dated 3/1/2022-3/31/2022 failed to evidence documentation of a treatment to the left lateral leg. The comprehensive care plan for Resident #2 failed to evidence a care plan regarding pressure injuries. On 3/16/2022 at 10:35 a.m., an observation of Resident #2 was made with LPN (licensed practical nurse) #1, wound care. Resident #2 was observed to have no open areas to the left lateral leg during the observation. On 3/16/2022 at 10:45 a.m., an interview was conducted with LPN #1. LPN #1 stated that the wound nurse practitioner was new at the facility and had conducted a whole house skin assessment on 3/2/2022. LPN #1 stated that the process was for them to go with the wound nurse practitioner and enter any new treatment orders and notes at the time of the assessment, however the notes were sometimes entered after the assessment. LPN #1 stated that Resident #2 should have had the order for Zinc oxide entered on 3/2/2022, as documented by the wound nurse practitioner. She stated the order was never put into place. LPN #1 stated that they needed to have an order entered into the medical record for Zinc oxide because it was a medication and had to be applied by the nursing staff. LPN #1 stated that the nursing assistants were only allowed to apply barrier cream. LPN #1 stated that Resident #2 was at high risk for pressure injury due to being very thin and the history of recurring pressure injuries. On 3/16/2022 at 12:15 p.m., an interview was conducted with LPN #5. LPN #5 stated that Resident #2 received barrier cream to the sacral area after receiving incontinence care but was not aware of any treatment orders for a pressure injury. LPN #5 stated that zinc required a physician order because it was a medication. LPN #5 stated that the nurses applied zinc when it was ordered and documented the application on the eTAR. The facility policy Pressure Injury Surveillance documented in part, .All pressure injuries will be tracked. A focused review will be completed on pressure injuries that develop or worsen in the facility through the Resident at Risk Risk meeting process. Corrective actions will be taken immediately, as needed . On 3/16/2022 at 5:20 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, administrator of a sister facility and RN (registered nurse) #3, staff development were notified of the findings. No further information was provided prior to exit. Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care and services for a pressure injury for two of 47 residents in the survey sample, Residents #39 and #2. The findings included: 1. For Resident #39, the facility staff failed to assess and measure a pressure injury (1) from January 2022 through March 2, 2022. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 1/6/2022, Resident #39 was coded as having both short and long term memory difficulties and was coded as being severely cognitively impaired for making daily decisions. In Section M, the resident was coded as having no unhealed pressure injuries. The nurse's note dated 12/19/2021 at 3:39 p.m. documented in part, Resident has non ruptured blister noted to her rt (right) inner heel. Measured 4x4. Elevated heel on pillow. Apply skin prep bid (twice a day) and monitor any change. In house wound consult .No sign and symptoms of verbal or non verbal pain or discomfort noted. The Weekly Non-Pressure Wound Observation Tool dated 12/19/2021 at 12:01 p.m. documented in part, Type of Wound - Other; Location - blister on the right heel, Describe the wound - non punctured blister, no infectious process. Date wound noted: 12/19/2021 .Comments: Blister not punctured. Drainage: none. Odor: none. Wound measurements: Length: 2 cm (centimeters), Width: 3 cm, Depth: blank. Describe wound edges and shape: Well defined. Treatment: placed skin prep applied, heels were floated. Evaluation: First observation. Comments: Wound care to treat and evaluate for healing. The Weekly Skin Review dated 12/27/2022 documented in part, Skin Condition: Open area - pre-existing - no site documented. The Weekly Skin Review dated 12/30/2021 documented in part, Skin Condition: Open area - pre-existing - no site documented. The Weekly Skin Review dated 1/3/2022 documented in part, Skin Condition: Open area - pre-existing - no site documented. The Weekly Skin Review dated 1/6/2022 documented in part, Skin Condition: Open area - pre-existing - no site documented. The Weekly Skin Review dated 1/10/2022 documented in part, Skin Condition: Open area - pre-existing - no site documented. The Weekly Skin Review dated 1/17/2022 documented in part, Skin Condition: Open area - pre-existing - RT (right) heel remains. The Weekly Skin Review dated 1/20/2022 documented in part, Skin Condition: Open area - pre-existing - Tx (treatment) to right heel remains. The Weekly Skin Review dated 1/24/2022 documented in part, Skin Condition: Open area - pre-existing - Tx continues to right heel. The Weekly Skin Review dated 1/27/2022 documented in part, Skin Condition: Open area - pre-existing - tx continues to right heel. The Weekly Skin Review dated 1/31/2022 documented in part, Skin Condition: Open area - pre-existing - Tx in progress to right heel. The Weekly Skin Review dated 2/7/2022 documented in part, Skin Condition: Open area - pre-existing- Tx in progress to right heel with skin prep. The Weekly Skin Review dated 2/14/2022 documented in part, Skin Condition: Open area - Pre-existing- no site documented. The Weekly Skin Review dated 2/21/2022 documented in part, Skin Condition: Open area - pre-existing - Tx continues to right heel with skin prep. The Weekly Skin Review dated 2/28/2022 documented in part, Skin Condition: Open area - pre-existing - right heel - tx in progress. The Weekly Skin Review dated 3/7/2022 documented in part, Skin Condition: Open area - pre-existing - Tx in progress to right heel. The Weekly Skin Review dated 3/14/2022 documented in part, Skin Condition: Open area - pre-existing - Tx in progress to right heel. On all of the above documents, there were no measurements of the heel wound. Review of the nurse's note from 1/1/2022 through 3/2/2022 revealed no documentation of the right heel wound measurements. The physician orders dated 12/19/2021 documented, Skin prep apply to right inner heel blister bid (twice a day) every day and evening shift. Review of the Treatment Administration Record for December 2021, January 2022, and February 2022, documented the skin prep as having been applied to right inner heel. The dietician note dated 1/7/2022 documented in part, Is the resident's skin intact? Yes. Does the resident have a pressure ulcer? No. The MD (medical doctor) note dated 1/7/2022 documented in part, Skin: no rashes, lesions, clubbing, cyanosis. No edema. The MD note dated 1/24/2022 documented in part, Skin: no rashes, lesions, ulcers. The MD note dated 2/17/2022 documented in part, Skin: No rashes, lesions or ulcers. The NP (nurse practitioner), wound specialist, note dated, 3/2/2022 documented, Right lateral heels wound .Pressure ulcer of right heel, unstageable. Assessment and Plan: Patient has a pressure injury. The NP wound specialist note dated 3/2/2022 documented in part, Opened DTI (deep tissue injury), now devolved into an unstageable pressure wound. Measurements: length - 0.95 cm (centimeters), width - 1.13 cm, depth - 0.2 cm. The comprehensive care plan dated 12/19/2021, and reviewed on 3/16/2022, documented in part, Focus: The resident has non rupture blister on right inner heel .Weekly treatment documentation to include measurement of each are of skin breakdown's width, length, depth, type of tissue and exudate and any other notable change or observations. On 3/16/2022 at 11:06 a.m. an observation was made of Resident #39's right heel with LPN (licensed practical nurse) #1, the wound care nurse. There was a black necrotic tissue, approximately the size of a dime, on the middle of the area on the right inner heel. The surrounding tissue was pink. An interview was conducted with LPN #1 on 3/16/2022 at 2:25 p.m. When asked if she was aware of the wound on Resident #39's right inner heel, LPN #1 stated, In late January. When asked when it was determined to be a deep tissue injury and no longer a blister, LPN #1 stated, In late January. When asked if there were any measurements of this wound prior to 3/2/2022, LPN #1 stated, No. When asked why there were no measurements prior to 3/2/2022, LPN #1 stated, I don't know. LPN #1 further stated the normal process when the nurse tells her about an area is for both of them to go in to look at the area of concern. The unit manager also goes with them to assess the area and put a treatment in place. An interview was conducted with RN (registered nurse) #5 on 3/16/2022 at 2:29 p.m. When asked if she was trained in wound care, RN #1 stated, No, but I know a pressure wound. When asked if a blister on the heel qualifies as a pressure injury, RN #1 stated, It depends on where it is located. When asked about Resident #39's right heel wound on which she discovered a blister on 12/19/2021, RN #1 stated she could not recall that. An interview was conducted with ASM (administrative staff member) #6, the nurse practitioner wound care specialist, on 3/16/2022 at 2:53 p.m. When asked if a blister on a heel is considered a pressure ulcer, ASM #6 stated If it's a fluid filled blister, it would be considered a stage 2. If it's open it would still be a stage 2. If it is more than superficial, then it could be a stage 3 or higher. When asked his first observation of Resident #39's right heel, ASM #6 stated, We did a full house skin sweep on 3/2/2022. It was a DTI (deep tissue injury) on her heel with a small scab. ASM #6 stated he changed the staging to an unstageable area at that time because of the necrotic tissue in the wound. When asked if Resident #39's wound was a pressure wound, ASM #6 stated, Yes, it's pressure. The facility policy, Pressure Injury Surveillance documented in part, Policy: A system of surveillance is utilized for preventing, identifying, reporting, and investigating any new or worsened pressure injuries in the facility. Policy Explanation and Compliance Guidelines: 1. The Director of Nursing serves as the leader in surveillance activities, maintains/reviews documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee. 2. RNs and LPNs participate in surveillance through Weekly Skin Review, a weekly assessment of residents, and reporting changes in condition to the resident's physicians and management staff, per protocol for notification of changes and in-house reporting of new or worsened pressure injuries .5. Surveillance activities will be monitored facility-wide, and may be broken down by role or unit, depending on the measure being observed. A combination of process and outcome measures will be utilized .7. All pressure injuries will be tracked. A focused review will be completed on pressure injuries that develop or worsen in the facility through the Residents at Risk Risk meeting process. Corrective actions will be taken immediately, as needed. 8. Data to be used in the surveillance activities may include, but are not limited to: a. 24 hour shift reports, incident reports, focused incident reviews b. Pressure injury/wound assessments c. Medication and treatment records d. Skills validations for dressing changes, turning/repositioning, perineal care e. Skin assessment data f. Rounding observation data. ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the director of nursing, ASM #4, the administrator from a sister facility, and RN #3, the staff development nurse, were made aware of the above concerns on 3/16/2022 at 5:30 p.m. No further information was provided prior to exit.

Based on observation, staff interview and clinical record review, it was determined that the facility staff failed to implement interventions to prevent injury from a fall for one of 47 residents in the survey sample, Resident # 28. The facility staff failed to place a fall mat on the floor next to Resident # 28's bed when they are were in bed. The findings include: Resident # 28 was admitted to the facility with a diagnosis that included but was not limited to: muscle weakness and a history of falls. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 12/30/2021, the resident scored 4 (four) out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely impaired of cognition for making daily decisions. On the following dates a times, Resident #28 was observed to bed, with no fall mat in place on the floor next to the bed: 03/15/22 at 12:40 p.m, 03/15/22 at 4:55 p.m., 03/16/22 at 8:05 a.m., and 03/16/22 at 12:00 p.m. At each observation, a fall mat was leaning against the wall at the foot of Resident #28's bed. The facility's fall risk assessment titled AHR-MORSE FALL SCALE V2 dated 11/19/2021 for Resident # 28 documented in part, Low Risk for Falling. The facility's progress note dated 11/27/2021 for Resident # 28 documented in part, .at 6:35 (a.m.) resident was noted on the floor next to bed, full body, neuro [neurological] assessment done while resident lie on the fall, .[Name of Physician] was notified, case manager was notified, resident was sent to the hospital. The facility's fall investigation for Resident # 28 dated 11/27/2021 documented in part, Resident c/o (complaint of) chest pain bout 6:30 am. (a.m.). Chest pain protocol initiated - O2, (oxygen), 3 (three) doses of Nitro, Aspirin given in am (a.m.). Unresolved. Resident rolled out of bed inspite [sic] of being placed at the middle and low bed position. No injuries sustained. The comprehensive care plan for Resident # 28 with a revision date of 11/27/2021 documented in part, Focus: The resident has had an actual fall related to sudden chest pains, dizziness, and shortness of breath. Date Initiated: 11/27/2021. Revision on: 11/29/2021 .Safety fall protocol in place- .fall mats in place . Date Initiated: 11/27/2021. Revision on: 11/29/2021. On 03/16/2022 at approximately 12:10 p.m. an interview and observation of Resident # 28's room was conducted with CNA [certified nursing assistant] # 1. When asked if Resident # 28 needed a fall mat next to their bed, CNA # 1 stated, Yes. He is a fall risk. After entering Resident # 28's room, CNA # 1 reached for the fall mat leaning against the wall at the foot of Resident # 28's bed. When asked if the fall mat should be on the floor next to the bed CNA # 1 stated, Yes, and placed the mat on the floor next to the bed. When asked who was responsible for placing the fall mat on the floor, CNA # 1 stated, The CNA or the nurse. On 03/16/2022 at approximately 12:20 p.m. an interview was conducted with LPN [licensed practical nurse] # 2. When asked if Resident # 28 needed a fall mat next to their bed LPN # 2 stated, No because he's not a fall risk. After LPN # 2 reviewed the comprehensive care plan dated 11/27/2021, LPN # 2 was asked again if Resident # 28 needed a fall mat. LPN # 2 stated, Yes, it should be down next to his bed. On 03/16/2022 at approximately 12:25 p.m., an interview was conducted with RN [registered nurse] # 2, unit manager. When asked if a fall mat should be on the floor next to Resident # 28's bed when they are in bed RN # 2 stated, Yes. When informed of the above observations RN # 2 stated, It should have been in place. The facility's policy FALLS/FALL WITH INJURY PREVENTION documented in part, POLICY STATEMENT: It is the policy of the facility to provide a safe environment for our residents. The facility's Fall Prevention initiative will provide strategies in attempt to decrease the number of falls and minimizes falls with injury. This policy will assure proper assessment and documentation of potential risk for falls, actual occurrence of falls and interventions to prevent future occurrences. On 03/16/2022 at approximately 5:00 p.m., ASM (administrative staff member) # 1, administrator, ASM # 2, director of nursing, ASM # 3, assistant director of nursing, ASM # 4, administrator from sister facility and RN # 4, staff development, were made aware of the 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, clinical record review, and facility document review, it was determined that the facility staff failed to provide respiratory care and services to two of 47 residents in the survey sample, Residents #2 and #315. The findings include: 1. The facility staff failed to provide oxygen at the prescribed rate for Resident #2. Resident #2 was admitted to the facility with diagnoses that included but were not limited to acute respiratory failure with hypoxia and heart failure. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/23/2022, the resident scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section O failed to evidence oxygen use. On 3/15/2022 at 12:19 p.m., an observation was made of Resident #2 in their room. Resident #2 was observed receiving oxygen via a nasal cannula attached to an oxygen concentrator. At this time an interview was conducted with Resident #2 who stated that they wore the oxygen all the time and had used oxygen for a long time. The top of the flowmeter ball was observed to be set below the line for 1 lpm (liter per minute). Additional observations of Resident #2 on 3/15/2022 at 2:48 p.m., and 4:25 p.m., and on 3/16/2022 at 8:05 a.m. revealed the findings as described above. The physician orders for Resident #2 documented in part, Oxygen at 1 liter per min (minute) via nasal cannula to maintain sats (saturations) above 92%. Order Date: 8/16/2021. The comprehensive care plan for Resident #2 failed to evidence use of oxygen. On 3/16/2022 at 12:15 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated Resident #2 received 1 liter of oxygen. LPN #5 stated that the oxygen flow rate was set by placing the top of the flowmeter ball at the line of the prescribed rate. LPN #5 observed Resident #2's oxygen with the top of the flowmeter ball set below the line for 1 lpm and stated that this was how they were trained to set the oxygen. On 3/16/2022 at approximately 5:15 p.m., RN (registered nurse) #3, staff development, ASM (administrative staff member) #2, the director of nursing and ASM #3, the assistant director of nursing were asked the process for setting the flowmeter ball on the oxygen concentrator. RN #3 stated that the line corresponding to the prescribed oxygen rate should go through the flowmeter ball to deliver the prescribed rate. The manufacturer's instructions for use provided by the facility for Resident #2's concentrator documented in part, .2. Check the flow meter to make sure that the flow meter ball is centered on the line next to the prescribed number of your flow rate . The facility policy, Oxygen Concentrator/Oxygen Utilization documented in part, .Oxygen will be administered to the resident per order . On 3/16/2022 at 5:20 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, administrator of a sister facility and RN (registered nurse) #3, staff development were notified of the findings. No further information was provided prior to exit. 2. The facility staff failed to obtain a physician's order for Resident #315's use of an incentive spirometer, and failed to store the incentive spirometer in a sanitary manner. Resident #315 was admitted to the facility with diagnoses including a heart attack. Resident #315's admission minimum data set was not completed. An admission assessment dated [DATE] documented Resident #315 was alert and oriented to person, place, time and situation. Review of Resident #315's March 2022 physician's orders failed to reveal a physician's order for an incentive spirometer. Resident #315's baseline care plan initiated on 3/7/22 failed to reveal documentation regarding an incentive spirometer. On 3/15/22 at 1:15 p.m., Resident #315 was observed sitting in a chair in the bedroom. An incentive spirometer was on the resident's over bed table. The incentive spirometer mouth piece was uncovered and exposed to air. At this time, an interview was conducted with the resident. Resident #315 stated, They told me to inhale 10 times. The resident did not specify who they were. When asked if the facility staff had provided a bag or another item to cover the mouth piece on the incentive spirometer, the resident stated they had not. On 3/16/22 at 8:34 a.m., the incentive spirometer remained uncovered and exposed to air on Resident #315's over bed table. On 3/16/22 at 2:53 p.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated residents should have a physician's order for an incentive spirometer. LPN #4 stated nurses must have orders from doctors. LPN #4 stated nurses can't just guess and need to obtain orders. When asked how an incentive spirometer should be stored, LPN #4 stated he had not cared for a patient with an incentive spirometer in a long time. On 3/16/22 at 3:37 p.m., an interview was conducted with RN (registered nurse) #1, regarding the storage on an incentive spirometer. RN #1 stated normally the nurses make sure it is dry, then places it in a zip lock bag to prevent infection. On 3/16/22 at approximately 5:50 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concerns. The facility policy titled, USE OF INCENTIVE SPIROMETER documented, 1. Get a physician's order prior to use .4. Ensure device is clean and kept in a sanitary manner. No further information was presented prior to exit.

Based on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to communicate consistently with the dialysis center for one of 47 residents in the survey sample, Resident #44. For Resident #44, the facility staff failed to evidence consistent communication via the dialysis communication book on multiple dates in 2022. The findings include: Resident #44 was admit to the facility on 4/5/2019 with a diagnosis of end stage renal failure requiring hemodialysis. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 1/11/2022, the resident scored a 15 on the BIMS (brief interview for mental status) score, indicating the resident is not cognitively impaired for making daily decisions. In Section O, Resident #74 was coded as receiving dialysis while a resident at the facility. The physician order dated 10/3/2020 documented, Dialysis Services [address of dialysis center] on Monday, Wednesday and Friday at 11:00 a.m. An interview was conducted with Resident #44 on 3/15/2022 at 2:08 p.m. When asked if she takes anything with her to dialysis, Resident #44 stated she takes a book with her to dialysis. She stated the book is kept at the nurse's station. On 3/16/2022 at 8:15 a.m. Resident #44's dialysis book was reviewed. There was only one page in the book; the page was dated 3/11/2022. The clinical record was reviewed for the months of January 2022 through March 15, 2022. The following dates were not located in the clinical record: 1/17/2022, 1/19/2022, 1/21/2022, 1/24/2022, 1/26/2022, 1/28/2022, 1/31/2022, 2/1/2022, 2/7/2022, and 2/21/2022. A request was made on 3/16/2022 at 3:29 p.m. for the missing dates above. On 3/17/2022 at 8:00 a.m. the following dates of documentation of communication with the dialysis facility was provided: 1/17/2022, 1/19/2022, 1/21/2022, 1/24/2022 and 2/21/2022. Still missing were the following dates: 1/26/2022, 1/28/2022, 1/31/2022, 2/1/2022, and 2/7/2022. The nurse's notes dated 1/26/2022 at 8:37 p.m. documented in part, Resident returned from dialysis. The nurse's note dated 1/28/2022 at 10:49 p.m. documented in part, Resident returned from dialysis. The nurse's note dated 1/31/2022 at 10:14 p.m. documented in part, Resident returned from dialysis. The nurse's note dated 2/1/2022 at 5:11 p.m. documented in part, Resident returned from dialysis. The nurse's note dated, 2/7/2022 at 4:59 p.m. documented in part, Resident returned from dialysis. The comprehensive care plan dated, 9/28/2020 and revised on 3/15/2022, documented in part, Focus: [Resident #74] has renal failure r/t (related to) End Stage Renal Disease/need for dialysis .Resident goes to Dialysis [name of dialysis center] 3 times a week on Mondays/Wednesdays and Fridays. An interview was conducted with LPN (licensed practical nurse) #5 on 3/16/2022 at 12:58 p.m. When asked the process for when a resident is sent to dialysis, LPN #5 stated, When we come in the morning that [Resident #44] goes to dialysis, we fill in the paper in the book and send the book with her. When asked if a new sheet is completed each time the resident goes to the dialysis center, LPN #5 stated, Yes, every time she goes to dialysis. LPN #5 further stated when the resident returns, the nurse has to check the book on a daily basis as sometimes the dialysis center will write recommendations. LPN #5 stated that sometimes the resident accidentally leaves the book at dialysis, so they have a second book to use, just in case. LPN #5 checked the second book and there were no communication papers in it. The facility policy, Coordination of Hemodialysis Services documented, Policy: Residents requiring an outside ESRD facility will have services coordinated by the facility. There will be communication between the facility and the ESRD facility regarding the resident. The facility will establish a Dialysis Agreement/Arrangement if there are any residents requiring Dialysis Services. The agreement shall include how the residents care is to be managed. Procedure: 1. The Dialysis Communication form will be initiated by the facility for any resident going to an ESRD center for hemodialysis. 2. Nursing will collect and complete the information regarding the resident to send to the ESRD Center. 3. The ESRD facility is to review the Dialysis Communication form and either: a. Complete the communication form and return with the resident OR b. Provide treatment information to the facility 4. Upon the resident's return to the facility, nursing will review the Dialysis Communication form and information completed by the dialysis center OR the information sent by the dialysis center; communicate with the resident's physician and other ancillary departments as needed, implement interventions as appropriate. 5. Nursing will complete the post dialysis information on the Dialysis Communication form and file the completed form in the Resident's Clinical record. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, administrator from a sister facility and RN (registered nurse) #3, the staff development nurse, were made aware of the above concern on 3/17/2022 at 9:29 a.m. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to administer medication in a sanitary manner for 1 of 6 residents in the Medication Administration observation, Resident #35. The facility nurse administered a medication which had been handled in an unsanitary manner to Resident #35. The findings include: Resident #35 was admitted to the facility with diagnoses including alcohol abuse and alcohol related hepatitis. On the most recent MDS (Minimum Data Set), a quarterly assessment with an ARD (Assessment Reference Date) of 3/7/22, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. A review of the clinical record revealed a physician's order dated 9/1/20 for Vitamin B1 (Thiamine) (1) 50 mg (milligrams) . On 3/16/22 at 8:17 AM, LPN #9 (Licensed Practical Nurse) was observed to prepare and administer medications for Resident #35. One of the medications prepared and administered was Vitamin B1 (Thiamine). LPN #9 donned gloves, and picked up the unsanitized pill cutter and the unsanitized stock bottle of Vitamin B1, thus contaminating her gloves. She poured a 100 mg pill of Vitamin B1 onto the pill cutter. She then used her contaminated, gloved finger to position the pill on the pill cutter. After cutting the pill in half, she dumped both halves from the pill cutter into the palm of her contaminated, gloved hand. She then picked up one half of the pill with her other contaminated, gloved hand, and placed it in the pill cup to administer to the resident. She placed the other half back into the stock pill bottle, contaminating all the other pills that remained in the bottle. On 3/16/22 at 9:12 AM, an interview was conducted with LPN #9. When asked about handling the Vitamin B1 with her hand and putting half of it back in the bottle, she stated that she had gloves on. When asked if she touched anything after putting gloves on, before handling the Vitamin B1 pill directly, such as the unsanitized pill cutter and unsanitized pill bottle, she stated that she should not have touched the pills, and scooped them up with a spoon instead, or poured them directly into a pill cup and then separated them to give the resident half for his ordered dose. She stated that this was an infection control concern. A review of the facility policy, Medication Pass/Administration was conducted. This policy documented, It is the policy of the facility to ensure safe administration of medications to our residents by licensed nurses according to acceptable professional standard 1. Cleanse hand before administering medications, and between resident contacts and after medication administration or resident contact. 2. Wear gloves as appropriate for administering and removing of some medications such as skin patches, eye drops, and ear drops. 3. Cleanse hand after removal of gloves. 4. Remove used gloves after removal of old patch (es), clean hands and wear a clean glove to administer a new patch. 5. Do not touch tablets with bare hands On 3/16/22 at 5:19 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, ASM #3 the Assistant Director of Nursing, ASM #4 Administrator of sister facility, and RN #3 (Registered Nurse) Staff Development, were made aware of the findings. No further information was provided by the end of the survey. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: .After touching a patient or the patient's immediate environment .After contact with blood, body fluids, or contaminated surfaces. This information is taken from the website https://www.cdc.gov/handhygiene/providers/guideline.html References: (1) Thiamine (vitamin B1) is used as a dietary supplement when the amount of thiamine in the diet is not enough. People most at risk for thiamine deficiency are older adults, those who are dependent on alcohol, or who have HIV/AIDS, diabetes, malabsorption syndrome (problems absorbing food), or have had bariatric surgery (an operation that helps you lose weight by making changes to your digestive system). Thiamine is used to treat beriberi (tingling and numbness in feet and hands, muscle loss, and poor reflexes caused by a lack of thiamine in the diet) and to treat and prevent Wernicke-Korsakoff syndrome (tingling and numbness in hands and feet, memory loss, confusion caused by a lack of thiamine in the diet). Thiamine is in a class of medications called vitamins. It is needed by the body to turn foods into energy, which is important for the growth, development, and function of cells. Information obtained from https://medlineplus.gov/druginfo/meds/a682586.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 the facility staff failed to provide evidence that all required information was provided to the hospital staff when five out of 47 residents in the survey sample were transferred to the hospital; Residents #101, #85, #71, #2 and #74. The findings include: Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence that all required information was provided to the hospital staff when five of 47 residents in the survey sample were transferred to the hospital, Residents #101, #85, #71, #2 and #74. The findings include: 1. The facility staff failed to provide evidence that care plan goals were provided to the hospital staff when Resident #101 was transferred to the hospital on 2/19/22. Resident #101 was admitted to the facility on [DATE]. Resident #101's diagnoses included but were not limited to: cerebral vascular accident, bladder neck obstruction and urinary tract infection. Resident #101's most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 3/2/22, coded the resident as scoring 7 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. Review of Resident #101's nursing progress note dated 2/19/22 at 3:02 PM revealed the following, [Resident #101] Out of bed in wheelchair, noted progressing weakness, unable to sit up straight. Slow respond to verbal and tactile stimuli. Transferred back in bed due to weakness. At lunch writer attempted to feed the resident, unable to open mouth, change in mental status, unable to respond to verbal stimuli .Notified nurse practitioner- send the resident to emergency room (ER) for further evaluation due to change in mental status and unable to respond to verbal stimuli. RP (responsible party) notified and given the change of status update. Resident was sent to the ER via 911 at 2:15 pm and given report to hospital. On 3/15/22 at approximately 5:00 PM a request was made for the evidence of information provided to the receiving facility when Resident #101 was transferred to the hospital. On 3/16/22 at 12:16 PM, an interview was conducted with ASM (administrative staff member) #1, the administrator and ASM #2 the director of nursing. ASM #1 provided a blank envelope compliance checklist: transfer/discharge requirements, which lists required documents. ASM #1 then stated, We recognized that the nurses are not making copies of the envelope of what is sent to the hospital for the residents going to the hospital. We have started whole house staff education for our nurses and going forward we will be making copies of this checklist and placing in the resident's record. ASM #2 then stated, We need to make sure the nurses are complying. From this point forward we will be checking on this. On 3/16/22 at 5:25 PM, ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, the administrator at sister facility and RN #3, staff development coordinator were informed of the above concern. According to the facility's Transfer or Discharge Requirements policy: Facility staff will ensure the following is provided when a resident is transferring or discharging from the facility. This is important for ensuring a safe and appropriate discharge which promotes continuity of care. List includes: face sheet, physician orders, diagnosis/allergies, advance directives, care plan goals, recent labs, isolation information, recent medications, recent nurse's notes, resident status, special instructions and copy of bed hold notice. No further information was provided prior to exit. 2. The facility staff failed to provide evidence that care plan goals were provided to the hospital staff when Resident #85 was transferred to the hospital on 2/3/22. Resident #85 was admitted to the facility with diagnoses including congestive heart failure, diabetes mellitus and bradycardia. Resident #85's most recent MDS (minimum data set) assessment, a Medicare five day assessment, with an assessment reference date of 1/19/22, coded the resident as scoring 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired. Review of Resident #85's nursing progress note dated 2/3/22 at 11:23 AM, revealed the following, About 11 AM resident stated that 'I am not doing good. I feel like passing out,' Checked resident's vital signs .Physician notified and new order given to send the resident to nearest ER (emergency room) for further evaluation and treatment. Resident left with ambulance. On 3/15/22 at approximately 5:00 PM a request was made for evidence of information provided to the receiving facility when Resident #85 was transferred to the hospital on 2/3/22. On 3/16/22 at 12:16 PM, an interview was conducted with ASM (administrative staff member) #1, the administrator and ASM #2 the director of nursing. ASM #1 provided a blank envelope compliance checklist: transfer/discharge requirements which lists required documents. ASM #1 then stated, We recognized that the nurses are not making copies of the envelope of what is sent to the hospital for the residents going to the hospital. We have started whole house staff education for our nurses and going forward we will be making copies of this checklist and placing in the resident's record. ASM #2 then stated, We need to make sure the nurses are complying. From this point forward we will be checking on this. On 3/16/22 at 5:25 PM, ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, the administrator at sister facility and RN #3, staff development coordinator were informed of the above concern. No further information was provided prior to exit. 3. The facility staff failed to evidence care plan goals were provided for Resident #71 to the receiving provider for a facility-initiated transfer on 1/29/2022. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 2/9/2022, the resident was assessed as being severely impaired for making daily decisions. The progress notes for Resident #71 documented in part, 1/29/2022 15:16 (3:16 p.m.) Resident observed in bed at beginning of shift with eyes closed and breathing through the mouth. O2 (oxygen) at 2L (two liters)/min (per minute) via nc (nasal cannula). BS (blood sugar) checked. Unable to get reading because BS was high .Resident continued with lip breathing with a lot of mucus from mouth. MD (medical doctor) notified. Order: Transfer resident to [Name of hospital] ER (emergency room) for further eval (evaluation) and treat. R/P (responsible party) notified. Resident pick up at 9:15 am via 911. The clinical record failed to evidence documentation of information provided to the hospital on 1/29/2022. On 3/16/2022 at 12:08 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that they sent an envelope containing documents with residents to the hospital when the resident is transferred out. LPN #5 stated that the envelope had a checklist on it that they followed. LPN #5 stated that they sent a face sheet, the history and physical, the progress notes, the care plan, the change in condition form, and labs in the envelope and called a report to the hospital. LPN #5 stated that they should document what was sent in the progress notes because they do not copy the envelope that was sent. LPN #5 stated that some of the nurses were good about making the notes and some were not. On 3/16/2022 at 12:16 p.m., ASM (administrative staff member) #1, the administrator stated that they did not have evidence of transfer documents sent to the hospital and that the nurses were not making copies of the envelope sent with the resident to the hospital containing the documents. ASM #1 stated that that going forward they planned to make copies of the envelopes. On 3/16/2022 at 5:20 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, administrator of a sister facility and RN (registered nurse) #3, staff development were notified of the findings. No further information was provided prior to exit. 4. The facility staff failed to evidence care plan goals were provided for Resident #2 to the receiving provider for a facility-initiated transfer on 3/9/2022. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/23/2022, the resident scored a 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact. The progress notes for Resident #2 documented in part, 3/9/2022 17:50 (5:50 p.m.) Resident was in bed on 2 iitters [sic] of oxygen via nasal canula [sic] at 8:40 am .Circa 9 am CNA (certified nursing assistant) caring for resident informed me that she was unable to eat her breakfast. Upon approaching her bedside, color appeared slightly cyanotic, skin cool to touch, resident was breathing without any difficulty, with oxygen @ 2L (liters) nasal cannula in use . was with definite change in mental status. Unable to respond verbally, no congestion observed. [Name of physician] was in house at the time and informed him of residents change in status. He ordered resident sent out 911. EMS (emergency medical services) was called . The progress notes further documented, 3/9/2022 22:34 (10:34 p.m.) Resident returned from the hospital at 8:45 pm. The clinical record failed to evidence documentation of information provided to the hospital on 3/9/2022. On 3/16/2022 at 12:08 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that they sent an envelope containing documents with residents to the hospital when transferred out. LPN #5 stated that the envelope had a checklist on it that they followed. LPN #5 stated that they sent a face sheet, the history and physical, the progress notes, the care plan, the change in condition form, and labs in the envelope and called a report to the hospital. LPN #5 stated that they should document what was sent in the progress notes because they do not copy the envelope that was sent. LPN #5 stated that some of the nurses were good about making the notes and some were not. On 3/16/2022 at 12:16 p.m., ASM (administrative staff member) #1, the administrator stated that they did not have evidence of transfer documents sent to the hospital and that the nurses were not making copies of the envelope sent with the resident to the hospital containing the documents. ASM #1 stated that that going forward they planned to make copies of the envelopes. On 3/16/2022 at 5:20 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, administrator of a sister facility and RN (registered nurse) #3, staff development were notified of the findings. No further information was provided prior to exit. 5. The facility staff failed to evidence care plan goals were provided to the receiving facility for a facility initiated transfer for Resident #74 on 1/31/2022. Resident #74 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set) assessment, a significant change Medicare five day assessment, with an ARD (assessment reference date) of 2/11/2022, the resident scored a one on the BIMS (brief interview for mental status) score, indicating the resident is severely cognitively impaired for making daily decisions. The nurse's note dated 1/31/2022 at 2:42 p.m. documented, Patient alert and restlessness with tachypnea and tachycardia .Patient stated, 'I am not feeding (sic) good,' moving all-around in bed, very irritable. MD (medical doctor) notified, new order given to give nebulizer treatment was given one time. Patient still noticed restlessness and fast breathing. Called 911 and sent to ER (emergency room) for further evaluation and treatment. MD made aware and responsible party, son [name of son] notified. Report is given to [Name of hospital] ER nurse. All paper work with med (medications) were given to 911 staff. Review of the clinical record on 3/15/2022 failed evidence documentation that the care plan goals were sent with the Resident # 74 upon transfer to the hospital on 1/31/2022. An interview was conducted with LPN (licensed practical nurse) #5 on 3/16/2022 at 12:08 p.m. When asked the process for sending a resident to the hospital, LPN #6 stated, When we transfer a resident to the hospital we send an envelope with them, the envelope has a checklist on it. We send a face sheet, the history and physical, the progress notes, the care plan, the change in condition form, and labs and we call a report to the hospital. We also send a bed hold notice with them. When asked where this should be documented, LPN #5 stated, We should document this in the progress note, we do not make a copy of anything. Some of the nurses are good about making the notes and some are not. On 3/16/2022 at 12:16 p.m. ASM (administrative staff member) #1, the administrator, stated, We recognized that the nurses are not making copies of the envelope of what is sent to the hospital for the residents going to the hospital. We have started a whole hospital education for our nurses and going forward will be making copies of this. ASM #2, the director of nursing, stated, We need to make sure the nurses are complying from this point forward. We will be checking on this. ASM #1, ASM #2, ASM #3, the assistant director of nursing, ASM #4, administrator from a sister facility, and RN (registered nurse) #3, the staff development nurse, were made aware of the above concern on 3/16/2022 at 5:30 p.m. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence written documentation to the Resident or RP (responsible party) and ombudsman upon transfer for five of 47 residents in the survey sample were transferred to the hospital; Residents #101, #85, #71, #2 and #74. The findings include: 1. The facility staff failed to evidence written documentation to the Resident or RP and Ombudsman when Resident #101 was transferred to the hospital on 2/19/22. Resident #101 was admitted to the facility on [DATE]. Resident #101's diagnoses included but were not limited to: cerebral vascular accident, bladder neck obstruction and urinary tract infection. Resident #101's most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 3/2/22, coded the resident as scoring 7 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired Review of Resident #101's nursing progress note dated 2/19/22 at 3:02 PM revealed the following, [Resident #101] Out of bed in wheelchair, noted progressing weakness, unable to sit up straight. Slow respond to verbal and tactile stimuli. Transferred back in bed due to weakness. At lunch writer attempted to feed the resident, unable to open mouth, change in mental status, unable to respond to verbal stimuli .Notified nurse practitioner- send the resident to emergency room (ER) for further evaluation due to change in mental status and unable to respond to verbal stimuli. RP (responsible party) notified and given the change of status update. Resident was sent to the ER via 911 at 2:15 pm and given report to hospital. On 3/15/22 at approximately 5:00 PM, a request was made for the evidence of written documentation to the Resident/RP and Ombudsman when Resident #101 was transferred to the hospital on 2/19/22. On 3/16/22 at 9:32 AM, an interview was conducted with ASM (administrative staff member) #1, the administrator who stated, We have not been sending notification to the ombudsman on hospital transfers. I have talked with the social worker and we will start doing that today, here is the proof of what we sent to the ombudsman this morning. ASM #1 provided copy of email sent to the Ombudsman dated 3/16/22 at 8:16 AM, with Resident #101's name listed. No evidence of written notification to RP was provided. An interview was conducted on 3/16/22 at 10:03 AM with OSM (other staff member) #5, the director of social services. When asked about ombudsman notification, OSM #5 stated, We are to notify the ombudsman, which is new to me. She stated she was just told this week, and are starting it now. I started at this facility in November. I will do at weekly notification to the ombudsman. I already have a relationship with the ombudsman and he comes in at least once a week. On 3/16/22 at 5:25 PM, ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, the administrator at sister facility and RN #3, staff development coordinator were informed of the above concern. According to the facility's Transfer & Discharge Notification policy which reveals, The facility will notify resident, or their representative as well as the Ombudsman of resident transfers and discharge. The facility will notify resident and the representative of transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility will send a copy of the notice to a representative of the Office of the State Long Term Care Ombudsman. No further information was provided prior to exit. 2. The facility staff failed to evidence written documentation to the Resident/RP and Ombudsman when Resident #85 was transferred to the hospital on 2/3/22. Resident #85 was admitted to the facility with diagnoses including congestive heart failure, diabetes mellitus and bradycardia. Resident #85's most recent MDS (minimum data set) assessment, a Medicare five day assessment, with an assessment reference date of 1/19/22, coded the resident as scoring 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired. Review of Resident #85's nursing progress note dated 2/3/22 at 11:23 AM, revealed the following, About 11 AM resident stated that 'I am not doing good. I feel like passing out,' Checked resident's vital signs .Physician notified and new order given to send the resident to nearest ER (emergency room) for further evaluation and treatment. Resident left with ambulance. On 3/15/22 at approximately 5:00 PM a request was made for the evidence of written documentation to the Resident or RP and Ombudsman when Resident #85 was transferred to the hospital on 2/3/22. On 3/16/22 at 9:32 AM, an interview was conducted with ASM (administrative staff member) #1, the administrator, who stated, We have not been sending notification to the ombudsman on hospital transfers. I have talked with the social worker and we will start doing that today, here is the proof of what we sent to the ombudsman this morning. ASM #1 provided copy of email sent to Ombudsman dated 3/16/22 at 8:16 AM, with Resident #85's name listed. No evidence of written notification to RP was provided. An interview was conducted on 3/16/22 at 10:03 AM with OSM (other staff member) #5, the director of social services. When asked about ombudsman notification, OSM #5 stated, We are to notify the ombudsman which is new to me. She stated she was just told this week. We are starting it now. I started at this facility in November. I will do at weekly notification to the ombudsman. I already have a relationship with the ombudsman and he comes in at least once a week. On 3/16/22 at 5:25 PM, ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, the administrator at sister facility and RN #3, staff development coordinator were informed of the above concern. No further information was provided prior to exit. 3. The facility staff failed to evidence written notification of transfer to the resident/RP or notification to the ombudsman for Resident #71's facility-initiated transfer on 1/29/2022. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 2/9/2022, the resident was assessed as being severely impaired for making daily decisions. The progress notes for Resident #71 documented in part, 1/29/2022 15:16 (3:16 p.m.) Resident observed in bed at beginning of shift with eyes closed and breathing through the mouth. O2 (oxygen) at 2L (two liters)/min (per minute) via nc (nasal cannula). BS (blood sugar) checked. Unable to get reading because BS was high .Resident continued with lip breathing with a lot of mucus from mouth. MD (medical doctor) notified. Order: Transfer resident to [Name of hospital] ER (emergency room) for further eval (evaluation) and treat. R/P (responsible party) notified. Resident pick up at 9:15 am via 911. The clinical record failed to evidence documentation of written notification of transfer to the resident/RP or notification to the ombudsman for the facility-initiated transfer on 1/29/2022. On 3/16/2022 at 12:08 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that they sent bed hold notice and clinical records for facility-initiated transfers but did not send any written notice of transfer to the resident or responsible party. On 3/16/2022 at 9:32 a.m., an interview was conducted with ASM (administrative staff member) #1, the administrator. ASM #1 stated that they had not been sending notification to the ombudsman for hospital transfers. ASM #1 stated that they had spoken with the social worker and had started doing this that morning. On 3/16/2022 at 10:03 a.m., an interview was conducted with OSM (other staff member) #5, the director of social work. OSM #5 stated that they only spoke with the responsible parties on the phone regarding the bed hold. OSM #5 stated that they had not been notifying the ombudsman of hospital discharges and that they were just told that they were to send them weekly starting now. On 3/16/2022 at 5:20 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, administrator of a sister facility and RN (registered nurse) #3, staff development were notified of the findings. No further information was provided prior to exit. 4. The facility staff failed to evidence written notification of transfer to the resident/RP or notification to the ombudsman for Resident #2's facility-initiated transfer on 3/9/2022. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/23/2022, the resident scored a 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact. The progress notes for Resident #2 documented in part, 3/9/2022 17:50 (5:50 p.m.) Resident was in bed on 2 iitters [sic] of oxygen via nasal canula [sic] at 8:40 am .Circa 9 am CNA (certified nursing assistant) caring for resident informed me that she was unable to eat her breakfast. Upon approaching her bedside, color appeared slightly cyanotic, skin cool to touch, resident was breathing without any difficulty, with oxygen @ 2L (liters) nasal cannula in use . was with definite change in mental status. Unable to respond verbally, no congestion observed. [Name of physician] was in house at the time and informed him of residents change in status. He ordered resident sent out 911. EMS (emergency medical services) was called . The progress notes further documented, 3/9/2022 22:34 (10:34 p.m.) Resident returned from the hospital at 8:45 pm. The clinical record failed to evidence documentation of written notification of transfer to the resident/RP or notification to the ombudsman for the facility-initiated transfer on 3/9/2022. On 3/16/2022 at 12:08 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that they sent bed hold notice and clinical records for facility-initiated transfers but did not send any written notice of transfer to the resident or responsible party. On 3/16/2022 at 9:32 a.m., an interview was conducted with ASM (administrative staff member) #1, the administrator. ASM #1 stated that they had not been sending notification to the ombudsman for hospital transfers. ASM #1 stated that they had spoken with the social worker and had started doing this that morning. On 3/16/2022 at 10:03 a.m., an interview was conducted with OSM (other staff member) #5, the director of social work. OSM #5 stated that they only spoke with the responsible parties on the phone regarding the bed hold. OSM #5 stated that they had not been notifying the ombudsman of hospital discharges and that they were just told that they were to send them weekly starting now. On 3/16/2022 at 5:20 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, administrator of a sister facility and RN (registered nurse) #3, staff development were notified of the findings. 5. The facility staff failed to provide written notification to the resident and/or responsible party for a facility initiated transfer, and failed to notify the ombudsman of a transfer to the hospital for Resident #74. Resident #74 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set) assessment, a significant change Medicare five day assessment, with an ARD (assessment reference date) of 2/11/2022, the resident scored a one on the BIMS (brief interview for mental status) score, indicating the resident is severely cognitively impaired for making daily decisions. The nurse's note dated 1/31/2022 at 2:42 p.m. documented, Patient alert and restlessness with tachypnea and tachycardia .Patient stated, 'I am not feeding (sic) good,' moving all-around in bed, very irritable. MD (medical doctor) notified, new order given to give nebulizer treatment was given one time. Patient still noticed restlessness and fast breathing. Called 911 and sent to ER (emergency room) for further evaluation and treatment. MD made aware and responsible party, son [name of son] notified. Report is given to [Name of hospital] ER nurse. All paper work with med (medications) were given to 911 staff. Review of the clinical record on 3/16/2022 failed to evidence a written notification for the reason for the transfer to the hospital on 1/31/2022 for Resident #74 was provided to the resident and/or responsible party. And further investigation revealed there was no notification of the ombudsman of the transfer of Resident #74 to the hospital on 1/31/2022. An interview was conducted with ASM (administrative staff member) #1, the administrator, on 3/16/2022 at 9:32 a.m. ASM #1 stated, We have not been sending notification to the ombudsman on hospital transfers. I've talked with the social worker and will start doing that today. Here is the proof of what we sent to the ombudsman this morning. An interview was conducted with OSM (other staff member) #5, the director of social services on 3/16/2022 at 10:03 a.m. When asked about notifying the ombudsman of a resident's transfer to the hospital, OSM #5 stated Notifying the ombudsman is new to me. I was just told this week about it and am starting it now. I will do it weekly, I already have a relationship with the ombudsman and he comes in at least once a week. Multiple requests were made for the documentation of the written notification to the resident and/or responsible party upon transfer to the hospital. Nothing was provided prior to exit. ASM #1, ASM #2, ASM #3, the assistant director of nursing, ASM #4, administrator from a sister facility, and RN (registered nurse) #3, the staff development nurse, were made aware of the above concern on 3/16/2022 at 5:30 p.m. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide a notice of bed hold when the resident was transferred to the hospital for four of 47 residents in the survey sample, Residents #101, #85, #71 and #74. The findings include: 1. The facility staff failed to evidence a bed hold was provided when Resident #101 was transferred to the hospital on 2/19/22. Resident #101 was admitted to the facility on [DATE]. Resident #101's diagnoses included but were not limited to: cerebral vascular accident, bladder neck obstruction and urinary tract infection. Resident #101's most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 3/2/22, coded the resident as scoring 7 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired Review of Resident #101's nursing progress note dated 2/19/22 at 3:02 PM revealed the following, [Resident #101] Out of bed in wheelchair, noted progressing weakness, unable to sit up straight. Slow respond to verbal and tactile stimuli. Transferred back in bed due to weakness. At lunch writer attempted to feed the resident, unable to open mouth, change in mental status, unable to respond to verbal stimuli .Notified nurse practitioner- send the resident to emergency room (ER) for further evaluation due to change in mental status and unable to respond to verbal stimuli. RP (responsible party) notified and given the change of status update. Resident was sent to the ER via 911 at 2:15 pm and given report to hospital. On 3/15/22 at approximately 5:00 PM a request was made for the evidence of a bed hold notification when Resident #101 was transferred to the hospital on 2/19/22. An interview was conducted on 3/16/22 at 10:03 AM with OSM (other staff member) #5, the director of social services. When asked about the bed hold notification being provided, OSM #5 stated, I talk with the family about a bed hold and talk with admitting about it. I communicate with the family. I do not know if anything is documented. An interview was conducted on 3/16/22 at 3:30 PM with OSM #8, the admissions director. When asked if a bed hold notification is provided to residents who are transferred to the hospital, OSM #8 stated, There is no evidence of documentation of bed hold offered to these residents. We do not give them a copy of the bed hold form. We verbally discussed with the RP. Not sure if it has been documented. On 3/16/22 at 5:25 PM, ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, the administrator at sister facility and RN #3, staff development coordinator were informed of the above concern. According to the facility's Bed Hold Notice Upon Transfer policy: At the time of transfer for the hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed. No further information was provided prior to exit. 2. The facility staff failed to evidence a bed hold was provided when Resident #85 was transferred to the hospital on 2/3/22. Resident #85 was admitted to the facility on [DATE]. Resident #85's diagnoses included but were not limited to: congestive heart failure, diabetes mellitus and bradycardia. Resident #85 was admitted to the facility with diagnoses including congestive heart failure, diabetes mellitus and bradycardia. Resident #85's most recent MDS (minimum data set) assessment, a Medicare five day assessment, with an assessment reference date of 1/19/22, coded the resident as scoring 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired. Review of Resident #85's nursing progress note dated 2/3/22 at 11:23 AM, revealed the following, About 11 AM resident stated that 'I am not doing good. I feel like passing out,' Checked resident's vital signs .Physician notified and new order given to send the resident to nearest ER (emergency room) for further evaluation and treatment. Resident left with ambulance. On 3/15/22 at approximately 5:00 PM a request was made for the evidence of a bed hold notification when Resident #101 was transferred to the hospital on 2/19/22. An interview was conducted on 3/16/22 at 10:03 AM with OSM (other staff member) #5, the director of social services. When asked about the bed hold being provided, OSM #5 stated, I talk with the family about a bed hold and talk with admitting about it. I communicate with the family. I do not know if anything is documented. An interview was conducted on 3/16/22 at 3:30 PM with OSM #8, the admissions director. When asked if a bed hold is provided to residents transferred to the hospital, OSM #8 stated, There is no evidence of documentation of bed hold offered to these residents. We do not give them a copy of the bed hold form. We verbally discussed with the RP. Not sure if it has been documented. On 3/16/22 at 5:25 PM, ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, the administrator at sister facility and RN #3, staff development coordinator were informed of the above concern. No further information was provided prior to exit. 3. The facility staff failed to provide bed hold notice for Resident #71's facility-initiated transfer on 1/29/2022. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 2/9/2022, the resident was assessed as being severely impaired for making daily decisions. The progress notes for Resident #71 documented in part, 1/29/2022 15:16 (3:16 p.m.) Resident observed in bed at beginning of shift with eyes closed and breathing through the mouth. O2 (oxygen) at 2L (two liters)/min (per minute) via nc (nasal cannula). BS (blood sugar) checked. Unable to get reading because BS was high .Resident continued with lip breathing with a lot of mucus from mouth. MD (medical doctor) notified. Order: Transfer resident to [Name of hospital] ER (emergency room) for further eval (evaluation) and treat. R/P (responsible party) notified. Resident pick up at 9:15 am via 911. The clinical record failed to evidence documentation of bed hold notice provided for the facility-initiated transfer on 1/29/2022. On 3/16/2022 at 12:08 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that they sent an envelope with documents with residents to the hospital with them when transferred out. LPN #5 stated that the envelope had a checklist on it that they followed. LPN #5 stated that the documents they sent to the hospital included a bed hold notice. LPN #5 stated that they should document what was sent in the progress notes because they do not copy the envelope that was sent. LPN #5 stated that some of the nurses were good about making the notes and some were not. On 3/16/2022 at 10:03 a.m., an interview was conducted with OSM (other staff member) #5, the director of social work. OSM #5 stated that they only spoke with the responsible parties on the phone regarding the bed hold. On 3/16/2022 at 3:30 p.m., an interview was conducted with OSM (other staff member) #8, the admissions director. OSM #8 stated that they did not have evidence of a bed hold provided to Resident #71. OSM #8 stated that they do not give a copy of the bed hold form, that they verbally discuss the bed hold with the responsible party and was unsure if it was documented. On 3/16/2022 at 5:20 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, administrator of a sister facility and RN (registered nurse) #3, staff development were notified of the findings. No further information was provided prior to exit. 4. The facility staff failed to provide a written copy of the bed hold policy upon transfer to the hospital on 1/31/2022 for Resident #74. Resident #74 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set) assessment, a significant change Medicare five day assessment, with an ARD (assessment reference date) of 2/11/2022, the resident scored a one on the BIMS (brief interview for mental status) score, indicating the resident is severely cognitively impaired for making daily decisions. The nurse's note dated 1/31/2022 at 2:42 p.m. documented, Patient alert and restlessness with tachypnea and tachycardia .Patient stated, 'I am not feeding (sic) good,' moving all-around in bed, very irritable. MD (medical doctor) notified, new order given to give nebulizer treatment was given one time. Patient still noticed restlessness and fast breathing. Called 911 and sent to ER (emergency room) for further evaluation and treatment. MD made aware and responsible party, son [name of son] notified. Report is given to [Name of hospital] ER nurse. All paper work with med (medications) were given to 911 staff. An interview was conducted with LPN (licensed practical nurse) #5 on 3/16/2022 at 12:08 p.m. When asked the process for sending a resident to the hospital, LPN #6 stated, When we transfer a resident to the hospital we send an envelope with them, the envelope has a checklist on it. We send a face sheet, the history and physical, the progress notes, the care plan, the change in condition form, and labs and we call a report to the hospital. We also send a bed hold notice with them. When asked where this should be documented, LPN #5 stated, We should document this in the progress note, we do not make a copy of anything. Some of the nurses are good about making the notes and some are not. A request was made for the documentation of the bed hold provided to Resident #74 and/or her responsible party on 3/15/2022 at 5:00 p.m. On 03/16/2022 at 3:31 p.m., OSM #8, the director of admissions stated, From what I understand, the family did not formally pay for a bed hold. OSM #8 stated she would further investigate this. On 3/16/2022 at 3:36 p.m. OSM #8 stated, We do not give them a copy of the bed hold form, it's verbally discussed with the RP (responsible party). When asked where the verbal discussion is documented, OSM #8 stated for [Resident #74], it is not documented. ASM #1, ASM #2, ASM #3, the assistant director of nursing, ASM #4, administrator from a sister facility, and RN (registered nurse) #3, the staff development nurse, were made aware of the above concern on 3/16/2022 at 5:30 p.m. No further information was provided prior to exit.

5. The facility staff failed to develop a care plan for use of a hand splint for Resident #71. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 2/9/2022, the resident was assessed as being severely impaired for making daily decisions. Section G documented Resident #71 as being totally dependent on two or more staff for bed mobility, transfers, dressing and personal hygiene. Section O documented Resident #71 using a splint or brace. On 3/15/2022 at approximately 12:45 p.m., an observation of Resident #71 was made in their room. Resident #71 was observed in bed wearing a hand splint on the right hand. The ADL (activities of daily living) documentation survey report for 3/1/2022-3/31/2022 documented in part, Restorative: Splint- Apply Bilateral upper hand resting splint x 2 hrs a day on at 11am, off at 1pm or as tolerated. The comprehensive care plan for Resident #71 failed to evidence use of a hand splint. On 3/16/2022 at 12:15 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that the care plans were the responsibility of the unit manager, the MDS staff, and the nurses. LPN #5 stated that the care plan was to show a progression of care and to guide them in patient care. LPN #5 stated that splints should be documented on the care plan. On 3/16/2022 at 2:19 p.m., an interview was conducted with LPN #3, MDS coordinator. LPN #3 stated that the purpose of the care plan was to coordinate resident care and work out a plan of care for the resident. LPN #3 stated that they go over the triggers after completing the comprehensive assessment and completed the care plan. LPN #3 stated that the nurses completed the care plans for changes in condition or specific incidents. LPN #3 stated that they would review Resident #71's record and see if the splint was addressed on the care plan. On 3/16/2022 at 4:18 p.m., LPN #3 stated that she had reviewed the record and there was an old care plan from the previous facility owners but it had not been carried over with the new company. LPN #3 stated that the splint should be on the current care plan. On 3/16/2022 at 5:20 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, administrator of a sister facility and RN (registered nurse) #3, staff development were notified of the findings. No further information was provided prior to exit. 6. For Resident #2, the facility staff failed to develop a care plan for the use of oxygen (A), and for skin integrity concerns (B). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/23/2022, the resident scored a 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact. Section M documented Resident #2 having 1 Stage 3 pressure ulcer. Section O failed to evidence documentation of oxygen use. A. Resident #2 was admitted to the facility with diagnoses that included but were not limited to acute respiratory failure with hypoxia and heart failure. On 3/15/2022 at 12:19 p.m., an observation was made of Resident #2 in their room. Resident #2 was observed receiving oxygen via a nasal cannula attached to an oxygen concentrator. At this time an interview was conducted with Resident #2 who stated that they wore the oxygen all the time and had used oxygen for a long time. The physician orders for Resident #2 documented in part, Oxygen at 1 liter per min (minute) via nasal cannula to maintain sats (saturations) above 92%. Order Date: 8/16/2021. The comprehensive care plan for Resident #2 failed to evidence use of oxygen. On 3/16/2022 at 12:15 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that the care plans were the responsibility of the unit manager, the MDS staff, and the nurses. LPN #5 stated that the care plan was to show a progression of care and to guide them in patient care. LPN #5 stated that the care plan was to be updated when there was any new treatment, infection or change in condition. LPN #5 stated that oxygen should be documented on the care plan. On 3/16/2022 at 2:19 p.m., an interview was conducted with LPN #3, MDS coordinator. LPN #3 stated that the purpose of the care plan was to coordinate resident care and work out a plan of care for the resident. LPN #3 stated that they go over the triggers after completing the comprehensive assessment and completed the care plan. LPN #3 stated that the nurses completed the care plans for changes in condition or specific incidents. LPN #3 stated that they would review Resident #2's record and see if the oxygen was addressed on the care plan. On 3/16/2022 at 4:18 p.m., LPN #3 stated that she had reviewed the record and oxygen was not on the care plan. LPN #3 stated that there should be a care plan for oxygen for Resident #2. On 3/16/2022 at 5:20 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, administrator of a sister facility and RN (registered nurse) #3, staff development were notified of the findings. B. The wound evaluation note dated 3/2/2022 documented in part, Left lateral leg, Length: 1.36cm (centimeter), Width: 0.80cm, Depth: 0.00cm .Date Wound Acquired: 3/2/22; Nonblanchable erythema (redness) surrounding a subcentimeter site of desquamation. Zinc oxide paste to wound and peri-wound Q (every) shift. Wound status: New; Acquired in house? Yes; Etiology: Pressure Ulcer- Stage 2 . The wound evaluation note dated 3/2/2022 documented in part, Sacrum, Length: 2.49cm, Width: 2.97cm, Depth 0.00cm .Date Wound Acquired: 3/2/22; Recurrent stage 3 pressure injury. Barrier cream to sacrum q shift. Wound status: New; Acquired in house? Yes; Etiology: Pressure Ulcer- Stage 3 . The comprehensive care plan for Resident #2 failed to evidence a care plan regarding pressure injuries or skin integrity. On 3/16/2022 at 12:15 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that the care plans were the responsibility of the unit manager, the MDS staff, and the nurses. LPN #5 stated that the care plan was to show a progression of care and to guide them in patient care. LPN #5 stated that almost all residents had the potential for skin integrity issues and were care planned for them. LPN #5 stated that Resident #5 should have a care plan for pressure injuries because there was a history of them. On 3/16/2022 at 2:19 p.m., an interview was conducted with LPN #3, MDS coordinator. LPN #3 stated that the purpose of the care plan was to coordinate resident care and work out a plan of care for the resident. LPN #3 stated that they go over the triggers after completing the comprehensive assessment and completed the care plan. LPN #3 stated that the nurses completed the care plans for skin conditions. LPN #3 stated that they would review Resident #2's record and see if pressure injuries/skin integrity was addressed on the care plan. On 3/16/2022 at 4:18 p.m., LPN #3 stated that she had reviewed the record and Resident #2 did not have a care plan for skin integrity and should have one. On 3/16/2022 at 5:20 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, administrator of a sister facility and RN (registered nurse) #3, staff development were notified of the findings. No further information was provided prior to exit. Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to develop and implement the comprehensive care plan for six of 47 residents in the survey sample, Residents #56, #28, #39 , #11, #71 and #2 . The findings include: 1. The facility staff failed to develop a comprehensive care plan to address Resident # 56's pain. Resident # 56 was admitted to the facility with a diagnosis that included by not limited to chronic pain. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/27/2022, the resident scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section J coded Resident # 56 as not having any pain in the past 5 (five) days. The physician's order sheet for Resident # 35 dated February 2022 documented in part: Oxycodone-Acetaminophen (1) 10-325 MG (milligram) Tablet. Give one tablet by mouth twice daily as needed. Order Date: 04/23/2021. Resident #56's eMAR (electronic medication administration record) for March 2022 documented the administration of the Oxycodone-Acetaminophen as documented above on the following dates and times, with no evidence of non-pharmacological interventions being attempted: 03/01/2022 at 4:31 p.m., 03/02/2022 at 7:23 a.m., 03/03/2022 at 4:54 p.m., 03/04/2022 at 5:42 p.m., 03/07/2022 at 7:00 p.m., 03/09/2022 at 9:19 p.m., 03/13/2022 at 5:22 a.m. and on 03/15/2022 at 4:44 p.m. The comprehensive care plan for Resident # 56 dated 04/29/2021 failed to evidence information related to pain. On 03/17/22 at approximately 10:52 a.m., an interview was conducted with Resident # 56. When asked if they receive pain medication as needed Resident # 56 stated, Sometimes. When asked if the staff try to alleviate their pain before giving them pain medication Resident # 56 stated Sometimes. On 03/16/2022 at approximately 2:20 p.m. an interview was conducted with LPN [licensed practical nurse] # 3, MDS coordinator regarding the comprehensive care plan for Resident # 56. When asked to describe the purpose for a care plan LPN # 3 stated, To coordinate resident care and work out a plan of care for the resident. When asked how the comprehensive care plan is developed for a resident LPN # 3 stated, Go with the triggers from the comprehensive assessment and develop the care plan and we follow the RAI (resident assessment instrument) manual When informed of a missing care plan to address Resident # 56's pain, LPN # 3 stated, I'll check the care plan. At approximately 4:18 p.m., LPN # 3 stated, There's no care plan for [Name of Resident # 56's] pain and there should be. The facility's policy Care Plans, Comprehensive Person-Centered documented in part, 8. The comprehensive, person-centered care plan will: a. Include e measurable objectives and time frames; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . The Resident Assessment Instrument (RAI) User's Manual. 4.7 The RAI and Care Planning documented in part, 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. Refer to 42 CFR 483.20(d), which notes that a nursing home must maintain all resident assessments completed within the previous 15 months in the resident's active record and use the results of the assessments to develop, review, and revise the resident's comprehensive plan of care. On 03/16/2022 at approximately 5:00 p.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, ASM # 3, assistant director of nursing, ASM # 4, administrator from sister facility and RN # 4, staff development, were made aware of the findings. No further information was provided prior to exit. References: (1) Indicated for the management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate. This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f2137f1a-b49a-40bd-97ac-cd6b36e295f4. 2. The facility staff failed to implement Resident # 28's comprehensive care plan for the use of a fall mat. Resident # 28 was admitted to the facility with a diagnosis that included but was not limited to: muscle weakness and a history of falls. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 12/30/2021, the resident scored 4 (four) out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely impaired of cognition for making daily decisions. On the following dates a times, Resident #28 was observed to bed, with no fall mat in place on the floor next to the bed: 03/15/22 at 12:40 p.m., 03/15/22 at 4:55 p.m., 03/16/22 at 8:05 a.m., and 03/16/22 at 12:00 p.m. At each observation, a fall mat was leaning against the wall at the foot of Resident #28's bed. The facility's fall investigation for Resident # 28 dated 11/27/2021 documented in part, Resident c/o (complaint of) chest pain bout 6:30 am. (a.m.). Chest pain protocol initiated - O2, (oxygen), 3 (three) doses of Nitro, Aspirin given in am (a.m.). Unresolved. Resident rolled out of bed inspite [sic] of being placed at the middle and low bed position. No injuries sustained. The comprehensive care plan for Resident # 28 with a revision date of 11/27/2021 documented in part, Focus: The resident has had an actual fall related to sudden chest pains, dizziness, and shortness of breath. Date Initiated: 11/27/2021. Revision on: 11/29/2021 .Safety fall protocol in place- .fall mats in place . Date Initiated: 11/27/2021. Revision on: 11/29/2021. On 03/16/2022 at approximately 12:20 p.m. an interview was conducted with LPN [licensed practical nurse] # 2. When asked if Resident # 28 needed a fall mat next to their bed LPN # 2 stated, No because he's not a fall risk. After informed of the above observations and reviewing the comprehensive care plan dated 11/27/2021 LPN # 2 was asked again if Resident # 28 needed a fall mat. LPN # 2 stated, Yes, it should be down next to his bed. When asked to describe the purpose of a care plan LPN # 2 stated, What kind of care to provide to the resident. When asked if the care plan was being followed if the fall mat was not on the floor next to the resident's bed LPN # 2 stated, No. On 03/16/2022 at approximately 12:25 p.m. an interview was conducted with RN [registered nurse] # 2, unit manager. When asked if a fall mat should be on the floor next to Resident # 28's bed when they are in bed RN # 2 stated, Yes. When informed of the above observations RN # 2 stated, It should have been in place. When asked to describe the purpose of a care plan RN # 2 stated, Tells how to take care of the resident. When asked if the care plan was being followed if the fall mat was not on the floor next to the resident's bed RN # 2 stated, Not at this time. On 03/16/2022 at approximately 5:00 p.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, ASM # 3, assistant director of nursing, ASM # 4, administrator from sister facility and RN # 4, staff development, were made aware of the findings. No further information was provided prior to exit. 4. The facility staff failed to develop a comprehensive care plan for the use of compression stockings for Resident #11. Resident #11 was admitted to the facility with the diagnoses including cerebral vascular disease and chronic obstructive pulmonary disease. On the most recent MDS (Minimum Data Set), an admission assessment with an ARD (Assessment Reference Date) of 12/9/21, the resident scored a 5 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely cognitively impaired for making daily decisions. A review of the physician's orders revealed the following order dated 12/2/21: Apply TED Hose/Compression Stockings (1) in the AM (morning) as resident tolerates. On 3/16/22 at 1:00 PM the resident was observed in bed without the stockings on. On 3/16/22 at 1:02 PM, an interview was conducted with LPN #10 (Licensed Practical Nurse). She stated that the resident had them on this morning when she was up, but that she wants them off when she is in bed. A review of the comprehensive care plan revealed no information regarding the use of compression stockings. On 3/16/22 at 2:20 PM an interview was conducted with LPN #3, the MDS nurse. She stated that the purpose of the care plan was, To coordinate the resident care, work out a plan of care for that resident. When asked if compression stockings should have been included in the care plan if there was an order at the time of admission for them, she stated it should have been. When asked who is responsible to develop the comprehensive care plan, she stated, MDS is responsible for the development of the care plan. A review of the facility policy, Care Plans, Comprehensive Person-Centered was reviewed. This policy documented, 8. The comprehensive, person-centered care plan will: .b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment . On 3/16/22 at 5:19 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, ASM #3 the Assistant Director of Nursing, ASM #4 Administrator of sister facility, and RN #3 (Registered Nurse) Staff Development, were made aware of the findings. No further information was provided by the end of the survey. References: (1) Compression stockings - You wear compression stockings to improve blood flow in the veins of your legs. Compression stockings gently squeeze your legs to move blood up your legs. This helps prevent leg swelling and, to a lesser extent, blood clots. If you have varicose veins, spider veins, or have just had surgery, your health care provider may prescribe compression stockings. Wearing stockings helps with: Aching and heavy feeling in legs; Swelling in legs; Preventing blood clots, primarily after surgery or injury when you are less active; Preventing complications of blood clots in the legs, such as post-phlebitic syndrome (pain and swelling in the leg) . Information obtained from https://medlineplus.gov/ency/patientinstructions/000597.htm 3. The facility staff failed to implement the comprehensive care plan to measure and observe the pressure injury for Resident #39. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 1/6/2022, Resident #39 was coded as having both short and long term memory difficulties and was coded as being severely cognitively impaired for making daily decisions. In Section M, the resident was coded as having no unhealed pressure injuries. The comprehensive care plan dated 12/19/2021, and reviewed on 3/16/2022, documented in part, Focus: The resident has non rupture blister on right inner heel .Weekly treatment documentation to include measurement of each are of skin breakdown's width, length, depth, type of tissue and exudate and any other notable change or observations. The nurse's note dated 12/19/2021 at 3:39 p.m. documented in part, Resident has non ruptured blister noted to her rt (right) inner heel. Measured 4x4. Elevated heel on pillow. Apply skin prep bid (twice a day) and monitor any change. In house wound consult .No sign and symptoms of verbal or non verbal pain or discomfort noted. The Weekly Non-Pressure Wound Observation Tool dated 12/19/2021 at 12:01 p.m. documented in part, Type of Wound - Other; Location - blister on the right heel, Describe the wound - non punctured blister, no infectious process. Date wound noted: 12/19/2021 .Comments: Blister not punctured. Drainage: none. Odor: none. Wound measurements: Length: 2 cm (centimeters), Width: 3 cm, Depth: blank. Describe wound edges and shape: Well defined. Treatment: placed skin prep applied, heels were floated. Evaluation: First observation. Comments: Wound care to treat and evaluate for healing. The Weekly Skin Review dated 12/27/2022 documented in part, Skin Condition: Open area - pre-existing - no site documented. The Weekly Skin Review dated 12/30/2021 documented in part, Skin Condition: Open area - pre-existing - no site documented. The Weekly Skin Review dated 1/3/2022 documented in part, Skin Condition: Open area - pre-existing - no site documented. The Weekly Skin Review dated 1/6/2022 documented in part, Skin Condition: Open area - pre-existing - no site documented. The Weekly Skin Review dated 1/10/2022 documented in part, Skin Condition: Open area - pre-existing - no site documented. The Weekly Skin Review dated 1/17/2022 documented in part, Skin Condition: Open area - pre-existing - RT (right) heel remains. The Weekly Skin Review dated 1/20/2022 documented in part, Skin Condition: Open area - pre-existing - Tx (treatment) to right heel remains. The Weekly Skin Review dated 1/24/2022 documented in part, Skin Condition: Open area - pre-existing - Tx continues to right heel. The Weekly Skin Review dated 1/27/2022 documented in part, Skin Condition: Open area - pre-existing - tx continues to right heel. The Weekly Skin Review dated 1/31/2022 documented in part, Skin Condition: Open area - pre-existing - Tx in progress to right heel. The Weekly Skin Review dated 2/7/2022 documented in part, Skin Condition: Open area - pre-existing- Tx in progress to right heel with skin prep. The Weekly Skin Review dated 2/14/2022 documented in part, Skin Condition: Open area - Pre-existing- no site documented. The Weekly Skin Review dated 2/21/2022 documented in part, Skin Condition: Open area - pre-existing - Tx continues to right heel with skin prep. The Weekly Skin Review dated 2/28/2022 documented in part, Skin Condition: Open area - pre-existing - right heel - tx in progress. The Weekly Skin Review dated 3/7/2022 documented in part, Skin Condition: Open area - pre-existing - Tx in progress to right heel. The Weekly Skin Review dated 3/14/2022 documented in part, Skin Condition: Open area - pre-existing - Tx in progress to right heel. On all of the above documents, there were no measurements of the heel wound. Review of the nurse's note from 1/1/2022 through 3/2/2022 revealed no documentation of the right heel wound measurements. The NP wound specialist note, dated 3/2/2022, documented in part, Opened DTI (deep tissue injury), now devolved into an unstageable pressure wound. Measurements: length - 0.95 cm (centimeters), width - 1.13 cm, depth - 0.2 cm. An interview was conducted with LPN #3, the MDS nurse, on 3/16/2022 at 2:22 p.m. When asked the purpose of the care plan, LPN #3 stated it was the plan of how to care for the resident. When asked if it should be followed, LPN #3 stated, Yes. An interview was conducted with LPN #1 on 3/16/2022 at 2:25 p.m. When asked if she was aware of the wound on Resident #39's right inner heel, LPN #1 stated, In late January. When asked when it was determined to be a deep tissue injury and no longer a blister, LPN #1 stated, In late January. When asked if there were any measurements of this wound prior to 3/2/2022, LPN #1 stated, No. When asked why there were no measurements prior to 3/2/2022, LPN #1 stated, I don't know. LPN #1 further stated the normal process when the nurse tells her about an area is for both of them to go in to look at the area of concern. The unit manager also goes with them to assess the area and put a treatment in place. ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the director of nursing, ASM #4, the administrator from a sister facility, and RN #3, the staff development nurse, were made aware of the above concerns on 3/16/2022 at 5:30 p.m. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. The facility failed to revise the comprehensive care plan to include bed rails for Resident #101. Resident #101's most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 3/2/22, coded the resident as scoring 7 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. The resident was coded as requiring extensive assistance in bed mobility. A review of Resident #101's care plan dated 2/17/22 revealed no information related to grab bars. A review of the physical therapy treatment encounter notes dated 3/2/22 which revealed the following, Bed mobility cue to use bed rail to roll to side. The resident was observed in bed with one quarter grab bars on 3/15/22 at 12:53 PM. When asked if he used the grab bars, Resident #101 stated, Yes, I use them on my one side to move a little. An interview was conducted on 3/16/22 at 2:20 PM with LPN (licensed practical nurse) #3, the MDS coordinator. When asked the purpose of the care plan, LPN #3 stated, The purpose is to coordinate the resident care, work out a plan of care for that resident. MDS is responsible for the development of the care plan. When asked if grab bars should be included on the care plan, LPN #3 stated, Yes I believe so. The care plan should be reviewed and revised to include them. When asked why the care plan should include the grab bars, LPN #3 stated, The care plan should include the grab bars because the resident could have injury with the grab bar and we need to review the care plan and check if they still need them. An interview was conducted on 3/16/22 at 3:03 PM with LPN #4. When asked if grab bars should be on the care plan, LPN #4 stated, Yes, they should be on the care plan. Usually under falls. On 3/16/22 at 5:25 PM, ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, the administrator at sister facility and RN #3, staff development coordinator were informed of the above concern. No further information was provided prior to exit. 6. A. The facility failed to revise the comprehensive care plan to include bed rails for Resident #81. Resident #81's most recent MDS (minimum data set) assessment, a Medicare five day assessment, with an assessment reference date of 2/16/22, coded the resident as scoring 9 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. The resident was coded as requiring extensive assistance in bed mobility. A review of Resident #81's care plan dated 2/9/22 revealed no information related to grab bars. A review of the physical therapy treatment encounter notes dated 2/11/22 which revealed the following, Using bedrails to roll side to side. The resident was observed in bed with one quarter grab bars on 3/16/22 at 7:53 AM. When asked if he used the grab bars, Resident #81 stated, Yes, I use them to help move and get up. An interview was conducted on 3/16/22 at 2:20 PM with LPN (licensed practical nurse) #3, the MDS coordinator. When asked the purpose of the care plan, LPN #3 stated, The purpose is to coordinate the resident care, work out a plan of care for that resident. MDS is responsible for the development of the care plan. When asked if grab bars should be included on the care plan, LPN #3 stated, Yes I believe so. The care plan should be reviewed and revised to include them. When asked why the care plan should include the grab bars, LPN #3 stated, The care plan should include the grab bars because the resident could have injury with the grab bar and we need to review the care plan and check if they still need them. An interview was conducted on 3/16/22 at 3:03 PM with LPN #4. When asked if grab bars should be on the care plan, LPN #4 stated, Yes, they should be on the care plan. Usually under falls. On 3/16/22 at 5:25 PM, ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, the administrator at sister facility and RN #3, staff development coordinator were informed of the above concern. No further information was provided prior to exit. 6. B. The facility failed to revise the comprehensive care plan to include brace for Resident #81. A review of Resident #81's care plan dated 2/9/22 revealed no information regarding a thoracic lumbar supporting brace. A review of the physician orders dated 2/9/22, revealed the following, To wear the thoracic lumber support brace when out of bed. Can apply himself when sitting on side of bed every shift. The resident was observed wearing his brace on 3/15/22 at 12:55 PM. When asked how often he wears his brace, Resident #81 stated, I put it on in the morning and keep it on till I go to bed. It helps with my back and posture. An interview was conducted on 3/16/22 at 2:20 PM with LPN (licensed practical nurse) #3, the MDS coordinator. When asked the purpose of the care plan, LPN #3 stated, The purpose is to coordinate the resident care, work out a plan of care for that resident. MDS is responsible for the development of the care plan. When asked if a brace should be included on the care plan, LPN #3 stated, Yes, a brace should be on the care plan. An interview was conducted on 3/16/22 at 3:03 PM with LPN #4. When asked if a brace should be on the care plan, LPN #4 stated, Yes, the brace should be on the care plan. On 3/16/22 at 5:25 PM, ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, the administrator at sister facility and RN #3, staff development coordinator were informed of the above concern. No further information was provided prior to exit. Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to review and/or revise the comprehensive care plan for 6 of 47 residents in the survey sample, Residents #33, #34, #86, #11, #101, and #81. The findings include: 1. The facility staff failed to review and revise Resident #33's comprehensive care plan for the use of grab bar bed rails. Resident #33 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/30/21, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is not cognitively impaired for making daily decisions. A physical therapy progress note dated 9/23/21 documented Resident #33 used bed rails for bed mobility. A review of Resident #33's comprehensive care plan dated 10/5/21 failed to reveal documentation regarding grab bar bed rails. A review of Resident #33's March 2022 physician's orders failed to reveal a physician's order for grab bar bed rails. On 3/15/22 at 1:07 p.m., Resident #33 was observed in bed with bilateral grab bar bed rails in the upright position. On 3/16/22 at 2:20 p.m., an interview was conducted with LPN (licensed practical nurse) #3 (the minimum data set coordinator). LPN #3 stated the purpose of the care plan is to coordinate resident care and work out a plan of care for that resident. LPN #3 stated she believed residents' care plans should be reviewed and revised to include the use of grab bars because grab bars can cause injury so staff has to review the care plan to see if residents still need grab bars. On 3/16/22 at approximately 5:50 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, Care Plan/Care Plan Meeting/Baseline Care Plan failed to document specific information regarding reviewing and revising the comprehensive care plan. No further information was presented prior to exit. 2. The facility staff failed to review and revise Resident #34's comprehensive care plan for the use of grab bar bed rails. Resident #34 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 12/28/21, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is not cognitively impaired for making daily decisions. An occupational therapy Discharge summary dated [DATE] documented a recommendation for grab bars. A review of Resident #34's comprehensive care plan dated 10/15/2 failed to revealed documentation regarding grab bar bed rails. A review of Resident #34's March 2022 physician's orders failed to reveal a physician's order for grab bar bed rails. On 3/15/22 at 1:36 p.m., Resident #34 was observed in bed with bilateral grab bar bed rails in the upright position. On 3/16/22 at 2:20 p.m., an interview was conducted with LPN (licensed practical nurse) #3 (the minimum data set coordinator). LPN #3 stated the purpose of the care plan is to coordinate resident care and work out a plan of care for that resident. LPN #3 stated she believed residents' care plans should be reviewed and revised to include the use of grab bars because grab bars can cause injury so staff has to review the care plan to see if residents still need grab bars. On 3/16/22 at approximately 5:50 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. 3. The facility staff failed to revise the comprehensive care plan for the use of compression stockings and a hand splint for Resident #86. On the most recent MDS (Minimum Data Set), a quarterly assessment with an ARD (Assessment Reference Date) of 2/9/22, Resident #86 was scored as having short term and long term memory problems and being moderately impaired in cognitive skills for daily decision making. The resident was coded as requiring supervision for eating and extensive assistance for all other areas of activities of daily living. A review of the clinical record revealed a physician's order dated 7/26/21 for Apply compression stockings (1) in am (morning) and remove at night. A review of the clinical record revealed a physician's order dated 12/30/21 for Apply right hand splint (2) every morning and remove at bedtime. On 3/16/22 at 12:06 PM, Resident #86 was observed up in her recliner, dressed. She did not have compression stockings or a hand splint on. 03/16/22 12:08 PM an interview was conducted with CNA #3 (Certified Nursing Assistant) and LPN #10 (Licensed Practical Nurse). They stated that the resident frequently refuses the stockings or wants them removed after they have been on a while. They stated that she does not like to wear them. Regarding the hand splint, they stated that they will put it on in the morning and then the resident will remove it at some point and won't wear it. A review of the comprehensive care plan failed to reveal any evidence of the compression stockings or hand splint being care planned for use. On 3/16/22 at 2:20 PM an interview was conducted with LPN #3, the MDS nurse. She stated that the purpose of the care plan was To coordinate the resident care, work out a plan of care for that resident. When asked if the comprehensive care plan should have been revised to include these items, she stated it should have been. When asked who is responsible for reviewing and revising the comprehensive care plan, she stated, The nurse caring for the resident. On 3/16/22 at 5:19 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, ASM #3 the Assistant Director of Nursing, ASM #4 Administrator of sister facility, and RN #3 (Registered Nurse) Staff Development, were made aware of the findings. No further information was provided by the end of the survey. References: (1) Compression stockings - You wear compression stockings to improve blood flow in the veins of your legs. Compression stockings gently squeeze your legs to move blood up your legs. This helps prevent leg swelling and, to a lesser extent, blood clots. If you have varicose veins, spider veins, or have just had surgery, your health care provider may prescribe compression stockings. Wearing stockings helps with: Aching and heavy feeling in legs; Swelling in legs; Preventing blood clots, primarily after surgery or injury when you are less active; Preventing complications of blood clots in the legs, such as post-phlebitic syndrome (pain and swelling in the leg) . Information obtained from https://medlineplus.gov/ency/patientinstructions/000597.htm (2) Splint - A splint is a rigid or flexible device that maintains in position a displaced or movable part, also used to keep in place and protect an injured part to support healing and to prevent further damage Purpose of Splinting: Immobilization; Support to promote healing; Positioning or supporting during function; Pain relief; Substitute for weak muscles; Correction and prevention of contracture & deformity; Restoring or maintaining of range of motion; Edema control . Information obtained from https://www.physio-pedia.com/Splint 4. The facility staff failed to revise the comprehensive care plan for nutritional needs related to weight loss for Resident #11. On the most recent MDS (Minimum Data Set), an admission assessment with an ARD (Assessment Reference Date) of 12/9/21, Resident #11 scored a 5 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely cognitively impaired for making daily decisions. The resident was coded as requiring limited assistance for eating. A review of the clinical record revealed the following weights: 3/3/2022 - 125.0 pounds, 2/3/2022 - 125.9 pounds, 1/4/2022 - 126.4 pounds, 12/30/2021 - 127.4 pounds, 12/16/2021 - 129.0 pounds, and 12/2/2021 - 129.4 pounds. This reflected a 4.4 pound weight loss in the approximately 90 day period since the resident was admitted and the weight that was obtained on 3/3/22. Further review of the clinical record revealed a dietary note dated 12/30/21 that documented, current weight: 127.4 lbs (pounds), down from weight on admission: 129.4 lbs. BMI (body mass index): 19.4, below healthy range for age. Diet: regular/regular/no added salt. Intake for the past 7 days 52% average Current diet is appropriate Supplement in place fortified foods with meals to help meet needs. Intake of meals not always meeting needs at this time. Met with resident in room, Resident stated she has enough to eat. Asked if she would like ice cream with meals, Resident stated yes, she would like that Plan: add ice cream to lunch and dinner meals, continue to monitor on weekly wts x 4 weeks. A dietary quarterly review dated 3/15/22 documented, Recent changes in Weight: Yes. Percent weight change in 30 days: 0.0. Percent weight change in 90 days: -3.40. Percent weight change in 180 days: n/a (not applicable) A review of the comprehensive care plan revealed nutritional related care plans for diabetes, anemia, and vitamin B12 deficiency. However, risk of weight loss and related nutritional needs had not been care planned after the resident exhibited a trend of mild weight loss in the first 90 days after admission. On 3/16/22 at 2:20 PM an interview was conducted with LPN #3, the MDS nurse. She stated that the purpose of the care plan was To coordinate the resident care, work out a plan of care for that resident. When asked if the care play should be revised if there was a weight loss since admission, she stated that it should be. When asked who is responsible for reviewing and revising the comprehensive care plan for nutritional and weight needs, she stated the dietician should be doing that. On 3/17/22 at 8:15 AM an interview was conducted with OSM #10 (Other Staff Member) the dietitian. When asked about a care plan related to the resident's weight loss and related nutritional needs, she stated that care plans are a joint effort and nutrition concerns are something the dietician would be involved in. She stated that the resident consumed 50% to 75% most days and 100% on some days. She stated that it would not have triggered a care plan for actual or significant weight loss as it was not a significant weight loss. When asked if, based on the 12/30/21 note wherein the resident was evidencing a trend of mild post admission weight loss, the weight loss should have been added to the care plan, she agreed. On 3/16/22 at 5:19 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, ASM #3 the Assistant Director of Nursing, ASM #4 Administrator of sister facility, and RN #3 (Registered Nurse) Staff Development, were made aware of the findings. No further information was provided by the end of the survey.

Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement a complete pain management program by implementing non-pharmacological interventions prior to the administration of a prn (as needed) pain medications for one of 47 residents in the survey sample, Residents # 56. The findings include: The facility staff failed to implement non-pharmacological interventions prior to the administration of oxycodone-acetaminophen (1) to Resident #56. Resident # 56 was admitted to the facility with a diagnosis that included by not limited to chronic pain. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/27/2022, the resident scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section J coded Resident # 56 as not having any pain in the past 5 (five) days. The physician's order sheet for Resident # 35 dated February 2022 documented in part: Oxycodone-Acetaminophen 10-325 MG (milligram) Tablet. Give one tablet by mouth twice daily as needed. Order Date: 04/23/2021. Resident #56's eMAR (electronic medication administration record) for March 2022 documented the administration of the Oxycodone-Acetaminophen as documented above on the following dates and times, with no evidence of non-pharmacological interventions being attempted: 03/01/2022 at 4:31 p.m., 03/02/2022 at 7:23 a.m., 03/03/2022 at 4:54 p.m., 03/04/2022 at 5:42 p.m., 03/07/2022 at 7:00 p.m., 03/09/2022 at 9:19 p.m., 03/13/2022 at 5:22 a.m. and on 03/15/2022 at 4:44 p.m. The comprehensive care plan for Resident # 56 dated 04/29/2021 failed to evidence information related to pain. On 03/17/22 at approximately 10:52 a.m., an interview was conducted with Resident # 56. When asked if they receive pain medication as needed Resident # 56 stated, Sometimes. When asked if the staff try to alleviate their pain before giving them pain medication Resident # 56 stated Sometimes. On 03/16/2022 at approximately 1:55 p.m. an interview was conducted with LPN (licensed practical nurse) # 2 regarding the procedure for administering prn (as needed) pain medication and documentation of non-pharmacological interventions. LPN # 2 stated, Assess the resident's pain, where the pain is and using a scale one to ten, with ten being the worse pain. Attempt interventions, like repositioning, to alleviate their pain, if it doesn't work administer the pain medication and recheck the resident for effectiveness. When asked how often the non-pharmacological interventions should be attempted LPN # 2 stated, Before you give the medication, every time. When asked about where the non-pharmacological interventions should be documented, LPN # 2 stated, It's documented in the nurse's notes. After reviewing the physician's orders, the March 2022 eMAR and the nurse's progress notes dated 03/01/2022 through 03/15/2022 for Resident # 56, LPN # 2 was asked if there was documentation that non-pharmacological interventions were attempted prior to Resident # 56 receiving the physician ordered pain medication of oxycodone on the dates listed above. LPN # 2 stated, No. The facility's policy Policy on Pain Management documented in part, POLICY STATEMENT: It is the policy of the facility to ensure that our residents are comfortable and free of pain as possible. Pain Management: Provide non pharmacological approach as needed or as requested by the resident. On 03/16/2022 at approximately 5:00 p.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, ASM # 3, assistant director of nursing, ASM # 4, administrator from sister facility and RN # 4, staff development, were made aware of the findings. No further information was provided prior to exit. References: (1) Indicated for the management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate. This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f2137f1a-b49a-40bd-97ac-cd6b36e295f4.

**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 maintain a complete and accurate clinical record for one of 47 residents in the survey sample, Resident #39. For Resident #39, the facility staff failed to document any notes related to a pressure injury from the end of January 2022 until March 2, 2022. The findings include: Resident #39 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 1/6/2022, the resident was coded as having both short and long term memory difficulties and was coded as being severely cognitively impaired for making daily decisions. In Section M, the resident was coded as having no unhealed pressure injuries. The nurse's note dated 12/19/2021 at 3:39 p.m. documented in part, Resident has non ruptured blister noted to her rt (right) inner heel. Measured 4x4. Elevated heel on pillow. Apply skin prep bid (twice a day) and monitor any change. In house wound consult .No sign and symptoms of verbal or non verbal pain or discomfort noted. The Weekly Non-Pressure Wound Observation Tool dated 12/19/2021 at 12:01 p.m. documented in part, Type of Wound - Other; Location - blister on the right heel, Describe the wound - non punctured blister, no infectious process. Date wound noted: 12/19/2021 .Comments: Blister not punctured. Drainage: none. Odor: none. Wound measurements: Length: 2 cm (centimeters), Width: 3 cm, Depth: blank. Describe wound edges and shape: Well defined. Treatment: placed skin prep applied, heels were floated. Evaluation: First observation. Comments: Wound care to treat and evaluate for healing. Review of the nurse's note from 1/1/2022 through 3/2/2022 revealed no documentation of the right heel wound measurements. The Weekly Skin Review dated 12/27/2022 documented in part, Skin Condition: Open area - pre-existing - no site documented. The Weekly Skin Review dated 12/30/2021 documented in part, Skin Condition: Open area - pre-existing - no site documented. The Weekly Skin Review dated 1/3/2022 documented in part, Skin Condition: Open area - pre-existing - no site documented. The Weekly Skin Review dated 1/6/2022 documented in part, Skin Condition: Open area - pre-existing - no site documented. The Weekly Skin Review dated 1/10/2022 documented in part, Skin Condition: Open area - pre-existing - no site documented. The Weekly Skin Review dated 1/17/2022 documented in part, Skin Condition: Open area - pre-existing - RT (right) heel remains. The Weekly Skin Review dated 1/20/2022 documented in part, Skin Condition: Open area - pre-existing - Tx (treatment) to right heel remains. The Weekly Skin Review dated 1/24/2022 documented in part, Skin Condition: Open area - pre-existing - Tx continues to right heel. The Weekly Skin Review dated 1/27/2022 documented in part, Skin Condition: Open area - pre-existing - tx continues to right heel. The Weekly Skin Review dated 1/31/2022 documented in part, Skin Condition: Open area - pre-existing - Tx in progress to right heel. The Weekly Skin Review dated 2/7/2022 documented in part, Skin Condition: Open area - pre-existing- Tx in progress to right heel with skin prep. The Weekly Skin Review dated 2/14/2022 documented in part, Skin Condition: Open area - Pre-existing- no site documented. The Weekly Skin Review dated 2/21/2022 documented in part, Skin Condition: Open area - pre-existing - Tx continues to right heel with skin prep. The Weekly Skin Review dated 2/28/2022 documented in part, Skin Condition: Open area - pre-existing - right heel - tx in progress. The Weekly Skin Review dated 3/7/2022 documented in part, Skin Condition: Open area - pre-existing - Tx in progress to right heel. The Weekly Skin Review dated 3/14/2022 documented in part, Skin Condition: Open area - pre-existing - Tx in progress to right heel. On all of the above documents, there were no measurements of the heel wound. The physician orders dated 12/19/2021 documented, Skin prep apply to right inner heel blister bid (twice a day) every day and evening shift. Review of the Treatment Administration Record for December 2021, January 2022, and February 2022, documented the skin prep as having been applied to right inner heel. The MD (medical doctor) note dated 1/7/2022 documented in part, Skin: no rashes, lesions, clubbing, cyanosis. No edema. The MD note dated 1/24/2022 documented in part, Skin: no rashes, lesions, ulcers. The MD note dated 2/17/2022 documented in part, Skin: No rashes, lesions or ulcers. The NP (nurse practitioner), wound specialist, note dated, 3/2/2022 documented, Right lateral heels wound .Pressure ulcer of right heel, unstageable. Assessment and Plan: Patient has a pressure injury. The NP wound specialist note dated 3/2/2022 documented in part, Opened DTI (deep tissue injury), now devolved into an unstageable pressure wound. Measurements: length - 0.95 cm (centimeters), width - 1.13 cm, depth - 0.2 cm. The comprehensive care plan dated, 12/19/2021 and reviewed on 3/16/2022, documented in part, Focus: The resident has non rupture blister on right inner heel .Weekly treatment documentation to include measurement of each are of skin breakdown's width, length, depth, type of tissue and exudate and any other notable change or observations. An interview was conducted with LPN #1 on 3/16/2022 at 2:25 p.m. When asked if she was aware of the wound on Resident #39's right inner heel, LPN #1 stated, In late January. When asked when it was determined to be a deep tissue injury and no longer a blister, LPN #1 stated, In late January. When asked if there were any measurements of this wound prior to 3/2/2022, LPN #1 stated, No. When asked why there were no measurements prior to 3/2/2022, LPN #1 stated, I don't know. LPN #1 further stated the normal process when the nurse tells her about an area is for both of them to go in to look at the area of concern. The unit manager also goes with them to assess the area and put a treatment in place. An interview was conducted with ASM (administrative staff member) #6, the nurse practitioner wound care specialist, on 3/16/2022 at 2:53 p.m. When asked if a blister on a heel is considered a pressure ulcer, ASM #6 stated If it's a fluid filled blister, it would be considered a stage 2. If it's open it would still be a stage 2. If it is more than superficial, then it could be a stage 3 or higher. When asked his first observation of Resident #39's right heel, ASM #6 stated, We did a full house skin sweep on 3/2/2022. It was a DTI (deep tissue injury) on her heel with a small scab. ASM #6 stated he changed the staging to an unstageable area at that time because of the necrotic tissue in the wound. When asked if Resident #39's wound was a pressure wound, ASM #6 stated, Yes, it's pressure. A second interview was conducted with LPN #1 on 3/16/2022 at 3:16 p.m. When asked if she wrote a note when she was made aware of the wound, LPN #1 stated, No I didn't do a wound note. When asked what the wound looked like when she saw it in late January, LPN #1 stated it was a DTI. LPN #1 stated, I requested the boot on her foot and offloading. When I reviewed the record at that time I saw there was already an order for skin prep in place. LPN #1 further stated, We use a camera to measure the wounds. When asked if she took a picture in January of the wound, LPN #1 stated, No, my ID (identification) doesn't work. When asked if she measured the wound from late January until March 2, 2022, LPN #1 stated, No. When asked if she saw the wound on Resident #39's heel from January through March, LPN #1 stated, Yes. When asked if she saw the wound but did not write a note, LPN #1 stated it was correct. When asked if she had the equipment to measure wounds when the camera is not working, or her access to the camera is not working, LPN #1 stated, Yes. LPN #1 stated the wound was Shrinking. A copy of the policy on a complete and accurate clinical record was requested on 3/16/2022 at 5:30 p.m. No policy was received. The following quotation is found in Lippincott's Fundamentals of Nursing 5th edition (2007, page 237): The client record serves as a legal document of the client's health status and care received .Because nurses and other healthcare team members cannot remember specific assessments or interventions involving a client years after the fact, accurate and complete documentation at the time of care is essential. The care may have been excellent, but the documentation must prove it. ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the director of nursing, ASM #4, the administrator from a sister facility, and RN #3, the staff development nurse, were made aware of the above concerns on 3/16/2022 at 5:30 p.m. No further information was provided prior to exit.

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to maintain one of three of the facility dumpsters in a sanitary manner. A trash bag approximately half full of trash was hanging on the outside of the dumpster and approximately twelve pairs of used plastic gloves and numerous pieces of debris were found lying on the ground around and behind the facility's dumpster. The findings include: On 03/15/22 at approximately 11:50 a.m., an observation of the facility's dumpsters was conducted with OSM (other staff member) # 1, dietary manager, OSM # 2, director of maintenance, OSM # 3, director of housekeeping and OSM # 4, housekeeper. The observation revealed that the facility had two trash dumpsters and one cardboard recycling dumpster and one dumpster for trash, next to each other located behind the facility. Observations of the area between and behind the two dumpsters revealed a broken mop handle between the two dumpsters, approximately 12 pairs of used plastic gloves, and numerous pieces of trash - behind the two dumpsters, mixed in and lying on top of decaying leaves and pine needles. Further observation revealed a trash bag, approximately half full of trash, hanging on the outside of the dumpster. When asked who was responsible for ensuring the dumpster area was kept clean, OSM # 2 stated, We call the company to come and empty the dumpsters and housekeeping is responsible for cleaning up around the dumpsters. The dumpsters were emptied this morning. When asked how often the dumpster area was cleaned and checked OSM # 3 stated, Every morning. When asked about the trash observed on the ground around the dumpsters OSM # 3 stated, [Name of OSM # 4] is responsible for cleaning up around the dumpster. OSM # 4 was asked how often they clean up around the dumpster, OSM # 4 stated, Every morning. When asked if they had come out to clean up around the dumpsters after they were emptied earlier that morning, OSM # 4 stated, No I was going to come out this afternoon. When asked why it was important to keep the dumpster areas clean and free from debris, OSM # 3 stated, For sanitary purposes, prevent rats and mice from coming around. The facility's policy External Environmental Cleaning documented in part, 5. Areas around the buildings (i.e., sidewalks, patios, gardens, dumpster area, etc.) shall be always maintained in a safe and orderly manner. On 03/16/2022 at approximately 5:00 p.m., ASM (administrative staff member) # 1, administrator, ASM # 2, director of nursing, ASM # 3, assistant director of nursing, ASM # 4, administrator from sister facility and RN # 4, staff development, were made aware of the findings. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, family interviews, staff interviews, facility documentation review, and clinical record review, the facility staff failed to implement policies and procedures regarding a choking incident and a bruise of unknown origin for 2 residents (Resident #82, #78) in a sample of 34 residents. 1. For Resident #82, the facility staff failed to investigate a choking incident. 2. For Resident #78, the facility staff failed to investigate a bruise of unknown origin. The findings include: 1. For Resident #82, the facility staff failed to investigate a choking incident. Resident #82, an [AGE] year old female was admitted to the facility on [DATE]. Diagnoses include dysphagia and dementia. Resident #82's most recent quarterly Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of 08/09/2018. Resident #82 was not coded with a Brief Interview of Mental Status (BIMS) score but cognitive skills for daily decision making were coded as severely impaired. Functional status for eating was coded as requiring extensive assistance. On 11/06/18 at 1:25 PM, the Resident was observed in her bed with family at bedside. The Resident was awake and the head of the head was elevated approximately 60 degrees. She had oxygen on at 2 liters/minute via nasal cannula. On 11/06/18 at approximately 3:00 PM, the nurse's notes were reviewed. An entry dated 10/16/18 at 2:02 PM documented, Family was feeding resident lunch, when she started choking. Upon suctioning resident, small pieces of watermelon were brought up. Patient is in stable condition. Vitals monitored and within normal limits. MD and speech therapy made aware. A nurse's note dated 10/24/18 documented, Resident observed with coughing nad (sic) congestion O2SAT 89-90%, MD made aware order received (sic) for chest xray order placed and done, result received (sic) Impression Right Basilar infiltrate and Pleural effusion, MD made aware order received (sic) for Levaquin 250mg by mouth daily for pneumonia PRN Robitussin administered for cough with effective result The physician's orders were reviewed. An ordered dated 01/09/18 documented, Mechanical soft diet with thin liquids. An order dated 10/09/18 documented, Mechanical soft diet with nectar thick liquids. An order dated 10/17/18 documented, ST to downgrade Pt to puree solid with nectar thick liquids. An order dated 10/24/18 documented, ST clarification order: 5X/WK (five times a week) for 5 weeks to continue to monitor pts (patient's) diet tolerance with moderate oropharyngeal dysphagia. An order dated 10/29/18 documented, Encouraged po (by mouth) nectar thickened liquids. Speech therapy notes were reviewed. An entry dated 10/09/18 documented, Pt. referred to ST (speech therapy) by nursing for coughing on thin liquids. Assessment summary included mild residue in oral cavity, pocketing of solids with a diet recommendation of mechanical soft textures and nectar thick liquids. An entry dated 10/10/18 documented, Pt's son reported he was concerned that pt would refuse nectar thick liquids, pt with no resistance to intake of nectar thick liquids. ST finding thin liquids at side of bed, reporting to nursing and removing liquids from the room. An entry dated 10/15/18 documented, ST educated staff of diet restrictions after finding thin liquids in the room and nurse attempting to get (sic) pt meds with thin liquids. An entry dated 10/17/17 documented, Pt reportedly choked last night, ST downgrading pt to puree. Pt with prolonged and disorganized mastication, needing cues to initiate swallowing and prolonged AP transit. Pt additionally more appropriate for pureed diet to level of alertness and edentulous status. An entry dated 10/18/18 documented, ST finding thin liquids at bedside, AGAIN, clearing from room and informing nursing of problem. An entry dated 10/19/18 documented, ST finding thin liquids at bedside AGAIN left by family in the evening. ST removing liquids and notifying nursing of issue. An entry dated 10/23/18 documented, ST finding thin liquids in pt's room AGAIN. ST in process of pursuing AMA (against medical advice) form due to families (sic) noncompliance with diet restrictions after education about purpose. On 11/07/18 at 8:40 AM, the Resident was observed awake in bed with the head of bed elevated approximately 60 degrees. She had oxygen on at 2 liters/minute via nasal cannula. On 11/7/18 at 9:00 AM, Employee A, dietary staff, was interviewed. Employee A explained that the facility used a dietary program called TrayCard System. He provided tray cards for Resident #82. He also provided the menus for Tuesday 10/16/18 (the day of the choking incident). The menu for 10/16/18 did not list watermelon. Employee A provided a snack schedule that included fruit as the snack for Tuesdays. Employee A stated that he does the food ordering for the facility. When asked to provide the invoice for the last time the facility ordered watermelon, Employee A stated that he ordered watermelon every week. When asked if the watermelon was delivered whole or precut, Employee A stated the watermelon was whole and the facility cut up the watermelon. When asked if there was documentation of the type of fruit served on Tuesday 10/16/18 for the 2:00 p.m. snack Employee A sated that he did not keep record. He stated that it could have been watermelon or cantaloupe. When asked how the fruit was delivered on the units for Tuesday snack day, Employee A stated that he sent large pans of cut up fruit and the staff portioned the fruit into cups. On 11/7/18 at 9:30 a.m., the Unit Manager, Licensed Practical Nurse A (LPN A), was interviewed. LPN A was asked if she knew anything about Resident #82's choking incident. She did not remember the details of the incident. She did not complete an incident report. On 11/7/18 at 9:45 AM, LPN B was interviewed. LPN B stated that the son had been feeding the Resident. LPN B stated that Certified Nursing Assistant A (CNA A) notified her that Resident #82 was choking. LPN B stated that she and LPN D responded. LPN B stated that LPN D suctioned the resident. LPN B stated that 2-3 pieces of watermelon were removed. She stated the watermelon pieces were long and skinny, about an inch long. LPN B could not remember if the watermelon was served by the facility that day or if the family brought in the fruit. On 11/07/18 at 1:00 PM, the Resident's son and daughter-in-law were at the Resident's bedside. When asked about the choking incident, the daughter-in-law stated they were not there when it happened but her brother-in-law (Resident's other son) was there when the choking incident occurred. When asked if her brother-in-law may have brought in food from home, she stated he never brings in food. On 11/7/18 at 1:45 p.m., Employee A was asked again to describe how the Tuesday fruit snack was prepared to send to the unit. Employee A provided an example of the container he used. It was a tall, cylindrical container. He stated that he filled the container half full. He stated that the fruit was cut in cubes less than an inch in size. He provided an example of the cut up watermelon for the survey team. The cubes were approximately 1- 1 ½ inch cubes. Employee A stated he sent 4 oz. plastic cups and a serving spoon for which the nursing staff would use to serve the fruit. Employee A stated he would send applesauce for residents on puree diet. On 11/07/18 at 3:50 PM, the Resident's younger son was interviewed. When asked about the choking incident, the son stated he arrived when CNA was finishing feeding his mom in the dining room. He stated the CNA was crushing large chunks of watermelon with a fork before feeding it to his mom. The son was shown the example of cut up watermelon provided by Employee A and he stated it looked like what the CNA was crushing and feeding to his mom that day. He also stated that the CNA left the dining room and he transported his mom back to her room and transferred her into her bed. While his mom was in the bed, he noticed she appeared to be choking so he called for the nurse. On 11/08/18 at 8:45 AM, CNA A was interviewed. CNA A stated on the day the Resident choked, the call bell was on and she entered the room, saw the Resident choking, and notified the nurse. CNA A stated that afterwards, she went into the dining room and saw the Resident's tray on the dining room table. She stated she was not in the dining room feeding the Resident that day and does not know who was. CNA A also stated the Resident was taken back to her room by the Resident's son. On 11/08/18 at 9:00 AM, the DON was interviewed. When asked what she knew about the choking incident, she stated I don't know much about it. When asked if she knew who fed the Resident watermelon that day, she said the daughter-in-law gave her watermelon. She stated the family usually brings in food from home. When asked about an incident report, she stated she didn't have an incident report. She stated sometimes residents with dysphagia will cough while they are being fed. She then stated if the Resident couldn't breathe, that would be a life and death situation. She also stated she didn't know the Resident needed to be suctioned. On 11/08/18 at 9:15 AM, CNA B was interviewed. When asked about the choking incident, CNA B stated she was feeding the Resident in the dining room that day but doesn't remember what the food was. She also stated she remembers the Resident's son came into the dining room. On 11/08/18 at 9:30 AM, LPN D was interviewed. When asked about the choking incident, LPN D states he was called to room by LPN B. He states the Resident was in the bed sweating, pale, clammy, and gasping for breath. He states suction was in the room on the crash cart. LPN D stated the son was in the room ('the one that is usually not here') and said his mom was choking. LPN D stated he looked in Resident's mouth and couldn't see anything. He suctioned her without results and then suctioned deeper. He stated a big piece of watermelon came out, then suctioned again and a smaller piece came out. He drew a picture to depict what the pieces looked like. He said the first piece was large, about a 3-inch slice. LPN D stated he did not see any food in the room. He also stated that LPN B told him the son gave his mom 'thickened liquids.' On 11/08/18 at 11:15 AM, the Administrator wanted to share what he learned about the choking incident. He apologized for not having an investigation. He stated he spoke with CNA B and she told him she was in the dining room that day but was not feeding the Resident. The Administrator stated CNA B told him the son was feeding the Resident and then brought the Resident back to her room. The Administrator stated he also spoke with CNA A. CNA A told the Administrator at the time of the incident, she went to alert LPN B and saw LPN D in the hall and asked for his assistance also. The Administrator stated the son told LPN B the son gave his mom thickened liquids but LPN D suctioned watermelon out. The Administrator stated when the son was asked if he brought in food, the son stated 'we don't bring in fruit' and another time stated 'we don't bring her food.' The facility policy (revised 10/01/2017) for investigating and reporting accidents/incidents was reviewed. The facility policy states that All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring at our facilities must be investigated and reported to the Administrator. In Section 2.1 under General Guidelines part 1B, the policy states an incident report must be completed for all reported accidents or incidents. The purpose of investigating and reporting incidents is to ensure the safety of all residents . and investigations into the cause of any incident will be tracked in order to improve care and to prevent future occurrences. On 11/08/18 at 12:00 PM, Resident's physician verified his handwritten progress note dated 10/23/18 documented, Pneumonia - possible aspiration In summary, this Resident was on a mechanical soft nectar thick liquids diet when the choking incident occurred on 10/16/18. The day before the choking incident occurred (10/15/18), a speech therapist witnessed a nurse attempting to give the Resident her medications with a thin liquid. There are conflicting reports about the choking incident such as where the watermelon came from (facility versus family), what size and consistency the watermelon was when the Resident ate it, and who fed the watermelon to the Resident. Seven days after the choking incident, the physician documented in the progress notes that Resident had possible aspiration pneumonia, ordered labs, chest x-ray, cough medicine, and antibiotics. There was not an investigation conducted by the facility staff and an incident report was not completed. Investigations and reporting assist facilities to identify risks, correct broken processes, and improve the health and safety of their residents. On 11/08/18 at approximately 3:00, the Administrator and the DON were notified of concerns and they offered no further information. 2. For Resident #78, the facility staff failed to investigate a bruise of unknown origin. Resident #78, an [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses include anemia, hypertension, diabetes, depression, Parkinson's, and Alzheimer's disease. Resident #78's most recent quarterly Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of 10/01/2018. Resident #78 was not coded with a Brief Interview of Mental Status (BIMS) score but cognitive skills for daily decision-making was coded as severely impaired. Functional status for bed mobility, transfers, dressing, and personal hygiene was coded as requiring extensive assistance. On 11/06/18 at 01:52 PM, the Resident was observed sitting in the day room, fully clothed. The Resident had a bruise on her right arm above and anterior to her elbow with approximately a 3- inch diameter. On 11/07/18 at approximately 12:45 PM, the Resident was observed sitting in the day area, eating lunch with staff assistance. She had a bruise on her right arm above and anterior to her elbow with approximately a 3- inch diameter. On the afternoon of 11/07/18, fall records for last 4 months for this Resident were requested from the DON. On 11/08/18, the DON stated there were no fall records for past four months for Resident #78. The care plan was reviewed. An entry dated 09/28/18 for a cut on Resident's finger included the following interventions: I need a weekly evaluation of wound healing. I need a daily observation of skin with routine care. I need a full skin evaluation weekly with bath/shower. Nurse's notes for September - November 2018 were reviewed. The bruise on the right arm was not addressed. On 11/08/18 at 8:40 AM, certified nursing assistant (CNA) C was asked about the origin of the bruise on this Resident's arm. The CNA was not aware the Resident had bruise on her right elbow. The CNA observed the bruise as the Resident was seated in the day room and the CNA stated 'it's an old bruise'. The bruise was yellowish in the center and purplish on the edges. Licensed practical nurse (LPN) E was standing nearby and stated that it was an old bruise but did not remember how the Resident acquired bruise but stated she 'wrote it up'. On 11/08/2018 at 10:15 AM, an incident report about Resident #78's bruise on her right arm was requested from the DON and she stated that's a new bruise so the incident report has not been written yet. On 11/08/18 at 10:30 AM, an interview with LPN E was conducted. LPN E stated she did a skin check on Resident #78 on Tuesday and that bruise (on the right arm) was not there. She went on to say that the Resident's daughter was walking her mom outside yesterday and then returned and showed the staff a bump on the back of the Resident's head. LPN E stated the bruise on the Resident's arm was a new bruise from yesterday. On 11/08/18 at approximately 2:45 PM, the DON presented an incident report about the bruise on the right arm. It was dated 11/08/18 at 9:30 AM and documented, Pt is noted with intact bruise to R (right) Upper arm close to the elbow. RP (responsible party) acknowledged holding pt on both arm (sic) by the elbow during ambulation out side (sic) the building yesterday. Intact bruise with dark-red puplish (sic) edges and slight greenish in color that measures 6x5x0. In summary, a bruise was observed on Resident #78's right arm above her elbow on 11/06/18 by this surveyor and there was no evidence the staff was aware of the bruise, conducted an assessment, started an investigation, reported findings, or initiated a treatment plan. On 11/08/18 at approximately 2:45 PM, the Administrator and DON were notified of concerns and they offered no further information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, family interviews, staff interviews, facility documentation review, and clinical record review, the facility staff failed to investigate a choking incident and a bruise of unknown origin for 2 residents (Resident #82, #78) in a sample of 34 residents. 1. For Resident #82, the facility staff failed to investigate a choking incident. 2. For Resident #78, the facility staff failed to investigate a bruise of unknown origin. The findings include: 1. For Resident #82, the facility staff failed to investigate a choking incident. Resident #82, an [AGE] year old female was admitted to the facility on [DATE]. Diagnoses include dysphagia and dementia. Resident #82's most recent quarterly Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of 08/09/2018. Resident #82 was not coded with a Brief Interview of Mental Status (BIMS) score but cognitive skills for daily decision making were coded as severely impaired. Functional status for eating was coded as requiring extensive assistance. On 11/06/18 at 1:25 PM, the Resident was observed in her bed with family at bedside. The Resident was awake and the head of the head was elevated approximately 60 degrees. She had oxygen on at 2 liters/minute via nasal cannula. On 11/06/18 at approximately 3:00 PM, the nurse's notes were reviewed. An entry dated 10/16/18 at 2:02 PM documented, Family was feeding resident lunch, when she started choking. Upon suctioning resident, small pieces of watermelon were brought up. Patient is in stable condition. Vitals monitored and within normal limits. MD and speech therapy made aware. A nurse's note dated 10/24/18 documented, Resident observed with coughing nad (sic) congestion O2SAT 89-90%, MD made aware order received (sic) for chest xray order placed and done, result received (sic) Impression Right Basilar infiltrate and Pleural effusion, MD made aware order received (sic) for Levaquin 250mg by mouth daily for pneumonia PRN Robitussin administered for cough with effective result The physician's orders were reviewed. An ordered dated 01/09/18 documented, Mechanical soft diet with thin liquids. An order dated 10/09/18 documented, Mechanical soft diet with nectar thick liquids. An order dated 10/17/18 documented, ST to downgrade Pt to puree solid with nectar thick liquids. An order dated 10/24/18 documented, ST clarification order: 5X/WK (five times a week) for 5 weeks to continue to monitor pts (patient's) diet tolerance with moderate oropharyngeal dysphagia. An order dated 10/29/18 documented, Encouraged po (by mouth) nectar thickened liquids. Speech therapy notes were reviewed. An entry dated 10/09/18 documented, Pt. referred to ST (speech therapy) by nursing for coughing on thin liquids. Assessment summary included mild residue in oral cavity, pocketing of solids with a diet recommendation of mechanical soft textures and nectar thick liquids. An entry dated 10/10/18 documented, Pt's son reported he was concerned that pt would refuse nectar thick liquids, pt with no resistance to intake of nectar thick liquids. ST finding thin liquids at side of bed, reporting to nursing and removing liquids from the room. An entry dated 10/15/18 documented, ST educated staff of diet restrictions after finding thin liquids in the room and nurse attempting to get (sic) pt meds with thin liquids. An entry dated 10/17/17 documented, Pt reportedly choked last night, ST downgrading pt to puree. Pt with prolonged and disorganized mastication, needing cues to initiate swallowing and prolonged AP transit. Pt additionally more appropriate for pureed diet to level of alertness and edentulous status. An entry dated 10/18/18 documented, ST finding thin liquids at bedside, AGAIN, clearing from room and informing nursing of problem. An entry dated 10/19/18 documented, ST finding thin liquids at bedside AGAIN left by family in the evening. ST removing liquids and notifying nursing of issue. An entry dated 10/23/18 documented, ST finding thin liquids in pt's room AGAIN. ST in process of pursuing AMA (against medical advice) form due to families (sic) noncompliance with diet restrictions after education about purpose. On 11/07/18 at 8:40 AM, the Resident was observed awake in bed with the head of bed elevated approximately 60 degrees. She had oxygen on at 2 liters/minute via nasal cannula. On 11/7/18 at 9:00 AM, Employee A, dietary staff, was interviewed. Employee A explained that the facility used a dietary program called TrayCard System. He provided tray cards for Resident #82. He also provided the menus for Tuesday 10/16/18 (the day of the choking incident). The menu for 10/16/18 did not list watermelon. Employee A provided a snack schedule that included fruit as the snack for Tuesdays. Employee A stated that he does the food ordering for the facility. When asked to provide the invoice for the last time the facility ordered watermelon, Employee A stated that he ordered watermelon every week. When asked if the watermelon was delivered whole or precut, Employee A stated the watermelon was whole and the facility cut up the watermelon. When asked if there was documentation of the type of fruit served on Tuesday 10/16/18 for the 2:00 p.m. snack Employee A sated that he did not keep record. He stated that it could have been watermelon or cantaloupe. When asked how the fruit was delivered on the units for Tuesday snack day, Employee A stated that he sent large pans of cut up fruit and the staff portioned the fruit into cups. On 11/7/18 at 9:30 a.m., the Unit Manager, Licensed Practical Nurse A (LPN A), was interviewed. LPN A was asked if she knew anything about Resident #82's choking incident. She did not remember the details of the incident. She did not complete an incident report. On 11/7/18 at 9:45 AM, LPN B was interviewed. LPN B stated that the son had been feeding the Resident. LPN B stated that Certified Nursing Assistant A (CNA A) notified her that Resident #82 was choking. LPN B stated that she and LPN D responded. LPN B stated that LPN D suctioned the resident. LPN B stated that 2-3 pieces of watermelon were removed. She stated the watermelon pieces were long and skinny, about an inch long. LPN B could not remember if the watermelon was served by the facility that day or if the family brought in the fruit. On 11/07/18 at 1:00 PM, the Resident's son and daughter-in-law were at the Resident's bedside. When asked about the choking incident, the daughter-in-law stated they were not there when it happened but her brother-in-law (Resident's other son) was there when the choking incident occurred. When asked if her brother-in-law may have brought in food from home, she stated he never brings in food. On 11/7/18 at 1:45 p.m., Employee A was asked again to describe how the Tuesday fruit snack was prepared to send to the unit. Employee A provided an example of the container he used. It was a tall, cylindrical container. He stated that he filled the container half full. He stated that the fruit was cut in cubes less than an inch in size. He provided an example of the cut up watermelon for the survey team. The cubes were approximately 1- 1 ½ inch cubes. Employee A stated he sent 4 oz. plastic cups and a serving spoon for which the nursing staff would use to serve the fruit. Employee A stated he would send applesauce for residents on puree diet. On 11/07/18 at 3:50 PM, the Resident's younger son was interviewed. When asked about the choking incident, the son stated he arrived when CNA was finishing feeding his mom in the dining room. He stated the CNA was crushing large chunks of watermelon with a fork before feeding it to his mom. The son was shown the example of cut up watermelon provided by Employee A and he stated it looked like what the CNA was crushing and feeding to his mom that day. He also stated that the CNA left the dining room and he transported his mom back to her room and transferred her into her bed. While his mom was in the bed, he noticed she appeared to be choking so he called for the nurse. On 11/08/18 at 8:45 AM, CNA A was interviewed. CNA A stated on the day the Resident choked, the call bell was on and she entered the room, saw the Resident choking, and notified the nurse. CNA A stated that afterwards, she went into the dining room and saw the Resident's tray on the dining room table. She stated she was not in the dining room feeding the Resident that day and does not know who was. CNA A also stated the Resident was taken back to her room by the Resident's son. On 11/08/18 at 9:00 AM, the DON was interviewed. When asked what she knew about the choking incident, she stated I don't know much about it. When asked if she knew who fed the Resident watermelon that day, she said the daughter-in-law gave her watermelon. She stated the family usually brings in food from home. When asked about an incident report, she stated she didn't have an incident report. She stated sometimes residents with dysphagia will cough while they are being fed. She then stated if the Resident couldn't breathe, that would be a life and death situation. She also stated she didn't know the Resident needed to be suctioned. On 11/08/18 at 9:15 AM, CNA B was interviewed. When asked about the choking incident, CNA B stated she was feeding the Resident in the dining room that day but doesn't remember what the food was. She also stated she remembers the Resident's son came into the dining room. On 11/08/18 at 9:30 AM, LPN D was interviewed. When asked about the choking incident, LPN D states he was called to room by LPN B. He states the Resident was in the bed sweating, pale, clammy, and gasping for breath. He states suction was in the room on the crash cart. LPN D stated the son was in the room ('the one that is usually not here') and said his mom was choking. LPN D stated he looked in Resident's mouth and couldn't see anything. He suctioned her without results and then suctioned deeper. He stated a big piece of watermelon came out, then suctioned again and a smaller piece came out. He drew a picture to depict what the pieces looked like. He said the first piece was large, about a 3-inch slice. LPN D stated he did not see any food in the room. He also stated that LPN B told him the son gave his mom 'thickened liquids.' On 11/08/18 at 11:15 AM, the Administrator wanted to share what he learned about the choking incident. He apologized for not having an investigation. He stated he spoke with CNA B and she told him she was in the dining room that day but was not feeding the Resident. The Administrator stated CNA B told him the son was feeding the Resident and then brought the Resident back to her room. The Administrator stated he also spoke with CNA A. CNA A told the Administrator at the time of the incident, she went to alert LPN B and saw LPN D in the hall and asked for his assistance also. The Administrator stated the son told LPN B the son gave his mom thickened liquids but LPN D suctioned watermelon out. The Administrator stated when the son was asked if he brought in food, the son stated 'we don't bring in fruit' and another time stated 'we don't bring her food.' The facility policy (revised 10/01/2017) for investigating and reporting accidents/incidents was reviewed. The facility policy states that All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring at our facilities must be investigated and reported to the Administrator. In Section 2.1 under General Guidelines part 1B, the policy states an incident report must be completed for all reported accidents or incidents. The purpose of investigating and reporting incidents is to ensure the safety of all residents . and investigations into the cause of any incident will be tracked in order to improve care and to prevent future occurrences. On 11/08/18 at 12:00 PM, Resident's physician verified his handwritten progress note dated 10/23/18 documented, Pneumonia - possible aspiration In summary, this Resident was on a mechanical soft nectar thick liquids diet when the choking incident occurred on 10/16/18. The day before the choking incident occurred (10/15/18), a speech therapist witnessed a nurse attempting to give the Resident her medications with a thin liquid. There are conflicting reports about the choking incident such as where the watermelon came from (facility versus family), what size and consistency the watermelon was when the Resident ate it, and who fed the watermelon to the Resident. Seven days after the choking incident, the physician documented in the progress notes that Resident had possible aspiration pneumonia, ordered labs, chest x-ray, cough medicine, and antibiotics. There was not an investigation conducted by the facility staff and an incident report was not completed. Investigations and reporting assist facilities to identify risks, correct broken processes, and improve the health and safety of their residents. On 11/08/18 at approximately 3:00, the Administrator and the DON were notified of concerns and they offered no further information. 2. For Resident #78, the facility staff failed to investigate a bruise of unknown origin. Resident #78, an [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses include anemia, hypertension, diabetes, depression, Parkinson's, and Alzheimer's disease. Resident #78's most recent quarterly Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of 10/01/2018. Resident #78 was not coded with a Brief Interview of Mental Status (BIMS) score but cognitive skills for daily decision-making was coded as severely impaired. Functional status for bed mobility, transfers, dressing, and personal hygiene was coded as requiring extensive assistance. On 11/06/18 at 01:52 PM, the Resident was observed sitting in the day room, fully clothed. The Resident had a bruise on her right arm above and anterior to her elbow with approximately a 3- inch diameter. On 11/07/18 at approximately 12:45 PM, the Resident was observed sitting in the day area, eating lunch with staff assistance. She had a bruise on her right arm above and anterior to her elbow with approximately a 3- inch diameter. On the afternoon of 11/07/18, fall records for last 4 months for this Resident were requested from the DON. On 11/08/18, the DON stated there were no fall records for past four months for Resident #78. The care plan was reviewed. An entry dated 09/28/18 for a cut on Resident's finger included the following interventions: I need a weekly evaluation of wound healing. I need a daily observation of skin with routine care. I need a full skin evaluation weekly with bath/shower. Nurse's notes for September - November 2018 were reviewed. The bruise on the right arm was not addressed. On 11/08/18 at 8:40 AM, certified nursing assistant (CNA) C was asked about the origin of the bruise on this Resident's arm. The CNA was not aware the Resident had bruise on her right elbow. The CNA observed the bruise as the Resident was seated in the day room and the CNA stated 'it's an old bruise'. The bruise was yellowish in the center and purplish on the edges. Licensed practical nurse (LPN) E was standing nearby and stated that it was an old bruise but did not remember how the Resident acquired bruise but stated she 'wrote it up'. On 11/08/2018 at 10:15 AM, an incident report about Resident #78's bruise on her right arm was requested from the DON and she stated that's a new bruise so the incident report has not been written yet. On 11/08/18 at 10:30 AM, an interview with LPN E was conducted. LPN E stated she did a skin check on Resident #78 on Tuesday and that bruise (on the right arm) was not there. She went on to say that the Resident's daughter was walking her mom outside yesterday and then returned and showed the staff a bump on the back of the Resident's head. LPN E stated the bruise on the Resident's arm was a new bruise from yesterday. On 11/08/18 at approximately 2:45 PM, the DON presented an incident report about the bruise on the right arm. It was dated 11/08/18 at 9:30 AM and documented, Pt is noted with intact bruise to R (right) Upper arm close to the elbow. RP (responsible party) acknowledged holding pt on both arm (sic) by the elbow during ambulation out side (sic) the building yesterday. Intact bruise with dark-red puplish (sic) edges and slight greenish in color that measures 6x5x0. The facility policy (revised 10/01/2017) for investigating and reporting accidents/incidents was reviewed. The facility policy states that All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring at our facilities must be investigated and reported to the Administrator. In Section 2.1 under General Guidelines part 1B, the policy states an incident report must be completed for all reported accidents or incidents. The purpose of investigating and reporting incidents is to ensure the safety of all residents . and investigations into the cause of any incident will be tracked in order to improve care and to prevent future occurrences. In summary, a bruise was observed on Resident #78's right arm above her elbow on 11/06/18 by this surveyor and there was no evidence the staff was aware of the bruise, conducted an assessment, started an investigation, reported findings, or initiated a treatment plan. On 11/08/18 at approximately 2:45 PM, the Administrator and DON were notified of concerns and they offered no further information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review, the facility staff failed for 1 resident (Resident #82) of 34 residents in the survey sample to review and revise the comprehensive care plan. 1. For Resident #82, the facility did not discontinue the use of adaptive utensils on the comprehensive care plan. The findings included: Resident #23, a [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, dysphagia, paralytic syndrome, hypertension, diabetes and chronic kidney disease. The most recent Minimum Data Set assessment was significant change assessment with an assessment reference date of 8/14/18. The resident was coded with a Brief Interview of Mental Status score of 9 indicating moderate cognitive impairment and required extensive assistance with activities of daily living. On 11/7/18, Resident #23 was observed eating breakfast and lunch in her room. She was observed to use regular utensils during both meals. Resident #23's comprehensive care plan was reviewed. The care plan dated 3/24/18 read, Resident requires angled utensils at every meal to enable her to help feed herself due to MS (multiple sclerosis). The comments section dated 9/17/18 read continue with plan of care. At the end of day meeting on 11/7/18, the Administrator and Director of Nursing were notified that Resident #23 was observed eating without her adaptive utensils. On 11/8/18 at 8:30 a.m., the Administrator provide the following Occupational Therapy note dated 4/25/17, pt (patient) does not want to use build up handles on utensils. The Administrator stated that the intervention should have been taken off the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation and clinical record review the facility failed for 1 resident (Resident #29) in a survey sample of 34 Residents to provide medications as ordered by physician. For Resident #29 the facility failed to obtain medication ordered by physician or obtain substitute until the medication was available. The findings include: Resident #29, a [AGE] year old man, was admitted to the facility on [DATE] with diagnoses including but not limited to Dysphagia, Muscular weakness, Aphasia (inability to talk), Parkinson's disease, and Hemiplegia. The most recent (Minimum Data Set) MDS with an (Assessment Reference Date) ARD of 02/19/2018 coded the Resident as having a (Brief Interview of Mental Status) of 15 indicating no cognitive impairment. On 11/7/2018 during clinical record review it was noted that Resident had order for Protonix Suspension 40 (milligrams) mg (by mouth) PO every day for (Gastro Esophageal Reflux Disease). The medication had been originally ordered on 10/13/2017. On review of the (Medication Administration Record) it was noted that the Resident missed 11 doses of the medication in October. 10/05/2018 at 6:00 AM 10/10/2018 at 6:00 AM 10/11/2018 at 6:00 AM 10/13/2018 at 6:00 AM 10/14/2018 at 6:00 AM 10/15/2018 at 6:00 AM 10/16/2018 at 6:00 AM 10/17/2018 at 6:00 AM 10/18/2018 at 6:00 AM 10/19/2018 at 6:00 AM 10/20/2018 at 6:00 AM On 11/8/2018 an interview was conducted with the DON who stated Well the insurance refused to pay for the liquid Protonix anymore and this Resident cannot swallow pills and he needs the liquid. She went on to say they used to cover it but then stopped paying for the liquid and the Pharmacy tried to get the doctor to substitute but the Doctor would not sign, he refused the Pharmacy Recommendations. The DON supplied three pharmacy recommendations titled Urgent - Non -Covered Medication - one notification was dated 07/25/18 the second one was dated 08/28/2018 and the third was dated 10/1/2018 all of the documents were marked as DENIED - Severe Dysphagia. The DON stated that the doctor finally substituted the Protonix with another medication when he saw the insurance would not cover it. The Doctor wrote an order on 10/21/2018 for Dexilant DR 60 mg by mouth once daily. Swallowing- may open capsule and sprinkle content onto apple sauce to be swallowed whole do not chew. The Administrator was made aware on 11/6/2018 and no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #82, the facility staff failed to ensure she was free from the psychotropic medication Seroquel which is not indicated for residents with a diagnosis of dementia. Resident #82, an [AGE] year old female was admitted to the facility on [DATE]. Diagnoses include dysphagia and dementia. Resident #82's most recent quarterly Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of 08/09/2018. Resident #82 was not coded with a Brief Interview of Mental Status (BIMS) score but cognitive skills for daily decision making were coded as severely impaired. Functional status for bed mobility, dressing, eating, and personal hygiene was coded as requiring extensive assistance. On 11/06/18 at 1:25 PM, the Resident was observed in her bed with family at bedside. The Resident was awake, calm, and the head of the head was elevated approximately 60 degrees. She had oxygen on at 2 liters/minute via nasal cannula. On 11/07/18 at 8:40 AM, the Resident was observed awake in bed, quiet, with the head of bed elevated approximately 60 degrees. She had oxygen on at 2 liters/minute via nasal cannula. The physician's orders were reviewed. An order dated 11/16/17 documented, Dental, Psych, Podiatric, Opthamological and Audiological services may be obtained for the resident as indicated. An order dated 11/16/17 documented, Quetiapine fumarate 25 mg tab. Give one tablet by mouth at bedtime for mood. An order dated 11/16/17 documented, Monitor and document mood and behavior every shift. The Medication Regime Review document with dates ranging from 12/6/17 to 10/9/18 was reviewed. The page contains monthly pharmacist signatures and dated. For monthly entries on 12/6/17, 1/8/18, 2/7/18, 3/8/18, 4/9/18, and 6/8/18, the box labeled see report for any noted irregularities and/or recommendations is selected. For monthly entries dated 5/4/18, 7/11/18, 8/13/18, 9/12/18, and 10/9/18, the box labeled NI (no irregularities) is selected. There was no other documentation on the form. The MAR (medication administration record) for October and November 2018 was reviewed. Quetiapine was signed off as being administered daily as scheduled. Under behavior charting, monitor and document mood and behavior every shift, there were staff initials daily and 0 behaviors documented daily. Resident notes were reviewed ranging August - November 2018. Asocial service entry dated 8/10/18 at 2:23 PM documented, She is pleasant and cooperative with care and no moods or behaviors have been documented. Resident is on Seroquel for mood and is being followed by psych group for medication management. A nurse's note dated 8/24/18 at 10:20 PM documented, no abnormal behavior/distress observed. A social services note dated 10/11/18 at 8:00 PM documented, No mood alteration has been documented. Resident continues on Seroquel for mood and Melatonin for sleep. Resident is generally pleasant but has a habit of grabbing or pinching at times. An interdisciplinary team meeting/MDS note dated 10/16/18 at 2:43 PM documented, Receives psychotropic medications for insomnia and mood disorder no adverse side effects noted at this time. A nurse's note dated 10/20/18 documented, Resident alert and verbally responsive. Pleasant and cooperative. A nurse's note dated 11/8/18 at 3:33 AM documented, Resident unable to comprehend commands when spoken to but would smile at staff speaking to her. The care plan was reviewed. A problem onset dated 11/29/17 documented, I am at risk for side effects from antipsychotic drug use due to mood. Interventions included, Administer my medication as ordered by physician. Observe me for adverse side effects, document and report to my physician. Monitor my behavior. There were no targeted behaviors listed on the care plan or non-pharmacological interventions associated with behaviors of grabbing or pinching as documented in the social services note. There was no evidence in the nurse's notes or care plan the Resident has been assessed to develop and implement Resident-specific behavior management associated with diagnosis of dementia and Resident's personal preference and expressions. On 11/08/18 at 11:45 AM, when LPN B was asked about behaviors exhibited by Resident #82, she stated she hasn't seen any behaviors in Resident #82. She went on to say Resident #82 is always sweet. On 11/08/18 at approximately 1:10 PM, the DON was asked about antipsychotics and she stated she would expect to see antipsychotics prescribed for residents with bipolar, schizophrenia, Tourette syndrome, and Huntington's (chorea). When asked why a resident with dementia is prescribed an antipsychotic, she stated they are used a lot for residents with dementia and behavior problems. She went on to say they don't want to chemically restrain or over-sedate (residents). On 11/08/18 at approximately 2:45 PM, the Administrator and DON were notified of concerns and they offered no further information. An antipsychotic such as Seroquel is contraindicated in elderly patients with dementia-related psychosis because of increased risk of death from CV disease or infection. (Nursing 2018 Drug Handbook, 2018, p. 1274). Based on staff interview, facility documentation and clinical record review the facility failed to ensure that 2 Residents (Resident #4 and #82) in a survey sample of 34 Residents were free from unnecessary medications. 1. For Resident #4, the facility failed to attempt gradual dose reduction of Psychotropic Drug Temazepam for a year. 2. For Resident #82, the facility staff failed to ensure she was free from the psychotropic medication Seroquel which is not indicated for residents with a diagnosis of dementia. The findings included: Resident #4, a [AGE] year old man, was admitted to the facility on [DATE] with diagnoses of but not limited to Diabetes, Hypertension, Atrial Fibrillation, and Depressive Disorder. On 11/06/2018 during clinical record review it was noted that Resident #4 had orders for Temazepam 15 (milligram) mg 1 capsule by mouth at bedtime and that order started on 5/7/2017 he also had an order for Wellbutrin ER 75 mg. (an antidepressant) twice daily. On 11/08/2018 at 11:00 AM an interview was conducted with the DON and she was asked why Resident was on Temazepam she stated Temazepam is a Hypnotic he takes it to help him sleep. When asked about the Wellbutrin she stated The Wellbutrin is an Antidepressant. Upon further investigation of the clinical record the Resident has had Pharmacy reviews every month however they failed to suggest a GDR for the Psychotropic medications. On 11/08/2018 during end of day meeting with DON she stated It was my understanding that only Psychoactive Medications like Seroquel and Zyprexa needed a GDR. On 11/08/2018 during clinical record review it was noted that according to the MDS from past year there has been no GDR for the Psychotropic medications. According to the MDS: Annual - 10/31/2017 Section N- Medications- Resident #4 was coded as having received Antidepressants as well as Hypnotics 7 days a week. According to section N-0450- Has GDR (Gradual Dose Reduction) been attempted the question was left blank. Section C - Last attempted GDR- NONE. Section E- Date physician document clinically contraindicated - NONE Quarterly MDS- 01/30/18 -Section N- Medications- Resident #4 was coded as having received Antidepressants as well as Hypnotics 7 days a week. According to section N-0450- Has GDR (Gradual Dose Reduction) been attempted the question was left blank. Section C - Last attempted GDR- NONE. Section E- Date physician document clinically contraindicated - NONE Quarterly -4/30/2018 -Section N- Medications- Resident #4 was coded as having received Antidepressants as well as Hypnotics 7 days a week. According to section N-0450- Has GDR (Gradual Dose Reduction) been attempted the question was left blank. Section C - Last attempted GDR-NONE. Section E- Date physician document clinically contraindicated - NONE Quarterly - 07/30/2018- Section N- Medications- Resident #4 was coded as having received Antidepressants as well as Hypnotics 7 days a week. According to section N-0450- Has GDR (Gradual Dose Reduction) been attempted the question was left blank. Section C - Last attempted GDR- NONE. Section E- Date physician document clinically contraindicated - NONE Administrator was notified of lack of GDR on 11/08/2018 no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff Interview, and facility Record Review, the facility staff failed to ensure that medications were not in an unlocked area, and available to residents. A wall cabinet on the [NAME] unit was open, unlocked, and could be easily accessed by wandering Residents. The cabinet contained 2 open gallon sized zip lock bags of various medications, on the bottom shelf, closest to the counter top. The findings include: On 11-17-18 at 9:17 a.m., The wall cabinet directly over the nursing station counter top, was opened by surveyors from the hallway. The cabinet contained 2 large gallon size zip lock bags full of open, and unopened medications. No nursing staff were in the nursing station, and Residents were wandering the halls freely. Some residents were noted to be in wheel chairs, and some were ambulatory. On 11-17-18 at 9:30 a.m., A Licensed Practical Nurse returned to the nursing station (LPN F), and surveyors pointed to the medications from the cabinet at that time, and asked her why the medications were there unlocked. LPN F stated We put them in the cabinet waiting to destroy them. LPN F then started to leave the nursing station, and was asked if she planned to leave the medications there, and she stated I am waiting for the DON (Director of Nursing). She then exited the nursing station again leaving the medications unattended. Surveyors then removed the medications from the cabinet and began documenting what was found in the bags. On 11-17-18 at 9:36 a.m., the nurse and DON arrived on the unit and spoke with surveyors. The DON was asked if medications should be left unlocked and unattended in the cabinet, and she stated no. A third surveyor observed the locked medication storage room, and LPN F stated that room was where medications should be stored, and pointed to a large bin which she stated was where medications were placed to return to the pharmacy. Those medications were opened, and unopened, but were not scheduled (controlled) drugs. LPN F stated all controlled drugs had to be destroyed by 2 nurses, the pharmacy would not take them back, one of the nurses present to destroy controlled medications was always the DON. The medications found in the unlocked cabinet were reviewed by 2 surveyors, and found to be; some new medications that were unopened and not expired, some opened medications with no open date, so expiration could not be known, and some open with an open date on the bottle, and were expired. The bags contained multiple bottles of those medications listed below, some open & some unopened. The items were as follows; Tylenol suppositories 325 mg (milligrams) unopened Sodium chloride tablets 1000 mg opened, and unopened Vitamin C 500 mg opened, and unopened Multivitamins opened, and unopened Zinc 220 mg opened, and unopened Dulcolax 5 mg opened Calcium carbonate 500 mg opened, and unopened Iron plus Vitamin C opened Loratidine opened Pepcid 10 mg opened Vitamin B complex opened Docusate 100 mg opened Senna plus 60 mg opened Magnesium oxide 400 mg opened Iron tablets opened Review of the pharmacy policy and procedure for medication storage was discussed with the DON. She stated that Facility staff should record the date opened on the medication container when the medication has been opened, and all medications must be stored in a locked area unavailable to residents. On 11-17-18, and 11-18-18, at the end of day debriefs the facility Administrator and DON were notified of the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation and clinical record review the facility failed to ensure that 1 Resident (Resident #55) of 34 residents was provided the therapeutic diet as ordered by physician. For Resident #55 the facility failed to ensure Resident was given the correct amount of fluids on his fluid restricted Renal Diet. The findings included: Resident #55 a [AGE] year old man was admitted to the facility with diagnoses of but not limited to End Stage Renal Disease, Dependent on Renal Dialysis, Dysphagia, (Methicillin Resistant Staphylococcus Aurous) MRSA to (Peripherally Inserted Central line Catheter) PICC line. On 11/7/2018 it was noted during clinical record review that Resident was on a fluid restricted renal diet due to his diagnosis of End Stage Renal Disease. The order in the chart dated 10/23/2018 that read Fluid Restrictions: Day 150 (milliliters) ml. Evening 100 ml, Night 50 ml, Total 300. The Remaining Fluid to Be Provided By Dietary. The order did not specify how much the additional fluid to be provided by Dietary was supposed to be. Further down on the list of orders was an order dated 10/19/18 that read Fluid Restriction 1.5 ml in 24 hours. During lunch observation on 11/8/2018 it was noted that the Resident only had 8 oz. tea on his lunch tray. On 11/8/2018 Employee A was asked to pull the Dietary Tickets for Resident #55. The dietary ticket showed Fluid Restriction 1400 ml / day. Breakfast states 620 ml, he was given 8 oz. each of Water and milk and 4 oz. of orange juice. Under that statement there is DISLIKES- MILK, REGULAR SUGAR. The Resident gets milk which is mentioned under dislikes and is using up 240 ml of his allotted 1500 ml of fluids. The DON was notified of the discrepancy in orders vs. Dietary tickets. DON stated she was not sure why the Dietary orders stated 1400 ml /day fluid restriction and the chart stated 1500 ml /day. The DON came back later that day and stated that she had spoken to the doctor and clarified that it should have been 1500 ml /day and 300 ml to be given by nursing staff the remaining 1200 ml by Dietary. The DON also stated she would check with the Resident's family to find out what the preferences are as resident is non English speaking. The Administrator was notified at the end of day meeting on 11/7/2018 and no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #59's care plan did not describe, nor address, his dementia needs, nor behaviors, for which the Resident received 5 psychotropic medications. Resident #59 was admitted to the facility on [DATE]. Diagnoses included but were not limited to; unspecified dementia, without behavioral disturbance, Alzheimer dementia, femur fracture, dysphagia, history of falling, cardiac disease, and cognitive communication deficit. Resident #59's most recent Minimum Data Set (an assessment protocol) was a quarterly assessment with an Assessment Reference Date of 10-17-18 coded Resident #59 with a BIMS (brief interview of mental status) score of 99, or unable to complete, due to cognitive impairment. Resident #59 required extensive assistance for his ADL's (activities of daily living such as bed mobility and toileting) of one to two staff members. The resident was incontinent of bowel & bladder. On 11-7-18 at 10:30 a.m., Resident #59 was observed in the back of the main dining/living room area of the locked Alzheimer's unit. The Resident was sitting in a high back wheel chair at a dining table alone. The Resident was against the wall to his left, and had a short knee wall behind him. The Resident was staring down at the table, and nothing was on the table. The surveyor approached the Resident and said hello, and asked the Resident his name, and other questions, the Resident did not look up or speak. On 11-8-18 at 11:00 a.m., during a second observation of Resident #59, the Resident was observed in the back of the main dining/living room area of the locked Alzheimer's unit. The Resident was sitting in a high back wheel chair at a dining table alone. The Resident was against the wall to his left, and had a short knee wall behind him. The Resident was staring down at the table, and a newspaper was on the table folded, the Resident was not looking at it, but was staring down at the table. The surveyor approached the Resident and said hello, and asked the Resident his name, and other questions, the Resident did not look up or speak. Review of the physician's orders in the clinical record revealed the resident was currently receiving the following 5 psychotropic medications, and melatonin for sleep at night; 1. Wellbutrin for depression 2. Depakote for unknown/no medical need given 3. Razadyne for dementia 4. Namenda for dementia 5. Seroquel for dementia with agitation Review of the current care plan dated 5-3-18, revealed only 4 care planned problem areas that could be related to dementia. three were developed on 5-3-18, and the last was added on 6-20-18. Those follow with their goals and interventions to be used: 1. PROBLEM. The resident is easily upset, he refuses care, attempts to hit staff, and very difficult to redirect. The GOAL. safety of residents and staff with no incident reports of injury to others thru nrst (sic) review. The INTERVENTIONS/approaches. approach resident with cayusion (sic), try to redirect resident, attend to needs as quickly as possible, continue full assist in care, ADL care. 2. PROBLEM. I am at risk for side effects from antidepressant medication use. The GOAL. I will have no injury related to medication usage/side effects thru next review. The INTERVENTIONS/approaches. administer my medication as ordered by physician, observe me for adverse side effects, document and report to physician, pharmacy consultant review of my medication monthly. 3. PROBLEM. I am at risk for side effects from antipsychotic drug use. The GOAL. I will have no serious injury related to medication usage/side effects thru next review. The INTERVENTIONS/approaches. administer my medication as ordered by physician, observe me for adverse side effects, document and report to physician, monitor my behavior. 4. dated 6-20-18 PROBLEM. Impaired decision making skills related to diagnosis of Alzheimer's disease as evidenced by staff assessments for cognition. The GOAL. Resident will accept judgement of staff/significant other regarding plan of care as appropriate thru next review date. The INTERVENTIONS/approaches. explain each activity/care procedure prior to beginning it, observe for changes in cognitive status, establish daily routine with resident, praise resident for each decision made, give resident two choices when presenting decisions, offer simple choices to resident, give resident no choice that will be overwhelming. Review of physician progress notes, to include geriatric psychiatric evaluations revealed that the only behavior documented in the clinical record was refusal of care, and agitation when staff pursued or insisted on giving care when the resident refused. Two gradual dose reductions were completed, (Razadyne in June 2018, and Seroquel in August 2018), with success, as no worsening of the Resident's refusal of care occurred afterward. The Medication, and Treatment Administration Records (MAR's/TAR's) were reviewed and revealed an area for Behavior charting. No behaviors were charted as ever occurring in the months of September, October, nor November 2018. For August 2018, only one time was behavior documented in a 4 month period, which was 8-30-18 at 3:00 p.m., and no nursing note describes what that episode consisted of. Review of nursing progress notes revealed no aggressive behaviors toward peers. The only behavior documented in the clinical record was refusal of care, and agitation when staff pursued or insisted on giving care when the resident refused. There were no targeted behaviors addressed on the plan of care, nor were there any non pharmacological interventions included for the Resident's refusal of care or agitation during refused care. There is no indication that the staff ever identified the possible reason for the refusal of care, nor were there any plans to mitigate the agitation and upset expressed by the Resident. The Resident had a flat and blunted, lethargic affect on both surveyor observations, and did not respond to direct questioning, nor did he interact with his surroundings. The Resident appeared as in a stupor, staring at the table, with no reaction to verbal stimuli. On 11-8-18, an interview was conducted with LPN E. LPN E was the Resident's care giver, and stated when asked, yes, I take care of him every day. LPN E stated that the Resident never bothered other Residents, he was just upset sometimes with staff when they tried to change him, or give him a bath. She further stated that the Resident liked the little area by the wall, and that he had a book he liked, and if staff gave it to him, he would sit quietly and was no problem at all. LPN A, the unit manager approached and stated, we don't have any problem with him except for incontinent care, then he can get agitated, but the medicine helps with this. LPN A was asked why he was not allowed to refuse, and she stated because he doesn't know what is best for himself because of his dementia. On 11-8-18 at 12:20 p.m., an interview was conducted with the care plan coordinator LPN H. LPN H was asked to tell surveyors how care planning was completed for dementia residents, she stated It can be done with behaviors included or not, but if the resident has behaviors we care plan it. She stated that the purpose of the care plan was to instruct staff on the care needed for this particular resident. She was asked to review Resident #59's care plan and tell me what his behaviors were, and what they were doing for them. LPN H stated he refuses care, and will hit staff, and is difficult to redirect. She was asked what do staff do when this happens? She reviewed the care plan, and stated I don't know. She was asked if she knew what triggered the refusals, and she stated I don't know. She was asked if he received the psychotropic medications for these behaviors, and she stated yes. The Facility policy entitled Behavior Management was reviewed and revealed training was given to staff in regard to resisting care, catastrophic reactions, agitation, redirection, and interventions that would be appropriate in treating these circumstances. Most were not used in Resident # 59's care plan. On 11-8-19 at 1:00 p.m., the Administrator and Director of Nursing (DON) were made aware of the findings. At the time of exit the DON stated there was no further information available to submit to surveyors. Based on observation, staff interview, facility documentation review, and clinical record review, the facility staff failed to develop and implement a comprehensive person centered care plan for three Residents (Residents #43, #20, and #59) of the 34 residents in the survey sample. 1. Resident #43 did not have a comprehensive care plan for dementia care. 2. Resident #20 did not have a comprehensive care plan for dementia care. 3. Resident #59's care plan did not describe, nor address, his dementia needs, or behaviors. The findings included: 1. Resident #43 did not have a comprehensive care plan for dementia care. Resident #43 was admitted to the facility on [DATE]. Diagnoses included, but not limited to, Dementia, muscular dystrophy and high blood pressure. Resident #43's Minimum Data Set (MDS, an assessment protocol) with an Assessment Reference Date of 9-7-18 coded Resident #43 with severe cognitive impairment. The MDS was completed as a significant change in status assessment as the resident had completed Hospice. The resident required extensive care with all ADL's (activities of daily living such as bed mobility and toileting) of two staff members. The resident was incontinent of bowel and bladder. The resident was coded with no behaviors during the seven day lookback. Review of the Hospice notes dated 8-22-18 revealed: Patient is in bed awake and confuse (sic). She appear (sic) lethargic, pale and thin. On 11/08/18 at 10:02 AM, A phone interview with Other A (Hospice nurse) regarding Resident #43's use of Haldol was conducted. The Hospice nurse stated, She has been discharged from Hospice a month ago. She also stated the Haldol was started because of increased screaming and yelling that would not subside and that it worked for her. She said Ativan did not work well, and the family did not want it used. 11/08/18 at 11:23 AM, a review of the clinical record including MAR's (medication administration record) revealed the resident started on 8-27-18 with Haldol 0.5 mg (milligrams) every day at bedtime for restlessness and agitation for 14 days. On 8-28-18, the order for Haldol was changed to give 0.5 mg every 4 hours as needed for restlessness and agitation for 14 days. None was given in September and it was discontinued after 14 days. On 9-14-18 the Haldol was increased to 0.5 mg twice daily. Review of Resident #43's care plan dated 9-14-18 contained the following: I am at risk for side effects from antipsychotic drug use for restlessness and agitation. The interventions included: * Administer my medication as ordered by physician * Observe me for adverse side effects * Monitor my behavior * Pharmacy consultant review of my medication monthly * Keep call light within arm's length of me and teach me how to use call light to request assistance There were no targeted behaviors, non pharmacological interventions to address behaviors or to address dementia care. The facility presented a form named Behavior Management. For yelling behaviors it included: Give the person something to eat or suck on (hard candy). Distract the resident by talking or getting the resident involved in a favorite activity. Provide comfort such as touch (holding hands), music, or comfort objects (dolls or stuffed animals). If cause is overstimulation, move the person to a quieter environment. If cause is too little stimulation, give more chances for human contact. On 11/08/18 at 12:41 PM, an interview was conducted with LPN (licensed practical nurse) H. LPN (H) stated, For dementia care, I will usually put that part in and will care plan with the behaviors. LPN (H) stated, It is not on the care plan (interventions to address behaviors due to dementia). 2. Resident #20 did not have a comprehensive care plan for dementia care. Resident #20 was admitted to the facility on [DATE]. Diagnoses included, but not limited to, Dementia, hypertension and prostate cancer. Resident #20's Minimum Data Set (MDS, an assessment protocol) with an Assessment Reference Date of 8-9-18 coded Resident #20 with severe cognitive impairment. The MDS was completed as a quarterly assessment. The resident required extensive care with all ADL's (activities of daily living such as bed mobility and toileting) of two staff members. The resident was incontinent of bowel and bladder. The resident was coded with behaviors not affecting others such as hitting 1-3 days during the 7 day lookback and wandering behaviors 4-6 days during the lookback period. Review of the care plan dated 8-13-18 revealed the following regarding behaviors: 1. Resident sleep (sic) on the floor difficult to redirect at time (sic). Interventions included not to argue with resident, Talk in a calm voice, redirect to sleep on the bed. 2. Attempt to get out of facility to go home wheeling the suitcase. Interventions included redirect resident in a calm manner, psych consult as needed, medications as needed and assist to secure unit when resident is actively exit seeking. On 11/08/18 at 12:41 PM, an interview with LPN (Licensed practical nurse) H- care planner was conducted regarding behaviors of Resident #20 . She stated he disrobes, is resistant to care and is physically abusive. She was not sure if he has wanderguard, but all the doors are secured by code (will alarm if resident goes out). LPN (H) stated you never can tell what causes his behaviors. LPN (H) was unsure what kind of kind of job the resident had done in the past. The LPN did state that the behaviors were not addressed on the care plan. Review of the Behavior Management form that was given to the surveyor by the DON (director of nursing) included behaviors such as wandering. The form included such interventions as minimizing day time napping, and that exercise is good, let them pace. For a resident exposing himself, look for the reason behind the behavior. He may simply need to go to the bathroom. Catastrophic reactions are emotional outbursts such as crying or yelling, hitting or screaming. When residents have a catastrophic reaction it is usually in response to failure or feeling overwhelmed. Interventions include: Approach calmly and slowly from the front, using a gentle but firm tone of voice. Do not argue, validate their feelings. Guide to a quiet place if necessary. If you are unable to calm the person and you need to protect yourself, get out of range or leave the room if the person is safe. On 11-8-18 at approximately 2:30 PM, the Administrator and DON were notified of the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. For Resident #82, the facility staff failed to assess for triggers, identify behaviors, and develop non-pharmacological interventions to provide Resident-specific dementia care and services. Resident #82, an [AGE] year old female was admitted to the facility on [DATE]. Diagnoses include dysphagia and dementia. Resident #82's most recent quarterly Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of 08/09/2018. Resident #82 was not coded with a Brief Interview of Mental Status (BIMS) score but cognitive skills for daily decision making were coded as severely impaired. Functional status for bed mobility, dressing, eating, and personal hygiene was coded as requiring extensive assistance. On 11/06/18 at 1:25 PM, the Resident was observed in her bed with family at bedside. The Resident was awake, calm, and the head of the head was elevated approximately 60 degrees. She had oxygen on at 2 liters/minute via nasal cannula. On 11/07/18 at 8:40 AM, the Resident was observed awake in bed, quiet, with the head of bed elevated approximately 60 degrees. She had oxygen on at 2 liters/minute via nasal cannula. The physician's orders were reviewed. An order dated 11/16/17 documented, Dental, Psych, Podiatric, Opthamological and Audiological services may be obtained for the resident as indicated. An order dated 11/16/17 documented, Quetiapine fumarate 25 mg tab. Give one tablet by mouth at bedtime for mood. An order dated 11/16/17 documented, Monitor and document mood and behavior every shift. The Medication Regime Review document with dates ranging from 12/6/17 to 10/9/18 was reviewed. The page contained monthly pharmacist signatures and dated. For monthly entries on 12/6/17, 1/8/18, 2/7/18, 3/8/18, 4/9/18, and 6/8/18, the box labeled see report for any noted irregularities and/or recommendations was selected. For monthly entries dated 5/4/18, 7/11/18, 8/13/18, 9/12/18, and 10/9/18, the box labeled NI (no irregularities) was selected. There was no other documentation on the form. The MAR (medication administration record) for October and November 2018 was reviewed. Quetiapine was signed off as being administered daily as scheduled. Under behavior charting, monitor and document mood and behavior every shift, there were staff initials daily and 0 behaviors documented daily. Resident notes were reviewed ranging August - November 2018. Asocial service entry dated 8/10/18 at 2:23 PM documented, She is pleasant and cooperative with care and no moods or behaviors have been documented. Resident is on Seroquel for mood and is being followed by psych group for medication management. A nurse's note dated 8/24/18 at 10:20 PM documented, no abnormal behavior/distress observed. A social services note dated 10/11/18 at 8:00 PM documented, No mood alteration has been documented. Resident continues on Seroquel for mood and Melatonin for sleep. Resident is generally pleasant but has a habit of grabbing or pinching at times. An interdisciplinary team meeting/MDS note dated 10/16/18 at 2:43 PM documented, Receives psychotropic medications for insomnia and mood disorder no adverse side effects noted at this time. A nurse's note dated 10/20/18 documented, Resident alert and verbally responsive. Pleasant and cooperative. A nurse's note dated 11/8/18 at 3:33 AM documented, Resident unable to comprehend commands when spoken to but would smile at staff speaking to her. The care plan was reviewed. A problem onset dated 11/29/17 documented, I am at risk for side effects from antipsychotic drug use due to mood. Interventions included, Administer my medication as ordered by physician. Observe me for adverse side effects, document and report to my physician. Monitor my behavior. There were no targeted behaviors listed on the care plan or non-pharmacological interventions associated with behaviors of grabbing or pinching as documented in the social services note. There was no evidence in the nurse's notes or care plan the Resident has been assessed to develop and implement Resident-specific behavior management associated with diagnosis of dementia and Resident's personal preference and expressions. On 11/08/18 at 11:45 AM, when LPN B was asked about behaviors exhibited by Resident #82, she stated she hasn't seen any behaviors in Resident #82. She went on to say Resident #82 is always sweet. On 11/08/18, at 1:00 PM, the MDS/care plan nurse was asked what would be on the care plan for residents with dementia and she stated you can have dementia with behaviors or without behaviors. When asked what would be on the care plan for a resident with dementia that had no behaviors and she stated dementia care but was unable to elaborate. On 11/08/18 at approximately 2:45 PM, the Administrator and DON were notified of concerns and they offered no further information. Based on observation, staff interview, facility record review, and clinical record review, the facility staff failed to provide adequate treatment and services for four Residents with dementia (Resident #59, #43, #20, and #82) in a survey sample of 34 Residents. 1. Resident #59 received 5 psychotropic medications without non-pharmacological interventions, and was medicated for behaviors, with none described or care planned for, other than refusing care, and attempting to hit staff when they did not afford him his right to refuse. 2. Resident #43 did not receive care and services for treatment of her dementia and was placed on an antipsychotic. 3. Resident #20 did not receive care and services to treat his dementia. Instead the resident was on two types of antipsychotics simultaneously. 4. For Resident #82, the facility staff failed to assess for triggers, identify behaviors, and develop non-pharmacological interventions to provide Resident-specific dementia care and services. The findings included: 1. Resident #59 received 5 psychotropic medications without non-pharmacological interventions, and was medicated for behaviors, with none described or care planned for, other than refusing care, and attempting to hit staff when they do not afford him his right to refuse. Resident #59 was admitted to the facility on [DATE]. Diagnoses included but were not limited to; unspecified dementia, without behavioral disturbance, Alzheimer dementia, femur fracture, dysphagia, history of falling, cardiac disease, and cognitive communication deficit. Resident #59's most recent Minimum Data Set (an assessment protocol) was a quarterly assessment with an Assessment Reference Date of 10-17-18 coded Resident #59 with a BIMS (brief interview of mental status) score of 99, or unable to complete, due to cognitive impairment. Resident #59 required extensive assistance for his ADL's (activities of daily living such as bed mobility and toileting) of one to two staff members. The resident was incontinent of bowel & bladder. On 11-7-18 at 10:30 a.m., Resident #59 was observed in the back of the main dining/living room area of the locked Alzheimer's unit. The Resident was sitting in a high back wheel chair at a dining table alone. The Resident was against the wall to his left, and had a short knee wall behind him. The Resident was staring down at the table, and nothing was on the table. The surveyor approached the Resident and said hello, and asked the Resident his name, and other questions, the Resident did not look up or speak. On 11-8-18 at 11:00 a.m., during a second observation of Resident #59, the Resident was observed in the back of the main dining/living room area of the locked Alzheimer's unit. The Resident was sitting in a high back wheel chair at a dining table alone. The Resident was against the wall to his left, and had a short knee wall behind him. The Resident was staring down at the table, and a newspaper was on the table folded, the Resident was not looking at it, but was staring down at the table. The surveyor approached the Resident and said hello, and asked the Resident his name, and other questions, the Resident did not look up or speak. Review of the physician's orders in the clinical record revealed the resident was currently receiving the following 5 psychotropic medications, and melatonin for sleep at night; 1. Wellbutrin for depression 2. Depakote for unknown/no medical need given 3. Razadyne for dementia 4. Namenda for dementia 5. Seroquel for dementia with agitation Review of the current care plan dated 5-3-18, revealed only 4 care planned problem areas that could be related to dementia. three were developed on 5-3-18, and the last was added on 6-20-18. Those follow with their goals and interventions to be used: 1. PROBLEM. The resident is easily upset, he refuses care, attempts to hit staff, and very difficult to redirect. The GOAL. safety of residents and staff with no incident reports of injury to others thru nrst (sic) review. The INTERVENTIONS/approaches. approach resident with cayusion (sic), try to redirect resident, attend to needs as quickly as possible, continue full assist in care, ADL care. 2. PROBLEM. I am at risk for side effects from antidepressant medication use. The GOAL. I will have no injury related to medication usage/side effects thru next review. The INTERVENTIONS/approaches. administer my medication as ordered by physician, observe me for adverse side effects, document and report to physician, pharmacy consultant review of my medication monthly. 3. PROBLEM. I am at risk for side effects from antipsychotic drug use. The GOAL. I will have no serious injury related to medication usage/side effects thru next review. The INTERVENTIONS/approaches. administer my medication as ordered by physician, observe me for adverse side effects, document and report to physician, monitor my behavior. 4. dated 6-20-18 PROBLEM. Impaired decision making skills related to diagnosis of Alzheimer's disease as evidenced by staff assessments for cognition. The GOAL. Resident will accept judgement of staff/significant other regarding plan of care as appropriate thru next review date. The INTERVENTIONS/approaches. explain each activity/care procedure prior to beginning it, observe for changes in cognitive status, establish daily routine with resident, praise resident for each decision made, give resident two choices when presenting decisions, offer simple choices to resident, give resident no choice that will be overwhelming. Review of physician progress notes, to include geriatric psychiatric evaluations revealed that the only behavior documented in the clinical record was refusal of care, and agitation when staff pursued or insisted on giving care when the resident refused. Two gradual dose reductions were completed, (Razadyne in June 2018, and Seroquel in August 2018), with success, as no worsening of the Resident's refusal of care occurred afterward. Physician orders were reviewed and documented that Occupational Therapy was ordered to be continued 3 times per week for 1 week on 11-1-18, and Physical therapy was ordered to be continued 3 times per week for 6 weeks beginning 10-25-18. This indicated that the Resident did follow directions and was able to be directed and redirected or therapy would not have been appropriate to order. The Medication, and Treatment Administration Records (MAR's/TAR's) were reviewed and revealed an area for Behavior charting. No behaviors were charted as ever occurring in the months of September, October, nor November 2018. For August 2018, only one time was behavior documented in a 4 month period, which was 8-30-18 at 3:00 p.m., and no nursing note describes what that episode consisted of. Review of nursing progress notes revealed no aggressive behaviors toward peers. The only behavior documented in the clinical record was refusal of care, and agitation when staff pursued or insisted on giving care when the resident refused. The only behaviors documented or described by staff is refusal of care, and agitation during care that is refused. There were no targeted behaviors addressed on the plan of care, nor were there any non pharmacological interventions included for the Resident's refusal of care or agitation during refused care. There is no indication that the staff ever identified the possible reason for the refusal of care, nor were there any plans to mitigate the agitation and upset expressed by the Resident. The Resident had a flat and blunted, lethargic affect on both surveyor observations, and did not respond to direct questioning, nor did he interact with his surroundings. The Resident appeared as in a stupor, staring at the table, with no reaction to verbal stimuli. On 11-8-18, an interview was conducted with LPN E. LPN E was the Resident's care giver, and stated when asked, yes, I take care of him every day. LPN E stated that the Resident never bothered other Residents, he was just upset sometimes with staff when they tried to change him, or give him a bath. She further stated that the Resident liked the little area by the wall, and that he had a book he liked, and if staff gave it to him, he would sit quietly and was no problem at all. LPN A, the unit manager approached and stated, we don't have any problem with him except for incontinent care, then he can get agitated, but the medicine helps with this. LPN A was asked why he was not allowed to refuse, and she stated because he doesn't know what is best for himself because of his dementia. On 11-8-18 at 12:20 p.m., an interview was conducted with the care plan coordinator LPN H. LPN H was asked to tell surveyors how care planning was completed for dementia residents, she stated It can be done with behaviors included or not, but if the resident has behaviors we care plan it. She stated that the purpose of the care plan was to instruct staff on the care needed for this particular resident. She was asked to review Resident #59's care plan and tell me what his behaviors were, and what they were doing for them. LPN H stated he refuses care, and will hit staff, and is difficult to redirect. She was asked what do staff do when this happens? She reviewed the care plan, and stated I don't know. She was asked if she knew what triggered the refusals, and she stated I don't know. She was asked if he received the psychotropic medications for these behaviors, and she stated yes. The Facility policy entitled Behavior Management was reviewed and revealed training was given to staff in regard to resisting care, catastrophic reactions, agitation, redirection, and interventions that would be appropriate in treating these circumstances. Most were not used in Resident # 59's care plan. On 11-8-19 at 1:00 p.m., the Administrator and Director of Nursing (DON) were made aware of the findings. At the time of exit the DON stated there was no further information available to submit to surveyors. 2. Resident #43 did not receive care and services for treatment of her dementia and was placed on an antipsychotic. Resident #43 was admitted to the facility on [DATE]. Diagnoses included, but not limited to, Dementia, muscular dystrophy and high blood pressure. Resident #43's Minimum Data Set (MDS, an assessment protocol) with an Assessment Reference Date of 9-7-18 coded Resident #43 with severe cognitive impairment. The MDS was completed as a significant change in status assessment as the resident had completed Hospice. The resident required extensive care with all ADL's (activities of daily living such as bed mobility and toileting) of two staff members. The resident was incontinent of bowel and bladder. The resident was coded with no behaviors during the seven day lookback. 11/07/18 01:35 PM, a clinical record review revealed Hospice was initiated 6-5-18 for senile degeneration and muscular dystrophy. On 11/08/18 at 10:00 AM, a review of the meal intakes for September, October and November, 2018 revealed the resident had eaten 0% for meals 3 times in September, and 8 times in October, and had eaten only 25 % 17 times in September, 43 times in October and 14 times in November. 11/08/18 at 10:02 AM, a phone interview with other A (Hospice nurse) regarding Resident #20's use of Haldol was conducted. The Hospice nurse stated, She has been discharged from Hospice a month ago. She also stated the Haldol was started because of increased screaming and yelling that would not subside and that it worked for her. She said Ativan did not work well, and the family did not want it used. 11/08/18 at 11:23 AM Review of the clinical record including MAR's revealed 8-27-18, the resident was taking Haldol 0.5 mg (milligrams) every day at bedtime for restlessness and agitation for 14 days. On 8-28-18, the order was given for Haldol give 0.5 mg every 4 hours as needed for restlessness and agitation for 14 days. None was given in September and it was discontinued after 14 days. On 7-11-18, a pharmacy recommendation addressed prn (as needed) haldol has been in place for more than 14 days. The physician declined the recommendation, Passed (sic) attempt to schedule results in worsening Sx (symptoms). Patient is Hospice. On 9-14-18 the Haldol was increased to 0.5 mg twice daily and had been given during the days of survey. [NAME] Nursing Drug Handbook 2011, pages 558 to 560, classified Haldol as an antipsychotic, used to treat schizophrenia and Tourette's. There is a black box warning for this drug which states, Increased risk of mortality in elderly patients with dementia related psychosis. Review of Resident #43's care plan dated 9-14-18 contained the following: I am at risk for side effects from antipsychotic drug use for restlessness and agitation. The interventions included: * Administer my medication as ordered by physician * Observe me for adverse side effects * Monitor my behavior * Pharmacy consultant review of my medication monthly * Keep call light within arm's length of me and teach me how to use call light to request assistance There were no yelling behaviors or non pharmacological interventions in the care plan. 3. Resident #20 did not receive care and services to treat his dementia. Instead the resident was on two types of antipsychotics simultaneously. Resident #20 was admitted to the facility on [DATE]. Diagnoses included, but not limited to, Dementia, hypertension and prostate cancer. Resident #20's Minimum Data Set (MDS, an assessment protocol) with an Assessment Reference Date of 8-9-18 coded Resident #20 with severe cognitive impairment. The MDS was completed as a quarterly assessment. The resident required extensive care with all ADL's (activities of daily living such as bed mobility and toileting) of two staff members. The resident was incontinent of bowel and bladder. The resident was coded with behaviors not affecting others such as hitting 1-3 days during the 7 day lookback and wandering behaviors 4-6 days during the lookback period. On 11/07/18 at 10:19 AM, an interview was conducted the Resident's son on the phone. The son stated he has heard from the nurses that he is sleeping a lot, but that he had violent behaviors and the medication had to be increased recently. On 11/07/18 at 12:59 PM LPN (licensed practical nurse) G, stated the resident had come out of his room wearing only brief and T shirt, tried to redirect him and he hit aide in the face. He was out of it completely had to lock myself in room because he was trying to get at me. Appetite good, does not eat at usual times, give snacks. Will not wake him up as he gets very agitated. On 11/07/18 at 1:03 PM the resident was observed sitting on side of bed, eating lunch. Would visibly flinch when construction worker drilling into wall next door. Cursed when noise would get louder next door. On 11/07/18 at 3:25 PM an interview was conducted with the DON (director of nursing) regarding behaviors. The DON stated he wanders outside the room, not exit seeking, can come out naked, and that it had been awhile since he has been loud and angry. On 11/08/18 at 8:45 AM, the resident was observed in room, in bed asleep. No tray was in the room. On 11/08/18 at 10:02 AM, A phone interview with other A (Hospice nurse) regarding Resident #20's use of Haldol was conducted. The Hospice nurse stated, He has been difficult to manage and had to have increased doses of Seroquel. She also stated the Haldol was used for agitation, he becomes restless, combative, refuses to follow commands and aggressive,. She stated that Haldol is normally used for restlessness but the behavior itself was the reason the Haldol was being used. On 11/08/18 at 10:49 AM, a review of the clinical record including MAR's (medication administration record), behavior records revealed the resident was started on 8-1-18 on Haldol 2 mg (milligrams) every 6 hours for psychosis. The resident also had an order dated 9-24-18 for Ativan (antianxiety) 0.5 mg every 4 hours as needed for agitation, which was discontinued on 10-17-18 (greater than 14 days). No Ativan was given during September. In October, the resident received Ativan on 10-4-18, 10-15-18, 10-16-18. On 10-16-18, the as needed order for Ativan was renewed for 14 more days without a physician making a visit to the resident. The resident received Ativan twice on 10-25-18 and once on 10-30-18. The resident was also taking Seroquel (antipsychotic) started on 7-16-18 at once daily for delusions. On 9-24-18, the Seroquel was increased to 50 mg twice daily. On 11-6-18, the Seroquel dose was increased to 100 mg twice daily. The resident continued on Haldol 2 mg every 6 hours. On 10-30-18, the Ativan was again renewed (without a physician assessment) and with no stop date and given on 10-3-18. On 11/08/18 at 11:33 AM, a review of the physician's notes documented the resident had vascular dementia. The psychiatric nurse practitioner documented in the 8-20-18 notes, Patient is very lethargic and on Haldol. Staff report he wakes up and become agitated at times. If he is in need of the Ativan (antianxiety) I will re add it to prn for later in the day, but his lethargy needs to be monitored and documented properly. Review of the psychiatric note dated 10-31-18 revealed the following: Patient noted to be very lethargic today and hard to wake up for visit again. The psychiatric NP (nurse practitioner) also noted; Watch lethargy and contact psych if it persists or worsens. Review of the care plan dated 8-13-18 revealed the following regarding behaviors: 1. Resident sleep (sic) on the floor difficult to redirect at time (sic). Interventions included not to argue with resident, Talk in a calm voice, redirect to sleep on the bed. 2. Attempt to get out of facility to go home wheeling the suitcase. Interventions included redirect resident in a calm manner, psych consult as needed, medications as needed and assist to secure unit when resident is actively exit seeking. On 11/08/18 at 12:41 PM, an interview with LPN (Licensed practical nurse) H- care planner was conducted regarding behaviors of Resident #20 . She stated he disrobes, is resistant to care and is physically abusive. She was not sure if he has wanderguard, but all the doors are secured by code (will alarm if resident goes out). LPN (H) stated you never can tell what causes his behaviors. LPN (H) was unsure what kind of kind of job the resident had done in the past. The LPN did state that the behaviors were not addressed on the care plan. 11/08/18 at 1:02 PM An interview with the DON was again conducted. She stated he fights with staff, gets agitated. She then described agitation as he tries to punch and kick. She stated Haldol is used for bipolar, schizophrenia, Touretts, Huntington's, to control behaviors for dementia. When asked about overuse of antipsychotic medications, the DON stated, You don't want to chemically restrain or decrease the quality of life. [NAME] Nursing Drug Handbook 2011, pages 558 to 560, classified Haldol as an antipsychotic, used to treat schizophrenia and Tourette's. There is a black box warning for this drug which states, Increased risk of mortality in elderly patients with dementia related psychosis. [NAME] Nursing Drug Handbook, 2011, pages 984-986 classified Seroquel as an antipsychotic, used to treat schizophrenia, acute manic episodes of bipolar disorder. It also has a black box warning in the elderly with dementia related psychosis are at increased risk of death. Review of the Behavior Management form that was given to the surveyor by the DON (director of nursing) included behaviors such as wandering. The form included such interventions as minimizing day time napping, and that exercise is good, let them pace. For a resident exposing himself, look for the reason behind the behavior. He may simply need to go to the bathroom. Catastrophic reactions are emotional outbursts such as crying or yelling, hitting or screaming. When residents have a catastrophic reaction it is usually in response to failure or feeling overwhelmed. Interventions include: Approach calmly and slowly from the front, using a gentle but firm tone of voice. Do not argue, validate their feelings. Guide to a quiet place if necessary. If you are unable to calm the person and you need to protect yourself, get out of range or leave the room if the person is safe. On 11-8-18 at approximately 2:30 PM, the Administrator and DON were notified of above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on on observation, staff interview, facility documentation review and clinical record review, the facility staff failed, for one resident (Resident #6) in the survey sample of 24 residents, to provide a dignified living experience during medication administration. The facility staff applied a pain patch to Resident #6's back, asked her to lean forward, and then used a black marker to write the day, month and year on it. The Findings included: Resident #6 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #6's diagnoses included a facial bruise from a fall, Hypertension, Atrial Fibrillation, Cardiovascular accident, and Asthma. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 6/5/17, coded Resident #6 as having a Brief Interview of Mental Status Score of 15, indicating no cognitive impairment. On 8/29/17 at 8:30 A.M. an observation was conducted of the facilities' medication administration process. The Licensed Practical Nurse (LPN-A) placed a Fentanyl Patch 25 milligrams (MG). on Resident #6's upper right back. LPN-A then asked Resident #6 to lean forward, she then used a black marker to write the month, day and year on the patch. On 8/29/17 at 8:35 A.M. an interview was conducted with LPN-A. When asked why she did not write the date on the patch prior to applying it to Resident #6, she stated, I usually write the date first but it's easier to peel the backing off if you date it after it's on the resident. I know that it is a dignity issue. On 8/29/17 a review was conducted of facility documentation, revealing the following Transdermal Delivery Policy (undated), Remove new patch from package and envelope. Label patch with date and nurse's initials. Apply new patch firmly against skin. On 8/29/17 at 4:30 P.M. the facility Administrator (Administration A) and Director of Nursing (Administration B) were informed of the findings. No further information was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility record review, and clinical record review, the facility staff failed to devise, and implement a comprehensive care plan for the use IV (intravenous) potassium and antibiotics for one Resident (Resident #1) in a survey sample of 24 Residents. For Resident #1, IV antibiotics, fluids, and Potassium were not appropriately care planned, and skin breakdown was care planned inappropriately. The findings included: Resident #1 was admitted to the facility on [DATE]. Resident #1's current diagnoses included; pneumonia, urinary tract infection, Dementia, congestive heart failure, and Hypertension. The most recent Minimum Data Set, (MDS) was a Significant change Assessment, with an Assessment Reference Date of 7-21-17. the MDS coded Resident #1 as severely cognitively impaired. Resident #1 was coded as being extensively dependent for all activities of daily living, and requiring a 1 person physical Assist. Resident #1 was first observed laying in bed, on her back, on 8-28-17 at 2:30 p.m., during entrance tour of the facility. Both of the Residents hands were swollen, and elevated on pillows, with pitting edema in both. The right hand was bruised on the back of the hand, in a circle approximately the size of a silver dollar. The Resident was unresponsive when LPN B attempted to arouse her by calling her name, and shaking her arm. There was an Intravenous (IV) medication pump in the room at bedside. Hanging from the pump was an open one liter bag of 5% dextrose, and 1/2 normal saline mixture, which had tubing connected to it, and it was filled with fluid. The 1000 ml (milliliter) bag had no noticeable fluid missing, and was still 1000 ml., and no fluid was hooked to the Resident, and the infusion was turned off. A large piece of medical tape was stuck on the bag of fluid which documented that it had been hung at 6:00 a.m., that morning 8-28-17, and was to infuse at 75 ml per hour. No additives were documented as being in the fluid. LPN B was interviewed at that time, and stated that the Resident was supposed to have antibiotics for pneumonia, and a urinary tract infection (UTI), and that the Resident was receiving fluids because she was very sick and not drinking. LPN B went on to say that the peripheral IV access in the Resident's right hand had become infiltrated and had to be discontinued by the nurse working over night, and that had occurred at 7:00 a.m. that morning. She stated that a doctor's order had been received to insert a PICC (peripherally inserted central line catheter) Line in the Resident's upper arm for the fluid and antibiotic infusions. There was a single lumen (port) PICC line noted in the Resident's upper inner arm, covered with a clear occlusive dressing. A PICC line is inserted in a major vein in the upper arm which flows directly into the vena cava of the heart, and is considered a central line because of it's proximity to the heart. Peripheral IV's are located in lower hands, and arms in lesser veins. On 8-28-17 several other observations of Resident #1 were conducted while waiting for clinical records to be copied and delivered to surveyors. An x-ray technician arrived at 5:00 p.m., with a portable x-ray machine and obtained an x-ray on Resident #1 to check placement of the PICC line for use. The technician stated the film would be read by a radiologist in a couple of hours, and results would be sent to the facility after that. The Resident remained unresponsive, and had not consumed any nutrition or fluids for at least 10 hours at this time, and it would be more hours before the IV could be accessed. Laboratory reports were reviewed in the clinical record and revealed that on 8-24-17 a complete blood count (CBC), basic metabolic profile (BMP), and urinalysis with culture and sensitivity (U/A with C&S) were obtained and resulted on 8-24-17 (4 days prior to survey). A review of Resident #1's clinical record was conducted after tour on 8-28-17 revealing an admission Care Plan dated 3-23-17, that had no measurable interventions, and denied the Resident's congestive heart failure history. A second care plan was derived on 3-30-17, and had been updated on 4-13-17, by the interdisciplinary team. No other records reveal any updates by the interdisciplinary team after 4-13-17 until the time of survey. There were interventions added in May 2017 for falls by the nursing staff, and in July 2017 for bed mobility and contractures by the nursing staff. On 8-24-17 interventions for IV antibiotics were added to the care plan, however the care plan stated the Resident had a PICC line, for the infusions which was incorrect, the Resident had a peripheral IV in her hand, and the fluids, and medications were not added to the plan. On 8-25-17 a skin breakdown problem was added to the care plan with no measurable goals, and an intervention to massage bony prominences, was added, which is a strictly forbidden practice when skin breakdown is a potential. Physician progress notes were reviewed and revealed 2 visits during Resident #1's acute illness. The first visit was on 8-23-17, where the doctor describes the Resident as seen for Obtundation. Webster's medical dictionary describes this definition as; Obtundation refers to less than full alertness (altered level of consciousness), typically as a result of a medical condition or trauma. The root word, obtund, means dulled or less sharp cf. obtuse angle. The note states the Resident is responsive non verbally to stimuli, has an altered mental status, and the doctor is ordering IV hydration and a palliative care consultation. Nursing progress notes were reviewed and revealed that the Resident had pneumonia, and a Urinary tract infection (UTI), and was unable to consume medications by mouth , and not able to swallow food, or drink, and drooled when attempts were made. No interventions for this new problem were care planned. Multiple order changes, medication and IV fluid changes occurred from 8-24-17 through 8-29-17, at the time of survey, with none of these implemented on the care plan. IV and PICC (peripherally inserted central line catheter) line care were not implemented on the care plan, and labs revealed new problems of high blood sodium, low blood potassium, and inability to consume food, medications, and fluids orally, which were not care planned. Clinical record Labs were reviewed, and revealed that a Normal sodium range is (137-145), and the Resident suffered from high sodium (hypernatremia) with a sodium level of (155) on 8-24-17, and (154) on 8-28-17. The Resident also experienced low potassium (hypokalemia), which was (3.2) on 8-24-17, and worsening on 8-28-17 at (2.9), and (2.9) again on 8-29-17. A normal blood potassium range is (3.5-5.5), which is a very narrow range due to the serious threat of small changes in potassium levels in blood. Potassium is a major mineral (electrolyte) responsible for cardiac health. Low potassium, or high potassium, can result in death. Multiple care plan omissions occurred, and an inappropriate skin intervention was planned, preventing nursing staff from planning needed care, providing effective care, and assessing the outcomes of care. The facility was notified of this deficient practice on 8-29-17 at the end of day debrief. No further information was provided by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility documentation and clinical record review, the facility staff failed to maintain the highest practicable well being for 1 Resident (Resident #1) in the survey sample of 24 residents. For Resident #1, the facility failed to ensure IV (intravenous) medications were administered per physician's orders, and standards of professional practice. The facility staff further failed to obtain an IV access timely, and provide care and services during an acute illness. The findings included: Resident #1 was admitted to the facility on [DATE]. Resident #1's current diagnoses included; pneumonia, urinary tract infection, Dementia, congestive heart failure, and Hypertension. The most recent Minimum Data Set, (MDS) was a Significant change Assessment, with an Assessment Reference Date of 7-21-17. the MDS coded Resident #1 as severely cognitively impaired. Resident #1 was coded as being extensively dependent for all activities of daily living, and requiring a 1 person physical Assist. Resident #1 was first observed lying in bed, on her back, on 8-28-17 at 2:30 p.m., during entrance tour of the facility. Both of the Residents hands were swollen, and elevated on pillows, with pitting edema in both. The right hand was bruised on the back of the hand, in a circle approximately the size of a silver dollar. The Resident was unresponsive when LPN B attempted to arouse her by calling her name, and shaking her arm. There was an Intravenous (IV) medication pump in the room at bedside. Hanging from the pump was an open one liter bag of 5% dextrose, and 1/2 normal saline mixture, which had tubing connected to it, and it was filled with fluid. The 1000 ml (milliliter) bag had no noticeable fluid missing, and was still 1000 ml., and no fluid was hooked to the Resident, and the infusion was turned off. A large piece of medical tape was stuck on the bag of fluid which documented that it had been hung at 6:00 a.m., that morning 8-28-17, and was to infuse at 75 ml per hour. No additives were documented as being in the fluid. LPN B was interviewed at that time, and stated that the Resident was supposed to have antibiotics for pneumonia, and a urinary tract infection (UTI), and that the Resident was receiving fluids because she was very sick and not drinking. LPN B went on to say that the peripheral IV access in the Resident's right hand had become infiltrated and had to be discontinued by the nurse working over night, and that had occurred at 7:00 a.m. that morning. She stated that a doctor's order had been received to insert a PICC (peripherally inserted central line catheter) Line in the Resident's upper arm for the fluid and antibiotic infusions. There was a single lumen (port) PICC line noted in the Resident's upper inner arm, covered with a clear occlusive dressing. A PICC line is inserted in a major vein in the upper arm which flows directly into the vena cava of the heart, and is considered a central line because of it's proximity to the heart. Peripheral IV's are located in lower hands, and arms in lesser veins. On 8-28-17 several other observations of Resident #1 were conducted while waiting for clinical records to be copied and delivered to surveyors. An x-ray technician arrived at 5:00 p.m., with a portable x-ray machine and obtained an x-ray on Resident #1 to check placement of the PICC line for use. The technician stated the film would be read by a radiologist in a couple of hours, and results would be sent to the facility after that. The Resident remained unresponsive, and had not consumed any nutrition or fluids for at least 10 hours at this time, and it would be more hours before the IV could be accessed. Laboratory reports were reviewed in the clinical record and revealed that on 8-24-17 a complete blood count (CBC), basic metabolic profile (BMP), and urinalysis with culture and sensitivity (U/A with C&S) were obtained and resulted on 8-24-17 (4 days prior to survey). A review of Resident #1's clinical record was conducted after tour on 8-28-17 revealing an admission Care Plan dated 3-23-17, that had no measurable interventions, and denied the Resident's congestive heart failure history. A second care plan was derived on 3-30-17, and had been updated on 4-13-17, by the interdisciplinary team. No other records reveal any updates by the interdisciplinary team after 4-13-17 until the time of survey. There were interventions added in May 2017 for falls by the nursing staff, and in July 2017 for bed mobility and contractures by the nursing staff. On 8-24-17 interventions for IV antibiotics were added to the care plan, however the care plan stated the Resident had a PICC line, for the infusions which was incorrect, the Resident had a peripheral IV in her hand, and the fluids, and medications were not added to the plan. On 8-25-17 a skin breakdown problem was added to the care plan with no measurable goals, and an intervention to massage bony prominences, was added, which is a strictly forbidden practice when skin breakdown is a potential. Physician progress notes were reviewed and revealed 2 visits during Resident #1's acute illness. The first visit was on 8-23-17, where the doctor describes the Resident as seen for Obtundation. Webster's medical dictionary describes this definition as; Obtundation refers to less than full alertness (altered level of consciousness), typically as a result of a medical condition or trauma. The root word, obtund, means 'dulled or less sharp' cf. obtuse angle. The note stated the Resident was responsive non verbally to stimuli, has an altered mental status, and the doctor was ordering IV hydration and a palliative care consultation. Nursing progress notes were reviewed and revealed that on 8-23-17 IV fluids of Dextrose 5% in 1/2 normal saline (D5 1/2 NS) were ordered by the doctor to begin at a rate of 75 ml (milliliters) per hour through a peripheral IV in the left hand. Also, a chest x-ray, and laboratory blood samples were ordered to be obtained, and were obtained. The following morning, on 8-24-17 further nursing notes document that the diagnostics results were sent to the doctor, and new orders were received from the doctor for 2 antibiotics. Those were; Zithromax 500 mg (milligrams) by mouth for 5 days for pneumonia, and Rocephin 1 gram daily IV for 5 days for UTI. Nursing notes go on to state that on 8-24-17 the Resident was not able to swallow the medication, food, or drink, and drooled when attempts were made. Nurses tried to contact the doctor with critical lab results, and were unable until 12:12 a.m., (midnight) 8-25-17 at which time the facility was not able to provide the Resident with the IV fluids (D5 1/2 NS) that the doctor had ordered, and the doctor agreed to give Dextrose 5%, since the D5 1/2 NS was unavailable, until the fluid could be obtained. This occurred on 8-25-17 at 11:39 p.m.(24 hours later). Nursing notes described Resident #1 as still having trouble swallowing on 8-25-17. On 8-26-17 at 8:26 a.m., the Resident was asking for water, and only able to take sips, still drooling and not able to take meds or fluids orally at 9:29 p.m. On 8-27-17 at 3:15 p.m., still drooling and unable to take medication by mouth, the doctor ordered to discontinue the IV Rocephin, and by mouth Zithromax which the Resident was never able to take, (4 days later) and ordered Levaquin 250 mg daily by mouth or IV for 5 days. Nursing notes and the Medication Administration Record (MAR) documented that on 8-28-17 at 7:09 a.m., the Resident's IV had to be removed. The Resident had not received any IV antibiotic since 5:00 a.m., on 8-27-17 (26 hours previously). Resident #1 was due to receive a first dose of a new morning antibiotic Levaquin IV, on 8-28-17, however, the facility could not infuse it, because there was no IV access. The nursing notes went on to state that the order for Levaquin on 8-27-17 by telephone order was discontinued on 8-28-17, and the (MAR) revealed the medication was given IV at 9:00 p.m. on 8-28-17 for one dose only (40 hours after the last antibiotic IV infusion on 8-27-17 at 5:00 a.m.). Clinical record Labs were reviewed, and revealed that a Normal sodium range is (137-145), and the Resident suffered from high sodium (hypernatremia) with a sodium level of (155) on 8-24-17, and (154) on 8-28-17. The Resident also experienced low potassium (hypokalemia), which was (3.2) on 8-24-17, and worsening on 8-28-17 at (2.9), and (2.9) again on 8-29-17. A normal blood potassium range is (3.5-5.5), which is a very narrow range due to the serious threat of small changes in potassium levels in blood. Potassium is a major mineral (electrolyte) responsible for cardiac health. Low potassium, or high potassium, can result in death. The following IV potassium information is taken from the National Institutes of Health; potassium chloride in sodium chloride (Potassium Chloride and Sodium Chloride) injection, solution National Institutes of Health Rx only DESCRIPTION Intravenous solutions with potassium chloride (IV solutions with KCl) are sterile and nonpyrogenic solutions in water for injection. They are for administration by intravenous infusion only. Acute treatment of symptomatic Hypokalemia for central venous infusions. Possible Adverse Reactions: 1. Hyperkalemia 2. PO administration may cause GI irritation, vomiting, diarrhea, bleeding. 3. IV administration may cause irritation, pain or phlebitis at the infusion site. 4. Rapid IV infusion may cause cardiac arrhythmias. Contraindications & Precautions Hypersensitivity to potassium chloride products Severe renal impairment or hyperkalemia Use with caution in patients with cardiac disease Nursing Implications Monitor serum potassium concentrations. If serum potassium level is not rising with effective potassium supplementation, consider checking a magnesium level. Continuous cardiac monitoring is mandatory for IV replacement especially for central infusions Watch IV site for signs of irritation or phlebitis. Give oral doses with the nearest feed. WARNINGS Solutions which contain potassium ions should be used with great care, if at all, in patients with hyperkalemia, severe renal failure and in conditions in which potassium retention is present. To avoid potassium intoxication, do not infuse these solutions rapidly. In patients with severe renal insufficiency or adrenal insufficiency, administration of potassium chloride may cause potassium intoxication. Solutions containing sodium ions should be used with great care, if at all, in patients with congestive heart failure, severe renal insufficiency and in clinical states in which there exists edema with sodium retention. In patients with diminished renal function, administration of solutions containing sodium or potassium ions may result in sodium or potassium retention. The intravenous administration of these solutions can cause fluid and/or solute overloading resulting in dilution of serum electrolyte concentrations, congested heart failure states or pulmonary edema. The risk of dilutional states is inversely proportional to the electrolyte concentration of administered parenteral solutions. The risk of solute overload causing congested states with peripheral and pulmonary edema is directly proportional to the electrolyte concentrations of such solutions. Geriatric Use: Clinical studies of Potassium Chloride in Dextrose Injection, USP In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy. These drugs are known to be substantially excreted by the kidney, and the risk of toxic reactions to these drugs may be greater in patients with impaired renal function. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function. PRECAUTIONS Potassium replacement therapy should be guided primarily by serial electrocardiograms. Plasma potassium levels are not necessarily indicative of tissue potassium levels. High plasma concentrations of potassium may cause death through cardiac depression, arrhythmias or arrest. Potassium-containing solutions should be used with caution in the presence of cardiac disease, particularly in digitalized patients or in the presence of renal disease. Care should be exercised to insure that the needle (or catheter) is well within the lumen of the vein and that extravasation does not occur. Nausea, vomiting, abdominal pain and diarrhea have been reported with potassium therapy. The signs and symptoms of potassium intoxication include paresthesias of the extremities, flaccid paralysis, listlessness, mental confusion, weakness and heaviness of the legs, hypotension, cardiac arrhythmias, heart block, electrocardiographic abnormalities such as disappearance of P waves, spreading and slurring of the QRS complex with development of a biphasic curve and cardiac arrest. There were no physician visits or notes from 8-23-17 until the night of 8-28-17 (5 days later) after the survey team had entered, found and discussed with staff the issues with IV care for Resident #1, and surveyors had left the building for the night. The doctor diagnosed sepsis, from pneumonia and the UTI, and hyponatremia (low sodium), which was incorrect, the Resident actually was hypernatremic (high sodium) and there was no mention of the hypokalemia (low potassium) in the progress note. Physician orders were reviewed and revealed new orders on 8-29-17 for Potassium chloride 10 meq (milliequivalents) IV for 2 doses, due to low potassium STAT (give immediately) order, then the order was changed to Potassium chloride 20 meq (milliequivalents) IV in dextrose 5% - 1/2 normal saline solution at 75 ml per hour for 1 liter bag dose, due to low potassium, after a stat BMP result is reported to the MD (doctor). The Resident had been hypokalemic for 5 days at this point, and the blood potassium issue had worsened. The physician was interviewed on 8-30-17 at 9:00 a.m., The doctor was asked why no potassium had been given on 8-24-17 when labs showed hypokalemia. The doctor stated that some of the fluids that he ordered, and potassium for IV administration, had not been available to the facility at the time of his order, because nursing homes don't usually infuse potassium IV. He further stated that he had changed orders to accommodate the facility in regard to IV fluids as well, because they were having trouble getting Dextrose 5% with 1/2 normal saline, so he ordered just 5% dextrose instead. He was further asked why IV antibiotics had not been given timely, and he stated that the PICC line had taken awhile to be instilled in the Resident. When asked if these things could have been accomplished in a more timely manner for this Resident who was now septic, he stated yes, she could have been sent to the hospital where these things would have been received immediately. The facility policy on medication administration was reviewed, and stated that doctor's orders must be followed. In summary of the evidence provided by the facility, Resident #1 was acutely ill with pneumonia, and a UTI. The Resident was not drinking or eating, and was unable to consume antibiotics by mouth for 5 days. Potassium IV, and ordered hydration fluids were not administered timely, and care was delayed because the facility was unable to provide the necessary services. The Resident was not transferred to an acute care setting (hospital) where those services could be provided timely. Fluids were unavailable because of lack of IV access for at least 12 hours. The Rocephin IV antibiotics were not administered from 5:00 a.m. 8-27-17 until the Levaquin was available at 9:00 p.m. on 8-28-17 (40 hours). By this time the Resident had been seen again by the doctor, and diagnosed as Septic. Medications such as IV potassium were unavailable in this setting as needed, and no monitoring or EKG's (electrocardiograms) were performed before, during or after the potassium infusions. The facility was notified of this deficient practice on 8-28-17, 8-29-17, and 8-30-17 at the end of day debrief. No further information was provided by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility documentation and clinical record review, the facility staff failed to provide specialized intravenous antibiotic and potassium infusion nursing care for 1 Resident (Resident #1) in the survey sample of 24 residents. For Resident #1, the facility failed to ensure IV (intravenous) medications were administered per physician's orders, and standards of professional practice. The facility staff further failed to obtain an IV access timely, during an acute illness. The findings included: Resident #1 was admitted to the facility on [DATE]. Resident #1's current diagnoses included; pneumonia, urinary tract infection, Dementia, congestive heart failure, and Hypertension. The most recent Minimum Data Set, (MDS) was a Significant change Assessment, with an Assessment Reference Date of 7-21-17. the MDS coded Resident #1 as severely cognitively impaired. Resident #1 was coded as being extensively dependent for all activities of daily living, and requiring a 1 person physical Assist. Resident #1 was first observed laying in bed, on her back, on 8-28-17 at 2:30 p.m., during entrance tour of the facility. Both of the Residents hands were swollen, and elevated on pillows, with pitting edema in both. The right hand was bruised on the back of the hand, in a circle approximately the size of a silver dollar. The Resident was unresponsive when LPN B attempted to arouse her by calling her name, and shaking her arm. There was an Intravenous (IV) medication pump in the room at bedside. Hanging fom the pump was an open one liter bag of 5% dextrose, and 1/2 normal saline mixture, which had tubing connected to it, and it was filled with fluid. The 1000 ml (milliliter) bag had no noticeable fluid missing, and was still 1000 ml., and no fluid was hooked to the Resident, and the infusion was turned off. A large piece of medical tape was stuck on the bag of fluid which documented that it had been hung at 6:00 a.m., that morning 8-28-17, and was to infuse at 75 ml per hour. No additives were documented as being in the fluid. LPN B was interviewed at that time, and stated that the Resident was supposed to have antibiotics for pneumonia, and a urinary tract infection (UTI), and that the Resident was receiving fluids because she was very sick and not drinking. LPN B went on to say that the peripheral IV access in the Resident's right hand had become infiltrated and had to be discontinued by the nurse working over night, and that had occurred at 7:00 a.m. that morning. She stated that a doctor's order had been received to insert a PICC (peripherally inserted central line catheter) Line in the Resident's upper arm for the fluid and antibiotic infusions. There was a single lumen (port) PICC line noted in the Resident's upper inner arm, covered with a clear occlusive dressing. A PICC line is inserted in a major vein in the upper arm which flows directly into the vena cava of the heart, and is considered a central line because of it's proximity to the heart. Peripheral IV's are located in lower hands, and arms in lesser veins. On 8-28-17 several other observations of Resident #1 were conducted while waiting for clinical records to be copied and delivered to surveyors. An x-ray technician arrived at 5:00 p.m., with a portable x-ray machine and obtained an x-ray on Resident #1 to check placement of the PICC line for use. The technician stated the film would be read by a radiologist in a couple of hours, and results would be sent to the facility after that. The Resident remained unresponsive, and had not consumed any nutrition or fluids for at least 10 hours at this time, and it would be more hours before the IV could be accessed. Laboratory reports were reviewed in the clinical record and revealed that on 8-24-17 a complete blood count (CBC), basic metabolic profile (BMP), and urinalysis with culture and sensitivity (U/A with C&S) were obtained and resulted on 8-24-17 (4 days prior to survey). A review of Resident #1's clinical record was conducted after tour on 8-28-17 revealing an admission Care Plan dated 3-23-17, that had no measurable interventions, and denied the Resident's congestive heart failure history. A second care plan was derived on 3-30-17, and had been updated on 4-13-17, by the interdisciplinary team. No other records reveal any updates by the interdisciplinary team after 4-13-17 until the time of survey. There were interventions added in May 2017 for falls by the nursing staff, and in July 2017 for bed mobility and contractures by the nursing staff. On 8-24-17 interventions for IV antibiotics were added to the care plan, however the care plan stated the Resident had a PICC line, for the infusions which was incorrect, the Resident had a peripheral IV in her hand, and the fluids, and medications were not added to the plan. On 8-25-17 a skin breakdown problem was added to the care plan with no measurable goals, and an intervention to massage bony prominences, was added, which is a strictly forbidden practice when skin breakdown is a potential. Physician progress notes were reviewed and revealed 2 visits during Resident #1's acute illness. The first visit was on 8-23-17, where the doctor describes the Resident as seen for Obtundation. Webster's medical dictionary describes this definition as; Obtundation refers to less than full alertness (altered level of consciousness), typically as a result of a medical condition or trauma. The root word, obtund, means dulled or less sharp cf. obtuse angle. The note states the Resident is responsive non verbally to stimuli, has an altered mental status, and the doctor is ordering IV hydration and a palliative care consultation. Nursing progress notes were reviewed and revealed that on 8-23-17 IV fluids of Dextrose 5% in 1/2 normal saline (D5 1/2 NS) were ordered by the doctor to begin at a rate of 75 ml (milliliters) per hour through a peripheral IV in the left hand. Also, a chest x-ray, and laboratory blood samples were ordered to be obtained, and were obtained. The following morning, on 8-24-17 further nursing notes document that the diagnostics with results were sent to the doctor, and new orders were received from the doctor for 2 antibiotics. Those were; Zithromax 500 mg (milligrams) by mouth for 5 days for pneumonia, and Rocephin 1 gram daily IV for 5 days for UTI. Nursing notes go on to say that on 8-24-17 the Resident was not able to swallow the medication, food, or drink, and drooled when attempts were made. Nurses tried to contact the doctor with critical lab results, and were unable until 12:12 a.m., (midnight) 8-25-17 at which time the facility was not able to provide the Resident with the IV fluids (D5 1/2 NS) that the doctor had ordered, and the doctor agreed to give Dextrose 5%, since the D5 1/2 NS was unavailable, until the fluid could be obtained. This occurred on 8-25-17 at 11:39 p.m.(24 hours later). Nursing notes described Resident #1 as still having trouble swallowing on 8-25-17. On 8-26-17 at 8:26 a.m., the Resident was asking for water, and only able to take sips, still drooling and not able to take meds or fluids orally at 9:29 p.m. On 8-27-17 at 3:15 p.m., still drooling and unable to take medication by mouth. The doctor ordered to discontinue the IV Rocephin, and by mouth Zithromax which the Resident was never able to take, (4 days later) and ordered Levaquin 250 mg daily by mouth or IV for 5 days. Nursing notes and the Medication Administration Record (MAR) documented that on 8-28-17 at 7:09 a.m., the Resident's IV had to be removed. The Resident had not received any IV antibiotic since 5:00 a.m., on 8-27-17 (26 hours previously). Resident #1 was due to receive a first dose of a new morning antibiotic Levaquin IV, on 8-28-17, however, the facility could not infuse it, because there was no IV access. The nursing notes went on to state that the order for Levaquin on 8-27-17 by telephone order was discontinued on 8-28-17, and the (MAR) revealed the medication was given IV at 9:00 p.m. on 8-28-17 for one dose only (40 hours after the last antibiotic IV infusion on 8-27-17 at 5:00 a.m.). Clinical record Labs were reviewed, and revealed that a Normal sodium range is (137-145), and the Resident suffered from high sodium (hypernatremia) with a sodium level of (155) on 8-24-17, and (154) on 8-28-17. The Resident also experienced low potassium (hypokalemia), which was (3.2) on 8-24-17, and worsening on 8-28-17 at (2.9), and (2.9) again on 8-29-17. A normal blood potassium range is (3.5-5.5), which is a very narrow range due to the serious threat of small changes in potassium levels in blood. Potassium is a major mineral (electrolyte) responsible for cardiac health. Low potassium, or high potassium, can result in death. The following IV potassium information is taken from the National Institutes of Health; potassium chloride in sodium chloride (Potassium Chloride and Sodium Chloride) injection, solution National Institutes of Health Rx only DESCRIPTION Intravenous solutions with potassium chloride (IV solutions with KCl) are sterile and nonpyrogenic solutions in water for injection. They are for administration by intravenous infusion only. ? Acute treatment of symptomatic Hypokalemia for central venous infusions. Possible Adverse Reactions: 1. Hyperkalemia 2. PO administration may cause GI irritation, vomiting, diarrhea, bleeding. 3. IV administration may cause irritation, pain or phlebitis at the infusion site. 4. Rapid IV infusion may cause cardiac arrhythmias. Contraindications & Precautions ? Hypersensitivity to potassium chloride products ? Severe renal impairment or hyperkalemia ? Use with caution in patients with cardiac disease Nursing Implications ? Monitor serum potassium concentrations. If serum potassium level is not rising with effective potassium supplementation, consider checking a magnesium level. ? Continuous cardiac monitoring is mandatory for IV replacement especially for central infusions ? Watch IV site for signs of irritation or phlebitis. . Give oral doses with the nearest feed. WARNINGS Solutions which contain potassium ions should be used with great care, if at all, in patients with hyperkalemia, severe renal failure and in conditions in which potassium retention is present. To avoid potassium intoxication, do not infuse these solutions rapidly. In patients with severe renal insufficiency or adrenal insufficiency, administration of potassium chloride may cause potassium intoxication. Solutions containing sodium ions should be used with great care, if at all, in patients with congestive heart failure, severe renal insufficiency and in clinical states in which there exists edema with sodium retention. In patients with diminished renal function, administration of solutions containing sodium or potassium ions may result in sodium or potassium retention. The intravenous administration of these solutions can cause fluid and/or solute overloading resulting in dilution of serum electrolyte concentrations, congested heart failure states or pulmonary edema. The risk of dilutional states is inversely proportional to the electrolyte concentration of administered parenteral solutions. The risk of solute overload causing congested states with peripheral and pulmonary edema is directly proportional to the electrolyte concentrations of such solutions. Geriatric Use: Clinical studies of Potassium Chloride in Dextrose Injection, USP In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy. These drugs are known to be substantially excreted by the kidney, and the risk of toxic reactions to these drugs may be greater in patients with impaired renal function. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function. PRECAUTIONS Potassium replacement therapy should be guided primarily by serial electrocardiograms. Plasma potassium levels are not necessarily indicative of tissue potassium levels. High plasma concentrations of potassium may cause death through cardiac depression, arrhythmias or arrest. Potassium-containing solutions should be used with caution in the presence of cardiac disease, particularly in digitalized patients or in the presence of renal disease. Care should be exercised to insure that the needle (or catheter) is well within the lumen of the vein and that extravasation does not occur. Nausea, vomiting, abdominal pain and diarrhea have been reported with potassium therapy. The signs and symptoms of potassium intoxication include paresthesias of the extremities, flaccid paralysis, listlessness, mental confusion, weakness and heaviness of the legs, hypotension, cardiac arrhythmias, heart block, electrocardiographic abnormalities such as disappearance of P waves, spreading and slurring of the QRS complex with development of a biphasic curve and cardiac arrest. There were no physician visits or notes from 8-23-17 until the night of 8-28-17 (5 days later) after the survey team had entered, found and discussed with staff the issues with IV care for Resident #1, and surveyors had left the building for the night. The doctor diagnosed sepsis, from pneumonia and the UTI, and hyponatremia (low sodium), which was incorrect, the Resident actually was hypernatremic (high sodium) and there was no mention of the hypokalemia (low potassium) in the progress note. Physician orders were reviewed and revealed new orders on 8-29-17 for Potassium chloride 10 meq (milliequivalents) IV for 2 doses, due to low potassium STAT (give immediately) order, then the order was changed to Potassium chloride 20 meq (milliequivalents) IV in dextrose 5% - 1/2 normal saline solution at 75 ml per hour for 1 liter bag dose, due to low potassium, after a stat BMP result is reported to the MD (doctor). The Resident had been hypokalemic for 5 days at this point, and the blood potassium issue had worsened. The physician was interviewed on 8-30-17 at 9:00 a.m., The doctor was asked why no potassium had been given on 8-24-17 when labs showed hypokalemia. The doctor stated that some of the fluids that he ordered, and potassium for IV administration, had not been available to the facility at the time of his order, because nursing homes don't usually infuse potassium IV. He further stated that he had changed orders to accommodate the facility in regard to IV fluids as well, because they were having trouble getting Dextrose 5% with 1/2 normal saline, so he ordered just 5% dextrose instead. He was further asked why IV antibiotics had not been given timely, and he stated that the PICC line had taken awhile to be instilled in the Resident. When asked if these things could have been accomplished in a more timely manner for this Resident who was now septic, he stated yes, she could have been sent to the hospital where these things would have been received immediately. The facility policy on medication administration was reviewed, and stated that doctor's orders must be followed. In summary of the evidence provided by the facility, Resident #1 was acutely ill with pneumonia, and a UTI. The Resident was not drinking or eating, and was unable to consume antibiotics by mouth for 5 days. Potassium IV, and ordered hydration fluids were not administered timely, and care was delayed because the facility was unable to provide the necessary services. The Resident was not transferred to an acute care setting (hospital) where those services could be provided timely. Fluids were unavailable because of lack of IV access for atleast 12 hours. The Rocephin IV antibiotics were not administered from 5:00 a.m. 8-27-17 until the Levaquin was available at 9:00 p.m. on 8-28-17 (40 hours). By this time the Resident had been seen again by the doctor, and diagnosed as Septic. Medications such as IV potassium were unavailable in this setting as needed, and no monitoring or EKG's (electrocardiograms) were performed before, during or after the potassium infusions. The facility was notified of this deficient practice on 8-28-17, 8-29-17, and 8-30-17 at the end of day debrief. No further information was provided by the facility.

Based on staff interview, the facility staff failed to ensure staff were trained in emergency procedures. Licensed Practical Nurse D (LPN D), and Certified Nursing Assistant A (CNA A) could not describe fully what response should be made to fire, disaster, and elopement protocols. The findings included: LPN D, and CNA A were interviewed by phone on 8-29-17 at 11:30 p.m. They both identified themselves, and were asked to describe what to do if a fire alarm sounded. Neither could state Extinguish the fire and continued to say evacuate. When asked if they had emergency power, they stated yes at the nursing station, and seemed unaware of any other emergency power outlets for Resident use. When asked about elopement protocols both stated they would report to the supervisor, and the supervisor would report to the administrator, and the administrator would call the state. Neither could answer how long that would take, and could not describe that police would be called even with cueing from the surveyor about calling the police if a Resident could not be located. The issues were reviewed with the Administrator, and Director of Nursing at the end of day meeting on 8-30-17.