Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to assess a resident for self-administration of medications, prior to leaving medication on the over bed table, for one of 48 residents in the survey sample, Resident #76. The findings include: The nurse administered morning medications to Resident #76 (R76) then left the cup with Miralax (used to treat constipation) (1) in it, on the overbed table and left the room. On 5/16/2023 at 8:09 a.m. LPN (licensed practical nurse) #4 was observed administering medications to R76. LPN #4 mixed the Miralax in a cup of water and took it into R76's room with the other medications. After administering the other medications, LPN #4 placed the cup of Miralax on the over bed table, then left the room. Observation was made on 5/16/2023 at 8:45 a.m. of R76's room. The cup with the Miralax was still on the overbed table. On the most recent MDS (minimum data set) assessment, a Medicare five day assessment, with an assessment reference date of 4/13/2023, the resident scored a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. Review of the clinical record failed to evidence a physician order for self-administering medications or an assessment for the self-administering of medications. An interview was conducted with LPN #4 on 5/16/2023 at 10:29 a.m. When asked if she left medication on the overbed table for R76. LPN #4 paused and then stated, yes, the Miralax. LPN #4 stated she is not supposed to do that. When asked if she had returned to R76's room since then, to see if the resident had drank the Miralax, LPN #4 stated, No, I haven't had a chance. The facility policy, Administering Medications documented in part, Medications shall be administered in a safe and timely manner, and as prescribed 24. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional nurse consultant, were made aware of the above findings on 5/16/2023 at 4:40 p.m. No further information was provided prior to exit

2. For Resident #66, the facility staff failed to implement the comprehensive care plan to monitor the pharmacist's drug regime reviews for identification of potential drug interactions. Resident #66 was admitted to the facility with diagnoses that included but were not limited to: CVA (cerebral vascular accident), anxiety disorder, cognitive communication deficit, and unspecified dementia without behavior/psychosis/mood/anxiety behaviors. A review of the comprehensive care plan dated 3/20/23, which revealed, PROBLEM/NEED: Psychotropic drug use APPROACHES: evaluate effectiveness and side effects of medications for possible decrease/elimination of psychotropic drugs. Monitor pharmacists drug regime review for identification of potential drug interactions. Monitor resident for signs of tremor and document. Report onset of increase to physician. A review of the physician's orders dated 3/22/23 included, Buspirone 5 mg (milligram) tablet give one tablet by mouth at bedtime (1), and Mirtazapine 15 mg take one tablet by mouth at bedtime (2) . A review of the MRR (monthly regimen reviews) for Resident #66, evidenced June, July, August, September and November 2022; February and May 2023 were present. Missing MRRs were October, December 2022; January, March and April 2023. Five of 12 MRRs were missing. An interview was conducted on 5/16/23 at 3:05 PM, with RNs (registered nurses) #1 and #2, MDS (minimum data set) coordinators, were interviewed. RN #1 stated the purpose of a care plan is to show the goals for a resident, and to show the staff what the plan of care is. RN #2 stated the care plan tells the staff what they should be doing for a resident, and what they should be watching for. She stated the care plan is a resource for staff if they are unfamiliar with a particular resident's needs. An interview was conducted on 5/17/23 at 9:30 AM, with ASM (administrative staff member) #5, the regional director of clinical services. When asked if the care plan includes approach of Monitor pharmacists drug regime review for identification of potential drug interactions and five of 12 MRRs were missing, was the care plan being followed, ASM #5 stated, no, it is not being followed. On 5/17/23 at 10:30 AM, ASM (administrative staff member) #1, the administrator was made aware of the findings. No further information was provided prior to exit. References: (1) Buspirone is used to treat anxiety disorders or in the short-term treatment of symptoms of anxiety. Buspirone is in a class of medications called anxiolytics. It works by changing the amounts of certain natural substances in the brain. https://medlineplus.gov/druginfo/meds/a688005.html. (2) Mirtazapine is used to treat depression. Mirtazapine is in a class of medications called antidepressants. It works by increasing certain types of activity in the brain to maintain mental balance. https://medlineplus.gov/druginfo/meds/a697009.html Based on observation, staff interview, and facility document review, the facility staff failed to implement the care plan for two of 48 residents in the survey sample, Residents #20 and #66. The findings include: 1. For Resident #20 (R20), the facility staff failed to implement the care plan to apply hand devices to prevent further contractures. On the following dates and times, R20 was observed in bed. R20's left and right hands were contracted. At all of these observations, the resident was not wearing hand devices/splints: 5/15/23 at 12:20 p.m. and 2:32 p.m.; and 5/16/23 at 8:57 a.m. and 10:46 a.m. A review of R20's physician orders revealed an order dated 2/9/23 which read: RNP (restorative nursing program) Splinting program seven days a week. A review of R20's care plan dated 8/27/20 revealed, in part: RNP splinting program seven days a week. A restorative nursing aide was not available for interview during the survey. On 5/16/23 at 4:30 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of the concern regarding Resident #20 not having hand splints in place. On 5/16/23 at 3:05 p.m., RNs (registered nurses) #1 and #2, the MDS (minimum data set) coordinators, were interviewed. RN #1 stated the purpose of a care plan is to show the goals for a resident, and to show the staff what the plan of care is. RN #2 stated the care plan tells the staff what they should be doing for a resident, and what they should be watching for. She stated the care plan is a resource for staff if they are unfamiliar with a particular resident's needs. On 5/17/23 at 10:29 a.m., LPN (licensed practical nurse) #6 stated the purpose of the care plan is for everyone to know what level of care should be given to each resident. She stated the nurse is responsible for making sure the care plan interventions are implemented. A review of the facility policy, Care Plans, Comprehensive Person-Centered, revealed, in part: The interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .The comprehensive, person-centered care plan will .aid in preventing or reducing decline in the resident's functional status and/or functional levels. No further information was provided prior to exit.

Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to follow professional standards of practice for the administration of medications, for one of 48 residents in the survey sample, Resident #76. The findings include: The nurse administered morning medications to Resident #76 (R76) then left the cup with Miralax (used to treat constipation) (1) in it, on the overbed table and left the room. On 5/16/2023 at 8:09 a.m. LPN (licensed practical nurse) #4 was observed administering medications to R76. LPN #4 mixed the Miralax in a cup of water and took it into R76's room with the other medications. After administering the other medications, LPN #4 placed the cup of Miralax on the over bed table, then left the room. Observation was made on 5/16/2023 at 8:45 a.m. of R76's room. The cup with the Miralax was still on the overbed table. On the most recent MDS (minimum data set) assessment, a Medicare five day assessment, with an assessment reference date of 4/13/2023, the resident scored a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. Review of the clinical record failed to evidence a physician order for self-administering medications or an assessment for the self-administering of medications. The facility policy, Administering Medications documented in part, Medications shall be administered in a safe and timely manner, and as prescribed 24. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional nurse consultant, were made aware of the above findings on 5/16/2023 at 4:40 p.m. No further information was provided prior to exit

Based on observation, staff interview, and facility document review, the facility staff failed to provide appropriate treatment and services to prevent further decrease in range of motion for bilateral hand contractures for one of 48 residents in the survey sample, Resident #20. The findings include: For Resident #20 (R20), the facility staff failed to apply hand devices/splints to prevent further contractures. On the following dates and times, R20 was observed in bed. R20's left and right hands were contracted. At all of these observations, the resident was not wearing hand devices: 5/15/23 at 12:20 p.m. and 2:32 p.m.; and 5/16/23 at 8:57 a.m. and 10:46 a.m. A review of R20's physician orders revealed an order dated 2/9/23 which read: RNP (restorative nursing program) Splinting program seven days a week. A review of R20's care plan dated 8/27/20 revealed, in part: RNP splinting program seven days a week. A restorative nursing aide was not available for interview during the survey. On 5/16/23 at 4:30 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. On 5/17/23 at 9:30 a.m., OSM (other staff member) #5, a physical therapy assistant and the rehab program manager, was interviewed. She stated R20 has contractures has contractures in both hands. She stated: The contractures are well-maintained through the hand splints. She stated the therapy staff screens each resident every quarter. She stated R20's hand splints are actually palm guards. She stated for R20, the palm guards, which ordinarily are put in place to prevent skin breakdown, actually serve a dual role of hand splint and skin protectant. She stated the palm guards are the least restrictive method to prevent R20's contractures from worsening. She stated the palm guards serve to maintain hand joint integrity, and prevent the pain and possible skin breakdown that come from worsening contractures. She stated the resident should be wearing the palm guards for most of the day and evening, and should be removed overnight. On 5/17/23 at 10:29 a.m., LPN (licensed practical nurse) #6 stated she finds out in report from the previous nurse or in the resident's orders that a resident needs a hand splint. She stated if a resident is new to the unit, the therapy staff provides instructions on how to apply the splints. She stated the nurse is ultimately responsible for applying the hand splint. She stated the hand splints are needed to keep the resident's contractures from progressing. On 5/17/23 at 10:45 a.m., CNA (certified nursing assistant) #4 was interviewed. She stated the nurse informs her of residents who need to wear hand splints, and it is her job to make sure the splints are applied. A review of the facility policy, Resident Mobility and Range of Motion, revealed, in part: Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM (range of motion) .Interventions may include .the provision of necessary equipment. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and facility document review, the facility staff failed to implement interventions to prevent an injury from a fall, for one of 48 residents in the survey sample, Resident #342. The findings include: For Resident #342 (R342), the facility staff failed to place fall mats beside the resident's bed. On the following dates and times, R342 was observed in bed. Fall mats were not visible on the floor beside the resident's bed on 5/15/23 at 12:04 p.m. and 2:25 p.m., and on 5/16/23 at 8:53 a.m. and 10:22 a.m. On 5/15/23 at 2:25 p.m., R342 was interviewed. The resident stated the facility staff has never put fall mats beside the bed. A review of R342's clinical record revealed the resident was admitted to the facility on [DATE]. A review of R342's orders revealed the following order, dated 5/11/23: Fall mats to floor while resident in bed. Check placement q (every) shift. The resident's comprehensive assessment and care plan had not yet been developed. On 5/17/23 at 10:29 a.m., LPN (licensed practical nurse) #6 was interviewed. She stated fall mats are ordered for all newly admitted residents until the facility can complete the comprehensive assessment. She stated the nurse is responsible for making sure the fall mats are implemented. On 5/17/23 at 10:45 a.m., CNA (certified nursing assistant) #4 was interviewed. She stated the nurse informs her of residents who need fall mats, and it is her job to make sure the fall mats are down beside the resident's bed when the resident is in the bed. She stated all newly admitted residents have orders for fall mats. On 5/17/23 at 10:56 a.m., ASM (administrative staff member) #2, the director of nursing, was 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 notice of Medicare non-coverage for two of three beneficiary protection notification resident reviews, Residents #50 and #62. The findings include: 1. For Resident #50 (R50), the facility staff failed to provide the resident and/or the responsible party with an ABN (advance beneficiary notice) to allow them to make an informed decision regarding their care. R50's last covered day of Medicare part A services was 2/28/2023. R50 was admitted to the facility on [DATE]. R50's diagnoses included but were not limited to congestive heart failure, type two diabetes mellitus and cerebral infarction. R50 remained in the facility at the time of the survey. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/17/2023, the resident scored 11 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately impaired for making daily decisions. On 5/16/2023 at approximately 10:00 a.m., ASM (administrative staff member) #1, provided a NOMNC (notice of Medicare Non-Coverage) for R50 signed on 2/16/2023 documenting services were ending 2/28/2023. ASM #1 stated that R50 was not provided an ABN notice. ASM #1 stated that the facility had conducted a mock survey in March of 2023 and identified a need for improvement in providing the ABN notices to residents, so they had put a plan of correction in place at that time. On 5/16/2023 at 10:31 a.m., ASM #1 provided a copy of the plan of correction put in place after the mock survey conducted 3/14/2023-3/17/2023 including a sign-in sheet documenting education provided to OSM (other staff member) #3, the business office manager, regarding ABN completion in a timely manner, informing residents of the right to appeal and how to appeal a notice of discharge. The plan was dated 3/17/2023. ASM #1 stated that this was the only staff member responsible for this task in the facility. ASM #1 stated that the date of compliance for the plan of correction was 4/14/2023. On 5/16/2023 at 1:41 p.m., an interview was conducted with OSM #3. OSM #3 stated that they were the only person in the facility responsible for providing the ABN and NOMNC to residents in the facility. OSM #3 stated that they provided residents with three days notice before their services ended. OSM #3 stated that they typed up the notices and took them to the resident and had the resident sign them if they were able to. OSM #3 stated that if the resident was not able to sign the notices themselves they had the responsible party sign the notice or notified them by telephone. OSM #3 stated that they had identified an issue with not providing the notices during the mock survey, and they had been educated on the process, and that they now knew which residents required the notices and when to provide them to the resident. OSM #3 stated that they had one resident discharged from Medicare Part A services since the date of compliance for the plan of correction on 4/14/2023 and the proper notices had been provided. Verification of the facility plan of correction was completed by staff interviews and review of the resident discharged from Medicare part A services after the plan of correction date of compliance of 4/14/2023. A review was made of the ABN and NOMNC notice provided for the other resident, Resident #136 (R136), with skilled services ending on 4/15/2023. The ABN notice was signed on 4/11/2023 and the NOMNC was signed on 4/11/2023. The resident remained in the facility. No concerns were identified. On 5/17/2023 at 12:00 p.m., ASM #5, the regional director of clinical services stated that the facility did not have a policy regarding providing ABN/NOMNC notices and that they followed the state regulations and guidelines. On 5/16/2023 at approximately 4:30 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant were made aware of the above concern. No further information was presented prior to exit. This was cited as past non-compliance. 2. For Resident #62 (R62), the facility staff failed to provide the resident and/or the responsible party with an ABN (advance beneficiary notice) to allow them to make an informed decision regarding their care. R62's last covered day of Medicare part A services was 1/31/2023. R62 was admitted to the facility on [DATE]. R62's diagnoses included but were not limited to cerebral infarction, hemiplegia, and congestive heart failure. R62 remained in the facility at the time of the survey. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 5/2/2023, 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 5/16/2023 at approximately 10:00 a.m., ASM (administrative staff member) #1, provided a NOMNC (notice of Medicare Non-Coverage) for R62 signed 1/26/2023 documenting services ending 1/31/2023. ASM #1 stated that R62 was not provided an ABN notice. ASM #1 stated that the facility had conducted a mock survey in March of 2023 and identified a need for improvement in providing the ABN notices to residents so they had put a plan of correction in place at that time. On 5/16/2023 at 10:31 a.m., ASM #1 provided a copy of the plan of correction put in place after the mock survey conducted 3/14-3/17/2023 including a sign-in sheet documenting education provided to OSM (other staff member) #3, the business office manager, regarding ABN completion in a timely manner, informing residents of right to appeal and how to appeal notice of discharge date d 3/17/2023. ASM #1 stated that this was the only staff member responsible for this task in the facility. ASM #1 stated that the date of compliance for the plan of correction was 4/14/2023. On 5/16/2023 at 1:41 p.m., an interview was conducted with OSM #3. OSM #3 stated that they were the only person in the facility responsible for providing the ABN and NOMNC to residents in the facility. OSM #3 stated that they provided residents with three days notice before their services ended. OSM #3 stated that they typed up the notices and took them to the resident and had the resident sign them if they were able to. OSM #3 stated that if the resident was not able to sign the notices themselves they had the responsible party sign the notice or notified them by telephone. OSM #3 stated that they had identified an issue with not providing the notices during the mock survey, and they had been educated on the process, and that they now knew which residents required the notices and when to provide them to the resident. OSM #3 stated that they had one resident discharged from Medicare Part A services since the date of compliance for the plan of correction on 4/14/2023 and the proper notices had been provided. Verification of the facility plan of correction was completed by staff interviews and review of the resident discharged from Medicare part A services after the plan of correction date of compliance of 4/14/2023. A review was made of the ABN and NOMNC notice provided for the other Resident #136 (R136) with skilled services ending on 4/15/2023. The ABN notice was signed on 4/11/2023 and the NOMNC was signed on 4/11/2023. The resident remained in the facility. No concerns were identified. On 5/16/2023 at approximately 4:30 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant were made aware of the above concern. No further information was presented prior to exit. This was cited as past non-compliance.

**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 evidence the monthly drug regimen reviews for one of 48 residents, Resident #66. The findings include: Resident #66 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: CVA (cerebral vascular accident), dysphagia, anxiety disorder, cognitive communication deficit, unspecified dementia without behavior/psychosis/mood/anxiety behaviors. A review of the comprehensive care plan dated 3/20/23, which revealed, PROBLEM/NEED: Psychotropic drug use APPROACHES: evaluate effectiveness and side effects of medications for possible decrease/elimination of psychotropic drugs. Monitor pharmacists drug regime review for identification of potential drug interactions. Monitor resident for signs of tremor and document. Report onset of increase to physician. A review of the physician's orders dated 3/22/23, revealed, Buspirone 5 mg (milligram) tablet, give one tablet by mouth at bedtime. Mirtazapine 15 mg take one tablet by mouth at bedtime. A review of the MRR (monthly regimen reviews) for Resident #66, evidenced a review in June, July, August, September and November 2022; February and May 2023 were present. There were no MRRs in October and December 2022; January, March and April 2023. Five of 12 MRRs were missing. An interview was conducted on 5/16/23 at 4:55 PM with ASM (administrative staff member) #4, the regional nurse consultant. When asked if there were MRRs for Resident #66, ASM #4 stated, the pharmacist is having some IT (information technology) issues and we have not been able to obtain them. When asked if these IT issues had existed for months, ASM #4 stated, No, it has been the last couple of hours since we have asked for them. An interview was conducted 5/16/23 at 5:00 PM with ASM #2, the director of nursing, who stated, We are looking for the rest of her MRRs. The pharmacist emails me a monthly report that includes all the residents that have no recommendations and who has recommendations. The pharmacist writes on note specifying the recommendations. An interview was conducted on 5/17/23 at 9:41 AM with OSM (other staff member) #4, the pharmacist. When asked about the process for completing medication regimen reviews for the residents, OSM #4 stated, We are on site every month, it does occur on site every month. Upon admission we will perform the MRR off site. When asked about the five of 12 missing MRR's, OSM #4 stated, I am still trying to figure out. I moved from the previous pharmacy company to this one to stay with the residents. I follow my customer. This is a new system for me. For some reason she [Resident #66] dropped off. I am having IT look into it. The resident was not uploading to my clinical software. When asked the recommendations for May 16, 2023, OSM #4 stated, The antidepressant and antianxiety medications are in compliance and I recommended we look at a GDR (gradual dose reduction). On 5/17/23 at 10:30 AM, ASM (administrative staff member) #1, the administrator was made aware of the findings. A review of the facility's Medication Regimen Review policy dated 9/18, revealed, Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. The MRR also involves collaborating with other members of the IDT (interdisciplinary team), including the resident, their family, and/or resident representative. The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure that the medications each resident receives are clinically indicated. No further information was provided prior to exit.

2. For Resident #84 (R84), RN (registered nurse) #4 failed to administer the physician prescribed medication calcium 500 mg (milligrams)/vitamin D 5 mcg (micrograms) on 5/16/23. RN #4 administered 25 mcg of vitamin D rather than the prescribed dosage. A review of R84's clinical record revealed a physician's order dated 3/24/23 for calcium 500mg/vitamin D 5mcg once a day. On 5/16/23 at 8:03 a.m., RN #4 was observed preparing and administering medications to R84. Instead of administering calcium 500mg/vitamin D 5mcg, RN #4 administered vitamin D 25 mcg. On 5/16/23 at 2:11 p.m., an interview was conducted with RN #4. RN #4 was made aware of the above observation. RN #4 presented R84's medication administration record that documented the physician's order for calcium 500mg/5 mcg vitamin D and stated she didn't know what she gave. On 5/16/23 at 4:35 p.m., ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were made aware of the above concern. 3. For Resident #132 (R132), RN (registered nurse) #4 failed to administer the correct amount of the physician prescribed medication Senna (used to treat constipation). Instead of administering two tablets of Senna to R132, RN #4 only administered one tablet. A review of R132's clinical record revealed a physician's order dated 3/27/23 for Senna 8.6 mg (milligrams)- two tablets twice a day. On 5/16/23 at 7:49 a.m., RN #4 was observed preparing and administering medications to R132. RN #4 administered one tablet of Senna to the resident. On 5/16/23 at 2:00 p.m., an interview was conducted with RN #4. RN #4 reviewed R132's physician's order for two tablets of Senna and stated she only gave one tablet. On 5/16/23 at 4:35 p.m., ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were made aware of the above concern. Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure a medication error rate less than 5% for three of five residents in the medication administration observation, Residents #76, #84 and #132. The findings include: 1. For Resident #76 (R76), the facility staff failed to administer Lasix (1) as ordered by the physician. On 5/16/2023 at 8:09 a.m. an observation was made of LPN (licensed practical nurse) #4 administering medications to Resident #76. LPN #4 poured the following medications: Senna 8.6 MG (milligram) tablet (1) - one tablet Vitamin B12 1000 MG (2) - one tablet Calcium Citrate 250 MG (3) - one tablet Metoprolol 25 MG tablet (4) Nitrofurantoin 50 MG capsule (5) - one capsule Miralax 17 GM (grams) (6) mixed in 120 ml (milliliters) of water. Review of the physician orders documented the above medication orders. There was a physician order for Lasix 20 MG Tablet (7), give 1 tab (tablet) PO (by mouth) QD (every day) Dx (diagnosis) CHF (congestive heart failure). An interview was conducted with LPN #4 on 5/16/2023 at 10:29 a.m. When asked if she gave R76 Lasix during the morning medication administration, LPN #4 pulled the cards holding the medications out of the medication cart. She looked through the cards of medications and there was no card for Lasix. LPN #4 stated, I guess I didn't give it. When asked should she have given it, LPN #4 stated, yes. The facility policy, Medication Administration documented in part, Medications shall be administered in a safe and timely manner and as prescribed. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional nurse consultant, were made aware of the above findings on 5/16/2023 at 4:40 p.m. No further information was provided prior to exit References: (1) Senna is used to treat constipation. This information was obtained from the following website: https://medlineplus.gov/druginfo/natural/652.html (2) Vitamin B12 is a supplement. This information was obtained from the following website: https://ods.od.nih.gov/factsheets/VitaminB12-Consumer/ (3) Calcium is a mineral your body needs to build and maintain strong bones and to carry out many important functions. Calcium is the most abundant mineral in the body. This information was obtained from the following website: https://ods.od.nih.gov/factsheets/Calcium-Consumer/ (4) Metoprolol is used alone or in combination with other medications to treat high blood pressure. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682864.html (5) Nitrofurantoin is used to treat urinary tract infections. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682291.html (6) Polyethylene glycol (Miralax) 3350 is used to treat occasional constipation. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a603032.html (7) Furosemide (Lasix) is used to treat edema [fluid retention; excess fluid held in body tissues] caused by various medical problems, including heart, kidney, and liver disease. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682858.html

**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 for one of four residents in the survey sample, to implement the abuse policy for reporting abuse, Resident #1. The findings include: The facility failed to implement their abuse policy to report occurrences according to regulations. A review of the facility grievance form, dated 5/2/22, revealed Detail of complaint/grievance: Resident claims that he was assaulted with a paper towel while being changed and cleaned. Resident claims CNA (certified nursing assistant) inserted paper towels in his rectum while she was cleaning him. Resident #1 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: CAD (coronary artery disease), anemia, non-traumatic brain dysfunction, non-Alzheimer's dementia, COPD (chronic obstructive pulmonary disease) and diabetes. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 9/6/22, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring total dependence for transfer and bathing; extensive assistance for bed mobility, dressing and hygiene and limited assistance for eating. A review of the comprehensive care plan with a date of 1/22/21 and revision date of 8/29/22, revealed, PROBLEM /NEED: Potential for injury for diagnosis of suicidal ideations, anxiety disorder, psychosis, dementia with behavioral disturbances, depression. Makes paranoid accusations against staff. APPROACHES: Monitor and document behavior as needed. Report increased negative behavior to the physician. Maintain resident environment free of clutter and safety hazards. The facility's policy titled Abuse, Neglect and Exploitation dated 10/24/22, included: Reporting/Response: the facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specific timeframes. Immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and not result in serious bodily injury. An interview was conducted on 11/16/22 at 11:10 AM, with OSM (other staff member) #1, the director of social services. When asked who followed up with Resident #1 regarding his allegation of sexual assault, OSM #1 stated, On Sunday (5/1/22), I talked with the nursing supervisor, who told me what the resident stated. She gave me her statement in writing. I came in on Monday (5/2/22), talked with the resident and he told me the story, the CNA was caring for him, she was assigned to him and she was cleaning him and he felt like he was sexually assaulted with her finger. His perception was that he was sexually assaulted. I did my investigation with the DON (director of nursing), we got written statements and had the NP (nurse practitioner) do an actual physical assessment. Later in the day was briefed that they could not prove the allegation. The DON said nursing will handle this. When asks who reports allegations of abuse, OSM #1 stated, The administrator or the DON report it to the state, I do not do this. An interview was conducted on 11/16/22 at 11:30 AM, with RN (registered nurse) #2, the infection preventionist. When asked her role, RN #2 stated, At the time of this event, I was the nursing supervisor on the weekend. RN #2 was asked to read and verify the statement she provided to OSM #1. RN #2 verified statement. When asked to detail the events, RN #2 stated, The resident stated this happened on Friday (4/29/22) evening and reported it to me on Sunday (5/1/22) at 11:54 AM. I had not heard anything in report nor had the resident told me this before. I assessed his rectal area, did not see any broken skin, no redness or any abnormalities. The resident was calm when I talked with him and had no other concerns. I informed the DON on Sunday. When asked if she files reports to agencies related to allegations of abuse, RN #2 stated, No, I follow my chain of command, inform the DON and administrator. Normally one of them will report. I do not report outside of the facility. An interview was conducted on 11/16/22 at 12:15 PM, with ASM (administrative staff member) #1, the administrator. When asked who was responsible to report allegations of abuse, ASM #1 stated, At that time it was the DON's responsibility to report to VDH-OLC (Virginia Department of Health-Office Licensure Certification) and others. I do not see where we sent an initial or final FRI (facility reported incident) but will look again. ASM #1 stated the policy states, reporting within 2 hours of allegation of abuse. The director of nursing did not report because she felt that after the investigation, the allegation was not substantiated, there was no physical evidence of abuse and the resident's story was not matching up. On 11/16/22 at 12:46 PM, ASM #1 stated, There are no records of a FRI being sent to your office either initially or final after investigation. On 11/16/21 at 12:50 PM, ASM #1, was made aware of the finding. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to report an allegation of abuse in a timely manner to the State Agency for one of four residents in the survey sample, Resident #1. The findings include: The facility failed to report an allegation of abuse to the State Agency. A review of the facility grievance form, dated 5/2/22, revealed Detail of complaint/grievance: Resident claims that he was assaulted with a paper towel while being changed and cleaned. Resident claims CNA (certified nursing assistant) inserted paper towels in his rectum while she was cleaning him. Resident #1 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: CAD (coronary artery disease), anemia, non-traumatic brain dysfunction, non-Alzheimer's dementia, COPD (chronic obstructive pulmonary disease) and diabetes. The facility's policy titled Abuse, Neglect and Exploitation dated 10/24/22, revealed, Reporting/Response: the facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specific timeframes. Immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and not result in serious bodily injury. An interview was conducted on 11/16/22 at 11:10 AM, with OSM (other staff member) #1, the director of social services. When asked who followed up with Resident #1 regarding his allegation of sexual assault, OSM #1 stated, On Sunday (5/1/22), I talked with the nursing supervisor, who told me what the resident stated. She gave me her statement in writing. I came in on Monday (5/2/22), talked with the resident and he told me the story, the CNA was caring for him, she was assigned to him and she was cleaning him and he felt like he was sexually assaulted with her finger. His perception was that he was sexually assaulted. I did my investigation with the DON (director of nursing), we got written statements and had the NP (nurse practitioner) do any actual physical assessment. Later in the day was briefed that they could not prove the allegation. OSM #1 stated the DON said nursing will handle this. When asked who reports allegations of abuse, OSM #1 stated, The administrator or the DON report it to the state, I do not do this. An interview was conducted on 11/16/22 at 11:30 AM, with RN (registered nurse) #2, the infection preventionist. When asked her role, RN #2 stated, At the time of this event, I was the nursing supervisor on the weekend. RN #2 was asked to read and verify the statement she provided to OSM #1. RN #2 verified statement. When asked to detail the events, RN #2 stated, The resident stated this happened on Friday (4/29/22) evening and reported it to me on Sunday (5/1/22) at 11:54 AM. I had not heard anything in report nor had the resident told me this before. I assessed his rectal area, did not see any broken skin, no redness or any abnormalities. The resident was calm when I talked with him and had no other concerns. I informed the DON on Sunday. When asked if she files reports to state agencies related to allegations of abuse, RN #2 stated, No, I follow my chain of command, inform the DON and administrator. Normally one of them will report. I do not report outside of the facility. An interview was conducted on 11/16/22 at 12:15 PM, with ASM (administrative staff member) #1, the administrator. When asked who was responsible to report allegations of abuse, ASM #1 stated, At that time it was the DON's responsibility to report to VDH-OLC (Virginia Department of Health-Office Licensure Certification) and others. I do not see where we sent an initial or final FRI (facility reported incident) but will look again. ASM #1 stated, the policy states, reporting within 2 hours of allegation of abuse. The director of nursing did not report because she felt that after the investigation, the allegation was not substantiated, there was no physical evidence of abuse and the resident's story was not matching up. On 11/16/22 at 12:46 PM, ASM #1 stated, There are no records of an FRI being sent to your office either initially or final after investigation. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain a comfortable, homelike environment for one of 44 residents in the survey sample, Resident #21. The facility staff failed to maintain Resident #21's wheelchair armrests in good repair. The plastic covering on the armrests was torn and cloth was exposed. The findings include: Resident #21 was admitted to the facility on [DATE]. Resident #21's diagnoses included but were not limited to diabetes, major depressive disorder and convulsions. Resident #21's annual minimum data set with an assessment reference date of 8/23/21, coded the resident's cognition as moderately impaired. On 11/15/21 at 2:01 p.m. and 11/16/21 at 7:59 a.m., observation of Resident #21 was conducted. The resident was sitting in a wheelchair. The plastic covering on both wheelchair armrests was torn with cloth exposed. On 11/16/21 at 2:07 p.m., an interview was conducted with CNA (certified nursing assistant) #2. CNA #2 stated the 11:00 p.m. to 7:00 a.m. CNAs are responsible for washing wheelchairs so she thought they would report torn wheelchair armrests. CNA #2 further stated if staff sees torn areas on wheelchair armrests then staff is supposed to notify maintenance with a work order in the computer system. On 11/16/21 at 4:42 p.m., an interview was conducted with OSM #3 (other staff member) #3 (the maintenance director). OSM #3 stated the maintenance staff inspects all resident wheelchairs including armrests every quarter and staff is supposed to report torn wheelchair armrests any other time via a work order in the computer system. OSM #3 stated he had previously ordered wheelchair armrests but had difficulty with getting the supply and the supply only recently came in. On 11/16/21 at 5:36 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the assistant administrator) and ASM #3 (the director of nursing) were made aware of the above concern. On 11/17/21 at 7:54 a.m., OSM #3 provided an invoice that documented wheelchair armrests were received at the facility on 10/15/21. OSM #3 also provided documentation to evidence Resident #21's wheelchair was inspected by the maintenance staff on 8/27/21 and stated he had not received any work orders from other staff regarding Resident #21's wheelchair armrests. On 11/17/21 at 9:42 a.m., ASM #1 and ASM #2 was made aware that the above findings remained a concern. The facility policy titled, Homelike Environment documented, Residents are provided with a safe, clean, comfortable, homelike environment and encouraged to use their personal belongings to the extent possible. The facility policy titled, Wheelchair Cleaning and Maintenance Inspection documented, It is the policy of this facility to conduct regular cleaning and inspections of all wheelchairs and resident transportation equipment to ensure that they are cleaned and safe. Repairs and cleaning shall not be limited to the routine cleaning and inspection procedures. Any observation of an uncleaned device or device that needs repair should be cleaned and/or reported for repairs through the Tels work-order system (computerized work order system for the Maintenance department). 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 that the facility staff failed to provide written notification of a transfer to the ombudsman for one of 44 residents in the survey sample, Resident #76. The facility failed to notify the ombudsman of Resident #76's transfer to the hospital on 7/27/21. The findings include: Resident #76 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses including a history of a stroke and diabetes. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/7/21, Resident #76 was coded as being severely cognitively impaired for making daily decisions, having scored six out of 15 on the BIMS (brief interview for mental status). A review of Resident #76's clinical record revealed the following progress note written on 7/27/21 at 1:20 p.m.: CNA (certified nursing assistant) came to this nurse to report resident coughing up blood. CNA was making rounds when resident yelled out 'someone help me.' Upon entering resident's room, nurse witnessed resident coughing up copious amounts of bright red blood and mucus mixture .Vital signs were taken .Resident nodded yes as to rationale for being sent out to hospital. RP (responsible party) made aware. Resident was transported via stretcher .RP was offered bed hold, which she refused. The resident did not return to the facility until 8/6/21. Further review of Resident #76's clinical record failed to reveal evidence that the ombudsman was notified of the resident's discharge to the hospital on 7/27/21. On 11/16/21 at 5:19 p.m., ASM (administrative staff member) #1, the administrator, ASM #4, the administrator of a sister facility, ASM #5, the nurse consultant, and ASM #3, the director of nursing, were informed of these concerns. On 11/17/21 at 8:36 a.m., ASM #1 was interviewed. When asked who is responsible for notifying the ombudsman when a resident is discharged to the hospital, he stated the social worker is responsible for this. ASM #1 stated the social worker at the time of Resident #76's discharge is no longer employed at the facility. ASM #1 stated the social worker ordinarily keeps a binder with all the ombudsman notifications in it, but the paper for Resident #76's discharge on [DATE] could not be located. A review of the facility policy, Transfer or Discharge Notice, revealed, in part: A resident and/or his or her representative (sponsor) will be given a thirty (30)-day advance notice of an impending transfer or discharge from the facility. Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge .The resident and/or representative (sponsor) will be notified in writing .a copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, it was determined that the facility staff failed to follow professional standards of practice for one of 44 residents in the survey sample, Resident # 106. The facility staff failed to ensure timely transcription of a an order for the use of a negative wound vac [vacuum]. The physician ordered the wound Vac on 11/12/21 and the order was not transcribed until 11/15/21. The findings include: Resident # 106's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/25/2021, coded Resident # 106 as scoring a 3 [three] on the brief interview for mental status (BIMS) of a score of 0 - 15, 3 [three] - being severely impaired of cognition for making daily decisions. The Wound Evaluation & Management Summary for Resident # 106 dated 11/12/2021 documented in part, Dressing Treatment Plan: Negative pressure wound therapy. The Physician's Telephone Order for Resident # 106 dated 11/15/21 documented, Cleanse wound to R [right] hip with hibiscus wipe with dampened 4x4 [four by four] gauze, pack wound with black foam. Apply negative pressure therapy run continuous at 120 mmHg [millimeters of mercury]. Change dressing Tues [Tuesday], Friday and PRN [as needed]. The comprehensive care plan for Resident # 106 dated 07/02/2021 documented in part, Problem/Need: Infection/Wound to R [right] Hip. At risk for pain, odor, and infection due to right hip wound and comorbidities. Under Approaches it documented in part, 11/15/21 New wound care order Negative pressure therapy continuously @ [at] 120 mmHg [millimeter of mercury] per order. On 11/17/2021 at 8:09 a.m., an interview was conducted with LPN [licensed practical nurse] # 2, wound nurse. LPN #2 was asked when the wound vac treatment was started for Resident # 106. LPN # 2 stated that Resident # 106 had the negative wound vac on 11/12/2021 and had discontinued the PICO vac [3] on the 11/12/2021. After reviewing the physician's telephone order for Resident # 106's use of the wound vac as listed above, LPN # 2 was asked why the order was dated 11/15/2021 when they stated that the wound vac started on 11/12/2021. LPN # 2 stated, The order was not written until 11/15/2021. When asked who was responsible for transcribing the order, LPN # 2 stated, I was responsible for obtaining the order. When asked to describe the procedure for obtaining the physician's order for Resident # 106's use of the wound vac, LPN # 2 stated, I print the recommendation from the wound doctor, scan it to the physician, the facility's medical director, write the telephone order, document it in the nurse's notes, notify the family all in the same day. When asked if the order for Resident # 106's wound vac was transcribed timely, LPN # 2 stated no. When asked about the date of the Approach on Resident # 106 comprehensive care plan, LPN # 2 stated that the care plan is updated when the order is written. On 11/15/2021 at approximately 12:00 p.m., during the entrance conference with ASM [administrative staff member] # 2, assistant administrator and ASM # 3, director of nursing, ASM # 3 stated that the facility's nursing staff follow [NAME]'s standard of nursing. On 11/17/2021 at approximately 10:22 a.m. a request was made to ASM # 1, administrator for facility policies and the [NAME] standard of nursing for transcribing physician's orders. At approximately 11:00 a.m., RN [registered nurse] # 2, assistant director of nursing, provided the survey team with requested policies. The facility was unable to provide the [NAME] standard of nursing for transcribing physician's orders. On 11/17/2021 at approximately 5:00 p.m., ASM [administrative staff member] # 1, administrator, ASM # 2, assistant administrator, ASM # 3, director of nursing, ASM # 4, administrator of sister facility and ASM # 5, nurse consultant, were made aware of the above findings. No further information was provided prior to exit. References: [1] Vacuum-assisted closure of a wound is a type of therapy to help wounds heal. It's also known as wound VAC. During the treatment, a device decreases air pressure on the wound. This can help the wound heal more quickly. The gases in the air around us put pressure on the surface of our bodies. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/vacuumassisted-closure-of-a-wound#:~:text=Vacuum%2Dassisted%20closure%20of%20a%20wound%20is%20a%20type%20of,the%20surface%20of%20our%20bodies. [2] A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/000739.htm. [3] The PICO* patient/population, intervention, comparison and outcomes] Single Use Negative Pressure Wound Therapy System is indicated for acute and chronic wounds and closed surgical incisions with low to moderate levels of exudate. This single use system is canister-free with a wear time of 7 to 14 days. Approved for both hospital and home care settings. This information was obtained from the website: https://www.woundsource.com/product/pico-single-use-negative-pressure-wound-therapy-system.

Based on staff interview and clinical record review, it was determined that the facility staff failed to maintain an accurate clinical record for one of 44 residents in the survey sample, Resident # 106. The facility staff documented on Resident # 106's November 2021 eTAR [electronic treatment administration record] the use of a PICO wound vac [vacuum] [1] that was discontinued on 11/12/2021. The findings include: Resident # 106 was admitted to the facility with diagnoses that included but were not limited to: dementia without complications [2], heart failure, artificial right hip joint. Resident # 106's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/25/2021, coded Resident # 106 as scoring a 3 [three] on the brief interview for mental status (BIMS) of a score of 0 - 15, 3 [three] - being severely impaired of cognition for making daily decisions. The Wound Evaluation & Management Summary for Resident # 106 dated, 11/12/2021 documented in part, Dressing Treatment Plan: Negative pressure wound therapy. The Physician's Telephone Order for Resident # 106 dated 11/15/21 documented, Cleanse wound to R [right] hip with hibiscus wipe with dampened 4x4 [four by four] gauze, pack wound with black foam. Apply negative pressure therapy run continuous at 120 mmHg [millimeters of mercury]. Change dressing Tues [Tuesday], Friday and PRN [as needed]. The comprehensive care plan for Resident # 106 dated 07/02/2021 documented in part, Problem/Need: Infection/Wound to R [right] Hip. At risk for pain, odor, and infection due to right hip wound and comorbidities. Under Approaches it documented in part, 11/15/21 New wound care order Negative pressure therapy continuously @ [at] 120 mmHg [millimeter of mercury] per order. The eTAR [electronic treatment administration record] dated November 2021 documented, Check function of PICO vac [vacuum] to R [right] hip. If you have Any concerns or questions please reach out to wound nurse for assistance. Discontinue Date: 11/15/2021. Further review of the eTAR revealed check marks on 11/12/21 at 6:30 a.m., 2:30 p.m. and at 10:30 p.m., on 11/13/21 at at 6:30 a.m., 2:30 p.m. and at 10:30 p.m., on 11/14/21 at 6:30 a.m., 2:30 p.m. and at 10:30 p.m. and on 11/15/21 at 6:30 a.m., 2:30 p.m. and at 10:30 p.m On 11/17/2021 at 8:09 a.m., an interview was conducted with LPN [licensed practical nurse] # 2, wound nurse. When asked when the wound vac was started for Resident # 106, LPN # 2 stated that Resident # 106 had the negative wound vac on 11/12/2021. LPN #2 stated the PICO vac [3] was discontinued on the 11/12/2021. After reviewing the physician's telephone order for Resident # 106's use of the wound vac as listed above, LPN # 2 was asked why the order was dated 11/15/2021 when they stated that the wound vac started on 11/12/2021. LPN # 2 stated, The order was not written until 11/15/2021. When asked who was responsible for transcribing the order LPN # 2 stated, I responsible for obtaining the order. After reviewing Resident # 106's eTAR dated November 2021 for the dates list above, LPN # 2 was asked if the documentation was correct or accurate. LPN # 2 stated that the eTAR was not accurate for the dates listed above due to the fact that the PICO was not in use on those dates. On 11/17/2021 at approximately 5:00 p.m., ASM [administrative staff member] # 1, administrator, ASM # 2, assistant administrator, ASM # 3, director of nursing, ASM # 4, administrator of sister facility and ASM # 5, nurse consultant, were made aware of the above findings. No further information was provided prior to exit. References: [1] The PICO* patient/population, intervention, comparison and outcomes] Single Use Negative Pressure Wound Therapy System is indicated for acute and chronic wounds and closed surgical incisions with low to moderate levels of exudate. This single use system is canister-free with a wear time of 7 to 14 days. Approved for both hospital and home care settings. This information was obtained from the website: https://www.woundsource.com/product/pico-single-use-negative-pressure-wound-therapy-system. [2] A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/000739.htm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and facility document review it was determined the facility staff failed to secure Medications in a safe and secure manner according to professional standards in three of three medication carts, (Wing 100-medication cart-two, Wing 200-medication cart-one and Wing 200-medication cart-two). The findings include: One whole pill and two half-loose unidentified pills were observed in the second drawer of the Wing 100-medication cart-two. Three half unidentified pills were observed in the second drawer of the left side of Wing 200-medication cart-one and an opened bottle of pills without a cap was observed in the third drawer on the right side of Wing 200-medication cart-one. One whole unidentified pill was observed in the second drawer of Wing 200-medication cart-two. On 11/16/21 at approximately 2:50 PM, an observation of Wing-200 medication cart-one was conducted with LPN (licensed practical nurse) #3. Observation inside the drawers of Wing-200 medication cart-one revealed the following: In drawer two on the left side of cart: three half loose unidentified pills. In drawer three on the right side of cart: One large bottle (capacity to hold 1000 tablets) of Docusate (laxative) (1) opened with no cap. On 11/16/21 at approximately 3:00 PM, an observation of Wing-200 medication cart-two was conducted with LPN #4. Observation inside the drawer of Wing-200 medication cart-two revealed in drawer two on the left side of cart: one whole loose unidentified pill. On 11/16/21 at approximately 3:10 PM, an observation of Wing-100 medication cart-two was conducted with LPN #5. Observation inside the drawer of Wing 100-medication cart-two revealed in drawer two on the left side of cart: two half loose unidentified pills. The loose pills in each drawer above were observed located behind the medication cards stored in each drawer. When asked about the loose medications in the drawers, LPN #3 stated, There are so many cards in the drawer that sometimes the pills pop out of the medication cards, that is the problem with the cards. An interview was conducted on 11/16/21 at 2:50 PM with LPN #3. When asked about the opened bottle of pills in the drawer, LPN #3 stated, Well I know the cap was here. I just took it off when I was giving the medications. LPN #3 was observed placing the cap that was in the drawer back on the open bottle of Docusate. An interview was conducted on 11/16/21 at 3:15 PM with LPN #5. When asked about the loose unidentified pills in the drawer, LPN #5 stated, We give a lot of meds here on the skilled side and there is a lot of medication cards for each resident. The drawer gets full, we are constantly pushing the cards back and forth, and we administer medications. That is why the pills sometimes pop out. I will dispose of those pills. On 11/16/21 at 5:15 PM, when asked what the standard of practice the facility followed, ASM (administrative staff member) #3, the director of nursing stated, We follow [NAME]. On 11/16/21 at 5:18 PM, ASM #1, the administrator, ASM #2, the assistant administrator, ASM #3, the director of nursing, ASM #4, the administrator of a sister facility and ASM #5, the regional nurse consultant were informed of the above findings. According to the facility's Storage of Medications policy, dated November 2020, which documents in part, The facility stores all drugs and biologicals in a safe, secure and orderly manner. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. No further information was provided prior to exit. References: (1) 2019 [NAME] Pocket Drug Guide for Nurses, Wolters, Kluwer, page 444. (2) Lippincott Nursing Procedures, 8th edition, Wolters, Kluwer, page 556.

Based on observation, staff interview and facility document review, it was determined that facility staff failed to store, and prepare food in in accordance with professional standards for food service safety. Facility staff were observed drying clean dishes using a cloth and paper towels and a fan with coated with gray dust and lint on the front and back blade guards was found blowing air over the area where dishes were washed and racked to dry. The findings include: On 11/16/2021 at approximately 9:35 a.m., an observation of the facility's dish room revealed OSM [other staff member] # 2, dietary aide removing and wiping dry clean trays, plates from the dishwashing racks on the clean dish line. OSM #2 then stacked the trays on top of each other on a ladder rack and stacked the dishes together, placing them in the dish storage rack. Observation of the wall behind the clean dish line revealed an 18 inch fan mounted on the wall, above and blowing on the clean trays, plates and silverware. On 11/16/2021 at approximately 9:45 a.m., an observation of the procedure described above was conducted with OSM # 1, dietary director. When asked about the drying procedure OSM # 1, stopped OSM # 2 from drying, provided them with a roll of paper toweling and informed them to use the One towel procedure. When asked to describe the One towel procedure OSM # 1 stated that they were to use one piece of paper towel for one piece of dish ware each. OSM # 1 was then asked to turn off the fan above the clean dish line. Observation of the fan when it stopped, revealed the fan blades, and the front and back blade guards coated with grey dust and lint. When asked about the fan, OSM # 1 stated that it helped dry the dishes. When asked who was responsible for cleaning the fan and how often it was done OSM # 1 stated that maintenance cleaned the fan. On 11/16/2021 at 10:15 an interview was conducted with OSM # 2, dietary aide. When asked how long they had been working in the dish room and who trained them, OSM # 2 stated that they had started two months ago and was trained by other staff members who worked in the dish room. When informed of the observation of them drying plates and trays with a cloth when the dishes came out dish washer, OSM # 2 stated, I use one cloth for the dishes and another one to dry the trays. When asked about the One towel procedure OSM # 2 stated that they did not know about it until OSM # 1 showed them. When asked about the fan, OSM # 2 stated that it helped dry off the excess water from the dishes and trays. On 11/16/2021 at approximately 2:10 p.m., an interview was conducted with OSM # 3, maintenance director. When asked if they were responsible for cleaning the wall mounted fan in the facility's dish room, OSM # 3 stated that it was not a part of the routine maintenance schedule but that they [maintenance department] would clean the fan when the kitchen asked. OSM # 3 further stated that if they did repairs on the fan they would clean it at that time. On 11/16/2021 at approximately 3:00 p.m., an interview was conducted with OSM # 1. When asked to describe the correct procedure for drying food trays and dishes after being washed, OSM # 1 stated, They should be air dried. When asked why they needed to be air dried, OSM # 1 stated, It doesn't harbor bacteria. When asked to describe the procedure for cleaning the wall mounted fan located in the dish room, OSM # 1 stated, We don't have a regular schedule. Maintenance will come in and clean when we call them. The facility's policy American Healthcare Dietary Policy and Procedural Manual documented in part, XII. Dishwashing. Procedure: 7. Allow clean dishes to air dry completely before storing. FDA Food Code (U.S. Food and Drug Administartion -2017): Drying 4-901.11 Equipment and Utensils, Air-Drying Required: Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms to equipment or utensils. 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 (B) May not be cloth dried except that UTENSILS that have been air-dried may be polished with cloths that are maintained clean and dry. On 11/16/2021 at approximately 5:00 p.m., ASM [administrative staff member] # 1, administrator, ASM # 2, assistant administrator, ASM # 3, director of nursing, ASM # 4, administrator of sister facility and ASM # 5, nurse consultant, were made aware of the above findings. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview and clinical record review, it was determined that the facility staff failed to provide accommodation of resident needs for one of 51 residents in the survey sample, Resident # 89. The facility staff failed to ensure Resident # 89's call bell (a device with a button that can be pushed to alert staff when assistance is needed), was within the resident's reach. The findings include: Resident # 89 was admitted to the facility on [DATE] with a re-admission of 04/14/16 with diagnoses that included but were not limited to intellectual disabilities (1), dementia (2), gastroesophageal reflux disease (3) and Parkinson's disease (4). Resident # 89's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 01/16/19, coded Resident # 89 as scoring an 3 (three) on the brief interview for mental status (BIMS) of a score of 0 - 15, 3 (three) - being severely impaired of cognition for making daily decisions. Resident # 89 was coded as being totally dependent of one staff member for activities of daily living. Section G0400 Functional Limitation in Range of Motion coded Resident # 89 as No impairment on both sides of her upper extremities (shoulder, elbow, wrist, hand). On 03/04/19 at approximately 7:00 p.m., an observation of Resident # 89 revealed she was lying in bed, awake, neat and clean. The head of the bed was slightly raised and a pillow was under Resident # 89's head. Observation of the call bell's placement revealed it was lying on the floor on the left side of the bed. When asked if she could locate the call bell Resident # 89 was unable to respond to the request and verbalized unintelligible speech On 03/05/19 at 3:04 p.m., an observation of Resident # 89 revealed she was lying in bed, awake, neat and clean. The head of the bed was slightly raised and a pillow was under her head. Observation of the call bell's placement revealed it was hanging off the left side of the bed just above the floor not within reach of Resident # 89. On 03/06/19 at 8:33 a.m., an observation of Resident # 89 revealed she was lying in bed, awake, neat and clean, watching television. The head of the bed was slightly raised. Observation of the call bell revealed it was a flat pressure switch. Observation of the call bell's placement revealed it was hanging off the left side of the bed just above the floor not within reach of Resident # 89. On 03/06/19 at 8:46 a.m., an observation of Resident # 89's call bell placement was conducted with CNA (certified nursing assistant) # 3. When asked if the call bell was placed in a position that Resident # 89 could reach and activate sated, It's not in reach. When asked to describe the procedure for the placement of a cell bell for a resident CNA # 3 stated, They should be placed in reach for when they need you. When asked how often the placement of the call bell should be checked CNA # 3 stated, Every time you go into the room. When asked if she was in Resident # 89's room earlier that morning CNA # 3 stated, I brought in tray for breakfast and set her up to feed herself and I just didn't think to check the call bell. On 03/26/19 at approximately 3:30 p.m. ASM (administrative staff member) # 1, the administrator and ASM # 3, regional nurse consultant, were made aware of the findings. No further information was provided prior to exit. References: (1) Refers to a group of disorders characterized by a limited mental capacity and difficulty with adaptive behaviors such as managing money, schedules and routines, or social interactions. Intellectual disability originates before the age of 18 and may result from physical causes, such as autism or cerebral palsy, or from nonphysical causes, such as lack of stimulation and adult responsiveness. This information was obtained from the website: https://www.report.nih.gov/NIHfactsheets/ViewFactSheet.aspx?csid=100 (2) A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/000739.htm. (3) Stomach contents to leak back, or reflux, into the esophagus and irritate it. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/gerd.html. (4) A type of movement disorder. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/parkinsonsdisease.html.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, facility document review, and in the course of an investigation of a Facility Reported Incident (FRI), it was determined that the facility staff failed to implement abuse policies and procedures for reporting allegations of potential abuse for two of 51 residents in the survey sample; Resident #29 and Resident #123. The facility staff failed to implement the abuse policy to ensure timely reporting to the State Agency and other officials of a resident to resident altercation and potential abuse between Resident #29 and Resident #123 that occurred on 4/25/19 at approximately 6:30 p.m. The incident was not reported until 4/26/19 at 11:04 a.m., approximately 16 hours after the incident occurred. The findings include: Resident #29 was admitted to the facility on [DATE] with the diagnoses of but not limited to cerebral vascular disease, high blood pressure, diabetes type 2, anxiety, depression, psychosis with hallucinations. Resident #29's Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 12/14/18, and coded Resident #29 as severely cognitively impaired in ability to make daily life decisions. The resident required total care for hygiene, bathing, dressing, ambulation, transfers; limited assistance for eating; and was incontinent of bowel and bladder. Resident #123 was admitted to the facility on [DATE] with the diagnoses of but not limited to dementia, depression, and asthma. The most recent MDS (Minimum Data Set) was an annual assessment with an ARD (Assessment Reference Date) of 1/16/19. The resident was coded as being moderately impaired in ability to make daily life decisions. The resident was coded as requiring total care for dressing, toileting, hygiene and bathing; and limited assistance for transfers and eating. A review of a FRI (Facility Reported Incident) investigation dated 4/25/18 involving Resident #29 and Resident #123 documented the following: At approximately 6:30 p.m., name of [Resident #29] and name of [Resident #123] were seen by name of [CNA #5] swinging at each other. The residents were located in the commons are of unit 400. Name of [Resident #29] lost his balance and fell hitting the back of his head on the wall. The residents were immediately separated. A head to toe assess was done by name of LPN #7 (Licensed Practical Nurse). Name of [Resident #123] was found to have two small scratches on the back of his neck. Name of [Resident #29] does not have any visible injury at this time. Both residents deny pain or discomfort. RP and MD [responsible party and medical doctor] are aware. Both residents were place on Q [every] 15 minute checks for 48 hours to monitor behaviors. There have been no further incidents at this time. An investigation is in progress and final outcome to follow. Further review of the FRI investigation revealed witness statements as follows: A written statement dated 4/25/18 by CNA #5 documented, I came around the corner and name of resident [Resident #29] and name of resident [Resident #123] were fighting. So I hollered for name of [CNA #6] and tried to break it up. Then name of [Resident #29] fell on the floor while they were fighting and hit his head on the wall then name of [CNA #6] and name of [CNA #7] were able to make them stop fighting and picked name of [Resident #29] up off the floor. A written statement dated 4/25/18 by CNA #6 documented, I was coming down the hall when another CNA asked me for help with names of [Resident #123 and Resident #29]. When I got over there I helped get them apart. Neither one of them said anything. A written statement dated 4/25/18 by CNA #7 documented, Coming back on unit, dont {sic} no {sic} how is {sic} started. Name of [CNA #5] call for another CNA. Then I came around and name of [Resident #29] was punching name of [Resident #123]. Name of [Resident #123] was cursing and trying to pull is {sic} arm away from name of [Resident #29] and we separted {sic} the two. Got name of [Resident #29] off floor. Name of [Resident #123] just told name of [Resident #29] turn him the hell a loose. Further review of the FRI revealed that on 4/26/18 at approximately 11:04 a.m., the facility faxed the FRI to the Office of Licensure (OLC) as noted on the fax confirmation report. An interview was conducted on 3/5/19 at approximately 5:24 p.m., with the ASM #1 (Administrative Staff Member, the Administrator). When asked about the reporting date and time of the FRI, ASM #1 stated, I don't have an answer right now to be honest with you. Let me look to see when I was notified. When asked which facility staff report FRI to the OLC, ASM #1 stated, the supervisor, the DON (Director of Nursing), the ADON (Assistant Director of Nursing) and the Assistant Administrator. In a follow up interview on 3/7/19 at approximately 6:26 p.m., with AMS #1, she stated, I have no further information and it was my fault it was missed. A review of the facility policy, Abuse, Neglect and Exploitation Prevention and Reporting documented, The Administrator, Director of Nursing or facility appointed designee should report allegations or suspected abuse, neglect or exploitation immediately to: Administrator .OLC .Other state Agencies in accordance with State Law .In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: .Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source .are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse .to the administrator of the facility and to other official (including the State Survey Agency .in accordance with State Law. No further information was provided by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, facility document review, and in the course of an investigation of a Facility Reported Incident (FRI), it was determined that the facility staff failed to implement abuse policies and procedures for reporting allegations of potential abuse for two of 51 residents in the survey sample; Resident #29 and Resident #123. The facility staff failed to ensure timely reporting to the State Agency and other officials in accordance with State law through established procedures for a resident to resident altercation and potential abuse between Resident #29 and Resident #123 that occurred on 4/25/19 at approximately 6:30 p.m. The incident was not reported to the State Agency until 4/26/19 at 11:04 a.m., approximately 16 hours after the incident occurred. The findings include: Resident #29 was admitted to the facility on [DATE] with the diagnoses of but not limited to cerebral vascular disease, high blood pressure, diabetes type 2, anxiety, depression, psychosis with hallucinations. Resident #29's Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 12/14/18, and coded Resident #29 as severely cognitively impaired in ability to make daily life decisions. The resident required total care for hygiene, bathing, dressing, ambulation, transfers; limited assistance for eating; and was incontinent of bowel and bladder. Resident #123 was admitted to the facility on [DATE] with the diagnoses of but not limited to dementia, depression, and asthma. The most recent MDS (Minimum Data Set) was an annual assessment with an ARD (Assessment Reference Date) of 1/16/19. The resident was coded as being moderately impaired in ability to make daily life decisions. The resident was coded as requiring total care for dressing, toileting, hygiene and bathing; and limited assistance for transfers and eating. A review of a FRI (Facility Reported Incident) investigation dated 4/25/18 involving Resident #29 and Resident #123 documented the following: At approximately 6:30 p.m., name of [Resident #29] and name of [Resident #123] were seen by name of [CNA #5] swinging at each other. The residents were located in the commons are of unit 400. Name of [Resident #29] lost his balance and fell hitting the back of his head on the wall. The residents were immediately separated. A head to toe assess was done by name of LPN #7 (Licensed Practical Nurse). Name of [Resident #123] was found to have two small scratches on the back of his neck. Name of [Resident #29] does not have any visible injury at this time. Both residents deny pain or discomfort. RP and MD [responsible party and medical doctor] are aware. Both residents were place on Q [every] 15 minute checks for 48 hours to monitor behaviors. There have been no further incidents at this time. An investigation is in progress and final outcome to follow. Further review of the FRI investigation revealed witness statements as follows: A written statement dated 4/25/18 by CNA #5 documented, I came around the corner and name of resident [Resident #29] and name of resident [Resident #123] were fighting. So I hollered for name of [CNA #6] and tried to break it up. Then name of [Resident #29] fell on the floor while they were fighting and hit his head on the wall then name of [CNA #6] and name of [CNA #7] were able to make them stop fighting and picked name of [Resident #29] up off the floor. A written statement dated 4/25/18 by CNA #6 documented, I was coming down the hall when another CNA asked me for help with names of [Resident #123 and Resident #29]. When I got over there I helped get them apart. Neither one of them said anything. A written statement dated 4/25/18 by CNA #7 documented, Coming back on unit, dont {sic} no {sic} how is {sic} started. Name of [CNA #5] call for another CNA. Then I came around and name of [Resident #29] was punching name of [Resident #123]. Name of [Resident #123] was cursing and trying to pull is {sic} arm away from name of [Resident #29] and we separted {sic} the two. Got name of [Resident #29] off floor. Name of [Resident #123] just told name of [Resident #29] turn him the hell a loose. Further review of the FRI revealed that on 4/26/18 at approximately 11:04 a.m., the facility faxed the FRI to the Office of Licensure (OLC) as noted on the fax confirmation report. An interview was conducted on 3/5/19 at approximately 5:24 p.m., with the ASM #1 (Administrative Staff Member, the Administrator). When asked about the reporting date and time of the FRI, ASM #1 stated, I don't have an answer right now to be honest with you. Let me look to see when I was notified. When asked which facility staff report FRI to the OLC, ASM #1 stated, the supervisor, the DON (Director of Nursing), the ADON (Assistant Director of Nursing) and the Assistant Administrator. In a follow up interview on 3/7/19 at approximately 6:26 p.m., with AMS #1, she stated, I have no further information and it was my fault it was missed. A review of the facility policy, Abuse, Neglect and Exploitation Prevention and Reporting documented, The Administrator, Director of Nursing or facility appointed designee should report allegations or suspected abuse, neglect or exploitation immediately to: Administrator .OLC .Other state Agencies in accordance with State Law .In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: .Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source .are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse .to the administrator of the facility and to other official (including the State Survey Agency .in accordance with State Law. No further information was provided by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to provide Resident #92 or the resident's representative written notification of the bed hold policy when the resident was discharged to the hospital on [DATE]. Resident #92 was admitted to the facility on [DATE]. Resident #92's diagnoses included but were not limited to high blood pressure, high cholesterol and convulsions. Resident #92's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/18/19, coded the resident as being cognitively intact. Review of Resident #92's clinical record revealed the resident presented with a fever and nausea, and was transferred to the hospital on [DATE]. A nurse's note signed by RN (registered nurse) #1 on 10/4/18 documented Resident #92 was admitted to the hospital for kidney stones and the resident's representative did not wish to have a bed hold. Further review of Resident #92's clinical record failed to reveal the resident and/or representative was provided written information regarding the facility bed hold policy. On 3/5/19 at 11:38 a.m., an interview was conducted with Resident #92. The resident voiced concern that she was not permitted to return to the same room when she was readmitted to the facility from the hospital on [DATE]. When asked if she was provided the facility bed hold policy when she was sent to the hospital, Resident #92 stated she was not. On 3/6/19 at 3:41 p.m., an interview was conducted with RN #1. RN #1 stated he provided verbal notice of the facility bed hold policy to Resident #92's representative when the resident was sent to the hospital. RN #1 stated he did not provide written notice of the bed hold policy to the representative. RN #1 stated the current facility process is to send the bed hold policy with the resident to the hospital but he could not provide evidence the bed hold policy was provided to Resident #92 (or the representative) when she was sent to the hospital on [DATE]. On 3/6/19 at 4:50 p.m., ASM (administrative staff member) #1 (the administrator), ASM #3 (the regional nurse consultant) and ASM #4 (the regional vice president of operations) was made aware of the above concern. No further information was presented prior to exit. Based on resident interview, staff interview, facility document review, and clinical record review, it was determined that facility staff failed to provide a bed hold policy to the resident or the resident's representative upon a transfer to the hospital for two of 51 residents in the survey sample, Residents # 45 and # 92. 1. The facility staff failed to provide Resident # 45 or the resident's representative written notification of the bed hold policy when the resident was transferred to the hospital on [DATE]. 2. The facility staff failed to provide Resident #92 or the resident's representative written notification of the bed hold policy when the resident was discharged to the hospital on [DATE]. The findings include: 1. The facility staff failed to provide Resident # 45 or the resident's representative written notification of the bed hold policy when the resident was transferred to the hospital on [DATE]. Resident # 45 was admitted to the facility on [DATE] and a re-admission on [DATE] with diagnoses that included but were not limited to: retention of urine, urinary tract infection (1), benign prostatic hyperplasia (2), diabetes mellitus (3) and hypertension (4). Resident # 45's most recent MDS (minimum data set), a 30-day assessment with an ARD (assessment reference date) of 12/19/18, coded Resident # 45 as scoring a 9 (nine) on the brief interview for mental status (BIMS) of a score of 0 - 15, 9 (nine) - being moderately impaired of cognition for making daily decisions. The nurse's Progress Notes, dated 11/25/2018 for Resident # 45 at 11:53 p.m. documented the resident was transferred to the hospital emergency room for evaluation. The note further documented, Attempts made to contact RP (responsible party) on all 3 numbers. (Name of Transport) squad in, stated both (Name of two Hospitals) were on diversion. Call placed by EMT (emergency medical technician) to (Name of Hospital) ER (emergency room) nurse, who stated they had no available beds but would accept resident with possible transfer to another hospital. Squad left with res en route to (Name of Hospital) at 2345 (11:45 p.m.). Review of the EHR (electronic health record) and the clinical record for Resident # 45 failed to evidence that Resident # 45 or the resident's representative was provided a written notification of the bed hold policy when the resident was transferred to the hospital on [DATE]. On 03/06/19 at 2:55 p.m., an interview was conducted with OSM (other staff member) # 3, admissions director regarding the facility's bed hold policy for residents who are transferred to the hospital. OSM # 3 stated, If they verbally said they want to hold the bed I will hold the bed. It's part of the discharge and transfer form. After review of Resident # 45's transfer form dated 11/25/18, OSM #3 stated that Resident # 45's transfer was before they developed the new forms and that there was no evidence that the bed hold policy was provided to Resident # 45 or Resident # 45's responsible party at the time of his transfer. The facility's policy Bed Hold Prior to Transfer documented, Prior to transferring a resident to the hospital, the facility will provide written information to the resident and/or the resident representative regarding bed hold. On 03/06/19 at approximately 3:30 p.m. ASM (administrative staff member) # 1, the administrator and ASM # 3, regional nurse consultant, were made aware of the findings. No further information was provided prior to exit. References: (1) An infection in the urinary tract. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/000521.htm. (2) An enlarged prostate. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/enlargedprostatebph.html. (3) A chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/001214.htm. (4) High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and clinical record review, it was determined that the facility staff failed to review and revise the comprehensive care plan for 1 of 51 residents in the survey sample, Resident 145. The facility staff failed to revise Resident #145's care plan to address and include the 2/11/19 physician ordered nebulizer treatments as needed for shortness of breath. The findings include: Resident #145 was admitted to the facility on [DATE]. Diagnoses for Resident #145 included but were not limited to High Blood Pressure, Depression, and Anxiety Disorder. Resident #145's Annual Minimum Data Set (annual assessment) with an Assessment Reference Date of 02/12/2019 coded Resident #145 with moderate cognitive impairment. In addition, the Minimum Data Set coded Resident #145 as requiring extensive assistance of one staff member with activities of daily living and limited assistance of one staff person for eating. On 03/06/2019, Resident #145's clinical record was reviewed. A physician order dated 02/11/2019 documented, Ipratropium Bromide/Albuterol Sulfate 0.5-3 (2.5) mg (milligrams)/3 ml (milliliters) (1) give nebulizer treatment every four hours as needed for shortness of breath. Resident #145's February 2019 medication administration record documented administration of Ipratropium Bromide/Albuterol Sulfate 0.5-3 (2.5) mg (milligrams)/3 ml (milliliters) give nebulizer treatment every four hours as needed for shortness of breath dated 02/11/2019. Resident #145's comprehensive care plan dated 02/12/2019 was reviewed and failed to evidence a revision to include the new physician treatment and intervention. On 03/05/2019 at approximately 8:40 a.m., Resident #145's nebulizer machine was observed on top of the dresser with an unbagged mask. On 03/05/2019 at approximately 1:59 p.m., Resident #145's nebulizer machine was observed on top of the dresser with an unbagged mask. An interview was conducted on 03/06/2019 at approximately 4:15 p.m. with RN (Registered Nurse) #2 (MDS Coordinator). RN #2 was asked if the physician ordered nebulizer treatment should be care planned. RN #2 stated that it should be care planned. RN #2 stated that Resident #145's care plan was recently updated and she did not carry the nebulizer treatment over because Resident #145 only used the nebulizer machine one time and it was an as needed order. A copy of the facility policy regarding care planning was requested from ASM (Administrative Staff Member) #1 (Administrator) on 03/06/2019 at approximately 4:50 p.m. The facility policy titled, Care Plans, Comprehensive Person-Centered, documented Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly, in conjunction with the required quarterly Minimal Data Set (MDS) assessment. On 03/06/2019 at approximately 6:00 p.m., ASM (Administrative Staff Member) #1 (Administrator), ASM #3 (Regional Nurse Consultant), and ASM #4 (Regional [NAME] President of Operations) were made aware of findings. No further information was presented prior to exit. References: (1) A medication used to prevent wheezing, difficulty breathing, chest tightness, and coughing in people with diseases that affect the lung and airways. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a601063.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility failed to clarify Resident #25's physician order for oxygen regarding the flow rate parameters for titration of the oxygen. Resident #25 was admitted to the facility on [DATE] with the diagnoses of but not limited to Chronic Obstructive Pulmonary Disease, acute respiratory failure with hypoxia, diabetes type 2, transient cerebral ischemic attack, high blood pressure, and depression. Resident #25's Minimum Data Set (MDS) was an annual assessment with an Assessment Reference Date (ARD) of 12/9/18, and coded Resident #25 as moderately cognitively impaired in ability to make daily life decisions. The resident was coded as requiring extensive care for toilet use, eating, and transfers; total care for hygiene, bathing, and dressing; and as continent of bowel and bladder. A review of the clinical record revealed a physician's order dated 2/28/18 that documented, O2 (oxygen) at 2L/MIN (2 liters per minute) via NC (nasal cannula) PRN (as needed) for SOB (shortness of breath), may titrate to maintain sats > 92 (oxygen saturations greater than 92 %). Further clinical record review revealed a standing physician's orders dated 7/19/18 that documented, SOB: O2 at 2L/M via NC prn for SOB. May titrate to maintain O2 sat > 92%. Check O2 sat Qshift (every shift). An interview was conducted on 3/6/19 at 11:29 a.m., with LPN #1 regarding Resident #25's physician order for O2. When asked how she would read the order, LPN #1 stated back the order as written and you may titrate it up to make O2 sat > 92. When asked how the nurse would follow the order, LPN #1 stated, We have a standing order for oxygen. She then presented the standing orders. When asked how high or how low the nurse can go with the oxygen rate, LPN #1 stated, Normally you would not go over 4 liters (per minute). If (the resident is) on 2 (liters per minute) you can go up to 3 (liters per minute) and see where sat (oxygen saturation) is. According to this, you would not know. I'd have to call the doctor. The doctor would have to say how high you can go up. LPN #1 stated, That order would need clarification. An interview was conducted on 3/5/19 at 11:36 a.m., with RN (registered nurse) #3 regarding Resident #25's physician order for oxygen. When asked how she would read the order, RN #3 stated, It does not say how many liters to go up to. The titrate part, I would have to get clarification on, cause we would need to know how high to go and at what increments. (The order) Does not say how or when to bring it down. RN #3 stated, I would have to get this order clarified by the doctor. A review of the facility policy, Oxygen Administration documented the following: Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. A review of the facility policy, Administering Medications documented the following: 5. If a dosage is believed to be inappropriate .for the resident .the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concern. On 3/7/19 at 6:26 p.m., AMS #1 (Administrative Staff Member - the Administrator) was made aware of the findings. No further information was provided by the end of the survey. Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to follow professional standards of practice for two of 51 residents in the survey sample, Residents #145 and #25. 1. The facility staff failed to clarify Resident #145's physician order for oxygen regarding the flow rate parameters for titration of the oxygen. 2. The facility failed to clarify Resident #25's physician order for oxygen regarding the flow rate parameters for titration of the oxygen. The findings include: 1. The facility staff failed to clarify Resident #145's physician order for oxygen regarding the flow rate parameters for titration of the oxygen. Resident #145 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: shortness of breath, diabetes, dementia, and interstitial lung disease [Interstitial lung disease is the name for a large group of diseases that inflame or scar the lungs. The inflammation and scarring make it hard to get enough oxygen (1)]. There was no MDS (minimum data set) assessment completed as the resident was admitted on the first day of survey. The Nursing admission Assessment dated 3/6/19, documented the resident as being alert and confused. The resident was documented as being dependent upon the staff for his activities of daily living. There was no documentation of oxygen use on this form. The nurse's note dated 3/4/19 at 11:08 p.m. documented in part, O2 (oxygen) sat (saturation - the percentage of oxygen in the blood stream) 96% on 2 L/M (liters per minute) via NC (nasal cannula - a tube with two prongs that inserts into the nose). The physician order dated 3/5/19, documented, O2 continuous @ (at) 2 L/M via nasal cannula. May Titrate to Maintain O2 sat 92%. The MAR (medication administration record) for March 2019 documented, O2 continuous @ 2 L/M via nasal cannula. May titrate to maintain O2 sat 92%. The Baseline Care Plan dated 3/5/19 at 2:00 p.m. documented in part, Special Treatments/Procedures: Oxygen was checked. Route: N/C (nasal cannula) LPM (liters per minute): 2. Frequency: continuous. An interview was conducted with LPN (licensed practical nurse) #1 on 3/6/19 at 11:29 a.m. The order above for oxygen was shown to LPN #1. When asked how she would follow that order, LPN #1 stated, Normally we can go up to 4 liters. If the resident is on 2 liters then we can go up to 3 liters and then check to see where the sat is. When asked how and when does the nurse go up in oxygen and down in the setting of the liter flow rate, LPN #1 stated, According to this, you wound not know. I'd have to call the doctor. The doctor would have to say how high you can go up. LPN #1 stated, That order would need clarification. An interview was conducted with RN (registered nurse) #3, the unit manager; on 3/6/19 at 11:36 a.m., RN #3 was asked to review the order above for oxygen. When asked how to read the order, RN #3 stated, It does not say how many liters to go up to. When asked about the meaning of the order for 'titrate,' RN #3 stated, I would have to get clarification because we would need to know how high to go and at what increments. When asked if the order documents how, and when, to bring the oxygen flow rate down, RN #3 stated, I would have to get this order clarified by the doctor. The facility policy, Medication and Treatment Orders documented in part, Orders for medications must include: a. Name and strength of the drug. b. Quantity or specific duration of therapy. c. Dosage and frequency of administration. d. route of administration. e. Reason or problem for which given. According to [NAME]'s Fundamentals of Nursing, 5th edition, page 553 documents the following statement, Always clarify with the prescriber any medication order that is unclear or seems in appropriate. Administrative staff member (ASM) #1, the administrator, ASM #3, the regional nurse consultant, and ASM #4, the regional vice president of operations, were made aware of the above findings on 3/6/19 at approximately 6:00 p.m. On 3/6/19 at 8:15 p.m. ASM #2, the director of nursing, was asked which professional standard of practice the facility follows, ASM #2 stated they follow their policies and [NAME]. No further information was obtained prior to exit. (1) This information was obtained from the following website: https://medlineplus.gov/interstitiallungdiseases.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to implement the physician ordered Prevalon boots to off load pressure on Resident #98's feet. On 3/5/19, Resident #98 was observed in bed without the physician ordered Prevalon boots in place. Resident #98 was admitted to the facility on [DATE]. Diagnoses for Resident #98 included but were not limited to Heart Failure, High Blood Pressure, and Depression. Resident #98's Minimum Data Set (significant change in status) with an Assessment Reference Date of 01/18/2019 coded Resident #98 with severe cognitive impairment. In addition, the Minimum Data Set coded Resident #98 as requiring total assistance of one staff member with activities of daily living and total dependence for eating (tube feeding). On 03/05/2019 at approximately at 8:40 a.m., Resident #98 was observed lying in bed, on her right side, under a light green colored blanket with feet exposed. Resident #98 had on gray socks and both feet were propped up on a pillow. On 03/05/2019 at approximately 1:59 p.m., Resident #98 was observed lying in bed, on her back, under a light green colored blanket with feet exposed. Resident #98 had on gray socks and both feet were observed propped up on a pillow. On 03/05/2019, Resident #98's clinical record was reviewed. Resident #98's care plan documented, Prevalon boots to bilateral lower extremities at all times dated 01/18/2019. Resident #98's physician order documented, Prevalon boots to bilateral lower extremities at all time dated 01/18/2019. Resident #98's Braden Risk Assessment Report (1) documented resident Risk score 11 and risk level high dated 01/18/2019. Resident #98 did not have prevalon boots on when observed at approximately 8:40 a.m. and at 1:59 p.m. On 03/05/2019 at approximately 3:51 p.m., Resident 98 was observed lying in bed, on her back, under a light green colored blanket with feet covered. LPN #4 (Licensed Practical Nurse) was asked to remove Resident #98's blanket to reveal both feet. Resident #98's feet were observed propped up on a pillow and the resident was not wearing prevalon boots. LPN #4 asked Resident #98, Where are your prevalon boots? Resident # 98 did not respond. LPN #4 then located the resident's prevalon boots behind the television and placed the boots on Resident #98's feet. An interview was conducted on 03/06/2019 at approximately 10:23 a.m. with RN (Registered Nurse) #1 (Unit Manager). RN #1 was asked what the purpose of physician orders. RN #1 stated that the purpose of physician orders was to ensure resident gets the care needed. RN #1 was asked how staff ensure physician orders are being followed. RN #1 stated that he reviews the orders and make rounds to ensure things are in in place or are being done. RN #1 was made aware of Resident #98 not wearing prevalon boots as ordered. RN #1 was asked the purpose of prevalon boots. RN #1 stated to prevent pressure. RN #1 stated that he made sure the resident was wearing her prevalon boots after looking at her orders. On 03/06/2019 at approximately 12:30 p.m., ASM (Administrative Staff Member) #1 (Administrator), ASM #3 (Regional Nurse Consultant), and ASM #4 (Regional [NAME] President of Operations) were made aware of findings. No further information was presented prior to exit. References: (1) A risk assessment scale used in identifying the risk of developing pressure sores. This information was obtained from the website: https://www.ncbi.nlm.nih.gov/pubmed/25608538 Based on observation, staff interview, facility document review and clinical record review it was determined the facility staff failed to provide the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for two of 51 residents in the survey sample, Residents #53 and #98. 1. The facility staff failed to assess, measure, monitor and track Resident #53's sacral pressure sore. 2. The facility staff failed to implement the physician ordered Prevalon boots to off load pressure on Resident #98's feet. On 3/5/19, Resident #98 was observed in bed without the physician ordered Prevalon boots in place. The findings include: 1. The facility staff failed to assess, measure, monitor and track Resident #53's sacral pressure sore. Resident #53 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: hypothyroid disease [decreased activity of the thyroid gland) (1)], rhabdomyolysis [is the breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood. These substances are harmful to the kidney and often cause kidney damage (2)], degenerative disc disease [disc disease is a common condition characterized by the breakdown [degeneration] of one or more of the discs that separate the bones of the spine (3)], and COPD [general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis (4)]. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/21/18, coded the resident as scoring a 8 on the BIMS (brief interview for mental status) score, indicating she was moderately impaired to make cognitive daily decisions. The resident was coded as being completely dependent upon one or more staff members for all of her activities of daily living. In Section M - Skin Conditions, the resident was coded as not having any pressure injuries. During the entrance conference on 3/4/19 at approximately 6:30 p.m., a request was made for a list of all residents who had pressure injuries. A Wound and Skin Status Report dated 3/4/19 at 11:56 a.m. was presented to this surveyor. Resident #53's name was documented on the form as having a pressure injury on her sacrum that was acquired on 2/20/19. She was not documented as having any other pressure injuries. The clinical record was reviewed. The nurse's note dated 2/6/19 at 4:27 p.m. documented in part, Resident observed to have a 0.5 L (length) X (by) 0.5 W (width) X 0.5 D (depth) open area to her right buttocks. New tx (treatment) order written. Review of the Wound Specialist's notes dated 2/8/19, documented in part, History of Present Illness: She has an unstageable (due to necrosis) of the right buttock of at least 1 days duration. There is moderate serosanguinous exudate .Unstageable (Due to necrosis) of the right buttock. Etiology: Pressure; Wound size: 1.6 x 1.3 x not measurable. Slough: 100%. The Wound Specialist's notes dated 2/22/19, documented in part, Unstageable (Due to Necrosis) of the right buttock. Etiology: pressure, Wound size: 1.6 x 1.3 x not measurable, Slough (including biofilm) 100%. The care plan did not document a date under Problem onset. The Problem/Need: Potential for skin breakdown due to incontinence. Under Approaches was documented in part, Assess skin for signs or symptoms of redness or break downs document and report to md (medical doctor) as needed. Air mattress to bed as ordered. Treatments as orders per physician. Dated 2/7/19, Tx (treatment) to right buttock. A request was made on 3/6/19 at approximately 3:00 p.m., to ASM (administrative staff member) #1, the administrator, and ASM #3, the regional nurse consultant, for any measurements and documentation of the wound on the resident's right buttock. No further documents were provided. An interview was conducted with LPN (licensed practical nurse) #10, the wound nurse, on 3/6/19 at approximately 4:30 p.m. When asked about the location in the clinical record for the assessment, measurements and tracking documentation,of the pressure injury on Resident #53's right buttocks, LPN #10 stated, It was an oversight. I didn't see that documented in (name of wound doctor's) notes. It's an oversight. A request was made to see the wound of Resident #53. An observation of Resident #53 was conducted with LPN #10 and RN (registered nurse) #3, the unit manager on 3/6/19 at 4:58 p.m. The right buttock was observed. The wound was noted to be healed. At this time LPN #10 stated, It was an oversight on my part (for not tracking and measuring the wound). It was my mistake. An interview was conducted on 3/6/19 at 5:50 p.m. with ASM #6, the wound care specialist. When asked to describe her involvement with Resident #53's wounds, ASM #6 stated that she only sees the resident every three to four weeks unless she has a new area. She is on hospice care. She stated that this resident has very fragile skin. She and the facility have tried as much as we can to prevent and heal her wounds. With everything they try, she still breaks down. She stated that the resident and responsible party has refused debridement of the wounds. They have tried nutritional interventions and she refuses them and she still breaks down. When asked when she was first aware of the right buttock wound, ASM #6 stated, According to my notes, it was 2/8/19. I saw her again on 2/22/19 because she had a new wound on her sacrum. I looked at the right buttock at the same time. The facility policy, Pressure Ulcers/Skin Breakdown - Clinical Protocol documented in part, 2. In addition, the nurse shall assess and document/report the following: b. Full assessment of pressure sore including location, stage , length , width and depth, presence of exudates or necrotic tissue. The policy presented by the facility, did not address the tracking, monitoring and measuring of the wounds, once found. Administrative staff member (ASM) #1, the administrator, ASM #3, the regional nurse consultant, and ASM #4, the regional vice president of operations, were made aware of the above findings on 3/6/19 at approximately 6:00 p.m. On 3/6/19 at 8:15 p.m. ASM #2, the director of nursing, was asked which professional standard of practice the facility follows, ASM #2 stated they follow their policies and [NAME]. No further information was provided prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 286. (2) This information was obtained from the following website: https://medlineplus.gov/ency/article/000473.htm (3) This information was obtained from the following website: https://ghr.nlm.nih.gov/condition/intervertebral-disc-disease. (4) 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, and clinical record review, it was determined that the facility staff failed to implement interventions to prevent accidents per the physician order for one of 51 residents in the survey sample, Resident #98 The facility staff failed to implement fall mat(s) on each side of Resident #98's bed for fall prevention per the comprehensive care plan and physician order on 03/05/2019. The findings include: Resident #98 was admitted to the facility on [DATE]. Diagnoses for Resident #98 included but were not limited to Heart Failure, High Blood Pressure, and Depression. Resident #98's Minimum Data Set (MDS) with an Assessment Reference Date of 01/18/2019 coded Resident #98 with severe cognitive impairment. In addition, the Minimum Data Set coded Resident #98 as requiring total assistance of one staff member with activities of daily living and total dependence for eating (tube feeding). On 03/05/2019 at approximately at 8:40 a.m., Resident #98 was observed lying in bed, on her right side, under a light green colored blanket with feet exposed. One fall mat was observed on the left side of Resident #98's bed on the floor. On 03/05/2019 at approximately 1:59 p.m., Resident #98 was observed lying in bed, on her back, under a light green colored blanket with feet exposed. One fall mat was observed on the left side of Resident #98's bed on the floor. On 03/05/2019, Resident #98's clinical record was reviewed. Resident #98's care plan dated 03/22/18 documented, Fall mat times two to bedside for safety. and Resident #98's physician order dated 12/17/2018 documented, Fall mat to each side of bed for safety. Resident #98's fall risk assessment dated [DATE] documented a total score of 12. The fall risk assessment dated [DATE] stated a score of 10 or higher indicates HIGH RISK for which a prevention protocol should be initiated immediately and documented on the care plan. An interview was conducted on 03/06/2019 at approximately 10:23 a.m. with RN (Registered Nurse) #1 (Unit Manager). RN #1 was asked about the purpose of fall mats. RN #1 stated that the purpose of fall mats are fall interventions put in place to help with falls. RN #1 was asked how staff ensure fall mats are in place. RN #1 stated that rounds are made to ensure that fall mats are in place. RN #1 was made aware of Resident #98 not having a fall mat on both sides of the bed. RN #1 stated that he corrected the issue after reviewing the orders and care plan. On 03/06/2019 at approximately 12:30 p.m., ASM (Administrative Staff Member) #1 (Administrator), ASM #3 (Regional Nurse Consultant), and ASM #4 (Regional [NAME] President of Operations) were made aware of findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review, it was determined that facility staff failed to provide care and services for a suprapubic catheter to prevent urinary tract infections for one of 51 residents in the survey sample, Residents # 45. The facility staff failed to ensure Resident # 45's catheter collection bag and tubing were not resting on the floor. The findings include: Resident # 45 was admitted to the facility on [DATE] and a re-admission on [DATE] with diagnoses that included but were not limited to: retention of urine, urinary tract infection (1), benign prostatic hyperplasia (2), diabetes mellitus (3) and hypertension (4). Resident # 45's most recent MDS (minimum data set), a 30-day assessment with an ARD (assessment reference date) of 12/19/18, coded Resident # 45 as scoring a 9 (nine) on the brief interview for mental status (BIMS) of a score of 0 - 15, 9 (nine) - being moderately impaired of cognition for making daily decisions. Resident # 45 was coded as being totally dependent of one staff member for activities of daily living. Section H Bladder and Bowel Resident # 45 was coded as A. Indwelling catheter (including suprapubic catheter [5] and nephrostomy tube). On 03/05/19 at 10:27 a.m., an observation of Resident # 45 revealed the resident lying in bed. Observation of the catheter collection bag revealed it was hanging off the right side of the bed. Further observation of the catheter collection bag and tubing revealed the collection bag and a section of the tubing was resting directly on the floor. On 03/05/19 at 10:49 a.m., an interview was conducted with Resident # 45. Before this surveyor entered Resident # 45's room, a nurse stated she had just administered Resident # 45's medication. After entering the room Resident # 45 was observed sitting up in bed. Observation of the catheter collection bag revealed it was hanging off the right side of the bed. Further observation of the catheter collection bag and tubing revealed the collection bag and a section of the tubing was resting directly on the floor. On 03/06/19 at 8:59 a.m., an observation of Resident # 45 revealed the resident lying in bed. Observation of the catheter collection bag revealed it was hanging off the right side of the bed. Further observation of the catheter collection bag and tubing revealed the collection bag and a section of the tubing was resting directly on the floor. The POS (physician's order sheet) for Resident # 45 dated March 2019 documented, Foley catheter care and check catheter anchor placement Q (every) shift. Order Date: 02/15/19. The comprehensive care plan for Resident # 45 dated 06/08/2015 documented, Problem/Need: Colostomy and indwelling urinary catheter. Under Approaches it documented, Change Foley catheter / Foley bag as ordered. On 03/06/19 at 9:05 a.m., an observation and interview of Resident # 45's catheter collection bag and tubing was conducted with RN (registered nurse) # 3. RN # 3 accompanied this surveyor into Resident # 45's room to observe the placement of Resident # 45's catheter collection bag and catheter tubing. Upon observing the 45's catheter collection bag and catheter tubing RN # 3 raised Resident # 45's bed until the catheter collection bag and catheter tubing was off the floor. RN # 3 stated, It should not be touching the floor. When asked why the catheter collection bag and catheter tubing should be off the floor, RN # 3 stated, To prevent infection. When asked how the facility ensures the catheter collection bag and catheter tubing are kept off the floor, RN # 3 stated, You do education for the placement of the bag and tubing so it doesn't touch the floor. When asked how often the catheter collection bag and catheter tubing is checked for placement, RN # 3 stated, It should checked whenever CNAs (certified nursing assistants) and nurses are checking on patient. The facility's policy Catheter Care, Urinary documented, Infection Control. 2. Maintain clean technique when handling or manipulating the catheter, tubing or drainage bag. b. Be sure the catheter tubing and drainage bag are kept off the floor. On 03/26/19 at approximately 3:30 p.m. ASM (administrative staff member) # 1, the administrator and ASM # 3, regional nurse consultant, were made aware of the findings. No further information was provided prior to exit. References: (1) An infection in the urinary tract. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/000521.htm. (2) An enlarged prostate. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/enlargedprostatebph.html. (3) A chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/001214.htm. (4) High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review, it was determined the facility staff failed to provide appropriate treatment and services to prevent complications of enteral feeding for one of 51 residents in the survey sample, Residents # 151. The facility staff failed to label Resident # 151's G-tube (1) feeding with Resident # 151's name, rate of feeding, Resident # 151's identification number, and the date and time, the feeding was started. The findings include: The facility staff failed to label Resident # 151's G-tube (1) feeding with the Resident # 151's name, rate of feeding, Resident # 151's identification number, and the date and time, the feeding was started. Resident # 151 was admitted to the facility on [DATE], with a re-admission on [DATE], with diagnoses that included but were not limited to: dysphagia (2), cerebral palsy (3), anemia (4) and gastrostomy (5). Resident # 151's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/22/19, coded Resident # 151 as scoring a 3 (three) on the brief interview for mental status (BIMS) of a score of 0 - 15, 3 (three) - being severely impaired of cognition for making daily decisions. Resident # 151 was coded as being totally dependent of one staff member for activities of daily living. Section K Swallowing/Nutritional Status coded Resident # 151 as having a Feeding tube. While a resident. On 03/05/19 at 10:07 a.m., an observation of Resident # 151 revealed she was in bed, the head of the bed was elevated and the resident was observed receiving a tube feeding. Observation of Resident # 151's room revealed a 1000-milliliter bag of Fibersource (6) hanging on a pole next to the bed, being infused through a G-tube, to Resident # 151 at 45 milliliters per hour. Observation of the Fibersource bag failed to evidence Resident # 151's name, rate of feeding, Resident # 151's identification number, and the date and time the feeding was started. On 03/05/19 at 11:00 a.m., an observation of Resident # 151 revealed she was in bed, the head of the bed was elevated and the resident was observed receiving a tube feeding. Observation of Resident # 151's room revealed a 1000-milliliter bag of Fibersource hanging on a pole next to the bed, being infused through a G-tube, to Resident # 151 at 45 milliliters per hour. Observation of the Fibersource bag failed to evidence Resident # 151's name, rate of feeding, Resident # 151's identification number, and the date and time the feeding was started. On 03/05/19 at 12:50 p.m., an observation of Resident # 151's tube feeding revealed the bag of Fibersource was taken down. The POS (physician's order sheet) dated March 2019 documented, Fibersource 1.2 CAL (calories) Liquid, 45 cc (cubic centimeters)/ hr (hour) via peg X (times) 20 hours. On at 1600 (4:00 p.m.) and off 1200 (12:00 p.m.). Start Date 1/15/18. On 03/05/19 at 12:55 p.m., an interview was conducted with LPN (licensed practical nurse) # 6. When asked about Resident # 151's bag of Fibersource, LPN # 6 stated she had taken it down and placed it in the trash container on the medication cart. LPN # 6 was asked to remove the feeding bag from the trash container so it could be examined. LPN # 6 put on a pair of plastic gloves and removed it from the trash container. An observation of the bag of Fibersource feeding was conducted with LPN # 6. The observation revealed that the label on the bag of Fibersource was filled in with Resident # 151's name, rate of feeding, Resident # 151's identification number, and the date and time the feeding was started. When asked who filled in the label on the bag of Fibersource feeding, LPN # 6 stated, After I did the flush at about 11:30 I put the information on the bag. When asked to describe the procedure of documenting on a resident's bag of tube feeding, LPN # 6 stated, It should have the resident's name, room number, bed, date and order for the infusion. When asked about the time for Resident # 151's tube feeding, LPN # 6 stated, It's started at 4 p.m. (4:00 p.m.) and it is cut off (stopped) at 12 (12:00 p.m., noon) each day. When asked when the label on Resident # 151's bag of tube feeding should have been filled in, LPN # 6 stated, Yesterday at 4 p.m. LPN # 6 further stated that LPN # 7 would have started the new bag of tube feeding for Resident # 151 on 03/04/19 at 4:00 p.m. On 03/05/19 at 3:37 p.m., an interview was conducted with LPN # 7. When asked to describe the process for starting a resident's tube feeding, LPN # 7 stated, Check the orders to make sure it is the right feeding for the resident. Spike it and prime it through the pump to push the air out of the tubing and make sure it is filled with feeding, check placement with stethoscope, flush with water, complete the label provided with patient's name, date time and rate of feeding, attach tubing to g-tube, clear volume and check settings and start the feeding. When asked how often the process she described is completed LPN # 7 stated, The process is done each time a new bag is hung. When asked why the label needs to be filled out, LPN # 7 stated, To make sure the resident is getting the proper feeding at the proper time at the proper rate and it is the right patient. When asked about Resident # 151's feeding, LPN # 7 stated, I hung her bag last night (03/04/19) When asked if she remembered putting the label on the bag and completing it, LPN # 7 stated, I would hope I did. When informed of the observations of Resident # 151's label on the tube-feeding bag being blank, LPN # 7 did not have a comment. The facility's policy Enteral Feedings - Safety Precautions documented, Preventing errors in administration. 2. On the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order. On 03/05/19 at approximately 5:15 p.m. ASM (administrative staff member) # 1, the administrator and ASM # 3, regional nurse consultant, were made aware of the findings. No further information was provided prior to exit. References: (1) A gastrostomy feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall. It goes directly into the stomach. This information was obtained from the website: https://medlineplus.gov/ency/article/002937.htm. (2) A swallowing disorder. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/swallowingdisorders.html. (3) A group of disorders that affect a person's ability to move and to maintain balance and posture. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/cerebralpalsy.html. (4) Low iron. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/anemia.html. (5) A gastrostomy feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall. It goes directly into the stomach. This information was obtained from the website: https://medlineplus.gov/ency/article/002937.htm. (6) Nutritionally complete, fiber-containing tube feeding formula for normal or elevated calorie and/or protein requirements. This information was obtained from the website: https://www.nestlehealthscience.us/brands/fibersource/fibersource-hn-hcp+

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. The facility staff failed to store Resident # 90's nebulizer mask in a sanitary manner. During multiple observations the resident's nebulizer mask sitting on top of the nebulizer machine uncovered. Resident # 90 was admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses that included but were not limited to: chronic obstructive pulmonary disease (1), bronchiectasis (2), and hypertension (3). Resident # 90's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/18/19, coded Resident # 90 as scoring a 8 on the brief interview for mental status (BIMS) of a score of 0 - 15, 8 - being moderately impaired of cognition for making daily decisions. Resident # 90 was coded as requiring limited to extensive assistance with activity of daily living of one staff member and was coded as being totally dependent of one staff member for toileting. On 3/04/19 at 6:57 p.m., an observation of Resident # 90's room revealed Resident # 90 was sitting next to her bed. The nebulizer machine was observed on the bed with the nebulizer mask laying on the top of the nebulizer machine uncovered. On 3/05/19 at 9:50 a.m., an observation of Resident# 90's room revealed Resident # 90 was sitting in a chair next to her bed. Observation of the nebulizer machine revealed it was on the bed and the nebulizer mask was sitting on top of the nebulizer machine uncovered. On 3/05/19 at 10:33 a.m., an observation of the Resident # 90's room revealed the Resident # 90 was sitting on a chair next to the door with the nebulizer machine on her bed. Observation of the nebulizer machine revealed the nebulizer mask was on top off the nebulizer machine uncovered. On 3/6/19 at approximately 10:15 a.m., an interview conducted with LPN (license practical nurse) # 1. When asked a nebulizer mask should be stored when not in use, LPN # 1 stated, It should be kept in a plastic bag with the resident's name and the date when the mask and the tubing were changed, this is done once a week usually on Sundays. When asked why it is important to cover the nebulizer mask after the resident has used it, LPN # 1 stated, To keep the nebulizer mask clean and free from germs. On 3/6/19 at approximately 3:30 p.m., ASM (administrative staff member) # 1, administrator and ASM # 3, regional corporate nurse consultant, RN (registered nurse) were made aware of the findings. When asked what standard the facility follows regarding their nursing care ASM # 1 stated, We follow the facility's policies. No further information was provided prior to exit. References: 1. Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. 2. A chronic condition where the walls of the bronchi are thickened from inflammation and infection. People with bronchiectasis have periodic flare-ups of breathing difficulties, called exacerbations. This information was obtained from the website: https://www.lung.org/lung-health-and-diseases/lung-disease-lookup/bronchiectasis/ 3. High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html 3. The facility staff failed to ensure proper storage Resident #145's nebulizer mask after use. On 3/5/19 during separate observations, Resident #145's nebulizer mask was observed on top of the residents dresser not stored in a bag. Resident #145 was admitted to the facility on [DATE]. Diagnoses for Resident #145 included but were not limited to High Blood Pressure, Depression, and Anxiety Disorder. Resident #145's Minimum Data Set (annual assessment) with an Assessment Reference Date of 02/12/2019 coded Resident #145 with moderate cognitive impairment. In addition, the Minimum Data Set coded Resident #145 as requiring extensive assistance of one staff member with activities of daily living and limited assistance of one staff person for eating. On 03/05/2019 at approximately 8:40 a.m., Resident #145's nebulizer machine was observed on top of the dresser, with the mask not stored in a bag. On 03/05/2019 at approximately 1:59 p.m., Resident #145's nebulizer machine was observed on top of the dresser, with the mask not stored in a bag. On 03/06/2019, Resident #145's clinical record was reviewed. A physician order dated 02/11/2019 documented, Ipratropium Bromide/Albuterol Sulfate 0.5-3 (2.5) mg (milligrams)/3 ml (milliliters) (1) give nebulizer treatment every four hours as needed for shortness of breath. Resident #145's comprehensive care plan date 02/12/2019 failed to document information regarding a nebulizer mask. An interview was conducted on 03/06/2019 at approximately 10:23 a.m. with RN #1 (Registered Nurse) (Unit Manager). RN #1 was asked what the protocol was for oxygen and nebulizer equipment storage. RN #1 stated that the nasal cannula or mask should be bagged and put away when not in use. RN #1 was made aware of observations above of the nebulizer mask on top of the resident's dresser, not stored in a bag. A copy of the facility policy regarding oxygen and nebulizer storage was requested from ASM (Administrative Staff Member) #1 (Administrator) on 03/06/2019 at approximately 4:50 p.m. The facility policy titled, Oxygen Administration, documented, Oxygen tubing, cannula/mask should be stored in a clean, clear plastic bag when not in use. On 03/06/2019 at approximately 6:00 p.m., ASM (Administrative Staff Member) #1 (Administrator), ASM #3 (Regional Nurse Consultant), and ASM #4 (Regional [NAME] President of Operations) were made aware of findings. No further information was presented prior to exit. References: (1) A medication used to prevent wheezing, difficulty breathing, chest tightness, and coughing in people with diseases that affect the lung and airways. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a601063.html 4. The facility staff failed to maintain a clean filter in Resident #117's oxygen concentrator. Observations of Resident #117's oxygen concentrator filter revealed the filter was covered in a light gray, dusty residue. Resident #117 was admitted to the facility on [DATE]. Resident #117's diagnoses included but were not limited to chronic kidney disease, heart failure and dehydration. Resident #117's most recent MDS (minimum data set), a 60 day Medicare assessment with an ARD (assessment reference date) of 2/11/19, coded the resident as being cognitively intact. Section O documented Resident #117 as receiving oxygen therapy. Review of Resident #117's clinical record revealed a physician's order dated 12/23/18, for continuous oxygen at two liters per minute. Further review of physician's orders failed to reveal any orders regarding the oxygen concentrator filter. Resident #117's comprehensive care plan dated 12/24/18, failed to reveal documentation regarding the oxygen concentrator filter. On 3/5/19 at 8:30 a.m., 3/5/19 at 2:00 p.m., and 3/6/19 at 8:30 a.m., observations of Resident #117's oxygen concentrator filter were conducted. The filter was covered in a light gray, dusty residue. On 3/6/19 at 10:28 a.m., an interview was conducted with LPN (licensed practical nurse) #4 (the nurse caring for Resident #117) and RN (registered nurse) #1 (the unit manager). LPN #4 and RN #1 were asked the facility process for cleaning oxygen concentrator filters. LPN #4 stated, I know that when I see that they are starting to get lint on the filter I take them off, rinse them out, clean, dry and put back on. LPN #4 and RN #1 were made aware of the above concern. LPN #4 stated she had not noticed the dirty filter. LPN #4 stated Resident #117 often sits in a chair near the oxygen concentrator and she (LPN #4) can't get to the filter on the concentrator. RN #1 was asked to observe the filter. On 2/6/19 at 3:41 p.m., another interview was conducted with RN #1. RN #1 stated, I cleaned it (the filter). It was rough. RN #1 stated the oxygen concentrator vendor is supposed to clean the filter each month. On 3/6/19 at 4:50 p.m., ASM (administrative staff member) #1 (the administrator), ASM #3 (the regional nurse consultant) and ASM #4 (the regional vice president of operations) was made aware of the above concern. The facility policy titled, Oxygen Administration failed to document information regarding the facility process for cleaning the concentrator filter. No further information was presented prior to exit. Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to respiratory care and services for five of 51 residents in the survey sample, Residents #53, #119, #145, #117, and #90. 1. The facility staff failed to administer oxygen per the physician order for Resident #53. On 3/5/19, Resident #53 was observed on separate occasions without her physician ordered continuous oxygen in place. The clinical record did not document staff reapplied the residents oxygen or any resident noncompliance with wearing the oxygen and notification to the physician 2. The facility staff failed to store a nebulizer mask in a sanitary manner, Resident #119's nebulizer mask was observed sitting on a chair next to the resident's bed on top of a plastic bag uncovered during multiple observations. 3. The facility staff failed to ensure proper storage Resident #145's nebulizer mask after use. On 3/5/19 during separate observations, Resident #145's nebulizer mask was observed on top of the residents dresser not stored in a bag. 4. The facility staff failed to maintain a clean filter in Resident #117's oxygen concentrator. Observations of Resident #117's oxygen concentrator filter revealed the filter was covered in a light gray, dusty residue. 5. The facility staff failed to store Resident # 90's nebulizer mask in a sanitary manner. During multiple observations the resident's nebulizer mask sitting on top of the nebulizer machine uncovered. The findings include: 1. The facility staff failed to administer oxygen per the physician order for Resident #53. On 3/5/19, Resident #53 was observed on separate occasions without her physician ordered continuous oxygen in place. The clinical record did not document staff reapplied the residents oxygen or any resident noncompliance with wearing the oxygen and notification to the physician. Resident #53 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: hypothyroid disease (decreased activity of the thyroid gland) (1), rhabdomyolysis (is the breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood. These substances are harmful to the kidney and often cause kidney damage) (2), degenerative disc disease (disc disease is a common condition characterized by the breakdown (degeneration) of one or more of the discs that separate the bones of the spine) (3), and COPD (general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis) (4). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/21/18, coded the resident as scoring a 8 on the BIMS (brief interview for mental status) score, indicating she was moderately impaired to make cognitive daily decisions. The resident was coded as being completely dependent upon one or more staff members for all of her activities of daily living. In Section O - Special Treatments, Procedures and Programs the resident was coded as using oxygen while a resident in the facility. Resident #53 was observed on 3/5/19 at 9:05 a.m. The resident was in her bed, drinking some water. The oxygen tubing was not on the resident. The tubing was observed hanging over the end of the tubing closest to the concentrator. The tubing was not touching the ground. The oxygen concentrator was running. A second observation was made of Resident #53 on 3/5/19 at 12:33 p.m. The resident was in bed asleep. The oxygen concentrator was running and the tubing was still hanging off the tubing, not on the resident. The third observation of Resident #53 on 3/5/19 at 3:42 p.m. revealed the resident receiving her oxygen via a nasal cannula (a tubing with two prongs that insert into the nose). The physician order dated 6/22/18, documented, O2 (oxygen) at 2L/min (liters per minute) continuous. The comprehensive care plan reviewed on 12/21/18, documented in part, Problem: Per staff Resident is non-compliant with O2 at times, takes O2 off. The Approaches documented in part, Encourage O2 use as ordered. Educate resident about being non-compliant with O2 use. Document and report to MD (medical doctor) and RP (responsible party) as needed. Replace O2 when noticed off. Review of the nurse's notes for 3/5/19 failed to evidence documentation of noncompliance by the resident with wearing her oxygen, or notification to the physician. An interview was conducted with LPN (licensed practical nurse) #9 on 3/6/19 at 3:28 p.m. When asked if oxygen was ordered for Resident #53, LPN #9 stated, Yes, at 2 L/min. When asked if she cared for Resident #53 on 3/4/19, LPN #9 acknowledged that she had. When asked how often she checked on her oxygen, LPN #9 stated, I check it while I am on med (medication) pass or whenever I am in the room. LPN #9 further stated, She does take it off. She claims she can't eat or drink with it on. Yesterday was the most I've seen it on her. The observations above were shared with LPN #9. LPN #9 stated, The hospice aide must not have put it on her after care. She has to have her oxygen on. When she doesn't have it on, her sats (oxygen saturation levels in her blood) can drop to 89 - 90%. When she's sitting in her room she is normally 90-91%. An interview was conducted with RN (registered nurse) #3 on 3/6/19. When asked oxygen is ordered for Resident #53, RN #3 stated, Yes, and I believe it's at 2L/min. When asked if the oxygen should be on at all times, RN #3 stated, Yes, if that's the doctor's order. The facility policy, Oxygen Administration documented in part, 7. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated. According to Fundamentals of Nursing, Fifth Edition, [NAME] & [NAME], 2007, page 851, Because oxygen is a drug, its use requires a prescription. Policies and standing orders often permit the nurse to administer oxygen in emergency situations if the physician is not immediately available to write an order. Although oxygen is generally safe when used properly, certain precautions must be observed. As with all drugs, the potential exists for causing harm with misuse. On page 852, Procedure 36-5, 3. Identify client and proceed with 5 rights of medication administration .Rationale: Oxygen is a drug and administering using the 5 rights avoids potential errors 11. Document procedure and observations. Rationale: Maintains legal record and communicates with healthcare team members. Administrative staff member (ASM) #1, the administrator, ASM #3, the regional nurse consultant, and ASM #4, the regional vice president of operations, were made aware of the above findings on 3/6/19 at approximately 6:00 p.m. On 3/6/19 at 8:15 p.m. ASM #2, the director of nursing, was asked which professional standard of practice the facility follows, ASM #2 stated they follow their policies and [NAME]. No further information was obtained prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 286. (2) This information was obtained from the following website: https://medlineplus.gov/ency/article/000473.htm (3) This information was obtained from the following website: https://ghr.nlm.nih.gov/condition/intervertebral-disc-disease. (4) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124. 2. The facility staff failed to store a nebulizer mask in a sanitary manner, Resident #119's nebulizer mask was observed sitting on a chair next to the resident's bed on top of a plastic bag uncovered during multiple observations. Resident #119 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: depression, alcohol use, pneumonia, lung cancer, shortness of breath and COPD [general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis (1)]. The most recent MDS (minimum data set) assessment, a Medicare 30 day assessment, with an assessment reference date of 2/27/19, coded the resident as scoring a 14 on the BIMS (brief interview for mental status) score, indicating the resident was capable of making daily cognitive decisions. The resident was coded as requiring limited to extensive assistance of one staff member for her activities of daily living. In Section O - Special Treatments, Procedures and Programs, the resident not coded for any respiratory services. An observation was made of Resident #119's room on 3/4/19 at 6:36 p.m. The nebulizer machine and mask were sitting on a chair next to the bed. The mask was sitting on top of a plastic bag. When asked when was the last time it was used, Resident #119 stated she had had her treatment at 6:00 p.m. An observation was made of Resident #119's room on 3/5/19 at 8:52 a.m. The nebulizer mask was still noted to be sitting on the plastic bag on the chair. When asked when it was used last, Resident #119 stated, Last night. An observation was made of the nebulizer mask in Resident #119's room on 3/5/19 at 10:12 a.m. An interview was conducted with Resident #119 at this time. When asked if the staff puts the nebulizer mask in the bag, Resident #119 stated, Sometimes they do and sometimes they don't. An observation was made of the nebulizer mask in Resident #119's room on 3/5/19 at 3:40 p.m. The nebulizer mask was in the bag. Resident #119 stated that she put it in the bag, not the staff. The physician order dated, 1/30/19, documented, Albuteral Sul (solution) 1.25 MG/ML (milligrams/milliliters) sol (solution) (Albuterol is used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by lung diseases such as asthma and chronic obstructive pulmonary disease [COPD]) (2) - inhale 1 unit dose via jet neb (nebulizer) Q (every) 6 hours while awake. The comprehensive care plan dated, 1/30/19 and revised on 2/6/19, failed to evidence documentation regarding the use of nebulizers for the treatment of the resident's COPD. An interview was conducted with LPN (licensed practical nurse) #1 on 3/6/19 at 1:31 p.m. When asked how a nebulizer mask should be stored when not in use, LPN #1 stated it should be stored in a plastic bag when not in use. When asked why that is done, LPN #1 stated, It's for sanitation reasons. An interview was conducted with RN (registered nurse) #3 on 3/6/19 at 1:33 p.m. When asked how a nebulizer mask should be stored when not in use, RN #3 stated, It should be stored in a plastic bag with the resident's name and date it was changed. When asked why it should be stored in a plastic bag, It's to keep it clean. The facility policy, Oxygen Admiration documented in part, 10. Oxygen tubing, cannula/mask should be stored in a clear plastic bag when not in use. Administrative staff member (ASM) #1, the administrator, ASM #3, the regional nurse consultant, and ASM #4, the regional vice president of operations, were made aware of the above findings on 3/6/19 at approximately 6:00 p.m. At this time, ASM #3 informed this surveyor that the policy for the storage of nebulizers is the same for the oxygen storage. No further information was provided prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124. (2) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682145.html

**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 pain management consistent with professional standards of practice, for one of 51 residents in the survey sample, Resident #148. The facility staff failed to clarify physician's orders for two as needed pain medications to determine which, as needed pain medication should be administered to Resident #148 based on pain parameters. The findings include: Resident #148 was admitted to the facility on [DATE] with a readmission on [DATE], with diagnoses that included but were not limited to: diabetes, high blood pressure, chronic kidney disease dependent on hemodialysis [a procedure used in toxic conditions and renal [kidney] failure, in which wastes and impurities are removed from the blood by a special machine (1)], COPD [general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis (2)], and depression. The most recent MDS (minimum data set) assessment, a Medicare 30 day assessment, with an assessment reference date of 2/21/19, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score indicating the resident was capable of making daily cognitive decisions. The resident was coded as requiring extensive assistance of one or more staff members for all of her activities of daily living. In Section J - Health Conditions, the resident was coded as having occasional pain with a pain level of 5 on a scale of 1 - 10, 10 being the worse pain they have ever been in. The physician order dated, 1/24/19 documented, Acetaminophen (Tylenol) [used to treat mild pain and fevers (3)], 325 MG (milligrams) Tablet, give two tabs (tablets) po (by mouth) q (every) 4 hours prn (as needed) for pain/fever >(greater than) 101. A second physician order dated 1/24/19 documented, Norco 5-325 Tablet [used to treat moderate to severe pain (4)] - Norco 5/325 mg take 1/2 tab po q4hours prn for pain. The January 2019 MAR (medication administration record) documented the above medication orders. The MAR documented the administration of the Acetaminophen on the following dates, times, with pain levels as follows: 1/17/19 at 1:23 a.m. for a pain level of 7 1/19/19 at 7:54 p.m. for a pain level of 4 1/22/19 at 12:49 a.m. for a pain level of 4 1/22/19 at 4:53 p.m. for a pain level of 6. 1/29/19 at 8:11 p.m. for a pain level of 4 1/30/19 at 10:22 p.m. for a pain level of 4 1/31/19 at 10:53 a.m. for a pain level of 4. The January 2019 MAR documented the above medication orders. The MAR documented the administration of the Norco on the following dates, times with pain levels as follows: 1/1/19 at 5:26 p.m. for a pain level of 4 1/2/19 at 6:13 p.m. for a pain level of 5 1/3/19 at 5:49 p.m. for a pain level of 6 1/6/19 at 6:12 p.m. for a pain level of 5. 1/7/19 at 6:11 p.m. for a pain level of 0 1/8/19 at 5:33 p.m. for a pain level of 5 1/11/19 at 4:04 p.m. for a pain level of 0 1/17/19 at 5:50 a.m. for a pain level of 7 1/24/19 at 8:39 p.m. for a pain level of 5 1/25/19 at 8:28 a.m. for a pain level of 5 1/25/19 at 3:46 p.m. for a pain level of 0 1/26/19 at 8:33 a.m. for a pain level of 5 1/26/19 at 6:03 p.m. for a pain level of 5 1/26/19 at 10:32 p.m. for a pain level of 5 1/28/19 at 8:54 p.m. for a pain level of 6. The February 2019 MAR (medication administration record) documented the above medication orders. The MAR documented the administration of the Acetaminophen on the following dates, times, with pain levels as follows: 2/1/19 at 8:05 a.m. for a pain level of 4 2/5/19 at 8:24 a.m. for a pain level of 5 2/5/19 at 11:43 a.m. for a pain level of 5 2/8/19 at 5:17 a.m. for a pain level of 4 2/21/19 at 9:51 a.m. for a pain level of 5 2/22/19 at 7:53 a.m. for a pain level of 5 2/23/19 at 9:42 a.m. for a pain level of 5 2/25/19 at 1:12 a.m. for a pain level of 4 2/26/19 at 9:01 a.m. for a pain level of 5. The February 2019 MAR documented the above medication orders. The MAR documented the administration of the Norco on the following dates, times with pain levels as follows: 2/1/19 at 5:00 a.m. for a pain level of 7 2/1/19 at 6:26 p.m. for a pain level of 3 2/2/19 at 11:55 p.m. for a pain level of 4 2/3/19 at 10:01 p.m. for a pain level of 5 2/4/19 at 6:21 p.m. for a pain level of 4 2/5/19 at 1:39 p.m. for a pain level of 6 2/6/19 at 8:33 a.m. for a pain level of 5 2/6/19 at 11:38 p.m. for a pain level of 6 2/7/19 at 11:09 p.m. for a pain level of 4 2/8/19 at 10:54 p.m. for a pain level of 9 2/9/19 at 11:53 p.m. for a pain level of 8 2/10/19 at 8:51 a.m. for a pain level of 5 2/10/19 at 10:34 p.m. for a pain level of 8 2/11/19 at 11:03 a.m. for a pain level of 5 2/13/19 at 8:58 a.m. for a pain level of 6 2/14/19 at 8:12 a.m. for a pain level of 5 2/15/19 at 8:55 a.m. for a pain level of 5 2/15/19 at 6:01 p.m. for a pain level of 4 2/17/19 at 1:21 a.m. for a pain level of 4 2/19/19 at 8:58 a.m. for a pain level of 5 2/19/19 at 6:41 p.m. for a pain level of 4 2/21/19 at 11:50 p.m. for a pain level of 4 2/25/19 at 7:54 a.m. for a pain level of 10. The March 2019 MAR documented the above medication oders. The MAR documented the administration of the Acetaminophen was administered on 3/3/19 at 6:08 a.m. for a pain level not documented. The March 2019 MAR documented the above medication orders. The MAR documented the administration of the Norco on the following dates, times with pain levels as follows: 3/1/19 at 12:41 a.m. for a pain level of 5 3/1/19 at 9:42 p.m. for a pain level of 5 3/3/19 at 12:09 a.m. for a pain level of 4 3/3/19 at 7:42 p.m. for a pain level of 5 3/6/19 at 9:36 a.m. for a pain level of 5. The comprehensive care plan dated as reviewed on 1/31/19, documented in part, Problem/Need: Potential for pain. The Approaches documented, Provide pain meds (medications) as ordered. Assess pain med effectiveness document and report to MD (medical doctor) as needed. Assess for signs and symptoms of break thru pain document and report to MD as needed. Assist with turning and repositioning for comfort. An interview was conducted with LPN (licensed practical nurse) #1 on 3/6/19 at 11:44 a.m. LPN #1 was asked to review the above physician orders for Acetaminophen and Norco. Once reviewed, LPN #1 was asked how the staff knows which medication to give the resident when they complain of pain, LPN #1 stated, I start with the lesser of the medications, then go up if that doesn't work, if needed. I will tell you with this resident she is alert and oriented and does ask for a specific medications. LPN #1 stated, I have seen orders that tell the nurse if they have pain from 1-4 you give, normally, some Tylenol, and if the pain is 5-10 on a pain scale you give them the stronger medication. When asked if she is capable of making the decision what to give, LPN #1 stated, Yes, I would give them the Norco if their pain was from 5-10 and Tylenol if their pain was 1-4. An interview was conducted with RN (registered nurse) #3, the unit manager, on 3/6/19 at 11:50 a.m. RN #3 was asked to review the above orders for pain medications. Once reviewed, RN #3 was asked how the nurses' know which medication to give, RN #3 stated, We need clarification of those orders. The pain level needs to be added to the orders. The facility policy, Administering Pain Medications documented in part, 6. Administer pain medications as ordered. According to Lippincott Manual of Nursing Practice, Eighth Edition: by [NAME] & [NAME], pg. 87 read: Nursing Alert: Unusual dosages or unfamiliar drugs should always be confirmed with the health care provider and pharmacist before administration. On pg. 15, the following is documented in part, Inappropriate Orders: 2. Although you cannot automatically follow an order you think is unsafe, you cannot just ignore a medical order, either. b. Call the attending physician, discuss your concerns with him, obtain appropriate .orders. c. Notify all involved medical and nursing personnel d. Document clearly. Administrative staff member (ASM) #1, the administrator, ASM #3, the regional nurse consultant, and ASM #4, the regional vice president of operations, were made aware of the above findings on 3/6/19 at approximately 6:00 p.m. On 3/6/19 at 8:15 p.m. ASM #2, the director of nursing, was asked which professional standard of practice the facility follows, ASM #2 stated they follow their policies and [NAME]. No further information was provided prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 266. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124. (3) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a681004.html (4) This information was obtained from the following website: https://medlineplus.gov/ency/article/002670.htm

**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 maintain a complete and accurate clinical record for one of 51 residents in the survey sample, Resident #138. The facility staff failed to document non-pharmacological interventions that were provided for Resident #138 in addition to administering as needed Tylenol (1) on multiple dates in February 2019. The findings include: Resident #138 was admitted to the facility on [DATE]. Resident #138's diagnoses included but were not limited to high blood pressure, vitamin B12 deficiency and constipation. Resident #138's most recent MDS (minimum data set), a significant change in status assessment with an ARD (assessment reference date) of 2/15/19, coded the resident's cognition as severely impaired. Section J coded Resident #138 as having received PRN (as needed) pain medication and non-medication intervention during the last five days. Section J further coded Resident #138 reported having frequent pain during the last five days. Review of Resident #138's clinical record revealed a physician's order dated 1/29/19, for Tylenol 650 mg (milligrams) every six hours PRN (as needed) for pain or a fever greater than 101. Review of Resident #138's February 2019 MAR (medication administration record) revealed the resident was administered PRN Tylenol on 2/4/19, 2/5/19, 2/6/19, 2/10/19, 2/11/19, 2/12/19, 2/14/19, 2/15/19 and 2/18/19. Further review of Resident #138's MAR, MAR notes and nurses' notes failed to reveal documentation that Resident #138 was offered non-pharmacological interventions prior to or in addition to the administration of PRN Tylenol on all the above dates. Review of Resident #138's comprehensive care plan dated 2/15/19 failed to reveal documentation regarding pain. On 3/6/19 at 11:32 a.m., an interview was conducted with LPN (licensed practical nurse) #5 (the nurse who administered PRN Tylenol to Resident #138 on all of the above dates except 2/10/19). LPN #5 confirmed she administered Tylenol to Resident #138 for pain. LPN #5 was asked what should be done prior to or in addition to administering PRN pain medication to a resident. LPN #5 stated, Well, see if you can reposition them, if there is something else non-pharmaceutical you can do. When asked if she documents the non-pharmacological interventions she provides, LPN #5 stated, Most of the time, yes. When asked if non-pharmacological interventions should be documented each time they are offered, LPN #5 stated, You should. When asked why, LPN #5 stated, Just to show that you didn't just give them a pill; that you tried something else to relieve their discomfort. LPN #5 stated she provided repositioning to Resident #138 each time she administered PRN Tylenol. When asked where she documented this non-pharmacological intervention, LPN #5 stated she really could not say where she documented this information but some residents' MARs have a drop down box containing a list where nurses can select the provided non-pharmacological intervention. LPN #5 stated she thought this process was generated by a certain way the orders are put into the computer system. When asked if she could recall if Resident #138's MAR had this option, LPN #5 stated she was not sure. Further review of Resident #138's MAR failed to reveal this option. On 3/6/19 at 4:50 p.m., ASM (administrative staff member) #1 (the administrator), ASM #3 (the regional nurse consultant) and ASM #4 (the regional vice president of operations) was made aware of the above concern. The facility policy regarding pain medication administration documented, 5. Evaluate and document the effectiveness of non-pharmacological interventions . No further information was presented prior to exit. (1) Tylenol is used to relieve pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a681004.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain infection control practices for one of 51 residents in the survey sample, Residents #108. The facility staff failed to wash or sanitize their hands after assisting other residents in the Cottage dining room and returning to feed Resident #108. The findings include: Resident #108 was admitted to the facility on [DATE] with the diagnoses of but not limited to Dysphagia, Schizophrenia, Alzheimer's disease, high blood pressure, sleep apnea, osteoporosis, depression with psychotic symptoms, and metabolic encephalopathy. Resident #108's most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 1/26/19. The resident was coded as requiring total assistance for all areas of activities of daily living. On 3/5/19 at approximately 1:30 p.m. to 1:50 p.m., observations were made in the Cottage dining room for the lunch meal. The following was observed: On 3/5/19 at approximately 1:30 p.m., CNA #4 (Certified Nursing Assistant) was sitting down at the table feeding Resident #108. On 3/5/19 at approximately 1:33 p.m., while feeding Resident #108, CNA #4 got up to assist another resident who was leaving the dining room and touched the personal wheelchair of another resident. CNA #4 then returned to the table to feed Resident #108, without washing or sanitizing her hands. On 3/5/19 at approximately 1:35 p.m., CNA #4 was observed standing up from feeding Resident # 108, to speak with another resident and was observed patting the resident on the back as the resident was leaving the dining room. CNA #4 then returned to the table to feed Resident #108 without washing or sanitizing her hands. On 3/5/19 at approximately 1:44 p.m., CNA #4 was observed standing up from feeding Resident # 108, to help another resident place her tray onto the tray cart. CNA #4 then returned to the table to feed Resident #108 without washing or sanitizing her hands. On 3/5/19 at approximately 1:45 p.m., CNA #4 was observed reaching across the table to assist another resident with his tray. CNA #4 then returned to feeding Resident #108 without washing or sanitizing her hands. On 3/05/19 at 3:44 p.m., in an interview with CNA #4, when asked what protocols the facility follows to maintain infection control in the dining room, CNA #4 stated, I should wash or sanitize my hands when I do other things before returning to feed a resident. When asked about the observations of assisting multiple residents back and forth and not washing or sanitizing her hands between them, CNA #4 stated, We do not have any sanitizers in the dining room, just the wipes (which were kept in a locked cabinet). I should have washed or sanitized my hands before feeding a resident again. A review of the facility policy, Handwashing/Hand Hygiene documented, All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other .residents Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .before and after direct contact with residents .before and after assisting a resident with meals. A review of the facility policy, Infection Control Guidelines for All Nursing Procedures documented, Employees must wash their hands .before and after direct resident contact .before and after assisting a resident with meals On 3/5/19 at 5:15 p.m., the Administrator (ASM #1 - Administrative Staff Member) were made aware of the findings. No further information as provided. In Fundamentals of Nursing 7th edition, 2009: [NAME] A. [NAME] and [NAME]: Mosby, Inc; Page 655. The nurse follows certain principles and procedures, including standard precautions, to prevent and control infection and its spread. During daily routine care the nurse uses basic medical aseptic techniques to break the infection chain. A major component of client and worker protection is hand hygiene. Contaminated hands of health care workers are a primary source of infection transmission in health care settings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to respect Resident # 86's dignity by standing next to her while providing assistance with feeding. Resident # 86 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: schizophrenia (1), anxiety (2), bipolar disorder (3), and dysphagia (4). Resident # 86's most recent comprehensive MDS (minimum [NAME] set) a quarterly assessment with an ARD (assessment reference date) of 01/12/19 coded the resident as scoring a 6 (six) on the brief interview for mental status (BIMS) of a score of 0 (zero) - 15, 6 (six) being severely impaired of cognition for daily decision making. Resident # 86 was coded as totally dependent of one staff member for activities of daily living. Resident # 86 was coded as totally dependent of one staff member for eating. Under Section K Swallowing/Nutritional Status Resident # 86 was coded as having a mechanically altered diet. On 03/06/19, an observation was conducted of Resident # 86 from 8:33 a.m. to 8:44 a.m. Resident # 86 was observed in her bed with the head of the elevated and the bed lowered close to the floor. CNA (certified nursing assistant) # 3 was observed bringing in Resident # 86's breakfast on a tray. CNA # 3 then placed the breakfast tray on Resident # 89's over-the-bed table, opened all the containers moved the table over the bed in front of Resident # 86 and provided verbal prompts to encourage Resident # 86 to try to feed herself. While standing next to Resident # 86's bed, CNA # 3 provided total assistance to Resident # 86 by feeding her the breakfast meal. On 03/06/19 at 8:46 a.m., an interview was conducted with CNA # 3. When asked if Resident # 86 was able to feed herself, CNA # 3 stated, 'Yes but she doesn't eat much so I provide assistance to try and get her to eat more. When asked what her position should be when assisting a resident with eating, CNA # 3 stated, I should be sitting down. When asked if she was sitting down while feeding Resident # 86 her breakfast, CNA # 3 stated, No I didn't think about it. I just wanted to get it done. When asked why it is important to sit next to or in front of a resident when feeding them, CNA # 3 stated, So you can be eye level with them. The comprehensive care plan for Resident # 86 dated 01/12/9 documented, Problem/Need. NUTRITIONAL RISK DUE TO MULTIPLE DIAGNOSIS MECHANICALLY ALTERED DIET RESTRICTIONS BELOW NORMAL IBW (ideal body weight) RANGE. Swallowing issues. Poor intake. Under Approaches it documented, Provide diet as ordered. Monitor weight as ordered. Monitor and provide food preferences. The facility's Resident Rights documented, 10. Is treated with consideration, respect, and full recognition of his dignity and individuality, including privacy in treatment and in care for his personal needs. The facility's policy Quality of Life - Dignity documented, policy Statement. Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Under Policy Interpretation and Implementation it documented, 2. 'Treated with dignity' means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. 12. Staff shall treat cognitively impaired residents with dignity and sensitivity. The facility's policy Assistance with Meals documented, 3. Residents Requiring Full Assistance: b. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: (1) Not standing over residents while assisting them with meals . On 03/26/19 at approximately 3:30 p.m. ASM (administrative staff member) # 1, the administrator and ASM # 3, regional nurse consultant, were made aware of the findings. No further information was provided prior to exit. References: (1) A mental disorder that makes it hard to tell the difference between what is real and not real. This information was obtained from the website: https://medlineplus.gov/ency/article/000928.htm. (2) Fear. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/anxiety.html#summary. (3) A brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks. This information was obtained from the website: https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml. (4) A swallowing disorder. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/swallowingdisorders.html. Based on observation, staff interview and facility document review, it was determined that the facility staff failed to provide a dignified, homelike dining experience in one of 3 facility dining rooms, the Cottage dining room and failed to promote resident dignity during a meal for one of 51 sampled residents, Resident # 86's. 1. In the Cottage dining room (the memory care unit), the 27 residents present for the lunch meal on 3/5/19, were served their meals cafeteria style, on trays. 2. The facility staff failed to respect Resident # 86's dignity by standing next to her while providing assistance with feeding during the breakfast meal on 3/6/19. The findings include: 1. On 3/05/19 at 1:08 p.m., observation of the Cottage dining room was conducted during the lunch meal. There were 27 residents in the dining room when the tray cart arrived at this time. The dining room staff served all 27 residents their meal on the trays, cafeteria style. No attempt was made to remove the residents' meals from the trays and place them on the table for a homelike dining experience. On 3/05/19 at 3:44 p.m., an interview was conducted with CNA #4 (Certified Nursing Assistant), one of the staff members serving the residents. When asked if the residents should be served their meals that way, CNA #4 stated, That's how I've been taught for 9 years. When asked if that is a cafeteria or homelike dining experience, CNA #4 she stated, Cafeteria. When asked what kind of dining experience are they supposed to have, CNA #4 stated, A home setting. When asked is it homelike if they are being served on trays, CNA #4 stated, Probably not, I don't think so. CNA #4 then stated, It isn't that way on the other units but on this unit that is how they do it. I don't know if it is because it is a different unit. When asked should it be different, CNA #4 stated, No, it should be the same. A review of the facility policy Quality of Life - Dignity documented, 1. Residents shall be treated with dignity and respect at all times. 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth . The policy did not specifically identify what style of dining should be utilized for a dignified, homelike dining experience. On 3/05/19 at 5:07 p.m., ASM #1 (Administrative Staff Member - The Administrator) was made aware of the findings. No further information was provided by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. The facility staff failed to evidence that the comprehensive care plan goals for Resident #153 were provided to the receiving facility when the resident was transferred to the hospital on 2/15/19. Resident #153 was admitted to the facility on [DATE]. Diagnoses for Resident #153 included but are not limited to dementia with behavioral disturbances, bipolar disorder, high blood pressure, and asthma. Resident #153's Minimum Data Set (MDS) was a significant change in status assessment with an Assessment Reference Date (ARD) of 1/15/19, and coded Resident #153 as severely impaired for cognitive skills for daily decision-making. A review of the clinical record revealed a nurse's note dated 2/15/19 at 12:45 p.m., that documented, 1:1 monitoring has continued since beginning of shift. at 1140-(Name of Doctor) in and spoke with md (medical doctor) re (regarding): transferring resident to more appropriate setting for safety of resident and other, and order written to go to (Name of hospital) ER (Emergency Room) for psych (psychiatric) eval (evaluation) for possible admission re: behaviors. This writer left msg (message) for rp (Responsible Party) to return call to facility. resident was oriented that he was being sent to (Name of hospital) ER in (Name of town, state) by stretcher for eval (evaluation) and possible admit to hospital to help with his previous behaviors, resident smiled and said 'okay.' at 1150 spoke with (Name of transport staff) at (Name of transport ambulance) to transport resident to (Name of hospital) er. at 1225 2 attendants with (Name of transport ambulance) in facility and enroute via stretcher to (Name of hospital) ER at 1235. at 1242 report was given to (name of ER staff) rn (Registered Nurse) at (Name of hospital) er. Further review of the clinical record failed to reveal what documentation was provided to the hospital. On 3/06/19 at 2:04p.m., an interview was conducted with LPN #8 (Licensed Practical Nurse), the unit manager for Resident #95. LPN #8 stated that when the resident goes to the hospital, the facility sends 2 copies of the facesheet, one for transport and one for hospital, the resident's History and Physical, immunization record, last recertification, last progress note, labs, Medication Administration Record, the transfer form, and the bed hold policy agreement. When asked about the comprehensive care plan goals, LPN #8 stated, We do not send the care plan. The facility policy, Transfer or Discharge, Emergency was reviewed. The policy did not include requirements of what documentation, including comprehensive care plan goals, must be provided to the receiving facility. On 3/7/19 at approximately 6:26 p.m., AMS #1 (Administrative Staff Member - the Administrator) was made aware of the findings. No further information was provided by the end of the survey. 6. The facility staff failed to provide evidence that all required information (including physician contact information, resident representative contact information, special instructions for ongoing care, advance directives and comprehensive care plan goals) was provided to the hospital staff when Resident #92 was transferred to the hospital on [DATE]. Resident #92 was admitted to the facility on [DATE]. Resident #92's diagnoses included but were not limited to high blood pressure, high cholesterol and convulsions. Resident #92's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/18/19, coded the resident as being cognitively intact. Review of Resident #92's clinical record revealed the resident presented with a fever and nausea, and was transferred to the hospital on [DATE]. Further review of Resident #92's clinical record (including nurses' notes) failed to reveal evidence that the facility staff provided the required information to hospital staff when the resident was transferred. On 3/6/19 at 10:28 a.m., an interview was conducted with LPN (licensed practical nurse) #4 and RN (registered nurse) #1. LPN #4 and RN #1 were asked to describe the information that is provided to hospital staff when a resident is transferred to the hospital. LPN #4 stated she provides physician orders, recent labs, recent x-rays, a history and physical, immunization record and face sheet. LPN #4 confirmed she does not provide comprehensive care plan goals. LPN #4 stated the nurses have a transfer form with instructions and a check off list. RN #1 stated a copy containing all the information on the check off list is sent to the hospital and a copy is placed in the resident's clinical record. RN #1 stated the process for sending information to the hospital had been revised multiple times over the last year and the process was recently revised so he was not sure if this process was in place when Resident #92 was transferred to the hospital. On 3/6/19 at 3:41 p.m., RN #1 confirmed he could not provide evidence that the required information was provided to hospital staff when Resident #92 was transferred to the hospital on [DATE]. On 3/6/19 at 4:50 p.m., ASM (administrative staff member) #1 (the administrator), ASM #3 (the regional nurse consultant) and ASM #4 (the regional vice president of operations) was made aware of the above concern. No further information was presented prior to exit. 3. The facility staff failed to evidence that comprehensive care plan goals for Resident # 137 were sent with the resident to the hospital for the transfer on 02/19/19. Resident # 137 was admitted to the facility on [DATE] with a readmission of 02/21/19 with diagnoses that included but were not limited to sepsis (1), gastrostomy (2), and hemiplegia (3). Resident # 137's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/14/19, coded Resident # 137 as scoring a 3 (three) on the staff assessment for mental status (BIMS) of a score of 0 - 15, 3(three) - being severely impaired of cognition for making daily decisions. The nurse's Progress Notes, dated 02/19/2019 for Resident # 137 documented, On last evening rounds this shift (2/18/19) resident was noted with (increased) audible congestion and had rbronchi (right bronchial) [lung] in upper lobes and rattles in all lung fields. VS (vital signs) were 101.8 (temperature), 189/96 (189 over 96 blood pressure). Pulse went to 127. PRN (as needed) Tylenol elixir 20.3 cc (cubic centimeters) per peg (tube feeding) given for (increased) temp (temperature) with cool water via (by) peg. Pox (Pulse oximetry) 88-91% on O2 (oxygen) 2 (two) L/nc (liters by nasal cannula), O2 (increased) to 4l?nc. NP (nurse practitioner) (Name of Nurse Practitioner) notifies and [sic] ordered send resident out to [sic] hospital ER (emergency room) for evaluation. RP (responsible party) (Name of Responsible Party) made aware and stated she would decline bed hold offer. Squad notified and in to p/u (pick up) resident at 0015 (12:15 a.m.), [sic] nonbreather mask applied, pox (increased) to 95% with O2. (Name of Transport) squad left facility with resident for (Name of Hospital) via stretcher at 0030 (12:30 a.m.) RP was called back and notified that resident was sent to (Name of Hospital) ER. Stated to let her know if resident will be admitted to hospital. Review of the clinical record and the facility's Resident Transfer Form dated 02/19/19 for Resident # 137 failed evidence documentation that the care plan goals were sent to (Name of Hospital) upon the transfer of Resident # 137. On 3/06/19 at 2:04p.m., an interview was conducted with LPN #8 (Licensed Practical Nurse), the unit manager for Resident #95. LPN #8 stated that when the resident goes to the hospital, the facility sends 2 copies of the facesheet, one for transport and one for hospital, the resident's History and Physical, immunization record, last recertification, last progress note, labs, Medication Administration Record, the transfer form, and the bed hold policy agreement. When asked about the comprehensive care plan goals, LPN #8 stated, We do not send the care plan. The facility policy, Transfer or Discharge, Emergency was reviewed. The policy did not include requirements of what documentation, including comprehensive care plan goals, must be provided to the receiving facility. On 03/06/19 at approximately 3:30 p.m. ASM (administrative staff member) # 1, the administrator and ASM # 3, regional nurse consultant, were made aware of the findings. No further information was provided prior to exit. References: (1) An illness in which the body has a severe, inflammatory response to bacteria or other germs. The symptoms of sepsis are not caused by the germs themselves. Instead, chemicals the body releases cause the response. This information was obtained from the website: https://medlineplus.gov/ency/article/000666.htm. (2) A gastrostomy feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall. It goes directly into the stomach. This information was obtained from the website: https://medlineplus.gov/ency/article/002937.htm. (3) Also called: Hemiplegia, Palsy, Paraplegia, Quadriplegia. Paralysis is the loss of muscle function in part of your body. It happens when something goes wrong with the way messages pass between your brain and muscles. Paralysis can be complete or partial. It can occur on one or both sides of your body. It can also occur in just one area, or it can be widespread. This information was obtained from the website: https://medlineplus.gov/paralysis.html. 4. The facility staff failed to provide the receiving facility with the Resident #45's comprehensive care plan goals for a facility initiated hospital transfer that occurred on 11/25/18. Resident # 45 was admitted to the facility on [DATE] and a re-admission on [DATE] with diagnoses that included but were not limited to: retention of urine, urinary tract infection (1), benign prostatic hyperplasia (2), diabetes mellitus (3) and hypertension (4). Resident # 45's most recent MDS (minimum data set), a 30-day assessment with an ARD (assessment reference date) of 12/19/18, coded Resident # 45 as scoring a 9 (nine) on the brief interview for mental status (BIMS) of a score of 0 - 15, 9 (nine) - being moderately impaired of cognition for making daily decisions. The nurse's Progress Notes, dated 11/25/2018 for Resident # 45 at 11:53 p.m. documented, At end of evening shift (2200) [10:00 p.m.] res (resident) was again offered water and juice, refused both. Total intake for shift was approx. (approximately) 120 cc (cubic centimeters), with much effort. Res cont (continues) to say I don't want any water or juice. Foley (catheter) 0 (zero) - (to) 100 cc cloudy amber urine, no stool in colostomy bag this shift. Res denies any pain when asked. At 2230 (10:30 p.m.) NP (nurse practitioner) (Name of Nurse Practitioner) notified and gave verbal order to send resident out to hospital ER (emergency room) for evaluation to rule out possible bowel obstruction. Night supervisor was made aware. Attempts made to contact RP (responsible party) on all 3 numbers. (Name of Transport) squad in, stated both (Name of two Hospitals) were on diversion. Call placed by EMT (emergency medical technician) to (Name of Hospital) ER nurse, who stated they had no available beds but would accept resident with possible transfer to another hospital. Squad left with res en route to (Name of Hospital) at 2345 (11:45 p.m.). Review of the facility's Resident Transfer Form dated 11/25/18 for Resident # 45 failed evidence documentation that the care plan goals were sent to (Name of Hospital) upon the transfer of Resident # 45. On 3/06/19 at 2:04p.m., an interview was conducted with LPN #8 (Licensed Practical Nurse), the unit manager for Resident #95. LPN #8 stated that when the resident goes to the hospital, the facility sends 2 copies of the facesheet, one for transport and one for hospital, the resident's History and Physical, immunization record, last recertification, last progress note, labs, Medication Administration Record, the transfer form, and the bed hold policy agreement. When asked about the comprehensive care plan goals, LPN #8 stated, We do not send the care plan. The facility policy, Transfer or Discharge, Emergency was reviewed. The policy did not include requirements of what documentation, including comprehensive care plan goals, must be provided to the receiving facility. On 03/06/19 at approximately 3:30 p.m. ASM (administrative staff member) # 1, the administrator and ASM # 3, regional nurse consultant, were made aware of the findings. No further information was provided prior to exit. References: (1) An infection in the urinary tract. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/000521.htm. (2) An enlarged prostate. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/enlargedprostatebph.html. (3) A chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/001214.htm. (4) High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html. Based on staff interview, clinical record review and facility document review, the facility staff failed to evidence all required documentation was provided to the receiving facility at the time of a facility initiated transfer, for seven of 51 sampled residents; ( Residents #95, #141, #137, #45, #153, #92, and #38). 1. The facility staff failed to evidence that the comprehensive care plan goals for Resident #95 were provided to the receiving facility when the resident was transferred to the hospital on 1/11/19. 2. The facility staff failed to evidence that the comprehensive care plan goals for Resident #141 were provided to the receiving facility when the resident was transferred to the hospital on [DATE], 12/23/18, and 1/23/19. 3. The facility staff failed to evidence that comprehensive care plan goals for Resident # 137 were sent with the resident to the hospital for the transfer on 02/19/19. 4. The facility staff failed to provide the receiving facility with the Resident #45's comprehensive care plan goals for a facility initiated hospital transfer that occurred on 11/25/18. 5. The facility staff failed to evidence that the comprehensive care plan goals for Resident #153 were provided to the receiving facility when the resident was transferred to the hospital on 2/15/19. 6. The facility staff failed to provide evidence that all required information (including physician contact information, resident representative contact information, special instructions for ongoing care, advance directives and comprehensive care plan goals) was provided to the hospital staff when Resident #92 was transferred to the hospital on [DATE]. 7. The facility staff failed to evidence that the comprehensive care plan goals were provided to the receiving facility when Resident #38 was transferred to the hospital on [DATE]. The findings include: 1. The facility staff failed to evidence that the comprehensive care plan goals for Resident #95 were provided to the receiving facility when the resident was transferred to the hospital on 1/11/19. Resident #95 was admitted to the facility on [DATE] with the diagnoses that included, but are not limited to atrial fibrillation, stroke, dementia with behaviors, bipolar disorder, anxiety disorder, and dysphagia. The most recent MDS (Minimum Data Set) was a significant change assessment with an ARD (Assessment Reference Date) of 1/25/19. The resident was coded as severely cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for all areas of activities of daily living. A review of the clinical record revealed a nurse's note dated 1/11/19 at 11:24 a.m. that documented, Resident reported to have discoloration to left lower extremity. Resident assessed by supervisor and pedal pulses unable to be found. Provider called and order obtained to send patient to ER (emergency room) for evaluation. RP (responsible party) called and messages left for two contacts to call back for updates. (Name of county) called for emergency transport. Resident unable to understand reason for transport and is unable to sign bed hold form. (Name of hospital) ER called and given report to (name of ER staff). (Name of county ambulance) departing with patient at 10:33 am to (name of hospital) ER. Further review of the clinical record failed to reveal what documentation was provided to the hospital. On 3/06/19 at 2:04p.m., an interview was conducted with LPN #8 (Licensed Practical Nurse), the unit manager for Resident #95. LPN #8 stated that when the resident goes to the hospital, the facility sends 2 copies of the facesheet, one for transport and one for hospital, the resident's History and Physical, immunization record, last recertification, last progress note, labs, Medication Administration Record, the transfer form, and the bed hold policy agreement. When asked about the comprehensive care plan goals, LPN #8 stated, We do not send the care plan. When asked what is included on the transfer form. LPN #8 stated, The resident's name, date time, where they are being sent to, the address, phone number, allergies, the reason for sending them, the code status. We use a checklist; it is in a packet of forms to be filled out. LPN #8 provided a copy of this packet and checklist. A review of the When Sending A Resident To The Hospital checklist failed to include that comprehensive care plan goals must be provided. The facility policy, Transfer or Discharge, Emergency was reviewed. The policy did not include requirements of what documentation, including comprehensive care plan goals, must be provided to the receiving facility. On 3/06/19 at 6:36 p.m., ASM #1 (Administrative Staff Member - the Administrator) was made aware of the findings. No further information was provided by the end of the survey. 2. The facility staff failed to evidence that the comprehensive care plan goals for Resident #141 were provided to the receiving facility when the resident was transferred to the hospital on [DATE], 12/23/18, and 1/23/19. Resident #141 was admitted to the facility on [DATE] with diagnoses that include but are not limited to dementia with behaviors, psychosis, psychotic disorder with hallucinations and delusions, anxiety disorder, glaucoma, chronic obstructive pulmonary disease, abdominal aortic aneurysm, Parkinsonism, benign prostatic hyperplasia, ileus, and dysphagia. The most recent MDS (Minimum Data Set) was a 30 day readmission assessment with an ARD (Assessment Reference Date) of 3/6/19. The resident was coded as being mildly impaired in ability to make daily life decisions. A review of the clinical record revealed the following: Regarding the 1/23/19 hospitalization: A nurse's note dated 1/23/19 documented, Nurse was at the nursing station when the gentleman that transports residents across the street for church service at 7 pm states that he went in resident's room and resident was unresponsive and drooling allover {sic} himself charge nurse immediately went to evaluate resident. Resident noted to be slouched over to the right side of his wheelchair and drool dripping from mouth Nurse called out resident's name a couple of times with no response so then nurse performed a forceful sternal rub again no stimulation verbally or physically from resident Supervisor contacted MD (medical doctor) to make aware of resident's condition. Order obtained to send to ER (emergency room) for further evaluation Charge nurse stayed with resident upon nursing assessment right sided face droop present, both pupils fixed, resident unable to speak all these symptoms are new onset. Symptoms appear to be stroke like EMS (emergency medical service) arrived to transport resident via stretcher to (name of hospital) for further evaluation Regarding 12/23/18 hospitalization: A nurse's note dated 12/23/18 documented, At 5:30 am CNA (certified nursing assistant) notified this writer of rectal bleeding; upon assessment: moderate amount dark red blood, mixed with clots oozing from rectum; blood continued to ooze post area being cleansed order given to transfer resident to acute care Regarding 12/13/18 hospitalization: A nurse's note dated 12/13/18 documented, Resident being transported to (hospital) via ambulance for eval (evaluation) of possible ileus and obstruction. Resident started with cold symptoms on 12/8 (2018) which led to a chest x-ray to rule out pneumonia the chest x-ray suggested possible colonic ileus, MD (medical doctor) made aware. MD ordered KUB (Kidney, Ureter, Bladder test) to investigate since resident had two bowel movements on the 11th. KUB performed on the 12th, called for results on the 13th, verbal results given as positive for colonic ileus, possible obstruction and abnormal gas pattern. MD notified and order obtained to send to hospital for eval (evaluation) Further review of the clinical record failed to reveal what documentation was provided to the hospital for each of the above hospitalizations. On 3/06/19 at 2:22 p.m., in an interview with RN #1 (Registered Nurse, the unit manager for Resident #141), when asked what paperwork is sent to the hospital, he stated, We send the transfer packet, face sheet, immunizations, we go right down the checklist. When asked if the comprehensive care plan goals are sent, RN #1 stated, We do not send the care plan goals. A review of the When Sending A Resident To The Hospital checklist failed to include that comprehensive care plan goals must be provided. The facility policy, Transfer or Discharge, Emergency was reviewed. The policy did not include requirements of what documentation, including comprehensive care plan goals, must be provided to the receiving facility. On 3/06/19 at 6:36 p.m., ASM #1 (Administrative Staff Member - the Administrator) was made aware of the findings. No further information was provided by the end of the survey. 7. The facility staff failed to evidence that the comprehensive care plan goals were provided to the receiving facility when Resident #38 was transferred to the hospital on [DATE]. Resident #38 was admitted to the facility on [DATE] with a recent readmission on [DATE], with diagnoses that included but were not limited to: urinary tract infection, diabetes, depression, dementia, kidney stones, and sepsis (destruction of tissue by bacterial toxins, contamination, infection) (1). The most recent MDS (minimum data set) assessment, a quarterly assessment with an assessment reference date of 2/27/19, coded the resident as having both short and long term memory difficulties. The nurse's note dated 11/10/18 at 2:02 a.m. documented in part, Late entry for evening shift - Res (resident) rested well in bed, IV (intravenous) of NS (normal saline) infusing in rt (right) forearm .Noted with increased coughing episode at supper, only ate a few bites. RP (responsible party) in to visit. Attendants in to pick up resident for (Name of Hospital) for evaluation of lethargy and decreased intake. Review of the clinical record failed to reveal any documentation evidencing what information was provided to the receiving hospital at the time of the residents transfer on 11/10/19. On 3/06/19 at 2:04p.m., an interview was conducted with LPN #8 (Licensed Practical Nurse), the unit manager for Resident #95. LPN #8 stated that when the resident goes to the hospital, the facility sends 2 copies of the facesheet, one for transport and one for hospital, the resident's History and Physical, immunization record, last recertification, last progress note, labs, Medication Administration Record, the transfer form, and the bed hold policy agreement. When asked about the comprehensive care plan goals, LPN #8 stated, We do not send the care plan. Administrative staff member (ASM) #1, the administrator, ASM #3, the regional nurse consultant, and ASM #4, the regional vice president of operations, were made aware of the above findings on 3/6/19 at approximately 6:00 p.m. No further information was obtained prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 527.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The facility staff failed to evidence that Resident #153's responsible party was provided with written notification of the hospital transfer when the resident was transferred to the hospital on 2/15/19. Resident #153 was admitted to the facility on [DATE]. Diagnoses for Resident #153 included but are not limited to dementia with behavioral disturbances, bipolar disorder, high blood pressure, and asthma. Resident #153's Minimum Data Set (MDS) was a significant change in status assessment with an Assessment Reference Date (ARD) of 1/15/19, and coded Resident #153 as severely impaired for cognitive skills for daily decision-making. A review of the clinical record revealed a nurse's note dated 2/15/19 at 12:45 p.m. that documented, 1:1 monitoring has continued since beginning of shift. at 1140-(Name of Doctor) in and spoke with md (medical doctor) re (regarding): transferring resident to more appropriate setting for safety of resident and other, and order written to go to (Name of hospital) ER (Emergency Room) for psych (psychiatric) eval (evaluation) for possible admission re: behaviors. This writer left msg (message) for rp (Responsible Party) to return call to facility. resident was oriented that he was being sent to (Name of hospital) ER in (Name of town, state) by stretcher for eval (evaluation) and possible admit to hospital to help with his previous behaviors, resident smiled and said 'okay.' at 1150 spoke with (Name of transport staff) at (Name of transport ambulance) to transport resident to (Name of hospital) er. at 1225 2 attendants with (Name of transport ambulance) in facility and enroute via stretcher to (Name of hospital) ER at 1235. at 1242 report was given to (name of ER staff) rn (Registered Nurse) at (Name of hospital) er. Further review of the clinical record revealed a nurse's note dated 2/15/19 at 5:46 p.m., that documented, at 1400 rp returned call to facility and made aware resident was sent to (Name of hospital) ER for psych (psychological) eval with possible admit. rp was asked about holding residents bed at $195 per day, rp declined stating 'I dont {sic} have the money.' (Name of administrative director) aware. Further review of the clinical record failed to reveal any evidence that the responsible party was notified in writing of the hospital transfer. A review of the Discharge/Transfer Form which was documented as being created January 2019, documented, I understand that I am being discharged /transferred from (facility). I understand the reason for discharge/transfer is: (two long lines provided for writing in the reason for the transfer) Responsible Party Signature: (long line provided for signature); Date: (line provided for date); Copy Given (a box to check for this option provided); Copy Mailed on: (a line provided for the writing in of the date the notice was mailed to the responsible party) The information regarding the mailing of notification of transfer to RP was not completed on the form. On 3/06/19 at 2:45 p.m., in an interview with OSM #2 (Other Staff Member, Director of Social Services) she stated that she sends the Discharge/Transfer form to the responsible party, but if the information is not completed regarding the mailing of notifying the RP of the transfer, I did not mail it. A review of the facility policy, Transfer or Discharge, Emergency documented, 4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures e. Notify the representative (sponsor) or other family member . The policy did not specify that notification must occur in writing. On 3/06/19 at 6:36 PM, ASM #1 (Administrative Staff Member - the Administrator) was made aware of the findings. No further information was provided by the end of the survey. 4. Resident #92 was transferred to the hospital on [DATE]. The facility staff failed to provide written notification of the transfer to Resident #92 and/or the resident's representative. Resident #92 was admitted to the facility on [DATE]. Resident #92's diagnoses included but were not limited to high blood pressure, high cholesterol and convulsions. Resident #92's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/18/19, coded the resident as being cognitively intact. Review of Resident #92's clinical record revealed the resident presented with a fever and nausea, and was transferred to the hospital on [DATE]. Further review of Resident #92's clinical record failed to reveal written notification of the transfer was provided to the resident and/or the representative. On 3/6/19 at 10:28 a.m., an interview was conducted with LPN (licensed practical nurse) #4 and RN (registered nurse) #1. LPN #4 and RN #1 was asked if nurses provide written notification to residents and/or their representatives when residents are transferred to the hospital. RN #1 stated they call the representative and send a written notice in a packet when residents are sent to the hospital. RN #1 stated he was not sure if written notice was provided when Resident #92 was transferred to the hospital on [DATE]. On 3/6/19 at 3:41 p.m., RN #1 confirmed he could not provide evidence that written notice was provided to Resident #92 and/or the representative when the resident was transferred to the hospital on [DATE]. On 3/6/19 at 4:50 p.m., ASM (administrative staff member) #1 (the administrator), ASM #3 (the regional nurse consultant) and ASM #4 (the regional vice president of operations) was made aware of the above concern. No further information was presented prior to exit. 2. The facility staff failed to provide Resident # 45 or the resident's representative written notification when the resident was transferred to the hospital on [DATE]. Resident # 45 was admitted to the facility on [DATE] and a re-admission on [DATE] with diagnoses that included but were not limited to: retention of urine, urinary tract infection (1), benign prostatic hyperplasia (2), diabetes mellitus (3) and hypertension (4). Resident # 45's most recent MDS (minimum data set), a 30-day assessment with an ARD (assessment reference date) of 12/19/18, coded Resident # 45 as scoring a 9 (nine) on the brief interview for mental status (BIMS) of a score of 0 - 15, 9 (nine) - being moderately impaired of cognition for making daily decisions. The nurse's Progress Notes, dated 11/25/2018 for Resident # 45 at 11:53 p.m. documented the resident was transferred to the hospital emergency room for evaluation. The note further documented, Attempts made to contact RP (responsible party) on all 3 numbers. (Name of Transport) squad in, stated both (Name of two Hospitals) were on diversion. Call placed by EMT (emergency medical technician) to (Name of Hospital) ER (emergency room) nurse, who stated they had no available beds but would accept resident with possible transfer to another hospital. Squad left with res en route to (Name of Hospital) at 2345 (11:45 p.m.). Further review of the clinical record failed to reveal any evidence that the responsible party was notified in writing of the hospital transfer. On 3/06/19 at 2:45 p.m., an interview was conducted with OSM #2 (Other Staff Member, Director of Social Services). OSM #2 stated she sends the Discharge/Transfer form to the responsible party, but that this only started in January 2019. A review of the Discharge/Transfer Form which was documented as being created January 2019, documented, I understand that I am being discharged /transferred from (facility). I understand the reason for discharge/transfer is: (two long lines provided for writing in the reason for the transfer) Responsible Party Signature: (long line provided for signature); Date: (line provided for date); Copy Given (a box to check for this option provided); Copy Mailed on: (a line provided for the writing in of the date the notice was mailed to the responsible party) This form was not utilized during the time of the above hospital transfer. On 03/06/19 at approximately 3:30 p.m. ASM (administrative staff member) # 1, the administrator and ASM # 3, regional nurse consultant, were made aware of the findings. No further information was provided prior to exit. References: (1) An infection in the urinary tract. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/000521.htm. (2) An enlarged prostate. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/enlargedprostatebph.html. (3) A chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/001214.htm. (4) High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html. Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to evidence written notification of the hospital transfer was provided to the resident and or responsible party for five of 51 residents in the survey sample; Residents #141, #45, #153, #92, #38. 1. The facility staff failed to evidence that Resident #141's responsible party was provided with written notification of the hospital transfer when the resident was transferred to the hospital on [DATE]. 2. The facility staff failed to provide Resident # 45 or the resident's representative written notification when the resident was transferred to the hospital on [DATE]. 3. The facility staff failed to evidence that Resident #153's responsible party was provided with written notification of the hospital transfer when the resident was transferred to the hospital on 2/15/19. 4. Resident #92 was transferred to the hospital on [DATE]. The facility staff failed to provide written notification of the transfer to Resident #92 and/or the resident's representative. 5. The facility staff failed to provide written notification to the resident and/or responsible party, of a facility initiated transfer for Resident #38 on 11/9/18. The findings include: 1. The facility staff failed to evidence that Resident #141's responsible party was provided with written notification of the hospital transfer when the resident was transferred to the hospital on [DATE]. Resident #95 was admitted to the facility on [DATE] with the diagnoses that included, but are not limited to atrial fibrillation, stroke, dementia with behaviors, bipolar disorder, anxiety disorder, and dysphagia. The most recent MDS (Minimum Data Set) was a significant change assessment with an ARD (Assessment Reference Date) of 1/25/19. The resident was coded as severely cognitively impaired in ability to make daily life decisions. A nurse's note dated 12/23/18 documented, At 5:30 am CNA notified this writer of rectal bleeding; upon assessment: moderate amount dark red blood, mixed with clots oozing from rectum; blood continued to ooze post area being cleansed order given to transfer resident to acute care Further review of the clinical record failed to reveal any evidence that the responsible party was notified in writing of the hospital transfer. On 3/06/19 at 2:45 p.m., in an interview with OSM #2 (Other Staff Member, Director of Social Services) she stated that she sends the Discharge/Transfer form to the responsible party, but that this only started in January 2019. A review of the Discharge/Transfer Form which was documented as being created January 2019, documented, I understand that I am being discharged /transferred from (facility). I understand the reason for discharge/transfer is: (two long lines provided for writing in the reason for the transfer) Responsible Party Signature: (long line provided for signature); Date: (line provided for date); Copy Given (a box to check for this option provided); Copy Mailed on: (a line provided for the writing in of the date the notice was mailed to the responsible party) This form was not utilized during the time of the above hospital transfer. A review of the facility policy, Transfer or Discharge, Emergency documented, 4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures e. Notify the representative (sponsor) or other family member . The policy did not specify that notification must occur in writing. On 3/06/19 at 6:36 p.m., ASM #1 (Administrative Staff Member - the Administrator) was made aware of the findings. No further information was provided by the end of the survey. 5. The faciltiy staff failed to provide written notification to the resident and/or responsible party, of a facility initiated transfer for Resident #38 on 11/9/18. Resident #38 was admitted to the facility on [DATE] with a recent readmission on [DATE], with diagnoses that included but were not limited to: urinary tract infection, diabetes, depression, dementia, kidney stones, and sepsis (destruction of tissue by bacterial toxins, contamination, infection) (1). The most recent MDS (minimum data set) assessment, a quarterly assessment with an assessment reference date of 2/27/19, coded the resident as having both short and long term memory difficulties. The nurse's note dated 11/10/18 at 2:02 a.m. documented in part, Late entry for evening shift - Res (resident) rested well in bed, IV (intravenous) of NS (normal saline) infusing in rt (right) forearm .Noted with increased coughing episode at supper, only ate a few bites. RP (responsible party) in to visit. Attendants in to pick up resident for (Name of Hospital) for evaluation of lethargy and decreased intake. Review of the clinical record failed to evidence the resident and or the resident representative were provided written notification of the 11/10/18 hospital transfer. On 3/06/19 at 2:45 p.m., in an interview with OSM #2 (Other Staff Member, Director of Social Services) she stated that she sends the Discharge/Transfer form to the responsible party, but that this only started in January 2019. Administrative staff member (ASM) #1, the administrator, ASM #3, the regional nurse consultant, and ASM #4, the regional vice president of operations, were made aware of the above findings on 3/6/19 at approximately 6:00 p.m. No further information was obtained prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 527.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3a. On 3/5/19 during separate observations Resident #98 was observed without prevalon boots in place per the physician orders and comprehensive care plan. Resident #98 was admitted to the facility on [DATE]. Diagnoses for Resident #98 included but were not limited to Heart Failure, High Blood Pressure, and Depression. Resident #98's Minimum Data Set (significant change in status) with an Assessment Reference Date of 01/18/2019 coded Resident #98 with severe cognitive impairment. In addition, the Minimum Data Set coded Resident #98 as requiring total assistance of one staff member with activities of daily living and total dependence for eating (tube feeding). On 03/05/2019 at approximately at 8:40 a.m., Resident #98 was observed lying in bed, on her right side, under a light green colored blanket with feet exposed. Resident #98 had on gray socks and both feet were propped up on a pillow. On 03/05/2019 at approximately 1:59 p.m., Resident #98 was observed lying in bed, on her back, under a light green colored blanket with feet exposed. Resident #98 had on gray socks and both feet were observed propped up on a pillow. On 03/05/2019, Resident #98's care plan was reviewed. Resident #98's care plan and physician order documented, Prevalon boots to bilateral lower extremities at all times dated 01/18/2019. Resident #98 did not have prevalon boots on when observed at approximately 8:40 a.m. and at 1:59 p.m. On 03/05/2019 at approximately 3:51 p.m., Resident 98 was observed lying in bed, on her back, under a light green colored blanket with feet covered. Resident #98's feet were covered. LPN (Licensed Practical Nurse) #4 was asked to remove Resident #98's blanket to reveal both feet. Resident #98 had on gray socks and both feet were observed propped up on a pillow. Resident # 98 was not wearing prevalon boots. LPN #4 asked Resident #98, Where are your prevalon boots? Resident # 98 did not respond. LPN #4 then placed prevalon boots on Resident #98's feet, which were located behind the television. An interview was conducted on 03/06/2019 at approximately 10:23 a.m. with RN #1 (Registered Nurse) (Unit Manager). RN #1 was asked what the purpose of the resident's care plan is. RN #1 stated that the care plan is what's used to let nursing staff know what the resident needs are. RN #1 was asked who is responsible for developing the care plan. RN #1 stated that the MDS (Minimal Data Set) Coordinator is responsible for developing the care plan. RN #1 was asked who is responsible for implementing the care plan. RN #1 stated that the MDS Coordinator is responsible for implementing the care plan. RN #1 was asked staff ensure care plan interventions are in place and implemented. RN #1 stated that rounds are made to ensure that care planned interventions are in place. RN #1 was made aware of Resident #98 not wearing prevalon boots as ordered and care planned. RN #1 stated that he made sure the resident was wearing her prevalon boots after looking at her orders. An interview was conducted on 03/06/2019 at approximately 2:42 p.m. with LPN #2 (Licensed Practical Nurse) (MDS Coordinator). LPN #2 was asked who is responsible for developing and updating resident's care plan. LPN #2 stated, MDS is responsible for developing and updating the care plans. LPN #2 was asked the purpose of the care plan. LPN #2 stated that the purpose of the care plan is to keep nursing staff informed of resident's plan of care. On 03/06/2019 at approximately 12:30 p.m., ASM (Administrative Staff Member) #1 (Administrator), ASM #3 (Regional Nurse Consultant), and ASM #4 (Regional [NAME] President of Operations) were made aware of findings. 3b. The facility staff failed to develop a comprehensive care to address Resident # 98's sacral wound and the care required. Resident #98's Minimum Data Set (MDS) with an Assessment Reference Date of 01/18/2019 coded Resident #98 in Section M Skin Conditions M0100 A., Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. Section M Skin Conditions M0150 Risk of Pressure Ulcers/Injuries coded, Resident is at risk of developing pressure ulcers/injuries. Section M Skin Conditions M0300 F. coded Resident #98 as having 1 unstageable pressure ulcer/injury (1) that was present upon admission. On 03/06/2019, Resident #98's clinical record was reviewed. A physician order dated 02/04/19 documented, Cleanse sacrum with dermal wound cleanser, pat dry, apply foam dressing every day and as needed. Resident #98 did not have a comprehensive care plan addressing her sacral wound and the care required. An interview was conducted on 03/06/2019 at approximately 2:42 p.m. with LPN #2 (Licensed Practical Nurse) (MDS Coordinator). LPN #2 (MDS Coordinator) was asked who is responsible for developing and updating resident's care plan. LPN #2 stated, MDS is responsible for developing and updating the care plans. LPN #2 (MDS Coordinator) was asked what is the purpose of the care plan. LPN #2 (MDS Coordinator) stated that the purpose of the care plan is to keep nursing staff informed of resident's plan of care. LPN #2 (MDS Coordinator) was made aware of Resident #98 not having a wound care plan to address the resident's sacral wound and the care required. LPN #2 (MDS Coordinator) reviewed Resident #98's care plan and validated that there was not a wound care plan in the comprehensive care plan and that Resident #98 did have a sacral wound. On 03/06/2019 at approximately 12:30 p.m., ASM (Administrative Staff Member) #1 (Administrator), ASM #3 (Regional Nurse Consultant), and ASM #4 (Regional [NAME] President of Operations) were made aware of findings. References: (1) Pressure ulcers are also called bedsores, or pressure sores. They can form when your skin and soft tissue press against a harder surface, such as a chair or bed, for a prolonged time. This reduces blood supply to that area. Lack of blood supply can cause the skin tissue in this area to become damaged or die. This information was obtained from the website: https://medlineplus.gov/ency.patientinstructions/000147.htm 3c. The facility staff failed to implement Resident #98's comprehensive care plan for fall mats per physician order. On 3/5/19, separate observations revealed Resident #98 in bed with only one fall mat on the floor, on the left side of the resident's bed, instead of a fall mat to each side of the bed per the physician's order and comprehensive care plan. On 03/05/2019 at approximately at 8:40 a.m., Resident #98 was observed lying in bed, on her right side, under a light green colored blanket with feet exposed. One fall mat was on the left side Resident #98's bed on the floor. On 03/05/2019 at approximately 1:59 p.m., Resident #98 was observed lying in bed, on her back, under a light green colored blanket with feet exposed. One fall mat was on the left side Resident #98's bed on the floor. On 03/05/2019, Resident #98's clinical record was reviewed. Resident #98's comprehensive care plan documented, Fall mat times two to bedside for safety dated 03/22/2018. Resident # 98 had a physician order that documented, Fall mat to each side of bed for safety dated 12/17/2018. An interview was conducted on 03/06/2019 at approximately 10:23 a.m. with RN #1 (Registered Nurse) (Unit Manager). RN #1 was asked what the purpose of the resident's care plan is. RN #1 stated that the care plan is what's used to let nursing staff know what the resident needs are. RN #1 was asked who is responsible for developing the care plan. RN #1 stated that the MDS (Minimal Data Set) Coordinator is responsible for developing the care plan. RN #1 was asked who is responsible for implementing the care plan. RN #1 stated that the MDS Coordinator is responsible for implementing the care plan. RN #1 was asked how staff ensure care plan interventions are implemented and in place. RN #1 stated that rounds are made to ensure that care plan interventions are in place. RN #1 was made aware of Resident #98 not having a fall mat on both sides of the bed. RN #1 stated that he corrected the issue after reviewing the orders and care plan. On 03/06/2019 at approximately 12:30 p.m., ASM (Administrative Staff Member) #1 (Administrator), ASM #3 (Regional Nurse Consultant), and ASM #4 (Regional [NAME] President of Operations) were made aware of findings. 4. The facility staff failed to develop Resident #138's a comprehensive care plan to address the residents pain and the care required to address the residents pain. Resident #138 was admitted to the facility on [DATE]. Resident #138's diagnoses included but were not limited to high blood pressure, vitamin B12 deficiency and constipation. Resident #138's most recent MDS (minimum data set), a significant change in status assessment with an ARD (assessment reference date) of 2/15/19, coded the resident's cognition as severely impaired. Section J coded Resident #138 as having received PRN (as needed) pain medication and non-medication intervention during the last five days. Section J further coded Resident #138 reported having frequent pain during the last five days. Section V documented pain as a triggered care area and documented pain as being addressed in the care plan. Review of Resident #138's clinical record revealed a physician's order dated 1/29/19 for Tylenol (1) 650 mg (milligrams) every six hours PRN for pain or a fever greater than 101. Review of Resident #138's February 2019 MAR (medication administration record) revealed the resident was administered PRN Tylenol on 2/4/19, 2/5/19, 2/6/19, 2/10/19, 2/11/19, 2/12/19, 2/14/19, 2/15/19 and 2/18/19. Review of Resident #138's comprehensive care plan dated 2/15/19 failed to reveal documentation regarding pain. On 3/6/19 at 11:32 a.m., an interview was conducted with LPN (licensed practical nurse) #5 (the nurse who administered PRN Tylenol to Resident #138 on all of the above dates except 2/10/19). LPN #5 confirmed she administered Tylenol to Resident #138 for pain. When asked if a resident who is receiving pain medication should have a pain care plan, LPN #5 stated, Yes. On 3/6/19 at 4:13 p.m., an interview was conducted with RN (registered nurse) #2 (the nurse responsible for developing care plans). RN #2 was made aware of the above concern. RN #2 confirmed Resident #2 should have had a pain care plan and stated she created one on this date. On 3/6/19 at 4:50 p.m., ASM (administrative staff member) #1 (the administrator), ASM #3 (the regional nurse consultant) and ASM #4 (the regional vice president of operations) was made aware of the above concern. The facility policy titled, Care Plans, Comprehensive Person-Centered documented, Policy Statement: A comprehensive, person-centered car plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . The CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) manual documented: SECTION V: CARE AREA ASSESSMENT (CAA) SUMMARY Intent: The MDS does not constitute a comprehensive assessment. Rather, it is a preliminary assessment to identify potential resident problems, strengths, and preferences. Care Areas are triggered by MDS item responses that indicate the need for additional assessment based on problem identification, known as triggered care areas, which form a critical link between the MDS and decisions about care planning. There are 20 CAAs in Version 3.0 of the RAI, which includes the addition of Pain and Return to the Community Referral. These CAAs cover the majority of care areas known to be problematic for nursing home residents. The Care Area Assessment (CAA) process provides guidance on how to focus on key issues identified during a comprehensive MDS assessment and directs facility staff and health professionals to evaluate triggered care areas. The interdisciplinary team (IDT) then identifies relevant assessment information regarding the resident's status. After obtaining input from the resident, the resident's family, significant other, guardian, or legally authorized representative, the IDT decides whether or not to develop a care plan for triggered care areas. No further information was presented prior to exit. (1) Tylenol is used to relieve pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a681004.html Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to develop and/or implement the comprehensive care plan for four of 51 residents in the survey sample, Residents #53, #104, #98 and #138. 1. On 3/5/19, Resident #53 was observed on separate occasions without her physician ordered continuous oxygen in place. The clinical record failed to evidence any documentation regarding staff reapplying the oxygen or the resident being noncompliant with wearing her oxygen and notification to the physician per the comprehensive care plan. 2. The facility staff failed to develop a comprehensive care plan to address Resident #104's diabetes and the care required. 3a. On 3/5/19 during separate observations Resident #98 was observed without prevalon boots in place per the physician orders and comprehensive care plan. 3b. The facility staff failed to develop a comprehensive care to address Resident # 98's sacral wound and the care required. 3c. The facility staff failed to implement Resident #98's comprehensive care plan for fall mats per physician order. On 3/5/19, separate observations revealed Resident #98 in bed with only one fall mat on the floor, on the left side of the resident's bed, instead of a fall mat to each side of the bed per the physician's order and comprehensive care plan. 4. The facility staff failed to develop Resident #138's a comprehensive care plan to address the residents pain and the care required to address the residents pain. The findings include: 1. On 3/5/19, Resident #53 was observed on separate occasions without her physician ordered continuous oxygen in place. The clinical record failed to evidence any documentation regarding staff reapplying the oxygen or the resident being noncompliant with wearing her oxygen and notification to the physician per the comprehensive care plan. Resident #53 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: hypothyroid disease [decreased activity of the thyroid gland (1)]; rhabdomyolysis [is the breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood. These substances are harmful to the kidney and often cause kidney damage (2)], degenerative disc disease [disc disease is a common condition characterized by the breakdown (degeneration) of one or more of the discs that separate the bones of the spine (3)], and COPD [general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis (4)]. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/21/18, coded the resident as scoring a 8 on the BIMS (brief interview for mental status) score, indicating she was moderately impaired to make cognitive daily decisions. The resident was coded as completely dependent upon one or more staff members for all of her activities of daily living. In Section O - Special Treatments, Procedures and Programs the resident was coded as using oxygen while a resident in the facility. Resident #53 was observed on 3/5/19 at 9:05 a.m., the resident was in her bed, drinking some water. The oxygen tubing was not on the resident. The oxygen tubing was observed hanging over the end of the tubing closest to the concentrator. The tubing was not touching the ground. The oxygen concentrator was running. A second observation was made of Resident #53 on 3/5/19 at 12:33 p.m. The resident was in bed asleep. The oxygen concentrator was running and the tubing remained hanging off the tubing closet to the concentrator, and was not on the resident. The third observation of Resident #53 on 3/5/19 at 3:42 p.m. revealed the resident receiving her oxygen via a nasal cannula (a tubing with two prongs that insert into the nose) connected do an oxygen concentrator that was running. The physician order dated 6/22/18, documented, O2 (oxygen) at 2L/min (liters per minute) continuous. The comprehensive care plan reviewed on 12/21/18, documented in part, Problem: Per staff Resident is non-compliant with O2 at times, takes O2 off. The Approaches documented in part, Encourage O2 use as ordered. Educate resident about being non-compliant with O2 use. Document and report to MD (medical doctor) and RP (responsible party) as needed. Replace O2 when noticed off. Review of the nurse's notes for 3/5/19 failed to evidence documentation of the staff reapplying the resident's oxygen or, that the resident was noncompliant with wearing her oxygen and notification to the physician of non-compliance. An interview was conducted with RN (registered nurse) #3, the unit manager, on 3/6/19 at 3:15 p.m. RN #1 was asked if a resident has an order for oxygen and to document noncompliance and notify the doctor and the residents oxygen was observed off the resident, is the staff following the comprehensive care plan if staff documented nothing, regarding reapplying the oxygen, noncompliance with wearing the oxygen, or physician notification. RN #3 stated it would not be following the care plan. An interview was conducted with LPN (licensed practical nurse) #9 on 3//6/19 at 3:33 p.m. When asked if the resident did not have her oxygen on per the physician order, and the care plan documents to administer oxygen per the physician order, were the staff following the care plan, LPN #9 stated, No. The facility policy, Care Plans, Comprehensive Person-Centered documented in part, 1. The Interdisciplinary Team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Administrative staff member (ASM) #1, the administrator, ASM #3, the regional nurse consultant, and ASM #4, the regional vice president of operations, were made aware of the above findings on 3/6/19 at approximately 6:00 p.m. No further information was provided prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 286. (2) This information was obtained from the following website: https://medlineplus.gov/ency/article/000473.htm (3) This information was obtained from the following website: https://ghr.nlm.nih.gov/condition/intervertebral-disc-disease. (4) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124. 2. The facility staff failed to develop a comprehensive care plan to address Resident #104's diabetes and the care required. Resident #104 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: diabetes, chronic kidney disease requiring hemodialysis [a procedure used in toxic conditions and renal [kidney] failure, in which wastes and impurities are removed from the blood by a special machine (1)], history of amputation of his left leg and toes on his right foot, and depression. The most recent MDS (minimum data set) assessment, a Medicare 30 day assessment, with an assessment reference date of 2/2/19, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was capable of making daily cognitive decisions. The resident was coded as requiring from limited to total assistance for his activities of daily living. In Section I - Health Conditions, the resident was coded as having diabetes. The comprehensive care plan dated 1/13/19 was reviewed. The care plan failed to address the resident's diabetes and care required including that he receives insulin. The physician orders dated 1/11/19 documented in part, Lantus Solostar 100unit/ML (milliliters) (a long acting insulin used to treat diabetes) (2) 5 units SQ (subcutaneously) daily for diabetes. An interview was conducted with LPN (licensed practical nurse) #1 on 3/6/19 at 11:55 a.m. When asked if a resident has diabetes, should that be addressed on their care plan, LPN #1 stated, I believe so. LPN #1 was asked to review Resident #104's care plan. After the review, LPN #1 was asked if the resident's diagnosis of diabetes was in the resident's plan of care, LPN #1 stated, I don't see it. An interview was conducted with RN (registered nurse) #3, the unit manager, on 3/6/19 at 11:57 a.m. When asked if a resident with diabetes should have a care plan to address the diabetes, RN #3 stated, Yes, it should be. RN #3 was asked to review Resident #104's care plan. After the review, RN #3 stated, It's not there. RN #3 looked in the clinical record and found the diabetes addressed on the baseline care plan but she said it didn't get carried over to the comprehensive care plan. When asked if it should have been carried over to the comprehensive care plan, RN #3 stated, Yes. Administrative staff member (ASM) #1, the administrator, ASM #3, the regional nurse consultant, and ASM #4, the regional vice president of operations, were made aware of the above findings on 3/6/19 at approximately 6:00 p.m. No further information was provided prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 266. (2) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a600027.html

Based on observation, staff interview, and facility document review it was determined facility staff failed to store food in a sanitary manner in the facility's kitchen. The facility staff failed to ensure an opened five-pound container of pimento spread available for use had an open date and a use-by-date. The findings include: On 03/04/19 at 6:30 p.m., an observation of the facility's kitchen was conducted with OSM (other staff member) # 1, cook. An observation of the single door reach-in refrigerator revealed a five-pound container of Pimento Spread with approximately two-thirds remaining and available for use. Observation of the Pimento Spread container failed to evidence an open date and a use-by-date. Further observation of the container revealed a black stamped date on the side of the container. Observation of the black stamp revealed it was blurred and unreadable. After looking at the black stamp and examining the container of Pimento Spread OSM # 1 stated, I can't read the use-by-date. When asked if there was, an open date posted on the container, OSM # 1 stated, No. When asked to describe the procedure for storing open food items in the kitchen, OSM # 1 stated, It should be dated when it was opened and a use-by-date. The facility's policy Covering, Labeling, Dating Food documented, Good storage guidelines include date labeling food correctly to determine when a food is no longer safe to consume and should be discarded. Food labeling is also a component of proper food storage to easily identify foods, especially when the food has been removed from the original packaging. Under Refrigeration storage it documented, All foods must be covered, labeled and dated with a date label. All food should be monitored each day to be assured that the foods will be used, consumed or discarded by the use-by-date or expired date. On 03/05/19 at approximately 5:15 p.m. ASM (administrative staff member) # 1, the administrator and ASM # 3, regional nurse consultant, were made aware of the findings. No further information was provided prior to exit.