Based on staff interview and clinical record review, it was determined that the facility staff failed to provide a written notice to the Office of the State Long-Term Care Ombudsman of a hospital transfer for one of 17 residents in the survey sample; Resident #10. The findings include: The facility staff failed to provide a written notice to the ombudsman about a hospital transfer when Resident #10 was transferred to the hospital on 9/21/22. A review of the clinical record revealed a nurse's note dated 9/21/22 that documented, Guest left the facility at about 1430 (2:30 PM) on transfer to [name of hospital] emergency room via [name of company] transportation as ordered. A physician's progress note dated 9/21/22 documented, Pt (patient) is complaining of chest pains Pt is being sent to the ER (emergency room) for further eval (evaluation) Review of the clinical record failed to reveal any evidence of written notification to the ombudsman. On 1/12/23 at 8:35 AM, in an interview with ASM #1 (Administrative Staff Member), the Administrator, she stated that the facility does not send an ombudsman notice for a resident who is not admitted to the hospital and came back. At 2:24 PM, she stated that it is not required in this scenario. On 1/12/23 at approximately 2:30 PM, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2, the Director of Nursing, were made aware of the findings. ASM #1 was provided a list of policies being requested. The list included one for ombudsman notification when a resident is discharged to the hospital. None was provided. No further information was provided by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and facility document review, it was determined that the facility staff failed to follow professional standards of practice for medication administration for one of six residents in the medication administration task; Resident #174. The findings include: For Resident #174, the facility staff failed to properly prepare a dose of the medication, Lactulose (1), for administration. A review of the physician's orders revealed one dated 1/9/23 for Lactulose 20 GM (grams) / 30 ML (milliliters), give 15 ml one time a day. On 1/11/23 at 9:21 AM, RN #2 (Registered Nurse) was observed to prepare and administer medications to Resident #174. For the administration of the Lactulose, which was supplied in a 30 ml cup, RN #1 did not measure out the 15 ml ordered dose. Instead, RN #2 encouraged the resident to consume the medication from the prefilled 30 ml cup and then estimated when the resident had consumed approximately half of the cup, then discarded the rest. On 1/11/23 at 5:18 PM an interview was conducted with RN #2. She stated that she should have measured out the correct dose of the medication to be sure the resident received exactly what was ordered. A review of the facility policy, Community Medication Oversight Program did not provide any procedures on how to administer medications, including the steps involved in preparing and dosing medications accurately. On 1/12/23 at approximately 2:30 PM, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2, the Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey. According to Fundamentals of Nursing, Seventh Edition, 2009: by [NAME] and [NAME], page 707, Professional standards, such as the American Nurses Association's Nursing: Scope and Standards of Nursing Practice (2004), apply to the activity of medication administration. To prevent medication errors, follow the six rights medication administration consistently every time you administer medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication, 2. The right dose, 3. The right client, 4. The right route, 5. The right time, and 6. The right documentation. References: (1) Lactulose is used to treat constipation Information obtained from https://medlineplus.gov/druginfo/meds/a682338.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide clinical services in a manner to promote a resident's highest level of well-being for two of 17 residents in the survey sample, Residents #23 and #7. The findings include: 1. For Resident #23 (R23), the facility staff failed to apply compression stockings per a physician's order. R23 was admitted to the facility on [DATE]. On the admission assessment dated [DATE], R23 was assessed to have both long term and short term memory problems. R 23 was admitted following recent surgery to repair a broken hip. On 1/11/23 at 9:35 a.m., 10:51 a.m., and 1:44 p.m., R23 was sitting up in bed. The resident was not wearing compression stockings at any of these times. A review of R23's physician's orders revealed the following order dated 1/6/23: Compression stockings Midgrade to the knee (BLE) in the morning and remove per schedule. A review of R23's baseline care plan failed to reveal any information regarding compression stockings. On 1/12/23 at 9:15 a.m., RN (registered nurse) #4 was interviewed. She stated she had worked the night shift, and thought she had helped remove R23's compression stockings at bedtime on 1/11/23, but could not be sure. She stated she was not sure how staff knew to apply compression stockings to a resident's legs. On 1/12/23 at 9:49 a.m., CNA (certified nursing assistant) #1 was interviewed. She stated she had been assigned to R23 on 1/11/23. She stated she did not put compression stockings on the resident on 1/11/23. She stated she did not know the resident needed compression stockings. She stated things like compression stockings show on her instructions in the EMR (electronic medical record), but she did not see those instructions for R23. On 1/12/23 at 12:28 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. Policies regarding compression stockings were requested, but not received prior to exit. No further information was provided prior to exit. 2. For Resident #7 (R7), who had a physician's order for fluid restriction, the facility failed to document the amount of fluid the resident received each shift. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 11/9/22, R7 was coded as cognitively intact for making daily decisions, having scored 13 out of 15 on the BIMS (brief interview for mental status). On 1/10/23 at 1:18 p.m., 1/11/23 at 9:35 a.m. and 10:22 a.m., R7 was sitting up in the room. At each observation, the resident had a small pitcher of water within reach. At each observation, the resident was unable to reliably answer questions about fluid intake. A review of R7's clinical record revealed the following order dated 11/27/22: Fluid restriction < 1.2 liters (less than 1.2 liters) a day every shift. A review of R7's TARs (treatment administration records) from November and December 2022, and from January 2023, revealed nurse initials and check marks for each shift in the fluid restriction area. There were no amounts of fluid in any of the TARs. A review of R7's care plan dated 11/28/22 revealed no information related to the fluid restriction. On 1/12/23 at 9:15 a.m., RN (registered nurse) #4 was interviewed. When asked if she had signed any of R7's TARs related to fluid restriction, she said she had done so. When asked what the check mark in the box meant, she stated, It means the resident is taking fluid as stated. When asked if there is any way to look at the TARs to determine how much fluid a resident is receiving each shift, and from both nursing and dietary, she stated, No. There is not. When asked how much fluid R7 receives on the trays from dietary as opposed to how much fluid nursing is allowed to administer with medications, she stated she did not know. She stated the resident usually has a 500 ml (milliliter) bottle of water at the bedside, and she tries to measure how much water the resident is drinking from it. When asked where she documents that amount, she stated, I don't really document it. When asked if all staff are following this procedure, she stated, I don't know. On 1/12/23 at 9:56 a.m., RN #1, the MDS coordinator, was interviewed. She stated she could not determine how much fluid the resident should be receiving on any shift, and could not say how much fluid the resident was actually receiving. She stated there was no way the facility could know whether the resident was receiving the correct amount of fluids with the way the TAR was currently structured. On 1/12/23 at 12:28 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Fluid Restriction, revealed, in part: It is the policy of this facility to ensure that fluid restrictions will be followed in accordance to physician's orders .The nurse will obtain and verify the physician's order for the fluid restriction and an order written to include the breakdown of the amount of fluid per 24 hours to be distributed between the food and nutrition department and the nursing department, and will be recorded on the medication record or other format as per facility protocol .The fluid restriction distribution will take into consideration the amount of fluid to be given at mealtimes, snacks, and medication passes. No further information was provided prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, the facility failed to follow and clarify an order for oxygen for one of 17 residents in the survey sample, Resident #17. The findings include: For Resident #7 (R7), the facility failed to clarify an order for oxygen, and to administer oxygen as ordered. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 11/9/22, R7 was coded as cognitively intact for making daily decisions, having scored 13 out of 15 on the BIMS (brief interview for mental status). The resident was coded as receiving oxygen prior to admission and during the look back period at the facility. On 1/10/23 at 1:18 p.m., 1/11/23 at 9:35 a.m. and 10:22 a.m., R7 was receiving oxygen via a nasal cannula from an oxygen concentrator. The concentrator was set at 1.5 lpm (liters per minute). A review of R7's clinical record revealed the following order dated 11/28/22: Oxygen 0.5L (liter) to 1L at bedtime. A review of R7's care plan dated 11/28/22 revealed nothing specifically related to the liters per minute or timing of oxygen administration. On 1/12/23 at 9:15 a.m., RN (registered nurse) #4 was interviewed. When asked to review R7's oxygen order, she stated it was unclear as to how much the oxygen the resident was supposed to be receiving. She stated the order provided clear instructions that the resident should only be receiving oxygen at night. On 1/12/23 at 10:41 a.m., RN #1, the MDS coordinator, was interviewed. After reviewing R7's oxygen order, she stated the order needed to have parameters set, and needed to be clarified. She stated the order was not being followed as currently written because the resident was receiving the oxygen during the daytime. On 1/12/23 at 12:28 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. Policies regarding oxygen administration were requested, but not received prior to exit. No further information was provided prior to exit.

Based on staff interview and facility document review, it was determined that the facility staff failed to complete annual performance evaluations for two of five CNA (certified nursing assistant) employee records reviewed, CNAs #2 and #3. The findings include: For CNA #2, no performance review had been completed since her hire date of 7/21/22. For CNA #3, no performance review had been completed since 7/13/21. Five CNA employee records were reviewed to determine compliance with the requirement for annual performance reviews. When the facility provided the requested documents, CNA #2's record contained no evidence of any performance reviews since her hire date of 7/21/22. CNA #3's record contained no evidence of a performance review since 7/13/21. On 1/22/23 at 10:08 a.m., ASM (administrative staff member) #1, the administrator, stated she was currently responsible for completing staff performance evaluations. When asked about CNA #2, she stated, It is in progress. I have started on it. When asked about CNA #3, she stated, His is due. I have not gotten a chance to start on it. ASM #1 acknowledged that the performance reviews are due annually. 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 ensure a medication was available for one of six residents in the medication administration task; Resident #174. The findings include: For Resident #174, the facility staff failed to ensure the physician ordered medication, Lidocaine gel (1), was available for use. A review of the physician's orders revealed one dated 1/9/23, to start on 1/10/23, for Lidocaine external gel 4%, apply to left buttock topically in the morning for pain, and remove per schedule. On 1/11/23 at 9:21 AM, RN #2 (Registered Nurse) was observed to prepare and administer medications to Resident #174. RN #2 was unable to locate the Lidocaine gel for Resident #174 in the medication cart. A review of the nurse's notes revealed one dated 1/11/23 that documented in relation to the lidocaine, Pharmacy contacted and reminded to deliver lidocaine patch. Second reminder pending. A nurse's note from the day before, 1/10/23, documented in relation to the lidocaine, new admission, medication pending, MD (medical doctor) made aware. A review of the January 2023 MAR (Medication Administration Record) also revealed that the resident did not get this medication on 1/10/23 and 1/11/23. On 1/11/23 at 5:18 PM an interview was conducted with RN #2. She stated that the medication was ordered when the resident was admitted and that pharmacy was notified and reminded twice and it still had not arrived and she did not know why A review of the facility policy, Community Medication Oversight Program documented on page 4, The dashboard is reviewed each shift to ensure medications are available, administered and documented On 1/12/23 at approximately 2:30 PM, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2, the Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey. References: Lidocaine belongs to the family of medicines called local anesthetics. This medicine prevents pain by blocking the signals at the nerve endings in the skin. https://www.mayoclinic.org/drugs-supplements/lidocaine-topical-application-route/proper-use/drg-20072776?p=1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to act upon pharmacy recommendations in a timely manner for one of 17 residents in the survey sample; Resident #19. The findings include: For Resident #19, a monthly pharmacy review was conducted on 12/23/22. The review documented in all capital letters at the top, ***CLINICALLY URGENT RECOMMENDATION. PROMPT RESPONSE REQUESTED.*** As of the survey, on 1/12/23, 2 of the 3 items identified on the review had not been addressed. On the most recent MDS (Minimum Data Set), an admission / 5-day assessment dated [DATE], Resident #19 was coded as being cognitively intact in ability to make daily life decisions. A review of the clinical record revealed a pharmacy note dated 12/23/22 that documented, See report for any noted irregularities and/or recommendations. A review of the pharmacy's report, dated 12/23/22 documented at the top, ***CLINICALLY URGENT RECOMMENDATION. PROMPT RESPONSE REQUESTED.*** This report identified 3 items to be addressed, as follows: 1. Directions for use (Medication): discharge order: brimonidine (1) 0/15% 1 drop both eyes twice daily; current order: brimonidine-dorzolamide 0.15-2% 1 drop both eyes twice daily. 2. discharge order: polyvinyl-povidone (2) 1.4-0.6% 1 drop four times daily PRN; current order: polyvinyl-povidone 1/4-0.6% 1 drop every 4 hours PRN. 3. Vancomycin (3) 750 film?? A review of the physician's orders revealed that the first item identified on the above pharmacy report had been addressed/corrected immediately. Items #2 and #3 were still unchanged and not addressed as of the survey on 1/12/23. On 1/12/23 at 12:44 PM, an interview was conducted with RN (Registered Nurse) #1. She stated that the recommendations were not addressed but should have been, given the pharmacy statement of the recommendations being clinically urgent. A review of the facility policy, 9. Medication Regimen Review documented, When the Consultant Pharmacist identifies an urgent medication irregularity during MRR that requires immediate action, the consultant pharmacist will notify the nurse and request the facility contact the attending physician to communicate the issue and obtain direction or new orders. 9.1 If the attending physician has not responded by the time the consultant pharmacist has completed his/her consultation for the day, the issue will be escalated to the Medical Director for immediate action. On 1/12/23 at approximately 2:30 PM, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2, the Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey. References: 1. Brimonidine is used to lower pressure in the eyes for patients with glaucoma. Information obtained from https://medlineplus.gov/druginfo/meds/a601232.html 2. polyvinyl-povidone is used to relieve dry, irritated eyes. Information obtained from https://www.webmd.com/drugs/2/drug-60574/polyvinyl-alcohol-w-povidone-ophthalmic-eye/details 3. Vancomycin is an antibiotic. Information obtained from https://medlineplus.gov/druginfo/meds/a604038.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and resident interview, it was determined that the facility staff failed to comply with all the requirements of a binding arbitration agreement for two of 17 residents in the survey sample; Residents #1 and #19. The findings include: 1. For Resident #1, the facility staff failed to ensure the binding arbitration agreement the resident signed at the time of the most recent admission [DATE]) met all the requirements by law. On the most recent MDS (Minimum Data Set), a quarterly assessment dated [DATE], Resident #1 was coded as being cognitively intact in ability to make daily life decisions. Resident #1 was coded as requiring supervision for eating and limited assistance for locomotion and hygiene; and extensive assistance to total care for all other areas of activities of daily living. A review of the resident's admission agreement was conducted and the following was revealed: VII. DISPUTE RESOLUTION A. Grievance Policy: The Nursing Facility's Resident Grievance Policy is available upon request and includes components required by applicable law. Contacts for all pertinent State regulatory and informational agencies and resident advocacy groups are listed in Exhibit 12. B. Waiver of Trial by Jury. While most issues can be resolved under the Grievance Policy, in the event that the parties are unable to resolve their differences short of litigation, the parties agree that any trial shall be before a judge and not a jury. Accordingly: WAIVER OF TRIAL BY JURY: THE PARTIES TO THIS AGREEMENT HEREBY KNOWINGLY AND UNCONDITIONALLY WAIVE ALL RIGHTS TO A TRIAL BY JURY IN ANY LAWSUIT OR COUNTERCLAIM THAT MAY BE FILED BY EITHER PARTY IN CONTRACT, TORT, EQUITY OR BY STATUTE ARISING OUT OF OR RELATED TO THIS AGREEMENT AND/OR ANY SERVICES OR CARE PROVIDED BY THE COMMUNITY TO THE RESIDENT. THIS WAIVER MEANS THAT IF ANY LAWSUIT IS BROUGHT, A JUDGE OF THE COURT AND NOT A JURY WILL DECIDE THE FACTS AND DETERMINE THE OUTCOME OF THE CASE. THE COMMUNITY SHALL INCLUDE THE MANAGER, OWNER AND/OR TENANT, AND ALL OF THEIR RESPECTIVE AFFILIATES, SUBSIDIARIES, PARENT COMPANIES AND SISTER COMPANIES AND ALL OF THEIR RESPECTIVE EMPLOYEES, AGENTS, CONTRACTORS, ASSIGNEES, OFFICERS AND DIRECTORS. THE UNDERSIGNED HAS HAD AN OPPORTUNITY TO REVIEW THIS PROVISION AND HAVE IT REVIEWED BY COUNSEL OF HIS/HER CHOICE. IF THE UNDERSIGNED IS ANYONE OTHER THAN THE RESIDENT, THE UNDERSIGNED WARRANTS AND REPRESENTS THAT HE/SHE HAS FULL LEGAL AND EXPRESS AUTHORITY TO WAIVE THE RESIDENT'S AND THE RESIDENT'S HEIRS', BENEFICIARIES' AND/OR ESTATE'S RIGHT TO A TRIAL BY JURY. I HAVE READ AND UNDERSTAND THE FOREGOING AND VOLUNTARILY AGREE TO ITS TERMS. The above form was dated 09-2018. The above document did not contain all the legally required, clearly identified language, including the requirements that: 1. The facility must not require any resident or his or her representative to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility and must explicitly inform the resident or his or her representative of his or her right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at, the facility. 2. The agreement must explicitly grant the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it. 3. The agreement must explicitly state that neither the resident nor his or her representative is required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility. In addition to the above missing, clearly explicit statements as required, an interview was conducted on 1/11/23 at 4:37 PM, with OSM #2 (Other Staff Member) the Admissions Director. She stated that she presses for residents to sign the above agreement, per her training that everyone is to sign the admission contract within 72 hours of admission. She stated that They are not required to sign it but I require them to sign it. On 1/12/23 at 11:30 AM, an interview was conducted with Resident #1. They were shown the agreement and stated that they understood it and was ok with it. However, they were not provided with an agreement that contained the current legally required language and statements, including items 1-3 above, as was required by law the date Resident #1 was readmitted . On 1/12/23 at approximately 2:30 PM, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2, the Director of Nursing, were made aware of the findings. The arbitration agreement policy was requested from ASM #1, however none was provided prior to exit. 2. For Resident #19, the facility staff failed to ensure the binding arbitration agreement the resident signed at the time of admission [DATE]) met all the requirements by law. On the most recent MDS (Minimum Data Set), an admission / 5-day assessment dated [DATE], Resident #19 was coded as being cognitively intact in ability to make daily life decisions. Resident #19 was coded as requiring supervision for eating and limited to extensive care for all other areas of activities of daily living. A review of the resident's admission agreement was conducted and the following was revealed: VII. DISPUTE RESOLUTION A. Grievance Policy: The Nursing Facility's Resident Grievance Policy is available upon request and includes components required by applicable law. Contacts for all pertinent State regulatory and informational agencies and resident advocacy groups are listed in Exhibit 12. B. Waiver of Trial by Jury. While most issues can be resolved under the Grievance Policy, in the event that the parties are unable to resolve their differences short of litigation, the parties agree that any trial shall be before a judge and not a jury. Accordingly: WAIVER OF TRIAL BY JURY: THE PARTIES TO THIS AGREEMENT HEREBY KNOWINGLY AND UNCONDITIONALLY WAIVE ALL RIGHTS TO A TRIAL BY JURY IN ANY LAWSUIT OR COUNTERCLAIM THAT MAY BE FILED BY EITHER PARTY IN CONTRACT, TORT, EQUITY OR BY STATUTE ARISING OUT OF OR RELATED TO THIS AGREEMENT AND/OR ANY SERVICES OR CARE PROVIDED BY THE COMMUNITY TO THE RESIDENT. THIS WAIVER MEANS THAT IF ANY LAWSUIT IS BROUGHT, A JUDGE OF THE COURT AND NOT A JURY WILL DECIDE THE FACTS AND DETERMINE THE OUTCOME OF THE CASE. THE COMMUNITY SHALL INCLUDE THE MANAGER, OWNER AND/OR TENANT, AND ALL OF THEIR RESPECTIVE AFFILIATES, SUBSIDIARIES, PARENT COMPANIES AND SISTER COMPANIES AND ALL OF THEIR RESPECTIVE EMPLOYEES, AGENTS, CONTRACTORS, ASSIGNEES, OFFICERS AND DIRECTORS. THE UNDERSIGNED HAS HAD AN OPPORTUNITY TO REVIEW THIS PROVISION AND HAVE IT REVIEWED BY COUNSEL OF HIS/HER CHOICE. IF THE UNDERSIGNED IS ANYONE OTHER THAN THE RESIDENT, THE UNDERSIGNED WARRANTS AND REPRESENTS THAT HE/SHE HAS FULL LEGAL AND EXPRESS AUTHORITY TO WAIVE THE RESIDENT'S AND THE RESIDENT'S HEIRS', BENEFICIARIES' AND/OR ESTATE'S RIGHT TO A TRIAL BY JURY. I HAVE READ AND UNDERSTAND THE FOREGOING AND VOLUNTARILY AGREE TO ITS TERMS. The above form was dated 09-2018. The above document did not contain all the legally required, clearly identified language, including the requirements that: 1. The facility must not require any resident or his or her representative to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility and must explicitly inform the resident or his or her representative of his or her right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at, the facility. 2. The agreement must explicitly grant the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it. 3. The agreement must explicitly state that neither the resident nor his or her representative is required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility. In addition to the above missing, clearly explicit statements as required, an interview was conducted on 1/11/23 at 4:37 PM, with OSM #2 (Other Staff Member) the Admissions Director. She stated that she presses for residents to sign the above agreement, per her training that everyone is to sign the admission contract within 72 hours of admission. She stated that They are not required to sign it but I require them to sign it. On 1/12/23 at 11:30 AM, an interview was conducted with Resident #19. They were shown the agreement and stated that they understood it and was ok with it. However, they were not provided with an agreement that contained the current legally required language and statements, including items 1-3 above, as was required by law the date Resident #19 was admitted . On 1/12/23 at approximately 2:30 PM, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2, the Director of Nursing, were made aware of the findings. The arbitration agreement policy was requested from ASM #1, however none was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and resident interview, it was determined that the facility staff failed to ensure the binding arbitration agreements contained explicit language for the selection of an arbitrator and venue, for two of 17 residents in the survey sample; Residents #1 and #19. The findings include: 1. For Resident #1, the facility staff failed to ensure the binding arbitration agreement the resident signed at the time of the most recent admission [DATE]) met all the requirements by law. On the most recent MDS (Minimum Data Set), a quarterly assessment dated [DATE], Resident #1 was coded as being cognitively intact in ability to make daily life decisions. During a review of the resident's admission agreement, the following document was reviewed: VII. DISPUTE RESOLUTION A. Grievance Policy: The Nursing Facility's Resident Grievance Policy is available upon request and includes components required by applicable law. Contacts for all pertinent State regulatory and informational agencies and resident advocacy groups are listed in Exhibit 12. B. Waiver of Trial by Jury. While most issues can be resolved under the Grievance Policy, in the event that the parties are unable to resolve their differences short of litigation, the parties agree that any trial shall be before a judge and not a jury. Accordingly: WAIVER OF TRIAL BY JURY: THE PARTIES TO THIS AGREEMENT HEREBY KNOWINGLY AND UNCONDITIONALLY WAIVE ALL RIGHTS TO A TRIAL BY JURY IN ANY LAWSUIT OR COUNTERCLAIM THAT MAY BE FILED BY EITHER PARTY IN CONTRACT, TORT, EQUITY OR BY STATUTE ARISING OUT OF OR RELATED TO THIS AGREEMENT AND/OR ANY SERVICES OR CARE PROVIDED BY THE COMMUNITY TO THE RESIDENT. THIS WAIVER MEANS THAT IF ANY LAWSUIT IS BROUGHT, A JUDGE OF THE COURT AND NOT A JURY WILL DECIDE THE FACTS AND DETERMINE THE OUTCOME OF THE CASE. THE COMMUNITY SHALL INCLUDE THE MANAGER, OWNER AND/OR TENANT, AND ALL OF THEIR RESPECTIVE AFFILIATES, SUBSIDIARIES, PARENT COMPANIES AND SISTER COMPANIES AND ALL OF THEIR RESPECTIVE EMPLOYEES, AGENTS, CONTRACTORS, ASSIGNEES, OFFICERS AND DIRECTORS. THE UNDERSIGNED HAS HAD AN OPPORTUNITY TO REVIEW THIS PROVISION AND HAVE IT REVIEWED BY COUNSEL OF HIS/HER CHOICE. IF THE UNDERSIGNED IS ANYONE OTHER THAN THE RESIDENT, THE UNDERSIGNED WARRANTS AND REPRESENTS THAT HE/SHE HAS FULL LEGAL AND EXPRESS AUTHORITY TO WAIVE THE RESIDENT'S AND THE RESIDENT'S HEIRS', BENEFICIARIES' AND/OR ESTATE'S RIGHT TO A TRIAL BY JURY. I HAVE READ AND UNDERSTAND THE FOREGOING AND VOLUNTARILY AGREE TO ITS TERMS. The above form was dated 09-2018. The above document did not contain all the legally required, clearly identified language, including the requirements that the agreement provides for the selection of a neutral arbitrator agreed upon by both parties; and the agreement provides for the selection of a venue that is convenient to both parties. In addition to the above missing, clearly explicit statement as required, an interview was conducted on 1/11/23 at 4:37 PM, with OSM #2 (Other Staff Member) the Admissions Director. She stated that she presses for residents to sign the above agreement, per her training that everyone is to sign the admission contract within 72 hours of admission. She stated that They are not required to sign it but I require them to sign it. On 1/12/23 at 11:30 AM, an interview was conducted with Resident #1. They were shown the agreement and stated that they understood it and was ok with it. However, they were not provided with an agreement that contained the current legally required language and statements, including above identified requirement, as was required by law the date Resident #1 was readmitted . On 1/12/23 at approximately 2:30 PM, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2, the Director of Nursing, were made aware of the findings. An arbitration agreements policy was requested from ASM #1, however none was provided prior to exit. 2. For Resident #19, the facility staff failed to ensure the binding arbitration agreement the resident signed at the time of admission [DATE]) met all the requirements by law. On the most recent MDS (Minimum Data Set), an admission / 5-day assessment dated [DATE], Resident #19 was coded as being cognitively intact in ability to make daily life decisions. During a review of the resident's admission agreement, the following document was reviewed: VII. DISPUTE RESOLUTION A. Grievance Policy: The Nursing Facility's Resident Grievance Policy is available upon request and includes components required by applicable law. Contacts for all pertinent State regulatory and informational agencies and resident advocacy groups are listed in Exhibit 12. B. Waiver of Trial by Jury. While most issues can be resolved under the Grievance Policy, in the event that the parties are unable to resolve their differences short of litigation, the parties agree that any trial shall be before a judge and not a jury. Accordingly: WAIVER OF TRIAL BY JURY: THE PARTIES TO THIS AGREEMENT HEREBY KNOWINGLY AND UNCONDITIONALLY WAIVE ALL RIGHTS TO A TRIAL BY JURY IN ANY LAWSUIT OR COUNTERCLAIM THAT MAY BE FILED BY EITHER PARTY IN CONTRACT, TORT, EQUITY OR BY STATUTE ARISING OUT OF OR RELATED TO THIS AGREEMENT AND/OR ANY SERVICES OR CARE PROVIDED BY THE COMMUNITY TO THE RESIDENT. THIS WAIVER MEANS THAT IF ANY LAWSUIT IS BROUGHT, A JUDGE OF THE COURT AND NOT A JURY WILL DECIDE THE FACTS AND DETERMINE THE OUTCOME OF THE CASE. THE COMMUNITY SHALL INCLUDE THE MANAGER, OWNER AND/OR TENANT, AND ALL OF THEIR RESPECTIVE AFFILIATES, SUBSIDIARIES, PARENT COMPANIES AND SISTER COMPANIES AND ALL OF THEIR RESPECTIVE EMPLOYEES, AGENTS, CONTRACTORS, ASSIGNEES, OFFICERS AND DIRECTORS. THE UNDERSIGNED HAS HAD AN OPPORTUNITY TO REVIEW THIS PROVISION AND HAVE IT REVIEWED BY COUNSEL OF HIS/HER CHOICE. IF THE UNDERSIGNED IS ANYONE OTHER THAN THE RESIDENT, THE UNDERSIGNED WARRANTS AND REPRESENTS THAT HE/SHE HAS FULL LEGAL AND EXPRESS AUTHORITY TO WAIVE THE RESIDENT'S AND THE RESIDENT'S HEIRS', BENEFICIARIES' AND/OR ESTATE'S RIGHT TO A TRIAL BY JURY. I HAVE READ AND UNDERSTAND THE FOREGOING AND VOLUNTARILY AGREE TO ITS TERMS. The above form was dated 09-2018. The above document did not contain all the legally required, clearly identified language, including the requirements that the agreement provides for the selection of a neutral arbitrator agreed upon by both parties; and the agreement provides for the selection of a venue that is convenient to both parties. In addition to the above missing, clearly explicit statements as required, an interview was conducted on 1/11/23 at 4:37 PM, with OSM #2 (Other Staff Member) the Admissions Director. She stated that she presses for residents to sign the above agreement, per her training that everyone is to sign the admission contract within 72 hours of admission. She stated that They are not required to sign it but I require them to sign it. On 1/12/23 at 11:30 AM, an interview was conducted with Resident #19. They were shown the agreement and stated that they understood it and was ok with it. However, they were not provided with an agreement that contained the current legally required language and statements, including above identified requirement, as was required by law the date Resident #1 was admitted . On 1/12/23 at approximately 2:30 PM, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2, the Director of Nursing, were made aware of the findings. An arbitration agreements policy was requested from ASM #1, however none was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to implement a complete immunization program for one of five residents immunization record reviews, Resident #10. The findings include: 1. For Resident #10 (R10), the facility staff failed to provide the pneumonia vaccination in a timely manner. R10 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 12/9/2022, the resident was assessed as being cognitively in making daily decisions. In Section O - Special Treatments, Programs and Procedures, the resident was coded as not being up to date on the pneumococcal vaccination and the vaccine not being offered. Review of R10's clinical record failed to evidence documentation of a pneumococcal vaccine being administered or offered. The admission Evaluation for R10, dated 9/1/2022, documented the date unknown for pneumococcal vaccine. On 1/11/2023 at approximately 9:00 a.m., a request was made to RN (registered nurse) #1, MDS coordinator/Infection Preventionist for evidence of pneumonia vaccination screening and offering for R10. On 1/11/2023 at approximately 10:30 a.m., RN #1 provided a resident pneumococcal vaccination consent documenting verbal consent for the pneumococcal vaccine to be administered to R10 by the responsible party dated 11/10/2022. RN #1 stated that there were delays in getting the vaccine from pharmacy and they were only able to get the vaccine in last week so it had not been administered yet. On 1/12/2023 at 1:10 p.m., an interview was conducted with RN #1. RN #1 stated that all residents were screened for immunizations on admission. RN #1 stated that if residents were eligible to receive the pneumococcal vaccine and consented to receive the vaccine they would order the vaccine from the pharmacy and administer it. RN #1 stated that there was a delay with the pharmacy getting the vaccine for R10 and it had come in last week. RN #1 stated that the night shift staff were responsible for reordering vaccines when needed and had reordered the pneumococcal vaccine but there was a delay. RN #1 stated that R10 should have received the pneumococcal vaccine and it was reasonable for them to have it by now after consenting on 11/10/2022. RN #1 stated that they would check with the pharmacy to see if they were able to get evidence of the delay in getting the vaccine in the facility. On 1/12/2023 at 1:49 p.m., RN #1 stated that they had attempted to reach the pharmacy and did not have anything to provide regarding the delay in obtaining the vaccine from the pharmacy. The facility policy, Influenza and Pneumococcal Immunizations dated 7/11/22 documented in part, .Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized . The facility policy, Infection Prevention and control program for skilled communities dated 2018 documented in part, .Upon move in, the resident's immunization status is evaluated and vaccination is offered if not previously vaccinated. Additionally, pneumococcal vaccination is offered yearly during influenza clinics . On 1/12/2023 at 2:30 p.m., ASM (administrative staff member) #1, the administrator was made of the above concern. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review and facility document review, the facility staff failed to develop and/or provide residents and/or their responsible party, with a summary of the baseline care plan for five of 17 residents in the survey sample, Residents #176, #18, #177, #174 and #23. The findings include: 1. For Resident #176 (R176), the facility staff failed to provide the resident and/or the responsible party with a summary of the baseline care plan. R176 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 1/8/2023, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 1/11/2023 at 9:42 a.m., an interview was conducted with R176 in their room. When asked about receiving a written summary of their baseline care plan, R176 stated that they did not recall receiving anything however their children were involved and may have gotten something. A review of R176's clinical record failed to evidence a written summary of the baseline care plan being provided to the resident and/or the responsible party. On 1/12/2023 at approximately 8:30 a.m., a request was made to ASM #1, the administrator for evidence of the baseline care plan being provided to R176 and/or the responsible party. On 1/12/2023 at 9:57 a.m., an interview was conducted with RN (registered nurse) #1, MDS coordinator/Infection preventionist. RN #1 stated that the floor nurses were responsible for developing the baseline care plan. RN #1 stated that it was the assistant director of nursing's responsibility to ensure the baseline care plan was completed within twenty-four hours and to provide the resident and/or the responsible party with a written copy and explain to them that it was a basic plan of care. RN #1 stated that they currently did not have an assistant director of nursing and were not sure if the written copy was being provided. On 1/12/2023 at 10:42 a.m., an interview was conducted with ASM (administrative staff member) #2, director of nursing. ASM #2 stated that the floor nurses were responsible for developing the baseline care plan based on the concerns the resident was admitted with. ASM #2 stated that the resident and/or responsible party should have access to and have a copy of the care plan. ASM #2 stated that they were onboarding at the facility and would have to check the process to see whether residents and/or the responsible parties were getting a written summary of the baseline care plan. On 1/12/2023 at 3:16 p.m., ASM #1 stated that they did not have evidence of a written summary of the baseline care plan being provided to R176 and/or the responsible party. On 1/12/2023 at approximately 3:20 p.m., ASM #1 was made aware of the concern. No further information was provided prior to exit. 2. For Resident #18 (R18), the facility staff failed to provide the resident and/or the responsible party with a summary of the baseline care plan. R18 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 12/13/2022, the resident scored 12 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately impaired for making daily decisions. On 1/11/2023 at 9:15 a.m., an interview was conducted with R18 in their room. When asked about receiving a written summary of their baseline care plan, R18 stated that they were unsure. A review of R18's clinical record failed to evidence a written summary of the baseline care plan being provided to the resident and/or the responsible party. On 1/12/2023 at approximately 8:30 a.m., a request was made to ASM #1, the administrator for evidence of the baseline care plan being provided to R18 and/or the responsible party. On 1/12/2023 at 9:57 a.m., an interview was conducted with RN (registered nurse) #1, MDS coordinator/Infection preventionist. RN #1 stated that the floor nurses were responsible for developing the baseline care plan. RN #1 stated that it was the assistant director of nursing's responsibility to ensure the baseline care plan was completed within twenty-four hours and to provide the resident and/or the responsible party with a written copy and explain to them that it was a basic plan of care. RN #1 stated that they currently did not have an assistant director of nursing and were not sure if the written copy was being provided. On 1/12/2023 at 10:42 a.m., an interview was conducted with ASM (administrative staff member) #2, director of nursing. ASM #2 stated that the floor nurses were responsible for developing the baseline care plan based on the concerns the resident was admitted with. ASM #2 stated that the resident and/or responsible party should have access to and have a copy of the care plan. ASM #2 stated that they were onboarding at the facility and would have to check the process to see whether residents and/or the responsible parties were getting a written summary of the baseline care plan. On 1/12/2023 at 3:16 p.m., ASM #1 stated that they did not have evidence of a written summary of the baseline care plan being provided to R18 and/or the responsible party. On 1/12/2023 at approximately 3:20 p.m., ASM #1 was made aware of the concern. No further information was provided prior to exit. 3. For Resident #177 (R177), the facility staff failed to provide the resident and/or the responsible party with a summary of the baseline care plan. R177 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 11/25/2022, the resident scored 1 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. A review of R177's clinical record failed to evidence a written summary of the baseline care plan being provided to the responsible party. On 1/12/2023 at approximately 8:30 a.m., a request was made to ASM #1, the administrator for evidence of the baseline care plan being provided to R177 and/or the responsible party. On 1/12/2023 at 9:57 a.m., an interview was conducted with RN (registered nurse) #1, MDS coordinator/Infection preventionist. RN #1 stated that the floor nurses were responsible for developing the baseline care plan. RN #1 stated that it was the assistant director of nursing's responsibility to ensure the baseline care plan was completed within twenty-four hours and to provide the resident and/or the responsible party with a written copy and explain to them that it was a basic plan of care. RN #1 stated that they currently did not have an assistant director of nursing and were not sure if the written copy was being provided. On 1/12/2023 at 10:42 a.m., an interview was conducted with ASM (administrative staff member) #2, director of nursing. ASM #2 stated that the floor nurses were responsible for developing the baseline care plan based on the concerns the resident was admitted with. ASM #2 stated that the resident and/or responsible party should have access to and have a copy of the care plan. ASM #2 stated that they were onboarding at the facility and would have to check the process to see whether residents and/or the responsible parties were getting a written summary of the baseline care plan. On 1/12/2023 at 3:16 p.m., ASM #1 stated that they did not have evidence of a written summary of the baseline care plan being provided to R177 and/or the responsible party. On 1/12/2023 at approximately 3:20 p.m., ASM #1 was made aware of the concern. No further information was provided prior to exit. 4. For Resident #174 (R174), the facility staff failed to provide the resident and/or the responsible party with a summary of the baseline care plan. R174 was admitted to the facility on [DATE]. R174's MDS (minimum data set) assessment was not due during the dates of the survey. The admission health assessment dated [DATE] documented R174 being modified independent with decisions regarding tasks of daily life. A review of R174's clinical record failed to evidence a written summary of the baseline care plan being provided to the responsible party. On 1/12/2023 at approximately 8:30 a.m., a request was made to ASM #1, the administrator for evidence of the baseline care plan being provided to R174 and/or the responsible party. On 1/12/2023 at 9:57 a.m., an interview was conducted with RN (registered nurse) #1, MDS coordinator/Infection preventionist. RN #1 stated that the floor nurses were responsible for developing the baseline care plan. RN #1 stated that it was the assistant director of nursing's responsibility to ensure the baseline care plan was completed within twenty-four hours and to provide the resident and/or the responsible party with a written copy and explain to them that it was a basic plan of care. RN #1 stated that they currently did not have an assistant director of nursing and were not sure if the written copy was being provided. On 1/12/2023 at 10:42 a.m., an interview was conducted with ASM (administrative staff member) #2, director of nursing. ASM #2 stated that the floor nurses were responsible for developing the baseline care plan based on the concerns the resident was admitted with. ASM #2 stated that the resident and/or responsible party should have access to and have a copy of the care plan. ASM #2 stated that they were onboarding at the facility and would have to check the process to see whether residents and/or the responsible parties were getting a written summary of the baseline care plan. On 1/12/2023 at 3:16 p.m., ASM #1 stated that they did not have evidence of a written summary of the baseline care plan being provided to R174 and/or the responsible party. On 1/12/2023 at approximately 3:20 p.m., ASM #1 was made aware of the concern. No further information was provided prior to exit.5. For Resident #23 (R23), the facility staff failed to develop a baseline care plan to include the resident's compression stockings. R23 was admitted to the facility on [DATE]. On the admission assessment dated [DATE], R23 was assessed to have both long term and short term memory problems. R 23 was admitted following recent surgery to repair a broken hip. On 1/11/23 at 9:35 a.m., 10:51 a.m., and 1:44 p.m., R23 was sitting up in bed. The resident was not wearing compression stockings at any of these times. A review of R23's physician's orders revealed the following order dated 1/6/23: Compression stockings Midgrade to the knee (BLE) in the morning and remove per schedule. A review of R23's baseline care plan failed to reveal any information regarding compression stockings. On 1/12/23 at 9:15 a.m., RN (registered nurse) #4 was interviewed. She stated she had worked the night shift, and thought she had helped remove R23's compression stockings at bedtime on 1/11/23, but could not be sure. She stated she was not sure how staff knew to apply compression stockings to a resident's legs. She stated she did not know who was responsible for developing a resident's baseline care plan. On 1/12/23 at 9:56 a.m., RN #1, the MDS coordinator, was interviewed. She stated the admitting nurse is responsible for initiating the care plan. She stated ordinarily the assistant director of nursing is responsible for completing the baseline care plan. She stated there is no current assistant director of nursing. On 1/12/23 at 10:41 a.m., ASM (administrative staff member) #2, the director of nursing, was interviewed. She stated the admitting nurse puts together a care plan of what they identify as the resident's needs. She stated compression stockings should be included on a baseline care plan. On 1/12/23 at 12:28 p.m., ASM #1, the administrator, and ASM #2 were informed of these concerns. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and facility document review it was determined that the facility staff failed to provide a complete pain management program including implementation of non-pharmacological interventions prior to the administration of as-needed pain medications for two of 17 residents in the survey sample, Residents #177 and #19. The findings include: 1. For Resident #177 (R177), the facility staff failed to evidence implementation of non-pharmacological interventions prior to administration of as-needed pain medication. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 11/25/2022, the resident scored 1 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. Section J documented R177 receiving as needed pain medications and not receiving non-medication interventions for pain. The physician order's for R177 documented in part, - Tylenol Oral Tablet 325 MG (milligram) (acetaminophen (1)) Give 2 tablet by mouth every 6 hours as needed for pain. Do not exceed 3 grams in 24 hours from all sources. Order Date: 10/28/2022. Start Date: 10/28/2022. The eMAR (electronic medication administration record) dated 11/1/2022-11/30/2022 documented the Tylenol as administered to R177 on 11/2/2022 for a pain level of six; on 11/5/2022 for a pain level of three; on 11/19/2022 for a pain level of three; and on 11/30/2022 for a pain level of two. The eMAR dated 12/1/2022-12/31/2022 documented the Tylenol as administered to R177 on 12/17/2022 for a pain level of four. The progress notes for R177 failed to evidence documentation of non-pharmacological interventions attempted or offered prior to the administration of the as needed pain medication on the dates and times listed above. The comprehensive care plan for R177 dated 10/28/2022 documented in part, The resident is on pain medication therapy r/t (related to) sacral wound. Date Initiated: 10/28/2022. Revision on: 10/28/2022 . On 1/12/2023 at 1:54 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 stated that when residents complained of pain they did a pain assessment first and then attempted non-pharmacological interventions like repositioning prior to administering pain medications. RN #2 stated that they would ask the resident to rate their pain or use the non-verbal scale if needed and administer the as needed medication when the non-pharmacological interventions were not effective. RN #2 stated that they documented the non-pharmacological interventions they attempted in the progress notes. RN #2 stated that if there were no progress notes to evidence the non-pharmacological interventions were attempted that it meant the nurse when straight to the pain medications, maybe because the residents pain was so intense. RN #2 stated that it was key to document what non-pharmacological interventions were used and their system had a process to allow them to enter the notes when administering medications. The facility policy Pain Management Program dated 1/2019 documented in part, .An effective pain management plan uses a multi-pronged approach. Pharmacologic therapy is a mainstay of treatment, but non-pharmacologic interventions are equally as important .Consider using multiple nondrug therapies to better meet resident's individual needs. All interventions are evaluated and documented in the same way as medication therapy. The licensed nurse and other members of the interdisciplinary team observe and evaluate interventions and their effectiveness in relieving the resident's pain. The resident's response is documented and the licensed nurse discusses the interventions and their effectiveness with the healthcare provider and they collaborate with the resident and legal representative to develop additional interventions and make revisions to the resident's pain management plan . On 1/12/2023 at approximately 2:30 p.m., ASM (administrative staff member) #1, the administrator was made aware of the concern. No further information was provided prior to exit. 2. For Resident #19, the facility staff failed to evidence non-pharmacological interventions were attempted prior to administration of as-needed (PRN) pain medication. On the most recent MDS (Minimum Data Set), an admission / 5-day assessment dated [DATE], Resident #19 was coded as being cognitively intact in ability to make daily life decisions. A review of the clinical record revealed a physician order dated 12/22/22 for Acetaminophen (1) Oral Tablet 500 MG (milligram) Give 1 tablet by mouth every 6 hours as needed for mild to moderate pain . A review of the clinical record revealed a physician order's dated 12/22/22 for Tramadol (2) Oral Tablet 50 MG Give 1 tablet by mouth every 4 hours as needed for moderate to severe pain . A review of the eMAR (electronic medication administration record) for December 2022 and January 2023 revealed the following: The resident received the as-needed acetaminophen on 12/22/22, twice on 12/23/22, 12/24/22 & 12/25/22, twice on 12/26/22, 12/27/22, twice on 12/29/22, 12/30/22 & 1/1/23, twice on 1/2/23, twice on 1/3/23. The resident received the Tramadol on 12/27/22, 12/28/22, 12/31/22, 1/1/23, 1/4/23, 1/5/23, 1/6/23, 1/8/23, 1/9/23, and twice on 1/10/23. A review of the progress notes for failed to reveal any evidence of documentation of non-pharmacological interventions being attempted or offered prior to the administration of the as-needed pain medication for each above administration. A review of the comprehensive care plan revealed one dated 12/23/22 for The resident is on pain medication therapy Tramadol and Acetaminophen r/t (related to) infection of prosthetic right hip joint. This care plan did not include any interventions for utilizing non-pharmacological interventions prior to the use of as-needed pain medication. On 1/12/2023 at 1:54 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 stated that when residents complained of pain they did a pain assessment first and then attempted non-pharmacological interventions like repositioning prior to administering pain medications. RN #2 stated that they would ask the resident to rate their pain or use the non-verbal scale if needed and administer the as needed medication when the non-pharmacological interventions were not effective. RN #2 stated that they documented the non-pharmacological interventions they attempted in the progress notes. RN #2 stated that if there were no progress notes to evidence the non-pharmacological interventions were attempted that it meant the nurse when straight to the pain medications, maybe because the residents pain was so intense. RN #2 stated that it was key to document what non-pharmacological interventions were used and their system had a process to allow them to enter the notes when administering medications. The facility policy Pain Management Program dated 1/2019 documented in part, .An effective pain management plan uses a multi-pronged approach. Pharmacologic therapy is a mainstay of treatment, but non-pharmacologic interventions are equally as important .Consider using multiple nondrug therapies to better meet resident's individual needs. All interventions are evaluated and documented in the same way as medication therapy. The licensed nurse and other members of the interdisciplinary team observe and evaluate interventions and their effectiveness in relieving the resident's pain. The resident's response is documented and the licensed nurse discusses the interventions and their effectiveness with the healthcare provider and they collaborate with the resident and legal representative to develop additional interventions and make revisions to the resident's pain management plan . On 1/12/23 at approximately 2:30 PM, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2, the Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey. References: 1. Acetaminophen is used to relieve mild to moderate pain. Information obtained from https://medlineplus.gov/druginfo/meds/a681004.html 2. Tramadol is used to relieve moderate to moderately severe pain. Information obtained from https://medlineplus.gov/druginfo/meds/a695011.html

Based on observation, staff interview, facility document review, and in the course of a complaint investigation, the facility staff failed to prepare, store, and serve food in a sanitary manner in one of one facility kitchen, and in one of one activity room refrigerator. The findings include: On 1/10/23 at 12:01 p.m., a food transportation cart was checked for cleanliness in the facility's main kitchen. The inside of the cart contained loose black debris on the bottom, and multiple patches of sticky material on the top and sides. Several shelves of prepared food, including vegetables and desserts, were inside the cart. OSM (other staff member) #3, the dietary manager looked inside the cart, and stated: It needs to be cleaned out, for sure. OSM #3 wore a hairnet that only partially covered her loose hair. Her bangs and loose hair stuck out from under the net, exposing it to food being prepared in the kitchen. In the walk-in refrigerator, a tray of bite size, roasted mixed vegetable had been left uncovered to cool. Also, a large block of cheese was opened and partially unwrapped, and had been left without a date. OSM #3 stated the vegetables should have been covered, and the cheese should have been fully rewrapped and dated. Several steam table trays were stacked on a storage rack. OSM #3 separated three of the trays, and all of the trays were wet, indicating wet nesting. OSM #3 also separated approximately 10 sheet pans which were stacked on top of each other on the storage rack. These pans also were wet, indicating wet nesting. OSM #3 stated these would need to be rewashed, and stacked on their sides to allow for air drying, and to prevent wet nesting. OSM #4, a sous chef, stood near the three compartment sink. The third compartment contained five knives, a serving spoon, and a vegetable peeler. The water in this compartment contained a greasy film and black debris on the surface. When asked to test the water for the ratio of sanitizer, OSM #4 and OSM #3 were unable to locate a test strip. OSM #3 stated the test strips were in the main chef's jacket pocket, and the chef's jacket was in his locker. This chef was not in the building on this day. OSM #4 stated the water needed to be changed out because it was dirty. On 1/12/23 at 9:04 a.m., ASM (administrative staff member) #2, the director of nursing was asked to look inside the refrigerator in the activity room. She verified this refrigerator was the one used by residents who needed to keep food cold. A sticky substance covered part of the bottom shelf of the refrigerator. The refrigerator contained three containers of partially-eaten desserts. None of these containers was labeled or dated. ASM #2 stated the desserts should have been thrown out, and the refrigerator needed a good cleaning. OSM #3 was unavailable for interview on 1/12/23. On 1/12/23 at 12:28 p.m., ASM #1, the administrator, and ASM #2 were informed of these concerns. A review of the facility policy, Food Storage, Preparation, and Storage, revealed, in part: A food storage area includes walk-in and reach in refrigerators and freezers, under counter refrigeration and freezer units, bistro and common area refrigeration and freezer units, and any dry storage units .Food is prepared on clean, sanitized surfaces with clean, sanitized equipment and tools. Appropriate precautions are taken to prevent cross-contamination during production .Keeping your hair covered reduces the risk you will contaminate your hands by touching your hair. Also, federal and state regulations require all employees to wear hats or hairnets when preparing food. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and facility document review, it was determined that the facility staff failed to store medications according to professional standards for one of one medication room. Two expired vials of Aplisol PPD (purified protein derivative) solution (1) was stored in the medication room refrigerator available for resident use. The findings include: On [DATE] at 3:59 p.m., observation of the medication room refrigerator was conducted with LPN (licensed practical nurse) #1. A plastic bottle containing one vial of opened PPD solution that was approximately one eighth full had a hand written date of [DATE] on in. Another plastic bottle containing one vial of opened PPD solution that was approximately half full had a hand written date of [DATE] on it. LPN #1 stated she would ask the director of nursing what the hand written date meant. LPN #1 stated PPD solution is good for 30 days after being opened. LPN #1 stated PPD vials that are open for more than 30 days should not be used and should be returned to the pharmacy. On [DATE] at 4:21 p.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 was shown the vials of PPD solution and stated the hand written date of [DATE] was the date the vials were opened. ASM #2 stated she would check to see how long PPD solution is good for after being opened. On [DATE] at 4:36 p.m., ASM #2 stated she called the pharmacy and PPD solution is good for 30 days once opened. ASM #2 stated the two vials of PPD solution had been open for more than 30 days and the vials would be discarded. The Aplisol PPD solution manufacturer's instructions documented, Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency . On [DATE] at 5:06 p.m., ASM #1 (the administrator) and ASM #2 were made aware of the above concern. The facility pharmacy medication storage guidance documented the following regarding Aplisol PPD solution, Date when opened and discard unused portion after 30 days. No further information was presented prior to exit. Reference: (1) Aplisol PPD solution is used in the diagnosis of tuberculosis (a lung disease). This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=1e91a67c-1694-4523-9548-58f7a8871134

**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 implement bed rail requirements for five of 17 residents in the survey sample, Residents #20, #22, #74, #13 and #8. The facility staff failed to obtain informed consent prior to the use of bed rails for Residents #20, #22, #74, #13 and #8. The findings include: 1. The facility staff failed to obtain informed consent for Resident #20's use of bed rails. Resident #20 was admitted to the facility on [DATE]. Resident #20's diagnoses included but were not limited to diabetes, chronic kidney disease and muscle weakness. Resident #20's admission minimum data set assessment with an assessment reference date of 7/28/21, coded the resident as being cognitively intact. Review of Resident #20's clinical record revealed a therapy communication form dated 7/22/21 that documented Resident #20 needed halo bars (bed rails) to help with bed mobility and transfers. Resident #20's comprehensive care plan initiated on 7/22/21 documented, Halo bar for enhanced bed mobility. A physician's order dated 8/10/21 documented, Halo bar for enhanced bed mobility. Further review of Resident #20's clinical record failed to reveal informed consent was obtained for the resident's use of bed rails. On 8/10/21 at 1:37 p.m., Resident #20 was observed lying in bed with bilateral bed rails up. On 8/11/21 at 2:37 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated nurses obtain informed consent for residents' use of bed rails. On 8/11/21 at 3:52 p.m., an interview was conducted OSM (other staff member) #3 (the physical therapist). OSM #3 stated he assesses residents for the use of bed rails and writes recommendations but he does not obtain informed consent. On 8/11/21 at 5:06 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 document titled, Bed Safety Program documented, Acknowledgement and Consent for Use of an Assistive Device: If it is determined that the use of an assistive device is appropriate and permitted by state, the Resident Care Director (RCD)/Health Care Manager (HCM) will: Inform the resident and/or legal representative of the potential risks and benefits of using the proposed assistive device. Review the Acknowledgement and Consent for the Use of a Transfer Assistive Device form and obtain the signature of the resident or legal representative acknowledging the risk of using an assist device . 2. The facility staff failed to obtain informed consent for Resident #22's use of bed rails. Resident #22 was admitted to the facility on [DATE]. Resident #22's diagnoses included but were not limited to osteoporosis, muscle weakness and heart disease. Resident #22's admission minimum data set assessment with an assessment reference date of 8/3/21, coded the resident's cognition as moderately impaired. Review of Resident #22's clinical record revealed a therapy communication form dated 7/29/21 that documented Resident #22 needed halo bars (bed rails) for safe mobility. Resident #22's comprehensive care plan initiated on 7/22/21 documented, Halo bar for enhanced bed mobility. A physician's order dated 8/10/21 documented, Halo bar for enhanced bed mobility. Further review of Resident #22's clinical record failed to reveal informed consent was obtained for the resident's use of bed rails. On 8/10/21 at 1:52 p.m., Resident #22 was observed lying in bed with bilateral bed rails up. On 8/11/21 at 2:37 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated nurses obtain informed consent for residents' use of bed rails. On 8/11/21 at 3:52 p.m., an interview was conducted OSM (other staff member) #3 (the physical therapist). OSM #3 stated he assesses residents for the use of bed rails and writes recommendations but he does not obtain informed consent. On 8/11/21 at 5:06 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. 3. The facility staff failed to obtain a consent for the use of halo bed rails, for Resident #74. Resident #74 was admitted to the facility on [DATE]. Resident #74's diagnoses included but were not limited to diabetes, congestive heart failure (abnormal condition characterized by circulatory congestion and retention of salt and water by the kidneys) (1), high blood pressure, and low back pain. A MDS (minimum data set) assessment had not been completed as the resident was newly admitted to the facility. The Service Evaluation and Health Assessment dated 8/9/2021 documented the resident had no difficulty with short or long-term memory. Resident #74 was documented as being independent in making decisions regarding tasks of daily living. In the Section, ADL (activities of daily living) Assessment (nursing); bed mobility, The form documented, Bed Mobility assistive devices needed, Yes was checked. Select All that Apply, a check mark was documented next to, bed mobility enabler/halo. Observation was made on 8/10/2021 at 4:11 p.m. of Resident #74 in her bed with halo rails on the bed up. Review of Resident #74's clinical record revealed a therapy communication form dated 8/10/2021 that documented Resident #74's needed halo bars (bed rails) to help with bed mobility and transfers. A therapy note dated 8/11/2021 documented in part, Resident #74 is up at EOB (edge of bed) with use of hallo bars to increase pt's (patient's) independence/safety in bed mobility. Further review of Resident #74's clinical record failed to evidence a consent for the use of the bed rails. Resident #74 had a physician order dated 8/11/2021 for Attach bilateral halo bars to encourage independence during bed mobility. The comprehensive care plan dated, 8/10/2021, documented in part, Focus: Bed mobility. The Interventions dated, 8/11/2021, documented in part, Halo bar for enhanced bed mobility. On 8/11/2021 at 10:54 a.m., ASM (administrative staff member) #2, the director of nursing, presented a documented titled, Acknowledgement and Consent for the Use of a Transfer Assistive Device. This form had Resident #74's name and the date of 8/10/2021. An interview was conducted with ASM #1, the administrator, on 8/11/2021 at 11:33 a.m. When asked about bed rails, ASM #1 stated all beds don't have side rails. If someone needs one, that is initiated by therapy. Therapy does the evaluation and assessment. Then they write an order for them [bed rails]. The nursing department then calls engineering department and the engineering department would put them on. An interview was conducted with LPN (licensed practical nurse) #2 on 8/11/2021 at 2:37 p.m., regarding the role a nurse plays in doing an assessment or obtaining a consent for the use of bed rails. LPN #2 stated, The residents don't have bedrails unless necessary. We need a physician order for them for residents who are high risk for falls. When asked how the nurse knows the resident needs the rails, LPN #2 stated, We do an assessment, a side rail assessment. When asked where that assessment is located, LPN #2 stated it's in the computer. LPN #2 stated, When an admission comes in, the nurse does a bed rail or bar assessment and if at that time they don't need it then the nurses don't bring it up to the doctor. If at a later time, the nurse feels the resident would need them, then we get an order from the doctor. When asked if they get consent from the resident or the responsible party for the use of the rails, LPN #2 stated, When we get the order, if the resident is not alert or cannot give consent we get consent. LPN #2 was asked if staff fill in a consent form at that time, LPN #2 stated, I'm sure there is a consent form. When asked where the assessment is located, LPN #2 stated, it's on the admission assessment as one of the 12 sections to complete. An interview was conducted with OSM (other staff member) #3, the physical therapist, on 8/11/2021 at 3:52 p.m. When asked if therapy has a role in obtaining the consent for the use of the bed rails, OSM #3 stated no. ASM #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concerns on 8/11/2021 at 5:06 p.m. No further information was obtained prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 138. 4. The facility staff failed to obtain a consent for the use of bed rails, halo rails, for Resident #13. Resident #13 was admitted to the facility on [DATE] with a readmission on [DATE], with diagnoses that included but were not limited to: fractures of thoracic vertebra (bones in the spine), diabetes, and high blood pressure. The most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 7/16/2021, coded the resident as scoring a 10 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired to make daily cognitive decisions. In Section G - Functional Status, the resident was coded as requiring extensive assistance of one or more staff members for moving in the bed. Observation was made of Resident #13 in bed, with halo rails on each side, on 8/10/2021 at 4:12 p.m. Review of Resident #13's clinical record revealed a therapy communication form dated 7/13/2021 that documented Resident #13's needed halo bars (bed rails) to help with bed mobility and transfers. A therapy note dated 7/30/2021 documented in part, Max (maximum) A (assist) for log rolling R (right) and L (left) with BUE (bilateral upper extremities) supported on halo bars. Further review of Resident #13's clinical record failed to evidence a consent for the use of side rails/halo rails. The Service Evaluation and Health Assessment form dated 6/25/2021, documented, Bed Mobility assistive devices needed, a No was checked. Resident #8 had a physician order dated 8/11/2021 that documented, Resident to use bilateral halo bars for safe bed mobility and transfers. The comprehensive care plan dated, 6/26/2021, documented in part, Focus: Bed mobility. The Interventions dated, 7/9/2021, documented in part, Remind and encourage me to use my enabler/device when repositioning in bed, has halo bars. On 8/11/2021 at 10:54 a.m., ASM (administrative staff member) #2, the director of nursing, presented a document titled, Acknowledgement and Consent for the Use of a Transfer Assistive Device. This form had Resident #74's name and the date of 8/10/2021. An interview was conducted with ASM #1, the administrator, on 8/11/2021 at 11:33 a.m. When asked about bed rails, ASM #1 stated all beds don't have side rails. If someone needs one, that is initiated by therapy. Therapy does the evaluation and assessment. Then they write an order for them. The nursing department then calls the engineering department and the engineering department would put them on. An interview was conducted with LPN (licensed practical nurse) #2 on 8/11/2021 at 2:37 p.m., regarding the role a nurse plays in doing an assessment or obtaining a consent for the use of bed rails. LPN #2 stated, The residents don't have bedrails unless necessary. We need a physician order for them for residents who are high risk for falls. When asked how the nurse knows the resident needs the rails, LPN #2 stated, We do an assessment, a side rail assessment. When asked where that assessment is located, LPN #2 stated it's in the computer. LPN #2 stated, When an admission comes in, the nurse does a bed rail or bar assessment and if at that time they don't need it then the nurses don't bring it up to the doctor. If at a later time, the nurse feels the resident would need them, then we get an order from the doctor. When asked if they get consent from the resident or the responsible party for the use of the rails, LPN #2 stated, When we get the order, if the resident is not alert or cannot give consent we get consent. LPN #2 was asked if staff fill in a consent form at that time, LPN #2 stated, I'm sure there is a consent form. When asked where the assessment is located, LPN #2 stated it's on the admission assessment as one of the 12 sections to complete. An interview was conducted with OSM (other staff member) #3, the physical therapist, on 8/11/2021 at 3:52 p.m. When asked if therapy has a role in obtaining the consent for the use of the bed rails, OSM #3 stated no. ASM #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concerns on 8/11/2021 at 5:06 p.m. No further information was obtained prior to exit. 5. The facility staff failed to obtain a consent for the use of bed rails, halo rails, for Resident #8. Resident #8 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: dementia (- a progressive state of mental decline, especially memory function and judgement, often accompanied by disorientation.)(1), high blood pressure and fracture of right femur (thighbone). The most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 7/5/2021, coded the resident as scoring a 7 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired to make daily cognitive decisions. In Section G - Functional Status, the resident was coded as requiring extensive assistance of one staff member for moving in the bed. Observation was made of Resident #8 in bed, with halo bars up on each side of the bed, on 8/10/2021 at 1:30 p.m. and 4:13 p.m. Review of Resident #8's clinical record revealed a therapy communication form dated 6/29/2021 that documented Resident #8's needed halo bars (bed rails) to help with bed mobility and transfers. A therapy note dated 7/7/2021 documented in part, bed mob (mobility) training, rolling with min A (minimum assist) using halo bar. Further review of Resident #8's clinical record failed to evidence a consent for the use of side rails/halo rails. The Service Evaluation and Health Assessment form dated 6/28/2021, documented, Bed Mobility assistive devices needed, a No was checked. Resident #13 had a physician order dated 7/9/2021 that documented, Halo bar for enhanced bed mobility. The comprehensive care plan dated, 6/29/2021, documented in part, Focus: Bed mobility. The Interventions dated, 8/10/2021, documented in part, Halo bar for enhanced bed mobility. The Intervention dated 8/10/2021, documented, Resident requires one person physical assist for bed mobility. On 8/11/2021 at 10:54 a.m., ASM (administrative staff member) #2, the director of nursing, presented a documented entitled, Acknowledgement and Consent for the Use of a Transfer Assistive Device. This form had Resident #8's name and the date of 8/10/2021. An interview was conducted with ASM #1, the administrator, on 8/11/2021 at 11:33 a.m. When asked about bed rails, ASM #1 stated all beds don't have side rails. If someone needs one, that is initiated by therapy. Therapy does the evaluation and assessment. Then they write an order for them. The nursing department then calls the engineering department and the engineering department would put them on. An interview was conducted with LPN (licensed practical nurse) #2 on 8/11/2021 at 2:37 p.m., regarding the role a nurse plays in doing an assessment or obtaining a consent for the use of bed rails. LPN #2 stated, The residents don't have bedrails unless necessary. We need a physician order for them for residents who are high risk for falls. When asked how the nurse knows the resident needs the rails, LPN #2 stated, We do an assessment, a side rail assessment. When asked where that assessment is located, LPN #2 stated it's in the computer. LPN #2 stated, When an admission comes in, the nurse does a bed rail or bar assessment and if at that time they don't need it then the nurses don't bring it up to the doctor. If at a later time, the nurse feels the resident would need them, then we get an order from the doctor. When asked if they get consent from the resident or the responsible party for the use of the rails, LPN #2 stated, When we get the order, if the resident is not alert or cannot give consent we get consent. LPN #2 was asked if staff fill in a consent form at that time, LPN #2 stated, I'm sure there is a consent form. When asked where the assessment is located, LPN #2 stated, it's on the admission assessment as one of the 12 sections to complete. An interview was conducted with OSM (other staff member) #3, the physical therapist, on 8/11/2021 at 3:52 p.m. When asked if therapy has a role in obtaining the consent for the use of the bed rails, OSM #3 stated no. ASM #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concerns on 8/11/2021 at 5:06 p.m. No further information was obtained prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124.

**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 maintain a complete and accurate clinical record for six of 17 residents in the survey sample, Residents #18, #20, #22, #74, #13 and #8. The findings include: 1. The facility staff failed maintain wound care physician notes in Resident #18's clinical record. Resident #18 was admitted to the facility on [DATE]. Resident #18's diagnoses included but were not limited to diabetes, major depressive disorder and history of stroke with paralysis. Resident #18's significant change in status minimum data set assessment with an assessment reference date of 6/28/21, coded the resident's cognition as moderately impaired. Review of a facility pressure injury document revealed Resident #18 presented with a facility acquired left heel pressure injury on 6/21/21, a facility acquired right heel pressure injury on 6/21/21, a facility acquired right first toe pressure injury on 7/26/21 and a facility acquired left first toe pressure injury on 8/2/21. Further review of Resident #18's clinical record, including the paper record and electronic record, revealed nursing assessments of the pressure injuries but failed to reveal any of the wound care physician's assessments. On 8/11/21 at 3:35 p.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated the wound physician sends wound care assessments to the facility secretary (health information coordinator) and the facility secretary is supposed to upload the assessments into the computer each week. On 8/11/21 at 3:40 p.m., ASM #2 presented wound care physician assessments for all of Resident #18's pressure injuries. The assessments were dated 6/28/21, 7/5/21, 7/12/21, 7/19/21, 7/26/21, 8/2/21 and 8/9/21. On 8/11/21 at 4:41 p.m., an interview was conducted with OSM (other staff member) #4 (the health information coordinator). OSM #4 stated she files every document that is placed in her filing bin and she files wound care physician assessments into the paper clinical record. OSM #4 stated the wound care physician assessments for Resident #18 were never placed in her filing bin. On 8/11/21 at 5:06 p.m., ASM #1 (the administrator) and ASM #2 were made aware of the above concern. ASM #2 stated the wound care physician was previously sending his notes to the former assistant director who was no longer employed but he will now be sending his notes to her (ASM #2). On 8/12/21 at 7:42 a.m., ASM #1 stated she could not find a policy for maintaining a complete and accurate clinical record. On 8/12/21 at 7:49 a.m., ASM #2 stated she obtained the wound care physician notes presented on 8/11/21 from the wound care physician's office on 8/11/21. No further information was presented prior to exit. 2. The facility staff failed to document a complete assessment of Resident #20's need for bed rails and the risk for entrapment. Resident #20 was admitted to the facility on [DATE]. Resident #20's diagnoses included but were not limited to diabetes, chronic kidney disease and muscle weakness. Resident #20's admission minimum data set assessment with an assessment reference date of 7/28/21, coded the resident as being cognitively intact. Review of Resident #20's clinical record revealed a therapy communication form dated 7/22/21 that documented Resident #20 needed halo bars (bed rails) to help with bed mobility and transfers. A therapy note dated 7/29/21 documented Resident #20 was able to reposition self in bed with the use of halo bars. Further review of Resident #20's clinical record, including nursing assessments and therapy documentation, failed to reveal a complete assessment that documented how the facility staff determined the resident's need for bed rails such as consideration of diagnoses, cognition and functional abilities/limitations and failed to reveal assessment of the risk for entrapment. On 8/10/21 at 1:37 p.m., Resident #20 was observed lying in bed with bilateral bed rails. On 8/11/21 at 3:52 p.m., an interview was conducted with OSM (other staff member) #3, the physical therapist and person who determined Resident #20's need for bed rails. OSM #3 stated residents' beds do not have bed rails when they are first admitted . OSM #3 stated after admission, the therapy staff complete an evaluation to determine if bed rails are needed to assist with bed mobility and transfers. OSM #3 stated that during his evaluation, he considers the necessity for bed rails, residents' diagnoses, current functional level, functional restrictions, cognitive level and risk for entrapment. OSM #3 stated his documentation did not reflect this assessment but he could include this information in his documentation going forward. On 8/11/21 at 5:06 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 document a complete assessment of Resident #22's need for bed rails and the risk for entrapment. Resident #22 was admitted to the facility on [DATE]. Resident #22's diagnoses included but were not limited to osteoporosis, muscle weakness and heart disease. Resident #22's admission minimum data set assessment with an assessment reference date of 8/3/21, coded the resident's cognition as moderately impaired. Review of Resident #22's clinical record revealed a therapy communication form dated 7/29/21 that documented Resident #22 needed halo bars (bed rails) for safe mobility. A therapy note dated 7/29/21 documented Resident #22 utilized bed rails for upper extremity support. Further review of Resident #22's clinical record including nursing assessments and therapy documentation, failed to reveal a complete assessment that documented how the facility staff determined the resident's need for bed rails such as consideration of diagnoses, cognition and functional abilities/limitations and failed to reveal assessment of the risk for entrapment. On 8/10/21 at 1:52 p.m., Resident #22 was observed lying in bed with bilateral bed rails. On 8/11/21 at 3:52 p.m., an interview was conducted with OSM (other staff member) #3, the physical therapist and person who determined Resident #22's need for bed rails. OSM #3 stated residents' beds do not have bed rails when they are first admitted . OSM #3 stated after admission, the therapy staff complete an evaluation to determine if bed rails are needed to assist with bed mobility and transfers. OSM #3 stated that during his evaluation, he considers the necessity for bed rails, residents' diagnoses, current functional level, functional restrictions, cognitive level and risk for entrapment. OSM #3 stated his documentation did not reflect this assessment but he could include this information in his documentation going forward. On 8/11/21 at 5:06 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. 4. The facility staff failed to document a complete assessment of Resident #74's need for bed rails and the risk for entrapment. Resident #74 was admitted to the facility on [DATE]. Resident #74's diagnoses included but were not limited to diabetes, congestive heart failure (abnormal condition characterized by circulatory congestion and retention of salt and water by the kidneys) (1), high blood pressure, and low back pain. A MDS (minimum data set) assessments had not yet been completed as the resident was newly admitted to the facility. The Service Evaluation and Health Assessment dated 8/9/2021 documented the resident had no difficulty with short or long term memory. Resident #74 was documented as being independent in making decisions regarding tasks of daily living. Observation was made on 8/10/2021 at 4:11 p.m. of Resident #74 in her bed with halo rails up on the bed. Review of Resident #74's clinical record revealed a therapy communication form dated 8/10/2021 that documented Resident #74's needed halo bars (bed rails) to help with bed mobility and transfers. A therapy note dated 8/11/2021 documented in part, Resident #74 is up at EOB (edge of bed) with use of hallo bars to increase pt's (patient's) independence/safety in bed mobility. Further review of Resident #74's clinical record including nursing assessments and therapy documentation, failed to reveal a complete assessment that documented how the facility staff determined the resident's need for bed rails, such as consideration of diagnoses, cognition and functional abilities/limitations and failed to reveal assessment of the risk for entrapment. The comprehensive care plan dated, 8/10/2021, documented in part, Focus: Bed mobility. The Interventions dated, 8/11/2021, documented in part, Halo bar for enhanced bed mobility. On 8/11/21 at 3:52 p.m., an interview was conducted with OSM (other staff member) #3, the physical therapist and person who determined Resident #74's need for bed rails. OSM #3 stated residents' beds do not have bed rails when they are first admitted . OSM #3 stated after admission, the therapy staff complete an evaluation to determine if bed rails are needed to assist with bed mobility and transfers. OSM #3 stated that during his evaluation, he considers the necessity for bed rails, residents' diagnoses, current functional level, functional restrictions, cognitive level and risk for entrapment. OSM #3 stated his documentation did not reflect this assessment but he could include this information in his documentation going forward. On 8/11/21 at 5:06 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. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 138. 5. The facility staff failed to document a complete assessment of Resident #13's need for bed rails and the risk for entrapment. Resident #13 was admitted to the facility on [DATE] with a readmission on [DATE], with diagnoses that included but were not limited to: fractures of thoracic vertebra (bones in the spine), diabetes, and high blood pressure. The most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 7/16/2021, coded the resident as scoring a 10 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired to make daily cognitive decisions. In Section G - Functional Status, the resident was coded as requiring extensive assistance of one or more staff members for moving in the bed. Observation was made of Resident #13 in bed, with halo rails up on each side, on 8/10/2021 at 4:12 p.m. Review of Resident #13's clinical record revealed a therapy communication form dated 7/13/2021 that documented Resident #13's needed halo bars (bed rails) to help with bed mobility and transfers. A therapy note dated 7/30/2021 documented in part, Max (maximum) A (assist) for log rolling R (right) and L (left) with BUE (bilateral upper extremities) supported on halo bars. Further review of Resident #13's clinical record including nursing assessments and therapy documentation failed to reveal a complete assessment that documented how the facility staff determined the resident's need for bed rails, such as consideration of diagnoses, cognition and functional abilities/limitations and failed to reveal assessment of the risk for entrapment. The comprehensive care plan dated, 6/26/2021, documented in part, Focus: Bed mobility. The Interventions dated, 7/9/2021, documented in part, Remind and encourage me to use my enabler/device when repositioning in bed, had halo bars. On 8/11/21 at 3:52 p.m., an interview was conducted with OSM (other staff member) #3, the physical therapist and person who determined Resident #13's need for bed rails. OSM #3 stated residents' beds do not have bed rails when they are first admitted . OSM #3 stated after admission, the therapy staff complete an evaluation to determine if bed rails are needed to assist with bed mobility and transfers. OSM #3 stated that during his evaluation, he considers the necessity for bed rails, residents' diagnoses, current functional level, functional restrictions, cognitive level and risk for entrapment. OSM #3 stated his documentation did not reflect this assessment but he could include this information in his documentation going forward. On 8/11/21 at 5:06 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. 6. The facility staff failed to document a complete assessment of Resident #8's need for bed rails and the risk for entrapment. Resident #8 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: dementia (- a progressive state of mental decline, especially memory function and judgement, often accompanied by disorientation.)(1), high blood pressure and fracture of right femur (thigh bone). The most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 7/5/2021, coded the resident as scoring a 7 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired to make daily cognitive decisions. In Section G - Functional Status, the resident was coded as requiring extensive assistance of one staff member for moving in the bed. Observation was made of Resident #8 in bed, with halo bars on each side of the bed, on 8/10/2021 at 1:30 p.m. and 4:13 p.m. Review of Resident #8's clinical record revealed a therapy communication form dated 6/29/2021 that documented Resident #8's needed halo bars (bed rails) to help with bed mobility and transfers. A therapy note dated 7/7/2021 documented in part, bed mob (mobility) training, rolling with min A (minimum assist) using halo bar. Further review of Resident #8's clinical record including nursing assessments and therapy documentation failed to reveal a complete assessment that documented how the facility staff determined the resident's need for bed rails, such as consideration of diagnoses, cognition and functional abilities/limitations and failed to reveal assessment of the risk for entrapment. The comprehensive care plan dated, 6/29/2021, documented in part, Focus: Bed mobility. The Interventions dated, 8/10/2021, documented in part, Halo bar for enhanced bed mobility. The Intervention dated 8/10/2021, documented, Resident requires one person physical assist for bed mobility. On 8/11/21 at 3:52 p.m., an interview was conducted with OSM (other staff member) #3 the physical therapist and person who determined Resident #13's need for bed rails. OSM #3 stated residents' beds do not have bed rails when they are first admitted . OSM #3 stated after admission, the therapy staff complete an evaluation to determine if bed rails are needed to assist with bed mobility and transfers. OSM #3 stated that during his evaluation, he considers the necessity for bed rails, residents' diagnoses, current functional level, functional restrictions, cognitive level and risk for entrapment. OSM #3 stated his documentation did not reflect this assessment but he could include this information in his documentation going forward. On 8/11/21 at 5:06 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. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124.

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to dispose of garbage in a sanitary manner. On 8/10/21, the facility staff failed to ensure trash in the garbage compactor was covered. Multiple flies were observed flying above the trash. The findings include: On 8/10/21 at 1:25 p.m., observation of the garbage compactor was conducted with OSM (other staff member) #1 (the director of dining services). The covered portion of the garbage compactor was full and multiple trash bags in the compactor were not covered. Multiple flies were observed flying above the exposed trash bags. OSM #1 stated the facility staff was not able to keep all trash covered when the compactor was full and the housekeeping department would have to call the trash compactor company to empty the compactor. On 8/11/21 at 12:47 p.m., an interview was conducted with OSM #2 (the housekeeping director). OSM #2 stated the housekeeping staff is supposed to compact the trash every time trash is placed into the compactor so the trash moves into the covered portion of the compactor. OSM #2 was made aware of the above observation and stated this was not the proper way to maintain the trash compactor. OSM #2 stated someone probably did not press the button to compact the trash and he needed to educate his staff. On 8/11/21 at 5:06 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, Trash Disposal documented, Employees will understand the importance of proper trash disposal. Proper trash removal aids in pest control & maintaining sanitary conditions. Outdoor Garbage Dumpsters: Keep doors closed when not in use . The policy did not document specific instructions for the trash compactor. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure a complete and accurate MDS (minimum data set) assessment for one of 18 residents in the survey sample, Resident #32. The facility staff failed to code the Medicare five day assessment accurately with the correct place of discharge for Resident #32. The findings include: Resident #32 was admitted to the facility on [DATE]. Diagnoses included but were not limited to: mitral valve insufficiency (1), high blood pressure, unsteadiness on feet and atherosclerotic heart disease (2). The most recent MDS (minimum data set), a Medicare five day assessment, with an ARD (assessment reference date) of [DATE] coded the resident as having a score of 15 out of 15 on the BIMS (brief interview for mental status) indicating the resident was cognitively intact to make daily decisions. Section A1800 documented the resident entered the facility from an acute hospital. Section A2100 documented the resident was being discharged to an acute hospital. Review of Discharge Note, dated [DATE] documented in part, the resident was discharged to home. On [DATE] at approximately 12:27 p.m., an interview was conducted with LPN (licensed practical nurse) #1. When asked if LPN #1 remembered Resident #32. LPN #1 replied, Yes, I discharged him. He was only here for a few days and then went home. When asked if Resident #32 was ever discharge from the facility to the hospital, LPN #1 replied, No. On [DATE] at approximately 12:34 p.m., Resident #32's MDS was reviewed with RN #2, the MDS coordinator. When RN #2 was asked if she remembered Resident #32, RN #2 replied, He was only here for about a week and was doing pretty good, then he went home. When asked why the resident did not have a discharge MDS assessment, RN #2 replied, I will check that out and get back with you. On [DATE] at approximately 02:24 p.m., a follow up interview was conducted with RN #2, while reviewing Resident #32's MDS. RN #2 stated at that time We did not do a discharge MDS because he was only here for a week. The RAI (resident assessment instrument) manual allows us to combine the five day assessment and discharge assessment. When asked about the discharge destination for Resident #32 on his Medicare five day assessment, RN #2 stated It says he went to the hospital. When asked if this destination was accurate, RN #2 replied It's not, he went home. I'm going to modify it now and send it in. I will let you know when it's done. On [DATE] 3:16 p.m., RN #2 provided this surveyor with a document titled CMS Submission Report dated [DATE] at 15: 01 that documented section A2100 was changed to Community On [DATE] at approximately 3:20 p.m., this surveyor was told by ASM (administrative staff member) #1, the Associate Executive Director that the facility does not have a policy on MDS assessment but follows the RAI manual. On [DATE] at approximately 4:00 p.m., ASM (administrative staff member) #1, the Associate Executive Director and ASM #2, the Director of Nursing were made aware of the findings. RAI Manual [DATE] - Coding Instructions for Section A2100 Select the 2-digit code that corresponds to the resident's discharge status. o Code 01, community (private home/apt., board/care, assisted living, group home): if discharge location is a private home, apartment, board and care, assisted living facility, or group home. o Code 02, another nursing home or swing bed: if discharge location is an institution (or a distinct part of an institution) that is primarily engaged in providing skilled nursing care and related services for residents who require medical or nursing care or rehabilitation services for injured, disabled, or sick persons. Includes swing beds. o Code 03, acute hospital: if discharge location is an institution that is engaged in providing, by or under the supervision of physicians for inpatients, diagnostic services, therapeutic services for medical diagnosis, and the treatment and care of injured, disabled, or sick persons. o Code 04, psychiatric hospital: if discharge location is an institution that is engaged in providing, by or under the supervision of a physician, psychiatric services for the diagnosis and treatment of mentally ill residents. o Code 05, inpatient rehabilitation facility: if discharge location is an institution that is engaged in providing, under the supervision of physicians, rehabilitation services for the rehabilitation of injured, disabled or sick persons. Includes IRFs that are units within acute care hospitals. o Code 06, ID/DD facility: if discharge location is an institution that is engaged in providing, under the supervision of a physician, any health and rehabilitative services for individuals who have intellectual or developmental disabilities. o Code 07, hospice: if discharge location is a program for terminally ill persons where an array of services is necessary for the palliation and management of terminal illness and CMS's RAI Version 3.0 Manual CH 3: MDS Items [A] [DATE] Page A-30 A2100: OBRA Discharge Status (cont.) related conditions. The hospice must be licensed by the State as a hospice provider and/or certified under the Medicare program as a hospice provider. Includes community-based (e.g., home) or inpatient hospice programs. o Code 08, deceased : if resident is deceased . o Code 09, long term care hospital (LTCH): if discharge location is an institution that is certified under Medicare as a short-term, acute-care hospital which has been excluded from the Inpatient Acute Care Hospital Prospective Payment System (IPPS) under §1886(d)(1)(B)(iv) of the Social Security Act. For the purpose of Medicare payment, LTCHs are defined as having an average inpatient length of stay (as determined by the Secretary) of greater than 25 days. o Code 99, other: if discharge location is none of the above. No further information was obtained prior to exit. 1. A heart problem involving the mitral valve, which separates the upper and lower chambers of the left side of the heart. In this condition, the valve does not close normally. This information was obtained from the website: https://medlineplus.gov/ency/article/000180.htm. 2. A disease in which plaque builds up inside your arteries. Plaque is a sticky substance made up of fat, cholesterol, calcium, and other substances found in the blood. Over time, plaque hardens and narrows your arteries. That limits the flow of oxygen-rich blood to your body. This information was obtained from the website: https://medlineplus.gov/atherosclerosis.html.

Based on observation and staff interview, and review of facility documents, the facility staff failed to properly maintain an ice machine to prevent the spread of disease, for one of two facility ice machines, (the ice machine in the main kitchen); and the facility staff failed to implement infection control practices to prevent the spread of infection and communicable disease, on one of one nursing units. 1. The main kitchen ice machine did not have an air gap for the ice machine drain. 2. The facility staff failed to clean a reusable plastic medication tray in between residents during medication administration. The findings include: 1. The facility staff failed to maintain an ice machine drainage system in a sanitary manner for one of two ice machines, the one in the main kitchen. The ice machine in the main kitchen was observed on 3/5/19 at approximately 10:15 a.m., with OSM (other staff member) #2, the Director of Dining and Hospitality. The white PVC (polyvinyl chloride) drainpipe was visible below the surface of the floor drain. OSM #2 was asked how a drainage pipe should be maintained. OSM #2 replied, It should be a distance above the floor. OSM #2 was asked why, OSM #2 replied, To prevent water from backing up into the machine. OSM #2 was asked how the facility ensures that backflow of water does not flow into the drainage pipe. OSM #2 replied, It's not but I will call maintenance to come and correct it. On 3/6/19 at approximately 3:45 p.m., a follow up observation and interview was conducted with OSM #2 of the ice machine in the main kitchen. Two large gray ice storage bins that were below the ice machine were removed to visualize the ice machine drainpipe system. A large gray pipe, which collects the drainage from the ice machine, connected to a white PVC pipe that descends at a gradient to the point it empties below the level of the floor. The white PVC had several white PVC pipes that empty into it. OSM #2 stated, Were running into problems trying to elevate the drain pipe because we would lose the gradient that is used to drain the other pipes as well as the ice machine. We have a couple of options we can elevate the ice machine or elevate the gray pipe but then we could not fit the ice storage bins underneath the ice machine. The facility policy titled, Ice Machine dated 10/2018 documented, Install and maintain machine per state and federal plumbing code regulations. On 3/6/18 at approximately 4:00 p.m., ASM (administrative staff member) #1, the Associate Executive Director and ASM #2, the Director of Nursing were made aware of the findings. No further information was obtained prior to exit. 2. The facility staff failed to clean a reusable plastic medication tray in between residents during medication administration. On 03/05/2019 at approximately 9:45a.m., an observation of the morning medication administration was conducted with RN (registered nurse) #1. During the medication pass, RN #1 used a small grey plastic tray to carry the cup of pills and cup of water into the residents' rooms. As the medications were administered to the residents, the plastic tray was placed on the bedside table. Upon finishing the medication administration for each resident, RN #1 carried the plastic tray out of the room and placed it on the medication cart while preparing the medications for the next resident. At no point during the observation did RN #1 wipe down or otherwise clean the plastic tray. The plastic tray was used in multiple resident rooms. On the morning of 03/06/2019, a brief interview was conducted with Administrative Staff Member (ASM) #4, the Assistant Director of Nursing. ASM #4 was asked about the facility practice for reusable medical equipment. ASM #4 stated that any equipment that was re-used should be cleaned in between use with one resident and the next. She stated that sanitizing wipes were available to wipe down reusable equipment. ASM #1, the Associate Executive Director, and ASM #2, the Director of Nursing, were informed of the findings at the end of day meeting on 03/06/2019. No further documentation was presented.

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to store a mop head and distribute food in a sanitary manner. 1. The facility staff failed to practice safe food handling techniques while taking foods temperatures on the steam table. 2. The facility staff failed to store a mop head in a sanitary manner, in the main kitchen. The findings included: 1. The facility staff failed to practice safe food handling techniques while taking foods temperatures on the steam table. On 3/5/19 at approximately 11:35 a.m., an observation was made of OSM (other staff member) #3, the cook, taking tray line temperatures. OSM #3 was observed taking a thermometer off a supply table. OSM #3 then proceeded to remove the thermometer probe cover, get a paper towel from the paper towel dispenser, wet it with tap water, and then wiped the probe. OSM #3 then began to take temperatures on the steam table. OSM #3 then used the same paper towel to wipe the temperature probe between taking temperatures on different food items. On 3/5/19 at approximately 11:45 a.m., an interview was conducted with OSM #3. OSM #3 was asked to explain how temperatures are usually taken of food on the steam table. OSM #3 replied, The food comes up from the kitchen I get my thermometer, clean it and then start taking temperatures. When asked how the thermometer is cleaned. OSM #3 replied, I usually use alcohol pads, but we are out. On 3/5/19 at approximately 11:50 a.m., an interview was conducted with OSM #2, the Director of Dinning and Hospitality. When asked how a thermometer is supposed to be sanitized prior to taking temperatures of food items. OSM #2 replied, We use thermometer alcohol probe wipes to sanitize the thermometer prior to use. We also clean the thermometer between taking temperatures. OSM #2 was asked why a thermometer should be sanitized prior to use. OSM #2 replied, It helps prevent any infection. Review of the facility policy titled, Food Temperatures dated 08/31/2018, documented in part Wash, rinse and sanitize a dial face, metal probe type thermometer with alcohol wipe. A practical range of 0 - 220 degrees Fahrenheit is recommended. Re-sanitize the thermometer after each use. On 3/6/18 at approximately 4:00 p.m., ASM (administrative staff member) #1, the Associate Executive Director and ASM #2, the Director of Nursing were made aware of the findings. No further information was obtained prior to exit. 2. The facility staff failed to store a mop head in a sanitary manner, in the main kitchen. On 3/5/19 at approximately 10:25 a.m., an observation was made a storage closet in the main kitchen with OSM (other staff member) #2, the Director of Dinning and Hospitality. A used moist mop head was observed laying on top of box of detergent. The mop head was immediately picked up by OSM #2 who stated, This mop does not belong here, it belongs hanging up in the mop closet. The mop head was then handed to another kitchen staff to take to the mop closet. OSM #2 then washed his hands. On 3/6/19 at approximately 10:36 a.m. an interview was conducted with OSM #2. OSM #2 was asked how mops are to be stored when not in use. OSM #2 replied, The mops should be hanging up in the mop closet. The facility policy titled, Janitor Closet dated 8/31/2018 documented, Mops should be washed, rinsed, wrung out, and allowed to air dry before returning to the janitor's closet. The closet should be orderly at all times. Detergents and cleaning agents must be stored off the floor. This prevents the products from becoming damp and hardened when detergents are stored in containers that are subject to moisture absorption. On 3/6/18 at approximately 4:00 p.m., ASM (administrative staff member) #1, the Associate Executive Director and ASM #2, the Director of Nursing were made aware of the findings. No further information was obtained prior to exit.