Based on observation, interview, staff interview, facility document review, and clinical record review, the facility staff failed to implement the care plan for one of 12 residents in the survey sample, Resident #10. The findings include: For Resident #10 (R10), the facility staff failed to implement Resident #10's care plan on 5/28/25 during incontinence care. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 416/25, R10 was coded as being cognitively intact. She was coded as being completely dependent on staff for bed mobility. On 5/28/25 at 1:18 p.m., R10 was observed lying in bed. She was awake and alert. She stated only one CNA (certified nursing assistant) was in the room earlier that morning to provide incontinence care for her. She stated the CNA was standing on R10's left, pulled the draw sheet too far, and the resident fell out of bed on the right side, landing on her knees. She stated she was still in a great deal of pain in both of her knees. She stated sometimes there are two CNAs when they provide incontinence care, and sometimes there is only one. A review of R10's care plan dated 4/10/25 revealed, in part: The resident is at risk for falls related to muscle weakness, related to recent hospitalization .The resident requires assistance with ADLs (activities of daily living) related to .weakness, recent hospitalization .2 person assist for bed mobility. A review of R10's Kardex for caregivers revealed, in part: Bed Mobility .2 person assist for bed mobility .draw sheet for turning and repositioning while in bed .lift sheet for turning and repositioning while in bed. A review of R10's clinical record revealed the following: 5/28/2025 08:02 (8:02 a.m.) Fall Note Description of the fall/V/S (vital signs) /injuries if any: Per CNA (certified nursing assistant) during perineal care, Resident slipped down to the floor. After assessment on Resident, there was no physical injuries, but Resident c/o (complained of) lateral knee pains .What interventions were in place at the time of the fall?: bed rails up, call bell, and personal belongings within reach, and bed in the lowest position. What are the risk factors that could have contributed to the fall?: Resident needs wide air mattress for comfort, and bed mobility. What new interventions were implemented in response to the fall?: Turned, repositioned, pain med administered, wired air mattress for comfort, and bed mobility ASAP (as soon as possible). On 5/29/25 at 9:03 a.m., LPN (licensed practical nurse) #3 was interviewed. He stated nurses and CNAs (certified nursing assistants) know how many staff members are required to provide care to a resident from the Kardex. After reviewing R10's Kardex, he stated the resident's care plan required two staff members at the bedside when incontinence care was being given because the resident was required to turn back in forth in bed for the care. He stated a care plan is developed to meet each resident's individual needs. He stated the charge nurse is responsible to oversee the CNAs and floor nurses to make sure the care plan is followed. On 5/29/25 at 10:10 a.m., CNA #2 was interviewed. She stated she provided incontinence care to R10 on 5/28/25 early in the morning. She stated she was in the process of changing the resident and grabbed the draw sheet. As she grabbed the draw sheet, R10 reached out to grab the grab bar. CNA #2 stated R10 let go of the grab bar and fell over the right side of the bed. She stated R10 should always have two staff members when she is being changed for safety. She stated all other staff members were busy with other things because it was almost time for shift change. She stated she was aware that the resident fell because there was not a second staff member on the resident's right side of the bed. On 5/28/25 at 10:32 a.m., ASM (administrative staff member) #1, the administrator, was informed of these concerns. A review of the facility policy, Care Planning, revealed, in part: A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care, and the necessary health-related care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being of the patient.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide nutritional care and services consistent with a resident's comprehensive plan of care for one of 12 residents in the survey sample, Resident #12. The findings include For Resident #12 (R12), the facility staff failed to accurately monitor and document the resident's breakfast meal intake on 5/29/25. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 3/4/25, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. R12's comprehensive care plan revised on 3/4/25 documented, Nutrition Risk r/t (related to) therapeutic diet orders, hx/o (history of) sepsis, copd (chronic obstructive pulmonary disease [lung disease]), gerd (gastroesophageal reflux disease), bipolar. Hx/o sig (significant) wt (weight) gain .Interventions: monitor intake and record each meal . R12's meal ticket for breakfast on 5/29/25 documented the tray contained scrambled egg substitute with vegetables, wheat toast, orange juice, and grits. On 5/29/25 at 9:16 a.m., R12's breakfast tray was observed. R12 had drank coffee and juice but did not eat any of the food (the eggs, grits, or toast). R12 stated he did not feel like eating. CNA (certified nursing assistant) #8 entered the room, removed R12's tray, and did not open the plate cover to observe how much food the resident had consumed. A review of R12's May 2025 ADL (activities of daily living) records revealed CNA #8 documented R12 consumed 51% to 75% of his breakfast. On 5/29/25 at 1:33 p.m., an interview was conducted with CNA #8. CNA #8 stated she monitors residents' meal intakes by watching what the residents eat and documenting accordingly. CNA #8 stated she picked up R12's tray that morning and the resident ate about 75% of his meal. On 5/29/25 at 1:37 p.m., in the presence of CNA #8, R12 stated he did not eat breakfast that morning. CNA #8 stated R12's wife eats food off the resident's tray. On 5/29/25 at 1:39 p.m., another interview was conducted with CNA #8 (not in the presence of R12). CNA #8 stated that although she knew R12's wife eats food off the resident's plate, she documented according to her observation of the resident's plate and did not ask R12 how much food he consumed. On 5/29/25 at 1:41 p.m., another interview was conducted with R12. R12 stated his wife did not eat any food off his plate that morning. On 5/29/25 at 2:05 p.m., an interview was conducted with OSM (other staff member) #8 (the registered dietician). OSM #8 stated he reviews residents' meal intakes when completing their nutritional assessments. On 5/29/25 at 2:50 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern. The facility policy titled, Meal Intake documented, Meal intake will be documented after each meal. No further information was presented prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure a resident was free from an unnecessary medication for one of 12 residents in the survey sample, Resident #9. The findings include: For Resident #9 (R9), the facility staff failed to hold the medication hydralazine (medication for high blood pressure) per the physician ordered parameter of a systolic blood pressure less than 140. A review of R9's clinical record revealed a physician's order dated 2/27/25 for hydralazine 50mg (milligrams)-one tablet by mouth two times a day for hypertension (high blood pressure). Hold for SBP (systolic blood pressure) less than 140. A review of R9's March 2025 MAR (medication administration record) revealed the resident was administered hydralazine on 3/4/25 at 9:00 a.m. although the resident's systolic blood pressure was 134, administered hydralazine on 3/4/25 at 10:00 p.m. although the resident's systolic blood pressure was 137, and administered hydralazine on 3/5/25 at 9:00 a.m. although the resident's systolic blood pressure was 138 (as evidenced by check marks on the MAR). A nurse's note dated 4/8/25 documented, NP (Nurse Practitioner), (name) and (name) and RP (Responsible Party), (name) aware on 3/4 at 2200 (10:00 p.m.) and on 3/5 at 0900 (9:00 a.m.), resident was given hydralazine outside of prescribed parameters, no adverse reactions or abnormalities noted at the time, BP (Blood Pressure) continued to be monitored. On 5/28/25 at 4:00 p.m., an interview was conducted with LPN (licensed practical nurse) #1 (the nurse who documented the above note). LPN #1 stated on certain days, she runs a report and looks to see if medications were administered out of physician ordered parameters. LPN #1 stated that on 3/4/25 and 3/5/25, the nurses gave R9 hydralazine without paying attention to the parameter. LPN #1 stated the parameter was to hold the medication if the resident's systolic blood pressure was less than 140. LPN #1 stated that on those dates the medication was administered and should not have been. On 5/29/25 at 2:50 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern. The facility policy titled, General Guidelines for Medication Administration documented, II. Administration. 2. Medications are administered in accordance with written orders of the prescriber. No further information was presented prior to exit.

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to follow infection control practices during ADL (activities of daily living) care for one of 12 residents in the survey sample, Resident #4. The findings include: For Resident #4 (R4), the facility staff failed to follow enhanced barrier precautions when providing ADL care including incontinence care, dressing and linen change on 5/29/25. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/6/25, the resident was assessed as being dependent for toileting, dressing and transfers. The assessment documented one venous or arterial ulcer present with dressing applications completed. Observation of R4's room on 5/28/25 at 11:53 a.m. revealed a sign located outside of the door which documented in part, Stop Enhanced Barrier Precautions . Wear gown and gloves when entering room to provide the following high-contact resident care activities: *Dressing *Bathing/Showering *Transferring *Changing Linens *Providing Hygiene *Changing briefs or assisting with toileting . A plastic bin located outside of R4's doorway contained yellow isolation gowns and gloves. The comprehensive care plan for R4 documented in part, The resident has a venous/stasis ulcer of the Right inner Lateral leg r/t (related to) PVD (peripheral vascular disease). Created on: 08/26/2021. Revision on: 04/20/2023. On 5/29/25 at 11:30 a.m., an observation was made of CNA (certified nursing assistant) #6 providing ADL care to R4. CNA #6 was observed providing incontinence care, changing a soiled brief, dressing R4 and changing soiled bed linens. CNA #6 was observed to wear gloves but failed to wear a gown during the care provided. After performing ADL care, LPN (licensed practical nurse) #7 assisted CNA #6 to transfer R4 from the bed to the wheelchair. Neither staff member wore a gown during the care provided. On 5/29/25 at 11:43 a.m., an interview was conducted with LPN (licensed practical nurse) #8, infection preventionist. LPN #8 stated that the criteria for residents to be on enhanced barrier precautions (EBP) was for chronic wounds with drainage, PICC (peripherally inserted central catheters) or anything that could cause an infection were an indication for EBP. She stated that the criteria was basically driven from the facility policy. LPN #8 stated that when on EBP, the staff wore gown and gloves when providing care such as wound care, bed baths, and ADL care. On 5/29/25 at 1:21 p.m., an interview was conducted with CNA #8 who stated that when a resident was on EBP there was a sign on the door and a bin outside of the room that held the gowns and gloves for them. She stated that they wore the gowns and gloves when they were providing care such as baths and incontinence care. The facility policy Enhanced Barrier Precautions (EBPs) effective 3/26/24, documented in part, Employees providing high-contact patient care activities will follow Enhanced Barrier Precautions (EBPs) for patients who meet the criteria . EBPs require the use of gown and gloves by staff during high-contact patient care activities as defined below: a. Dressing, b. Bathing/showering, c. Transferring, d. Changing linens, e. Providing hygiene, f. Changing briefs or assisting with toileting . On 5/29/25 at 2:51 p.m., ASM (administrative staff member) #1, the administrator and ASM #5, regional director of clinical services were made aware of the concern. No further information was provided prior to exit.

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide notification to the responsible party of a change in resident treatment for one of 33 residents in the survey sample, Resident #309. The findings include: For Resident #309 (R309), the facility staff failed to notify the responsible party of the Losartan (1) medication being held due to low blood pressure. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 11/29/2023, the resident scored 5 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. The comprehensive care plan for R309 documented in part, Cardiac: the resident is at risk for cardiac complications secondary to hypertension r/t (related to) bilateral lower edema. Created on: 12/05/2023. Revision on: 12/18/2023. Review of R309's progress notes revealed the following: - 11/27/2023 0821 (8:21 a.m.) Note Text : Losartan Potassium Oral Tablet 100 MG, med withheld due to low BP, BP-92/57. - 11/27/2023 1300 (1:00 p.m.) Medical Progress Note . VS (vital signs) show hypotension today and currently on supplemental O2 (oxygen) and labs show AKI (acute kidney injury), hypocapnia, hyperglycemia and leukocytosis. CXR (chest x-ray) shows mild pneumonia in left base . Assessment and Plan: .AKI/hypocapnia, Hold Losartan, Start BMP (basic metabolic profile) in a few days. Hypotension, Hold BP (blood pressure) meds (medications), Check BP in 1 hr, HTN (hypertension) hold Losartan 2/2 (secondary to) AKI and hypotension . The progress notes failed to evidence notification of the responsible party for the holding the Losartan secondary to the acute kidney injury and hypotension. The physician orders documented in part, Losartan Potassium Oral Tablet 100 MG (milligram) (Losartan Potassium) Give 1 tablet by mouth one time a day for HTN. On hold starting 11/27/2023 16:09 (4:09 p.m.). Order Date: 11/22/2023 . The eMAR (electronic medication administration record) for R309 documented the Losartan tablet administered from 11/23/2023 through 11/26/2023 and held on 11/27/2023. Review of R309's medical record documented a medical power of attorney dated 12/29/2020 granting power of attorney to a family member. On 3/27/2024 at 1:46 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that if a medication was held due to low blood pressure they alerted the physician or nurse practitioner to get orders to hold the medication or to give the medication at a later time. She stated that after the physician or nurse practitioner were notified, staff also informed the responsible party and documented the notification in the medical record. On 3/27/2024 at 2:27 p.m., an interview was conducted with LPN #4. LPN #4 stated that if a medication was held they called the nurse practitioner and notified the responsible party. She stated that they wrote a progress note when holding a medication and documented in the note about the physician or nurse practitioner and responsible party notification. A request was made to LPN #4 for evidence of responsible party notification of the Losartan being held on 11/27/2023. On 3/27/2024 at approximately 3:00 p.m., LPN #3 stated that they were unable to find evidence of the responsible party being notified of the Losartan being held due to hypotension on 11/27/2023. The facility policy Significant Change of Condition dated 11/1/2019 documented in part, . Responsible party will also be notified of a change in condition . Notification of the responsible party shall be documented in the progress notes including time and name of person notified . On 3/28/2024 at 8:49 a.m., ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. Reference: (1) Losartan is used alone or in combination with other medications to treat high blood pressure. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a695008.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 that the facility staff failed to provide the required notification, to the Ombudsman, for a facility-initiated transfer for one of 33 residents in the survey sample, Residents #92 (R92). The findings include: For R92, the facility staff failed to have evidence that written notification was provided to the ombudsman for a facility-initiated transfer on 12/04/2023. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 02/24/2024, R92 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R92 was cognitively intact for making daily decisions. The facility's progress noted for R92 dated 12/04/2023 documented, Resident transferred out to (Name of Hospital) ER (emergency room) r/t (related to) fluctuations in blood pressure readings @ (at) 2100 (9:00 p.m.) 12/4/23. This nurse called hospital and spoke with (Name of Registered Nurse) in ER who states resident is being admitted for UTI (urinary tract infection), low blood pressure and possible sepsis (1). NP (nurse practitioner) notified. Review of the EHR (electronic health record) for R92 failed to include evidence that written notification of the transfer was provided to the ombudsman for the facility-initiated transfer on 12/04/2023. On 03/27/24 at approximately 1:06 p.m., an interview was conducted with OSM (other staff member) #6, director discharge planning. OSM #6 stated she did not have evidence that the ombudsman was notified of R92's transfer to the hospital on [DATE]. When asked to describe the procedure for notifying the ombudsman of a resident's discharge or transfer she stated the facility's notice of transfer form is faxed to the ombudsman the same day the resident is transferred. The facility's policy Notice of Transfer/Discharge documented in part, Procedure: 7. Provide designated copies of the completed (Name of Corporation) Notice of Transfer/Discharge form to each of those specified on the form, which includes the Ombudsman. 9. Once the document has been scanned into PCC (point click care - electronic health record), complete a Social Work and Discharge Planning Progress Note confirming the following: b. Date the notice was sent to the Ombudsman and the method by which it was sent (The Ombudsman should be notified as close as possible to the actual time of a facility-initiated transfer or discharge. On 03/27/2024 at approximately 4:15 p.m., ASM (administrative staff member) # 1, administrator, and ASM # 2, director of nursing were made aware of the above findings. No further information was provided prior to exit. Reference: (1) An illness in which the body has a severe, inflammatory response to bacteria or other germs. This information was obtained from the website: https://medlineplus.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services for a pressure injury for one of 33 residents in the survey sample, Resident #97. The findings include: For Resident #97 (R97), the facility staff failed to clean a pair of scissors immediately before pressure injury wound care was provided. R97 was admitted to the facility with a stage four pressure injury (1) on the left buttock. R97's comprehensive care plan dated 1/18/24 failed to document information regarding sanitation during wound care. A review of R97's clinical record revealed a physician's order dated 3/12/24 to cleanse the left buttock with normal saline, pack with collagen particles, cover with moist gauze, and cover with bordered foam. On 3/27/24 at 1:55 p.m., during an observation of R97's pressure injury wound care, LPN (licensed practical nurse) #2 removed a pair of scissors from her pocket, placed the scissors on a clean field, picked up the scissors, cut a piece of collagen with the scissors, then placed the collagen into R97's wound. LPN #2 did not clean the scissors in between removing them from her pocket and cutting the collagen that was placed into R97's wound. On 3/27/24 at 2:15 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated she cleaned the scissors while setting up in the hall but did not clean the scissors in between removing the scissors from her pocket and cutting the collagen. LPN #2 stated she should have cleaned the scissors after removing them from her pocket for sanitation. On 3/27/24 at 4:14 p.m. ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing were made aware of the above concern. The facility policy titled, General Wound Care/Dressing Changes failed to document specific information regarding cleaning scissors for wound care. Reference: (1) A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. This information was obtained from the website: https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide urinary catheter care and services for one of 33 residents in the survey sample, Resident #97. The findings include: For Resident #97 (R97), the facility staff failed to maintain the resident's urinary catheter (1) drainage bag in a sanitary manner. R97's comprehensive care plan dated 1/19/24 failed to document information regarding the placement of the resident's urinary catheter drainage bag. A review of R97's clinical record revealed a physician's order dated 2/21/24 that documented an order for a Foley (urinary) catheter related to a neurogenic bladder. On 3/27/24 at 8:26 a.m., R97 was observed lying in a low bed. The resident's urinary catheter drainage bag was attached to the bed frame and the bag was sitting on the floor. On 3/27/24 at 2:34 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated a urinary catheter drainage bag should not touch the floor for infection control reasons and also because someone's feet or a wheelchair could, yank on it. On 3/27/24 at 4:14 p.m. ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing were made aware of the above concern. The facility policy titled, Indwelling Urinary Foley Cath. & Drain Bag Changes failed to document specific information regarding the placement of the drainage bag. Reference: (1) A urinary catheter is a tube placed in the body to drain and collect urine from the bladder. This information was obtained from the website: https://medlineplus.gov/ency/article/003981.htm

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide urostomy care and services for one of 33 residents in the survey sample, Resident #259. The findings include: For Resident #259 (R259), the facility staff failed to obtain physician's orders for the type of urostomy wafer/pouch to use, and for how often the urostomy wafer/pouch should be changed. R259's comprehensive care plan dated 2/27/24 documented, The resident has a Urostomy. Change wafer and provide site care as ordered . A review of R259's clinical record revealed physician's orders to monitor urostomy output every shift and monitor for signs and symptoms of infection every shift. Further review of the clinical record failed to reveal physician's orders for the type of urostomy wafer/pouch to use, and for how often the urostomy wafer/pouch should be changed. On 3/27/24 at 2:34 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated residents with urostomies should have physician's orders to monitor for output and to monitor the site. LPN #3 stated residents with urostomies should also have physician's orders for the type of device and how often to change it to ensure nurses are using the right device and the device is being changed. On 3/27/24 at 3:24 p.m., LPN #3 stated she read the manufacturer's instructions for the urostomy wafer/pouch being used for R259 and the instructions did not document how often to change the device. LPN #3 stated she spoke to R259 and one nurse who stated the resident's urostomy wafer/pouch is changed every three to four days. LPN #3 stated she also talked to another nurse who didn't specify she changes R259's urostomy pouch/wafer every three to four days but stated she changes it when she notices sediment. On 3/27/24 at 4:14 p.m. ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing were made aware of the above concern. The facility did not provide a policy regarding urostomies. The manufacturer's instructions for the urostomy pouch used for R259 failed to document specific directions for when to change the pouch. Urostomy pouches are special bags that are used to collect urine after some types of bladder surgery. Instead of going to your bladder, urine will go outside of your abdomen into the urostomy pouch. The surgery to do this is called a urostomy. Part of the intestine is used to create a channel for the urine to drain. It will stick outside your abdomen and is called the stoma. The urostomy pouch is attached to the skin around your stoma. It will collect the urine that drains out of your urostomy. The pouch is also called a bag or appliance. The pouch will help: Prevent urine leaks Keep the skin around your stoma healthy Contain odor Types of Urostomy Pouches Most urostomy pouches come as either a 1-piece pouch or 2-piece pouch system. Different pouching systems are made to last different lengths of time. Depending on the type of pouch you use, it may need to be changed every day, every 3 days, or once a week. A 1-piece system is made up of a pouch that has an adhesive or sticky layer on it. This adhesive layer has a hole that fits over the stoma. A 2-piece pouch system has a skin barrier called a flange. The flange fits over the stoma and sticks to the skin around it. The pouch then fits onto the flange. Both kinds of pouches have a tap or spout to drain the urine. A clip or another device will keep the tap closed when urine is not being drained .Buying and Storing Supplies: Your provider will write a prescription for your supplies . This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000480.htm Changing the pouch Different pouching systems are made to last different lengths of time. Some are changed every day, some every 3 days or so, and some just once a week. It depends on type of pouch you use. This information was obtained from the website: https://www.cancer.org/cancer/managing-cancer/treatment-types/surgery/ostomies/urostomy/management.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide medically related social services to maintain the highest practicable physical, mental and psychosocial well-being for two of 33 residents in the survey sample, Residents #86 and #62. The findings include: For Resident #86 (R86) and Resident #62 (R62), the facility staff failed to evidence comprehensive medically related social service assessments for continued ability to consent to intimate relations. R86 and R62 shared a semi-private room in the facility, planned to be married and were currently sexually active. R86 most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/25/2024 assessed the resident as scoring 6 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were severely impaired for making daily decisions. The 8/25/2023 MDS assessment documented R62 scoring 13 out of 15 on the BIMS assessment, indicating they were cognitively intact at that time and the 11/25/2023 MDS assessment documented R62 scoring 9 out of 15 on the BIMS assessment, indicating they were moderately impaired for making daily decisions at that time. R62 most recent MDS assessment, an annual assessment with an ARD of 3/3/2024 assessed the resident as scoring 13 out of 15 on the BIMS assessment, indicating they were cognitively intact for making daily decisions. The previous assessment, a quarterly MDS with an ARD of 9/1/2023 assessed R62 as scoring 15 out of 15 on the BIMS assessment, indicating they were cognitively intact for making daily decisions. On 3/26/2024 at 12:10 p.m., an observation was made of R86 and R62's room. R86 was not in the room at the time. R62 was observed dressed lying on the bed. When asked about their roommate, R62 stated that he shared the room with his fiance and they were getting married soon. He stated that his girlfriend was in the dining room at that time. On 3/26/2024 at 3:59 p.m., an observation was made of R86 and R62 in their shared room. At this time an interview was conducted. R86 was observed to be oriented to person, place and month/year at that time. When asked about the shared room, R86 stated that she shared the room with her boyfriend and she loved him. R62 stated that the wedding was planned in June of this year at the facility and R86 was observed smiling. When asked about intimate relations, R86 and R62 both stated that they had relations and that staff allowed them privacy in the room when they were intimate. Both residents stated that they got along well and were happy with their living situation. The nursing progress notes for R86 documented in part, - 6/20/2023 15:45 (3:45 p.m.) This nurse spoke with resident's daughter/RP (responsible party) [Name of RP] about resident wanting to have sexual relations with another resident in the facility. Just to make RP aware that this is what resident is asking to do with another resident. RP stated that she understands and is fine with what [the resident] wants to do. - 10/4/2023 12:33 (12:33 p.m.) Resident RP [Name of RP] called and is fine with resident moving into a room with male resident. RP says she does not have any issues with it as long as it is allowed. A Room Change Notification for R86 dated 10/5/2023 documented R86 moving to the room with R62 at the request of R86. The psychiatric evaluations for R86 documented in part, - 6/21/2023 .She denies any anxiety or depression and states she really enjoys spending time with her boyfriend at the facility. She states he is very good to her . - 10/25/2023 .Pt (patient) has moved in the same room with her boyfriend who is also a patient at the faility [sic]. She states they get along well and she is happy about the move . Additional psychiatric evaluations dated 11/20/2023, 1/5/2024, and 2/23/2024 failed to evidence documentation of evaluation of R86's ability to continue to consent to be involved in an intimate relationship with another resident at the facility. The Discharge Planning admission Assessment for R86 dated 4/30/2023 and 11/9/2023 documented the resident planning to stay at the facility for long term care. The assessments failed to evidence continuing assessment for R86's cognitive abilities to engage in the relationship and ability to consent. The Discharge Planning Reassessment for R86 dated 7/31/2023 and 11/24/2023 failed to evidence documentation regarding the intimate relationship between R62 and R86. The assessments failed to evidence continuing assessment for R86's cognitive abilities to engage in the relationship and ability to consent. On 3/26/2024 at 4:27 p.m., a request was made to ASM (administrative staff member) #1, the administrator, for evidence of continued assessments for the ability to continue to consent for the sexual relationship between R86 and R62. On 3/27/2024 at approximately 8:00 a.m., ASM #1 provided the psychiatric nurse practitioner notes dated 6/21/2023, 8/30/2023 and 10/25/2023 and the nursing progress notes dated 6/20/2023 and 10/4/2023. The notes provided failed to evidence continued assessment for R86's cognitive abilities to engage in the relationship and ability to consent. On 3/27/2024 at 9:43 a.m., an interview was conducted with ASM #3, psychiatric nurse practitioner. ASM #3 stated that she followed R86 at the facility. She stated that R86 had requested to move into the room with R62 and she had evaluated both residents separately at that time to ensure that it was a mutual decision and that R86 was not coerced in any way to make the decision. She stated that the residents had been together for awhile and had plans to get married soon. She stated that she felt that R86 understood the decision that she was making but could not say that she was cognitively intact because that would mean that she was 100% able to make all decisions. She stated that R86 did make some decisions that were not the best but they were health related which were her main concern and what she followed R86 for. She stated that as far as intimate relations, R86 understood enough to make the decision to be involved and she did not have any concerns about her being involved in anything that she did not want to be in. She stated that R86's cognition waxed and waned and she had never come across as being coerced in the relationship. On 3/27/2024 at 10:29 a.m., an interview was conducted with OSM (other staff member) #6, the director of social services/discharge planner. OSM #6 stated that R86 did have a low BIMS score which indicated she was cognitively impaired but her cognition varied from day to day. She stated that the nurse had spoken with R86's responsible party because R86 and R62 were adamant about moving in together and getting married. She stated that the nurse had gotten permission from the RP for R86 to move in with R62 and they had also notified the RP that R86 wanted to have intimate relations with R62. She stated that when residents in the facility wanted to have intimate sexual relationships they had conversations with the residents to make sure that they were getting along and if things were happening quarterly and annually. She stated that she documented these in the discharge planning assessments. She stated that the former social service assistant did the last assessment for R86. She reviewed the assessment dated [DATE] and stated that she did not see anything regarding an assessment for cognitive ability to continue to consent for intimate relationships but would expect to see it documented. She stated that she thought that because the staff saw R86 everyday and were always observing for any changes that they did not always document it. The facility policy Medically Related Social Services dated 2022 documented in part, .In conjunction with medical and clinical staff, Social Work and Discharge Planning Staff will identify and provide assistance in meeting patients' psychosocial and medically related social service needs. Procedure: 1. Conduct initial and ongoing reviews of patients to assess needs. 2. Advocate for reasonable accommodation of individual patient needs or preferences except when the health or safety of other patients would be endangered; . 5. Provide emotional support and guidance in decision making. 6. Document interventions in patient medical record . The facility policy Standards of Documentation dated 2022 documented in part, Social Work and Discharge planning staff will provide timely and ongoing documentation in the patient's medical record to provide evidence of assessment of patient needs, for establishment of an individualized and appropriate interdisciplinary care plan, and to keep all interdisciplinary team members informed of psychosocial events impacting patient care/treatment . On 3/27/2024 at approximately 4:45 p.m., ASM #1, the administrator, and ASM #2, the director of nursing were made aware of the concern. On 3/28/2024 at 8:45 a.m., ASM #2 stated that R86's psychosocial needs were being assessed on an ongoing basis and any changes would be reported and reassessed as needed. He stated that the psychiatric nurse practitioner was following R86 and they had a counselor who was scheduled to see both residents. No additional documentation or written evidence or assessment was provided at that time. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide complete and accurate documentation for one of 33 residents, Resident #15. The findings include: The facility staff failed to evidence complete and accurate documentation for incontinence care for Resident #15. Resident #15 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), ESRD (end stage renal disease) and dementia. Resident #15's most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/7/24, coded the resident as scoring a 14 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 maximal assist for bed mobility, transfer, eating and hygiene. A review of Resident #15's comprehensive care plan dated 6/29/23 revealed, FOCUS: The resident is at increased risk for complications secondary to requiring hemodialysis secondary to ESRD. INTERVENTIONS: hemodialysis on M-W-F. Observe for signs and symptoms of complications related to ESRD including but not limited to fluid overload, hemorrhage, infection to the access site, hypotension, respiratory and/ or cardiac distress and notify physician as indicated. A review of the physician's order 2/2/23 revealed, 1500ml (milliliters) Fluid Restriction every shift for ESRD on HD (hemodialysis) 1500cc Fluid Restriction 1380ml 7a-7p and 120ml 7p-7a. A review of the February 2024 MAR (medication administration record) reveals documentation on 7pm-7am shift on 2/13 and 2/27 as 1380 ml. A review of the March 2024 MAR reveals documentation on 7pm-7am shift on 3/25 and 3/26 as 1500 ml. An interview was conducted on 3/27/24 at 3:40 PM with LPN (licensed practical nurse) #5. When asked if she remembered Resident #15's fluid restriction, LPN #5 stated, yes. She is usually asleep most of the night and then she is up early for dialysis. She takes a little water with her medication. When asked did she consume 1380 ml of fluid on night shift, LPN #5 stated, oh no, if that was documented then it was mis documented. I must have been in the middle of my documentation and was interrupted and documented that in error. When asked if Resident #15's medical record was complete and accurate, LPN #5 stated, no, it is not. On 3/27/24 at 4:30 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the Director of Nursing, were made aware of the findings. A review of the facility's Documentation Summary policy revealed Licensed nurses and CNAs (certified nursing assistant) will document all pertinent nursing assessments, care interventions and all follow up actions in the medical record. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence bed inspections for three of 33 residents in the survey sample, Residents #15, #38 and #54. The findings include: 1.The facility staff failed to perform bed rail inspections for the use of positioning / assist bars for Resident #15. Resident #15 was observed in bed with bilateral grab bars on 3/26/24 at 3:10 PM and 3/27/24 at 3:45 PM. Resident #15 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), ESRD (end stage renal disease) and dementia. Resident #15's most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/7/24, coded the resident as scoring a 14 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 maximal assist for bed mobility, transfer, eating and hygiene. A review of Resident #15's comprehensive care plan dated 5/22/20 revealed, FOCUS: The resident has Activity Intolerance and Fatigue. INTERVENTIONS: DEVICES: Assist bars/ Grab bars/ Bed rails aid in turning and positioning. A review of the physician orders dated 2/3/23 revealed, Grab bars for bed mobility. On 3/26/24 at approximately 2:30 PM the bed audit book 2024 was provided. A review of the bed safety audit form identified beds were inspected 3/26/24. The inspections included space less than four inches between mattress rails or footboard. On 3/27/24 at 9:40 AM ASM (administrative staff member) #1, the administrator stated, yes, the bed inspections were done yesterday. We have a new maintenance director. I will see if he can find the ones from 2023. On 3/27/24 at 1:10 PM an interview was conducted with OSM (other staff member) #2, the maintenance technician. When asked about the bed inspections, OSM #2 stated, we did them yesterday. We could not find any documents for 2023, but I will check with the director. 3/27/24 at 1:20 PM an interview was conducted with OSM #3, the maintenance director. When asked about the bed inspections, OSM #3 stated, it has been 10 days since I have been onsite here. I have been doing audits and realized that the prior 2023 bed inspections did not meet all the criteria. When asked what criteria is evaluated, OSM #3 stated, we look for the space between mattress/rails and footboard to make sure there is no entrapment concerns. We check for bed functionality and if all the bed parts are in good repair. The other form from 2023, did not identify any of those items. On 3/27/24 at 4:30 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the Director of Nursing, were made aware of the findings. A review of the facility's Bed System Audits policy revealed Maintenance will maintain an inventory of all beds in order to conduct annual and intermittent bed system audits to identify and mitigate areas of risk for possible entrapment and bed safety. No further information was provided prior to exit. 2.The facility staff failed to perform bed rail inspections for the use of positioning / assist bars for Resident #38. Resident #38 was observed in bed with bilateral grab bars on 3/26/24 at 3:00 PM and 3/27/24 at 8:23 AM. Resident #38 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), cerebrovascular accident and hemiparesis/hemiplegia. Resident #38's most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/7/24, 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 maximal assist for bed mobility, transfer, eating and hygiene. A review of Resident #38's comprehensive care plan dated 4/28/21 revealed, FOCUS: The resident has ADL (activities of daily living) self-care performance deficit related to Amputation bilateral BKA (below the knee amputation), Impaired balance and Limited Mobility. INTERVENTIONS: DEVICES: assist bar to aid in bed mobility in turning and positioning. A review of the physician orders dated 2/3/23 revealed, Grab bars for bed mobility. On 3/26/24 at approximately 2:30 PM the bed audit book 2024 was provided. A review of the bed safety audit form identified beds were inspected 3/26/24. The inspections included space less than four inches between mattress rails or footboard. On 3/27/24 at 9:40 AM ASM (administrative staff member) #1, the administrator stated, yes, the bed inspections were done yesterday. We have a new maintenance director. I will see if he can find the ones from 2023. On 3/27/24 at 1:10 PM an interview was conducted with OSM (other staff member) #2, the maintenance technician. When asked about the bed inspections, OSM #2 stated, we did them yesterday. We could not find any documents for 2023, but I will check with the director. 3/27/24 at 1:20 PM an interview was conducted with OSM #3, the maintenance director. When asked about the bed inspections, OSM #3 stated, it has been 10 days since I have been onsite here. I have been doing audits and realized that the prior 2023 bed inspections did not meet all the criteria. When asked what criteria is evaluated, OSM #3 stated, we look for the space between mattress/rails and footboard to make sure there is no entrapment concerns. We check for bed functionality and if all the bed parts are in good repair. The other form from 2023, did not identify any of those items. On 3/27/24 at 4:30 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the Director of Nursing, were made aware of the findings. No further information was provided prior to exit. 3.The facility staff failed to perform bed rail inspections for the use of positioning / assist bars for Resident #54. Resident #54 was observed in bed with bilateral grab bars on 3/26/24 at 2:45 PM and 3/27/24 at 8:55 AM. Resident #54 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: obstructive and reflux uropathy, chronic hepatitis and quadriplegia. Resident #54's most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/7/24, 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 maximal assist for bed mobility, transfer, eating and hygiene. A review of Resident #54's comprehensive care plan dated 1/16/23 revealed, FOCUS: The resident requires assistance with ADL (activities of daily living) relate to chronic health conditions, inability to perform ADLs, weakness; Diagnoses of Quadriplegia. INTERVENTIONS: DEVICES: Assist bars/ Grab bars/ Bed rails aid in turning and positioning. A review of the physician orders dated 2/3/23 revealed, Grab bars for bed mobility. On 3/26/24 at approximately 2:30 PM the bed audit book 2024 was provided. A review of the bed safety audit form identified beds were inspected 3/26/24. The inspections included space less than four inches between mattress rails or footboard. On 3/27/24 at 9:40 AM ASM (administrative staff member) #1, the administrator stated, yes, the bed inspections were done yesterday. We have a new maintenance director. I will see if he can find the ones from 2023. On 3/27/24 at 1:10 PM an interview was conducted with OSM (other staff member) #2, the maintenance technician. When asked about the bed inspections, OSM #2 stated, we did them yesterday. We could not find any documents for 2023, but I will check with the director. 3/27/24 at 1:20 PM an interview was conducted with OSM #3, the maintenance director. When asked about the bed inspections, OSM #3 stated, it has been 10 days since I have been onsite here. I have been doing audits and realized that the prior 2023 bed inspections did not meet all the criteria. When asked what criteria is evaluated, OSM #3 stated, we look for the space between mattress/rails and footboard to make sure there is no entrapment concerns. We check for bed functionality and if all the bed parts are in good repair. The other form from 2023, did not identify any of those items. On 3/27/24 at 4:30 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the Director of Nursing, were made aware of the findings. No further information was provided prior to exit.

Based on observation, staff interview, and facility document review, the facility staff failed to store food in a sanitary manner in one of one kitchen. The findings include: 1. The facility staff failed to store a scoop used for dry pureed bread mix in a sanitary manner. On 3/26/24 at 11:30 a.m., 3/26/24 at 4:30 p.m., and 3/27/24 at 10:20 a.m., a scoop was observed sitting inside of a container of dry pureed bread mix. The handle of the scoop was touching the inside of the container. On 3/27/24 at 1:11 p.m., an interview was conducted with OSM (other staff member) #5 (the dietary manager). OSM #5 stated sometimes the cook uses the scoop inside the dry pureed bread mix throughout the day and at the end of the day, he washes the scoop and hangs it up. OSM #5 stated most of the time, the cook removes the scoop from the container as soon as he uses it. OSM #5 stated the scoop should not be stored in the container because you want to make sure it isn't cross contaminated and someone else hasn't used it for other purposes. On 3/27/24 at 4:14 p.m. ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing were made aware of the above concern. The facility policy titled, Food Storage-Dry Goods documented, It is the Center policy to insure all dry goods will be appropriate stored in accordance with guidelines of the FDA Food Code. 2. The facility staff failed to ensure a vendor wore a hair restraint while in the kitchen. On 3/26/24 at 11:24 a.m., a vendor delivering boxes of food was observed walking through the kitchen twice without a hair restraint. No staff was observed asking the vendor to use a hair restraint. On 3/27/24 at 1:11 p.m., an interview was conducted with OSM (other staff member) #5 (the dietary manager). OSM #5 stated vendors are supposed to wear hair restraints in the kitchen and normally she monitors to ensure this is done. OSM #5 stated the regular vendor knows to wear a hair restraint, but he was off on 3/27/24 and a different vendor made the delivery. On 3/27/24 at 4:14 p.m. ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing were made aware of the above concern. The facility policy titled, Staff Attire documented, 1. The Dining Services Director insures that all staff members have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained.

Based on resident interview, facility document review and clinical record review, the facility staff failed to allow one of 37 residents in the survey sample to withdraw more than twenty dollars from their personal fund account at a time, Resident #99 (R99). The findings include: On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 4/1/2022, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is not cognitively impaired for making daily decisions. An interview was conducted with R99 on 4/19/2022 at approximately 12:30 p.m. R99 stated the facility keeps changing the rules about getting my money out. R99 stated the facility is only allowing the resident to take twenty dollars at one time. An interview was conducted with OSM (other staff member) #5, the receptionist, on 4/20/2022 at 3:24 p.m. When asked the process for residents to access their money in the personal fund account, OSM #5 stated the residents come to the front desk and ask for their money, the residents are given the money and a receipt is printed OSM #5 stated the residents can get $20 at a time. When asked why are they limited to $20, OSM #5 stated the facility only keeps so much on hand and has to replenish it. When asked if there was a new system put into place for the residents to obtain their money, OSM #5 stated a few months ago some changes were made. When asked how residents are notified of changes in the procedure for obtaining their money, OSM #5 stated residents are told verbally. OSM #5 stated a letter was sent to the responsible parties but the process for the residents is the same. When asked how long the $20 limit had been in effect, OSM #5 stated it was an old (former corporation name) operating system. When asked if a resident wants more than $20 how do they do that, OSM #5 stated larger amounts are given to the resident with a check that takes a few days to obtain. When asked, doesn't the resident have the right to their money, OSM #5 stated, absolutely. The resident can get $80 if it is approved by the administrator. The facility policy, Patient Trust Fund, documented in part, Policy: Requests for cash from the Patient Trust Fun petty cash box will be disbursed in accordance with Medicare and Medicaid regulations. Procedure: 1. According to State Regulations request for less than $50.00 ($100.00 for a Medicare Part A patient) in cash must be honored on the same day; requests for $50.00 ($100.00 for a Medicare Part A patient) or more in cash must be honored within three banking days. 2. Upon request for $20.00 or less from a patient: Cash will be disbursed immediately to the patient and a withdrawal properly signed .3. Upon request for $21.00 to $49.00 ($100.00 for a Medicare Part A patient): a. The patient should be given $20.00 in cash immediately. b. A withdrawal is prepared for the total amount of the requested cash. c. The amount given in cash is entered on the CAS - personal use cash line of the withdrawal. d. The amount of the check written for the balance of the request is entered on the withdrawal on the CHK - personal use line. e. The patient initials the CAS line to indicate the cash was received. f. A check, made payable to the Center Administrator, is written for the balance of the requested cash. g. The check is taken to the Patient Trust Fund bank and cashed. h. The balance of the requested cash is disbursed to the patient before the next of the business day. i. The patient signs the withdrawal after the balance of the cash requested is received. 4. Upon request for $50.00 ($100.00 for Medicare Part A patient) or more: a. A check, made payable to the Center Administrator, is written for the amount of the cash request. b. The Center has three (3) business working days to cash the check and disburse the funds to the patient, but every effort should be made to secure the cash by the next business day. c. The Patient Fund Withdrawal is written when the check is written. d. The patient signs the Patient Fund Withdrawal ticket after the money has been received. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and RN (registered nurse) #1, the unit manager, were made aware of the above findings on 4/20/2022 at approximately 5:15 p.m. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide respiratory care and services for 2 of 37 residents in the survey sample, Residents #33 and #97. The facility staff failed to administer oxygen to Resident #33 (R33) per the physician prescribed rate of three liters per minute. The facility staff failed to store a nebulizer mask in a sanitary manner for Resident # 97 (R97). The findings include: 1. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 2/4/22, the resident scored 6 out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely cognitively impaired for making daily decisions. A review of R33's clinical record revealed a comprehensive care plan dated 8/12/21 that documented, The resident has altered respiratory status/difficulty breathing r/t (related to) pneumonia. R33's April 2022 physician's order sheet documented a physician's order dated 3/28/22 for oxygen at three liters per minute as needed to keep the resident's oxygen saturation level above 90%. On 4/19/22 at 10:55 a.m. and 1:54 p.m., R33 was observed in a wheelchair in the bedroom, receiving oxygen at three and a half liters per minute. On 4/20/22 at 12:53 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated nurses are supposed to check residents' oxygen concentrator flow rate every shift. LPN #2 stated the middle of the ball in the oxygen concentrator flow meter should run through the three liter line if the physician's order is for three liters. On 4/20/22 at approximately 5:15 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The oxygen concentrator manufacturer's instructions documented, 2. Check the flow meter to make sure that the flow meter ball is centered on the line next to the prescribed number of your flow rate. The facility policy titled, Respiratory/Oxygen Equipment documented, 3. Set appropriate flow rate and place oxygen delivery device on the patient. No further information was presented prior to exit.2. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 3/24/2022, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is not cognitively impaired for making daily decisions. Observation was made on 4/19/2022 at approximately 11:15 a.m. of R97's room. A nebulizer machine was observed on the night stand. The nebulizer mask was sitting on the machine with no covering on it, open to air. A second observation was made on 4/20/2022 at 9:02 a.m. of R97's room. The nebulizer mask was sitting on the nebulizer machine without any covering. An interview was conducted with R97 at that time. When asked if she uses the nebulizer machine and mask, R97 stated she uses it three to four times a day and had just used it early this morning. The physician order dated, 1/24/2022, documented, Formoterol Furmarate Nebulization Solution (used to control wheezing, shortness of breath, and chest tightness caused by chronic obstructive pulmonary disease) (1) 20 MCG/ML (micrograms per milliliter) - 2 ml inhale orally via nebulizer two times a day for COPD (chronic obstructive pulmonary disease). The comprehensive care plan dated, 12/8/2021, documented in part, Focus: The resident has altered respiratory status/difficulty breathing r/t (related to) COPD. The Interventions documented in part, Administer medications/puffers as ordered. An interview was conducted with LPN (licensed practical nurse) #2 on 4/20/2022 at 12:56 p.m. When asked how a nebulizer mask is stored when it is not in use, LPN #2 stated it should be in a bag. When asked why it is stored in a bag, LPN #2 stated they didn't know but that's what they were taught to do. The facility policy provided entitled, Respiratory/Oxygen Equipment documented in part, Licensed staff will administer and maintain respiratory equipment, oxygen administration and oxygen equipment per physician's order and in accordance with standards of practice. The policy addresses the care of Non-heated/heated Aerosol Trach Collar/Mask but the facility staff highlighted, Store mask/collar in storage bag when not in use. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and RN (registered nurse) #1, the unit manager, were made aware of the above findings on 4/20/2022 at approximately 5:15 p.m. No further information was provided prior to exit.

Based on staff interview, facility document review and employee record review, the facility staff failed to perform annual performance evaluations on two of five CNA (certified nursing assistant) record reviews. The findings include: On 4/20/2022 at 9:23 a.m. OSM (other staff member) #7, the human resources staff member, presented the documentation of annual performance evaluations for three of the five CNAs; CNA #5, CNA #1, CNA #7. OSM #7 stated that CNA #4 and CNA #6 got an across the board raise so no performance evaluations were completed. The facility policy, Merit Increase documented in part, Policy: (Initials of company) will evaluate employees annually and reward eligible employees for performance through annual merit increases .Procedure: 1. Employees may earn merit increases for performance .4. Generally, all employees will receive a performance appraisals annually. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and RN (registered nurse) #1, the unit manager, were made aware of the above findings on 4/20/2022 at approximately 5:15 p.m. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to honor a resident's preferences for one of 37 residents in the survey sample, Resident #309 (R309). The findings include: 1. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/11/22, R309 scored 14 out of 15 on the BIMS (brief interview for mental status), indicating she is cognitively intact for making decisions. On 4/19/22 at 11:34 a.m., R309 was interviewed. R309 stated she had concerns about not getting the food that was the meal ticket for each meal. R309 stated it was rare for them to receive anything close to what they had repeatedly told staff they were able to eat. On 4/19/22 at 1:37 p.m., R309 sat in a wheelchair at the overbed table. An open plate of food was on a tray on the overbed table. R309 was not eating. The meal ticket on R309's tray included the following items: shrimp and vegetable stir fry, orange twist, buttered white rice, roll, margarine, frosted carrot cake, 2% milk, hot coffee or hot tea. R309's meal tray contained the following items: steamed shrimp (unseasoned and without sauce, per R309), steamed mixed vegetables (without any sauce), rice, cold tea, and yellow cake with chocolate icing. The tray did not contain hot coffee or tea, 2% milk, or an orange twist. R309 stated this was typical for her meal trays; the facility substituted other items without informing the resident, and the resident was unaware of an option to get any other items. R309 stated someone from the dietary staff met with the resident within a couple of days of admission. R309 told the staff of the preference for eggs and bacon for breakfast, milk on every tray at every meal, and an extra sandwich at lunch. R309 stated she had trouble with nausea often, and the sandwich was something she felt she could always eat. R309 stated she rarely received bacon, and never received milk. R309 stated she had sometimes asked for an alternate or for additional food, but the staff usually told her that the kitchen was all out. CNA (certified nursing assistant) #3 entered the room. CNA #3 stated she was unaware of any substitutions made on the menu for that meal. CNA #3 stated the shrimp and vegetables were not stir fried, as the published menu stated. CNA #3 it might be possible for her to go to the kitchen to see if there was any other food for R309, but she had not had very good luck in doing so in a really long time. She stated, Sometimes they have something else and sometimes they don't. CNA #3 was not aware of any way to address the missing items from R309's tray. On 4/20/22 at 9:32 a.m., R309 sat in a wheelchair at the overbed table. An open plate of food was on a tray on the overbed table. R309 was not eating. The meal ticket on R309's tray included the following items: Orange juice, scrambled egg substitute, orange twist, wheat toast, margarine, oatmeal, 2% milk, hot coffee or tea. R309's meal tray contained the following items: oatmeal, cooked egg products in a perfect square, orange sliver, and biscuit. The tray did not contain milk or wheat toast. On 4/20/22 at 9:53 a.m., OSM (other staff member) #1, the culinary service manager, entered the room and was interviewed. OSM #1 stated the daily menus are posted in the hallway across from the nurse station. OSM #1 stated only 2 main entrees are offered (a primary and an alternate), and each resident receives the primary entree at every meal. She stated if the resident wants something different, the CNA who served the meal is responsible for being knowledgeable about the alternates, going to the kitchen, and obtaining the alternate meal for the resident. OSM #1 stated she had not yet met with R309 to determine the resident's preferences because OSM #1 had been out of work for a period of time. OSM #1 stated another member of the culinary services staff had met with R309. OSM #1 was shown R309's breakfast tray, and was asked to compare the tray to the meal ticket. OSM #1 stated R309 had not received scrambled eggs, milk, or wheat toast. OSM #1 stated R309 had not received wheat toast. When asked if OSM #1 was aware that R309 had expressed a preference for eggs and bacon for breakfast, and milk at every meal, OSM #1 stated she was not. R309 told OSM #1 that she had requested the nurse to call the kitchen at 7:30 a.m. this morning to specifically ask for extra bacon. OSM #1 agreed there was no bacon at all on R309's tray. A review of R309's Food Preferences Interview form dated 4/7/22 revealed, in part: Breakfast 2% milk; Lunch 2% milk; Dinner 2% milk .Breakfast: milk, scrambled eggs, toast, jelly, bacon; Lunch: milk, tuna sandwich extra; Dinner: milk. On 4/20/22 at 10:44 a.m., OSM #1 and OSM #2, the regional director of culinary services, were interviewed. OSM #1 stated the tray line staff are responsible for making sure the food on the residents' trays match the meal tickets and the residents' stated food preferences. OSM #2 stated that when a staff member meets with a resident, the staff member is responsible for informing other members of the culinary services staff of the resident's preferences. The staff member should make changes as needed to each resident's meal tickets as an additional way of communicating a resident's preferences. OSM #1 stated several staff members have met with R309 during the resident's stay at the facility, and that R309 has been one who will switch on you in a heartbeat. On 4/20/22 at 5:09 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. Policies regarding resident meal preferences were requested. On 4/21/22 at 8:40 a.m., ASM #1 stated the facility did not have a policy related to central line care. No further information was provided prior to exit.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to implement infection control practices for one of nine residents during the medication administration observation, Resident #105. The facility staff failed to administer oral medication to Resident #105 (R105) in a sanitary manner. The findings include: On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/31/22, the resident scored 3 out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely cognitively impaired for making daily decisions. On 4/20/22 at 7:55 a.m., an observation of LPN #1 preparing and administering medications was conducted. LPN #1 popped a pill out of a blister pack and the pill dropped on top of the medication cart. LPN #1 scooped the pill into the medication cup then administered the pill to R105. LPN #1 had not disinfected the cart prior to the medication pass or dropping the pill on the cart. On 4/20/22 at 1:14 p.m., an interview was conducted with LPN #1. LPN #1 stated a pill dropped on top of the medication cart should be thrown away for infection control reasons. LPN #1 stated she did not have a reason or excuse for scooping the dropped pill into the medication cup and administering the pill to R105. LPN #1 stated it was just her instinct. On 4/20/22 at approximately 5:15 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility pharmacy policy titled, Oral Medication Administration documented, 3. For solid medications: a. Pour or push the correct number of tablets or capsules into the soufflé cup, taking care to avoid touching the tablet or capsule unless wearing gloves. The policy did not include specific information regarding dropping a pill on the medication cart. No further information was presented prior to exit.

Based on staff interview, facility document review and clinical record review, the facility staff failed to follow physician's orders for three of 37 residents in the survey sample, Resident # 93 (R93), Resident #15 (R15) and Resident #75 (R75). The facility staff failed to monitor a fluid restriction for R93; and failed to provide care and services for a central venous access (central line) for R15 and R75. The findings include: 1. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 3/31/2022, R93 scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section O - Special Treatments, Procedures and Programs, the resident was coded as receiving dialysis. The physician order dated 4/11/2022, documented, Fluid Restriction (1200 ml [milliliters]) Give the following fluid volume with medication administration: 7-3 [7:00 a.m. to 3:00 p.m.] meds: (120 ml with morning meds and 120 ml afternoon meds) 3-11 [3:00 p.m. to 11:00 p.m.] meds: 120 ml (evening meds) 11-7 [11:00 p.m. to 7:00 a.m.] meds: 40 ml (night meds). Remainder 600 ml with daily meals (120 ml breakfast, 240 ml lunch, 240 ml dinner) every shift for Fluid Restriction. The MAR (medication administration record) documented the above order. The MAR documented two opportunities for indicating the amount of fluids taken, one for days and one for nights. On 4/15/2022 the days documented 1340 ml, the nights documented 550 ml consumed, for a total of 1890 ml in a 24 hour period. On 4/19/2022, the days documented 960 ml and the nights documented 960 ml consumed, for a total of 1920 ml in a 24 hour period. Review of the nurse's notes dated 4/11/2022 through 4/19/2022, failed to evidence documentation regarding the fluid restriction. The comprehensive care plan dated, 7/2/2020 and revised on 4/19/2022, documented in part, Focus: Nutrition Risk r/t (related to) ESRD (end stage renal disease) on HD (hemodialysis) .+1200 ml fluid restriction. LPN (licensed practical nurse) #3 was interviewed on 4/20/2022 at 4:16 p.m. When asked who is responsible for monitoring the physician ordered fluid restriction for a resident, LPN #3 stated she looks at the meal trays as they are handed out and then the CNA (certified nursing assistants) usually provides information on how much they are drinking. LPN #3 stated the residents have a certain amount of cups. When asked where the amount of fluids a resident consumes is documented, LPN #3 stated it is documented in the MAR. When asked who monitors the fluid restriction, LPN #3 stated each nurse on each shift monitors the amount for the shift. LPN #3 stated she monitors and records it for 3-11 shift. When asked if anyone is responsible for monitoring the totals for the day, LPN #3 stated, no, the nurse monitors it when she puts it in for her shift. When asked the purpose of a fluid restriction for R93, LPN #3 stated the resident is a dialysis patient and his kidneys are not working properly. Again asked who is monitoring the exact amount the resident is taking, LPN #3 stated that was a good question. The MAR was reviewed with LPN #3. On 4/20/2022 at 4:43 p.m., RN (registered nurse) #2, and RN #1, both unit managers, were interviewed. When asked the purpose of a fluid restriction for a resident on dialysis, RN #2 stated so the resident will not go into fluid overload between dialysis as they can't rid themselves of the fluid. When asked who monitors the fluid restriction, RN #2 stated the nursing staff. When asked who looks at it to see if the resident is over or under the physician ordered fluid restriction, RN #2 stated it should have a total for the day and the nurses should look at it at the end of their shift. Each nurse is responsible on their shift to monitor it. RN #1 stated, typically we, the nurses, go around to the residents on fluid restrictions and make sure there are no extra cups in the room, everything they drink is recorded. RN #1 stated the physician orders specify what the resident are supposed to get each shift. RN #1 stated each nurse is documenting what they gave. The above orders were reviewed with RN #1, when asked about documentation, RN #1 stated, the nurse signing off at 3:00 p.m. should tell the oncoming nurse how much they gave the resident and then the next nurse will document the total until 7:00 p.m. When asked what are the potential consequences for R93 to go over their fluid restriction, RN #2 stated, a lot could arise, congestive heart failure, fluid overload or edema. The facility policy, Fluid Management/Fluid Restriction documented in part, Policy: The nursing staff will assess and monitor adherence to fluid management for patients placed on fluid restriction .Procedure: 7. Document fluid intake. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and RN (registered nurse) #1, the unit manager, were made aware of the above findings on 4/20/2022 at approximately 5:15 p.m. No further information was provided prior to exit. 2. On the most recent MDS, (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/18/22, R15 scored 12 out of 15 on the BIMS (brief interview for mental status), indicating the resident is moderately cognitively impaired for making daily decisions. On 4/19/22 at 4:05 p.m., R15 was sitting up in a wheelchair. During the interview, R15 stated concern about the central line used to administer IV antibiotics. R15 stated the antibiotic was complete, but the central line had remained. The resident was worried about getting an infection from the central line. The central line access was located on R15's right upper arm. The dressing was dated 4/4/22. On 4/20/22 at 12:38 p.m., R15 was sitting up in bed, awake and alert. The dressing on R15's central line access on the right upper arm was unchanged from the previous day, and dated 4/4/22. A review of R15's physician orders revealed the following: Mid-line (type of central venous access) dressing change Q (every) Sunday and prn (as needed) every day shift every Sun (Sunday) for infection prevention .Midline flush - 10 ml (milliliters) NS (normal saline) infuse medication, then 10 ml NS flush and follow with 5 ml 10 units/mlv heparin (2) one time a day. Both orders were dated 3/2/22 and were discontinued 4/12/22. A review of R15's MARs (medication administration records) and TARs (Treatment Administration Records) for April 2022 revealed no evidence R15's central line dressing was changed after 4/4/22. R15's MARs revealed the normal saline and heparin flushes were administered as ordered between 3/2/22 and 4/12/22. The clinical record contained no evidence R15's central line access was assessed or flushed between 4/12/22 and 4/20/22. A review of R15's comprehensive care plan dated 5/25/20 and updated 3/2/22 revealed, in part: (Central line) catheter .change dressing with a transparent dressing weekly or as needed .flush as ordered. On 4/20/22 at 12:54 p.m., LPN (licensed practical nurse) #2 was interviewed. When asked about specific interventions to care for a central line, she stated there should be orders in place to have the dressing changed weekly. She stated if a resident has completed treatment requiring use of the central line, the nurses should still be assessing the site and flushing it regularly to make sure no blood clots form within or around the line. On 4/20/22 at 1:08 p.m., LPN #1 was interviewed. She stated the nursing staff should have orders to change the central line dressing once a week, and as needed. She stated sometimes a provider will want to leave a central line in place beyond completion of a round of IV medications in case additional laboratory tests reveal the necessity for additional IV medications. She stated a nurse needs an order to do anything with a central line, including flushing and dressing changes. She stated flushes should continue as part of routine central line care, whether or not the line is being used for medication administration. She stated it is important to change the central line dressing in order to prevent infection, and to allow a nurse to see the access site more clearly. On 4/20/22 at 1:54 p.m., ASM (administrative staff member) #3, a nurse practitioner, was interviewed. She stated central line care should include flushes every shift to check for blood return and to clear the line, as well as dressing changes each week. She stated if the line is not flushed regularly, even if it is not in use, it could develop blood clots. She stated central line care should include dressing changes each week. She stated if a dressing is not changed regularly, there is a higher risk of bacteria getting into the central line and causing an infection. When asked if she knew why R15's central line was still in place, she stated R15 was cleared from isolation on 4/19/22, and should have the central line removed today. On 4/20/22 at 5:09 p.m., ASM #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. No further information was provided prior to exit. 3. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 3/18/2022, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is not cognitively impaired for making daily decisions. On 4/19/2022 at approximately 11:20 a.m. R75 was observed resting in bed. A PICC line was observed on the resident's right arm just above the elbow. The dressing on the PICC line was dated 4/8/2022. On 4/20/2022 at 8:30 a.m., a second observation was made of R75's PICC line dressing. The same dressing was in place dated 4/8/2022. R75 was asked if the staff has changed the dressing on the PICC line since they returned to the facility on 4/11/2022. R75 stated the dressing had not been changed since before they left the hospital. When asked if the nurses look at the dressing and measure it, R75 stated, not really. R75 stated they just do the flush before and after the antibiotic and infuse the antibiotic. The physician order dated 4/12/2022 documented, PICC line dressing change on admission, then Q (every) week on Sunday and PRN (as needed) every day shift every Sunday for infection Prevention. A physician order dated 4/17/2022 documented, PICC line - measure external portion of PICC line catheter weekly with dressing changes every night shift every Sunday. There were no orders to flush the PICC line. The MAR (medication administration record) for April 2022 documented the above order for the PICC line dressing. The order of 4/17/2022 did not appear on the MAR. On 4/17/2022 a 9 was documented. The Chart Codes documented a 9 equal Other/See Progress Note. The nurse's note dated 4/17/2022 at 12:45 p.m. documented, PICC line dressing change on admission, then Q week on Sunday and PRN every day shift every Sun for Infection Prevention - Being done on 3-11 p.m. There was no documentation that the dressing was completed on 3-11 p.m. shift on 4/17/2022. The comprehensive care plan dated, 4/19/2022 documented in part, PICC/Midline catheter Medication administration for Osteomyelitis to right foot. The Interventions documented in part, Change dressing with a transparent dressing weekly or as need. Flush as ordered. Monitor insertion site for redness, drainage and pain. An interview was conducted with LPN (licensed practical nurse) #1 on 4/20/2022 at 1:08 p.m. When asked how a nurse cares for a resident with a PICC line, LPN #1 stated there should be orders for the dressing changes, the resident may come with orders for laboratory tests and the SASH (Saline, antibiotic, saline, heparin) protocol. LPN #1 stated the dressing should be changed at least weekly and as needed. When asked if there should be orders for the flushes, LPN #1 stated yes. When asked where the flushes are documented, LPN #1 stated on the MAR or in a nurse's note. When asked if she had observed R75's PICC line this morning, LPN #1 stated she observed it once on rounds this morning. When asked if she noticed anything, LPN #1 stated it looked like it needed to be changed. When asked if she checked the date, LPN #1 stated she did not. When asked why the dressing is changed weekly, LPN #1 stated because of infection control; the nurse needs to observe the site, and when the dressing is changed, the nurse has to measure the amount of tubing is hanging out from the insertion site. When asked where this measurement is documented, LPN #1 stated it should be with the order for the dressing change. An interview was conducted with ASM (administrative staff member) # 3, the nurse practitioner, on 4/20/2022 at 1:53 p.m. When asked what kind of care should central lines, PICC, Midline catheters receive from the staff, ASM #3 stated they should be flushed every shift, to make sure it's flushing and maintaining the integrity of the line. ASM #3 stated she was not sure of the facility protocol. When asked if the nurses need orders for the flushes and dressing changes, ASM #3 stated there is a plan of care in the electronic medical record system that should populate, but yes the nurses need orders for daily PICC care. When asked why should there be orders to flush the line, ASM #3 stated the PICC line can clot and that's why there should be orders for heparin flush or regular flush. When asked why there should be orders for a dressing change, ASM #3 stated if the dressing is loose then bacteria can get in and cause an infection. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and RN (registered nurse) #1, the unit manager, were made aware of the above findings on 4/20/2022 at approximately 5:15 p.m. Policies regarding central line care were requested. On 4/21/22 at 8:40 a.m., ASM #1 stated the facility did not have a policy related to central line care. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to follow the menu for one of 37 residents in the survey sample, Resident #309; and for the dinner meal on 4/19/22. The findings include: 1. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/11/22, R309 scored 14 out of 15 on the BIMS (brief interview for mental status), indicating she is cognitively intact for making decisions. On 4/19/22 at 11:34 a.m., R309 was interviewed. R309 stated she had concerns about not getting the food that was on the meal ticket for each meal. R309 stated it was rare for them to receive anything close to what they had repeatedly told staff they were able to eat. On 4/19/22 at 1:37 p.m., R309 sat in a wheelchair at the overbed table. An open plate of food was on a tray on the overbed table. R309 was not eating. The meal ticket on R309's tray included the following items: shrimp and vegetable stir fry, orange twist, buttered white rice, roll, margarine, frosted carrot cake, 2% milk, hot coffee or hot tea. R309's meal tray contained the following items: steamed shrimp (unseasoned and without sauce per R309), steamed mixed vegetables (without any sauce), rice, cold tea, and yellow cake with chocolate icing. The tray did not contain hot coffee or tea, 2% milk, or an orange twist. R309 stated this was typical for her meal trays; the facility substituted other items without informing the resident, and the resident was unaware of an option to get any other items. CNA (certified nursing assistant) #3 entered the room. CNA #3 stated she was unaware of any substitutions made on the menu for that meal. CNA #3 stated the shrimp and vegetables were not stir fried, as the published menu stated. CNA #3 stated it might be possible for her to go to the kitchen to see if there was any other food for R309, but she had not had very good luck in doing so in a really long time. She stated, Sometimes they have something else and sometimes they don't. CNA #3 was not aware of any way to address the missing items from R309's tray. On 4/20/22 at 9:32 a.m., R309 sat in a wheelchair at the overbed table. An open plate of food was on a tray on the overbed table. R309 was not eating. The meal ticket on R309's tray included the following items: Orange juice, scrambled egg substitute, orange twist, wheat toast, margarine, oatmeal, 2% milk, hot coffee or tea. R309's meal tray contained the following items: oatmeal, cooked egg products shaped in a square, orange sliver, and biscuit. The tray did not contain milk or wheat toast. On 4/20/22 at 9:53 a.m., OSM (other staff member) #1, the culinary service manager, entered the room and was interviewed. OSM #1 the daily menus are posted in the hallway across from the nurse station. OSM #1 stated only 2 main entrees are offered (a primary and an alternate), and each resident receives the primary entree at every meal. She stated if the resident wants something different, the CNA who served the meal is responsible for being knowledgeable about the alternates, going to the kitchen, and obtaining the alternate meal for the resident. When asked if the lunch meal on 4/19/22 contained any substitutions, OSM #1 stated she was not aware of any substitutions. When asked if carrot cake was served for lunch yesterday, OSM #1 stated, I think so. When informed that R309 received yellow cake with chocolate icing, OSM #1 stated she suddenly remembered that she could not get carrot cake from her supplier, so she had to substitute a chocolate cake. When asked about the substitution of steamed shrimp and vegetables for the published menu item of shrimp and vegetable stir fry, she stated the facility never offers stir fry. When asked how the facility informs residents about menu substitutions/changes, she stated she changes the item on meal tickets and changes the posted menus. When asked how residents who cannot see the posted menu in the hallway or read the small print on the meal tickets are informed of substitutions, she did not answer. When shown the lunch meal ticket from the day before which listed carrot cake and shrimp and vegetable stir fry, OSM #1 stated she had not been at the facility very long, and she was still learning. On 4/20/22 at 10:44 a.m., OSM #1 and OSM #2, the regional director of culinary services, were interviewed. OSM #1 stated the cooks should be utilizing a production sheet for each meal. The production sheet contains all the food items that should be cooked/prepared for each meal. She stated that the cook is responsible for making sure that what is cooked matches what is on the production sheet. When asked who checks to make sure the food items match the production sheet, she stated she guessed she does that. She stated she had been out on medical leave recently, and she was not sure who had checked the cooks on those days. When asked the process that is followed when a substitution needs to be made on the menu, OSM #2 stated the facility cooks in batches. He stated the facility orders pre-made cakes from the food distributor, and there has been a shortage of carrot cake. OSM #1 and OSM #2 were unaware that any residents had been informed of this substitution. When asked about the steamed shrimp and vegetables, OSM #2 stated that it is just the cooking method that did not match the menu item. He stated when the staff is cooking high volume, there is no way to stir fry or make meals to order. He stated: Country fried steak is not made in the country. When asked if the shrimp or vegetables at lunch on 4/19/22 contained any sort of stir fry sauce, he stated he did not know. A review of the facility's Menu Substitution Record revealed no information related to these specific concerns. On 4/20/22 at 5:09 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Menu Planning, revealed, in part: Menu substitutions shall be limited to preferences of the Center's patients and emergency situations .Menu substitutions refer to unavoidable situations or emergencies. No further information was provided prior to exit.2. Observation was made on 4/19/2022 at 4:59 p.m. of the dinner served. A test tray was requested. OSM (other staff member) #2, the regional director of culinary services, served a pureed diet tray and a regular diet tray. The dinner menu documented, sliced baked ham, pineapple sauce, orange twist, home fried potatoes, steamed cabbage, corn bread and margarine. The puree tray consisted of pureed beef, pureed California blend vegetables, and mashed potatoes and pureed bread. When asked why the pureed diet did not have the ham, OSM #2 stated he'd go check with the cook. OSM #2 returned and stated the cook said the beef was easier and made a better puree than the ham. At 5:06 p.m. the menu was reviewed with OSM #2. When asked where the pineapple relish was on the test trays, OSM #2 stated there was an au jus on the ham. When asked if an au jus is the same as a relish, OSM #2 didn't answer. When asked where the orange twist was on the test tray, OSM #2 stated the orange twist is just a garnish. OSM #2 was asked why there wasn't cabbage on the trays, OSM #2 did not know the answer. OSM #1, the culinary services manager for the facility, was then asked about the cabbage. OSM #1 stated the cabbage did not come in with their delivery today so she made the decision to substitute with the California Blend. When asked how she informs the residents of a change in the menu, OSM #1 stated she went out and told a few residents. The facility policy, Food Quality and Palatability documented in part, 1. The Dining Services Director and Cook(s) are responsible for food preparation. Menu items are prepared according to the menu, production guidelines and standardized recipes. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and RN (registered nurse) #1, the unit manager, were made aware of the above findings on 4/20/2022 at approximately 5:15 p.m. No further information was provided prior to exit

Based on observation, staff interview, and facility document review, the facility failed to store food in a sanitary manner in one of two refrigerators in the main kitchen. The findings include: The facility kitchen was observed on 4/19/2022 at 10:10 a.m. A container of sliced American cheese was observed in a refrigerator with and open date of 3/6/2022 and a use by date of 3/10/2022. A second container with shredded cheddar cheese did not have a date when opened, but had a use by date of 3/10/2022. When asked if these containers of cheese should be still available for use, OSM (other staff member) #1, the culinary services manager, stated the staff probably put the wrong dates on it. When asked if it should be available for use with the dates on it, OSM #1 stated, No, I guess not. The facility policy, Food Storage: Cold documented in part, The Dining Services Director/Cook(s) insures that all food items are stored properly in covered containers, labeled and dated. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and RN (registered nurse) #1, the unit manager, were made aware of the above findings on 4/20/2022 at approximately 5:15 p.m. No further information was provided prior to exit.

Based on observation and staff interview, the facility staff failed to maintain one of one dumpsters in a sanitary manner. The findings include: On 4/19/2022 at approximately 10:35 a.m. the facility dumpster was observed with OSM (other staff member) # 1, the culinary services manager. There were 11 used gloves around the dumpster area. A 12th used glove was found just outside the door to go back into the building. When asked who was responsible for maintaining the dumpster area, OSM #1 stated it is between dietary and maintenance. When asked if the gloves should be on the ground, OSM #1 stated, no. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and RN (registered nurse) #1, the unit manager, were made aware of the above findings on 4/20/2022 at approximately 5:15 p.m. A request was made for the policy on maintaining the dumpster area on 4/20/2022 at 5:30 p.m. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #13 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: cerebral infarction (1), congestive heart failure (2), diabetes (3).Resident #13's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 11/7/19, coded the resident as scoring 5 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. Resident #38 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: dementia (4), diabetes, hypertension (high blood pressure) (5). Resident #38's most recent MDS (minimum data set) assessment, an entry assessment, with an ARD (assessment reference date) of 12/9/19, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the residents cognition was intact. The facility policy, Abuse, Neglect, Exploitation & Misappropriation dated 11/28/16, documented in part, Patients of the Center have the legal right to be free from verbal, sexual, mental and physical abuse. Abuse includes sexual abuse (sexual harassment/inappropriate touching, sexual coercion, sexual assault or allowing a patient to be sexually assaulted by another, inciting any of the above). The Facility Reported Incident (FRI) dated 7/5/19, documented in part, Incident date: 7/5/19. Resident's involved (name of Resident #13) and (name of Resident #38). Injuries: (A check mark was documented next to)-No. Incident type: Allegation of abuse/mistreatment. Describe incident: (name of Resident #38) and (name of Resident #13) were in the common area (Television room) on (alphabet letter)-Side unit. (Name of Resident #38) was found caressing (name of Resident #13)'s buttocks. The Final Report dated, 7/9/19, documented in part, This is follow up report to an initial report filed 7/5/19. Investigation summary: On 7/5/19 at around 3:00 PM, name of Resident #38's hand was partially in name of Resident #13's brief. Both residents were separated and both denied any inappropriate touching. Name of Resident #13 stated she felt safe. LPN (licensed practical nurse) #3's witness statement dated 7/5/19 at 5:43 PM documented, (Name of Resident #13)'s pants were down and (name of Resident #38)'s right hand was in the back of her pull up. (Name of Resident #38) denied touching (name of Resident #13) inappropriately. Both residents were separated. An interview was conducted on 2/13/20 at 7:49 AM with LPN (licensed practical nurse) #6. When asked to define abuse, LPN #6 stated, Abuse is physical, sexual, and inappropriate touching and taking belongings. When asked if LPN #6 remember the 7/5/19 incident between Resident #13 and Resident #38, LPN #6 stated, I do remember the situation. It was reported to me. He [Resident #38] had his hand on her [Resident #13's] butt and was touching her. When asked if that is abuse, LPN #6 stated, Yes it was inappropriate touching, that is abuse. An interview was conducted on 2/12/20 at 5:01 PM with ASM (administrative staff member) #5, the regional nurse consultant. When asked if inappropriate touching is considered abuse, ASM #5 stated, Yes, this would be considered abuse. ASM #3, the director of nursing, nurse's note in Resident #13's clinical record dated 7/5/19 at 7:23 PM, documented in part, Noted standing in television room beside another resident, assisted to her bedroom and then with her ADL's (activities of daily living). Resident's son and nurse practitioner made aware of incident. Resident #13's care plan dated 5/29/19, documented in part, Focus: Cognition and Communication: The resident has a communication problem and impaired cognition related to disease process. The Interventions documented and dated 5/29/19, Anticipate and meet needs. Be conscious of resident position when in groups, activities, dining room to promote proper communication with other. An interview was conducted with Resident #38 on 2/12/20 at 8:00 AM. When asked if Resident #38 remembered the 7/5/19 incident with Resident #13, Resident #38 stated, No. A LPN (licensed practical nurse) note in Resident #38's clinical record dated 7/5/19 at 5:02 PM, documented in part, Resident is continuing to need redirection from entering patients room. Resident can be redirected without complication and is frequently monitored. ASM #3, the director of nursing, note in Resident #38's clinical record dated 7/5/19 at 7:37 PM, documented in part, Noted in the television room on [alphabet letter]-side with his arm around another resident's lower back who was standing beside him. Resident was asked to remove his hands around the other resident's lower back; he was then assisted to the hallway. Resident #38's care plan dated 2/2/14, documented in part, Focus: The resident exhibits adverse behavioral symptoms of history of masturbation in public and taking other resident's food related to dementia. The Interventions documented and dated 2/2/14, Minimize potential for the resident's disruptive behaviors of masturbating in public and taking other resident's food by offering tasks which divert attention, or providing privacy for resident. ASM #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional nurse consultant, was made aware of the above concern on 2/12/20 at 6:03 PM. No further information was provided prior to exit. References: (1) Cerebral infarction: hemorrhage or blockage of the blood vessels of the brain leading to a lack of oxygen and resulting symptoms-loss of ability to move body part, ability to speak or weakness. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 111. (2) Congestive Heart Failure: abnormal condition characterized by circulatory congestion and retention of salt and water by the kidneys. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 133. (3) Diabetes: altered glucose metabolism caused by the inability of insulin to function normally in the body. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 160. (4) Dementia: progressive state of mental decline. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 154. (5) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 282. Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure three of 59 sampled residents, (Residents #25, #21 and #13) were free from abuse. On 11/15/18, Resident #25 was hit in the chest by Resident #31. On 12/22/19, Resident #21 was hit in the face by Resident #28 and on 7/5/19, Resident #38 was observed with his hand inside Resident #13's brief and was caressing Resident #13's buttocks. The findings include: 1. Resident #25 was admitted to the facility on [DATE]. Resident #25's diagnoses included but were not limited to diabetes, chronic kidney disease and repeated falls. Resident #25's quarterly MDS (minimum data set) with an ARD (assessment reference date) of 11/26/19, coded the resident's cognition as moderately impaired. Resident #31 was admitted to the facility on [DATE]. Resident #31's diagnoses included but were not limited to paralysis, heart disease and difficulty swallowing. Resident #31's quarterly MDS with an ARD of 12/3/19, coded the resident as being cognitively intact. Review of Resident #31's clinical record revealed a nurse's note dated 11/15/18 that documented, Resident was coming out of the dining room, when the resident in front of him was not moving out of the way fast enough, so (Resident #31) took (sic) pushed the other resident out of the way and continued down the hall way to his room. neither (sic) residents have any injuries. resident (sic) stated incident did not occur. resident (sic) has no s/s (signs or symptoms) of distress or discomfort. RP (Responsible party) (name) aware and Dr. (name) Aware (sic). will (sic) continue to monitor. A FRI (facility reported incident) submitted to the state agency on 11/15/18 documented, Report date: 11/15/2018. Incident date: 11/15/2018. Residents involved: (Name of Resident #31) (Name of Resident #25). While residents were leaving the dining room, (Resident #31) asked (Resident #25) to speed up. (Resident #31) then backhanded (Resident #25) in the upper chest. Residents were separated. No further interaction was noted between both residents and they continued wheeling themselves through the hallway . A witness statement signed by OSM (other staff member) #6 (the human resources manager) on 11/15/18 documented, On November 15, 2018 at approximately 1:15 pm (Resident #31) and (Resident #25) were leaving the dining room. (Resident #25) was asked by (Resident #31) to speed up. (Resident #31) backhanded (Resident #25) in the upper chest area and told him to get up the hallway. No further interaction took place and both residents continued up the hall. A follow up report dated 11/20/18 documented, This summary is in regards to the facility reported incident on 11/15/2018 . It was reported on Thursday November 15, 2018 that the aforementioned residents (Resident #25 and Resident #31) got into a physical altercation with each other. It was reported that (Resident #31) reached out pushed (Resident #25's) chest as he was trying to pass by him .Both residents have been monitored and no untoward distress has been noted on either resident from the said altercation. Both residents have had no further behaviors or incidents noted between them and other residents. On 2/12/20 at 9:27 a.m., an interview was conducted with OSM #6, regarding the above incident. OSM #6 stated both residents were coming out of the dining room and Resident #31 backhanded Resident #25 in the arm. OSM #6 stated she did not know if the act was malicious but it was a deliberate hit. OSM #6 was asked if a resident hitting another resident is abuse. OSM #6 stated, It can be. Yes. If it's deliberate, it's always going to be some type of abuse. On 2/12/20 at 6:10 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #5 (the regional nurse consultant) were made aware of the above concern. The facility policy titled, Patient Protection documented, POLICY: There is a zero tolerance for mistreatment, abuse, neglect, misappropriation of property, or any crime against a patient of the Health and Rehabilitation Center. PROCEDURE: 4. Any and all suspected or witnessed incidents of patient/patient abuse, neglect, theft, and/or exploitation or any reasonable suspicion of a crime against a patient/patient Center brought to the attention of the Center's Administration will result in internal investigation, appropriate and timely reporting to the State Survey Agency (SSA) and other legally designated agencies, as well as staff corrective action . No further information was presented prior to exit. 2. Resident #21 was admitted to the facility on [DATE]. Resident #21's diagnoses included but were not limited to chronic pain syndrome, muscle weakness and major depressive disorder. Resident #21's quarterly MDS (minimum data set) with an ARD (assessment reference date) of 11/19/19, coded the resident's cognition as severely impaired. Resident #28 was admitted to the facility on [DATE]. Resident #28's diagnoses included but were not limited to repeated falls, muscle weakness and anemia (a blood disorder). Resident #28's quarterly MDS with an ARD of 11/27/19, coded the resident's cognition as severely impaired. Review of Resident #28's clinical record revealed a nurse's note dated 12/22/19 that documented, Staff member reported that resident [Resident #28] hit another resident [Resident #21] in the dining room. Resident [Resident #28] separated from other resident, 1:1 provided as needed . A FRI (facility reported incident) submitted to the state agency on 12/23/19 documented, Report date: 12-23-19. Incident date: 12-22-19. Residents involved: (Name of Resident #21) (Name of Resident #28). Incident reported between (Resident #21) and (Resident #28) in the dining room during lunch. It was about 12:45 pm when (Resident #28) hit (Resident #21) in the face. Residents were separated immediately and (Resident #28) was taken to the unit (illegible word) charge nurse. No injuries noted at this time. Investigation initiated. A witness statement signed by the dietary staff member on 12/23/19 documented, On 12-22-19 @ (at) 12:45 pm & 12:50 pm (Resident #28) had hit (Resident #21) in the face and tried to hit her with a coffee cup. I had removed (Resident #21) to her room and (Resident #28) to nurse (name) on [letter of alphabet] side side (sic). Charge Nurse. A follow up report dated 12/27/19 documented, This summary is in regard to the facility reported incident on 12/23/19 . During lunch on Sunday, (Resident #28) struck (Resident #21) in the face at the dining table. This was witnessed by (name of dietary staff member) who immediately separated the residents and notified (name) LPN (licensed practical nurse). Residents were assessed for injuries and/or pain and none noted. Residents have seen Psych [psychiatric] services after the incident to address any psychosocial needs .After review of the medical record and interviews with family and staff, it is the centers' finding that the incident did occur as reported, however neither resident has an ongoing untoward outcome related to incident . The dietary staff member who witnessed the 12/22/19 incident was not available for interview during the survey. On 2/12/20 at 4:17 p.m., an interview was conducted with LPN (licensed practical nurse) #4, Resident #28's charge nurse when the incident occurred on 12/22/19. LPN #4 stated she did not witness the incident but she was told by someone from the kitchen that Resident #28 was brought back to the unit because Resident #28 hit Resident #21 in the dining room. LPN #4 confirmed abuse has occurred when one resident hits another resident. On 2/12/20 at 6:10 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #5 (the regional nurse consultant) were made aware of the above concern. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #13 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: cerebral infarction (1), congestive heart failure (2), diabetes (3).Resident #13's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 11/7/19, coded the resident as scoring 5 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. Resident #38 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: dementia (4), diabetes, hypertension (high blood pressure) (5). Resident #38's most recent MDS (minimum data set) assessment, an entry assessment, with an ARD (assessment reference date) of 12/9/19, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the residents cognition was intact. The facility policy, Abuse, Neglect, Exploitation & Misappropriation dated 11/28/16, documented in part, Patients of the Center have the legal right to be free from verbal, sexual, mental and physical abuse. Immediately upon notification of any alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, the administrator will immediately report to the state agency, but not later than two hours after the allegation is made, if the events that caused the allegation involve abuse. A Facility Reported Incident (FRI) dated 7/5/19, documented in part, Incident date: 7/5/19. Resident's involved (name of Resident #13) and (name of Resident #38). Injuries: (A check mark was documented next to)-No. Incident type: Allegation of abuse/mistreatment. Describe incident: (name of Resident #38) and (name of Resident #13) were in the common are (Television room) on (alphabet letter)-Side unit. (Name of Resident #38) was found caressing (name of Resident #13)'s buttocks. The FRI documented per the witness statement that the incident occurred at 3:00 PM on 7/5/19. The report was faxed to the State Agency on 7/5/19 at 6:58 PM (three hours and fifty-eight minutes after alleged abuse). The Final Report dated, 7/9/19, documented in part, This is follow up report to an initial report filed 7/5/19. Investigation summary: On 7/5/19 at around 3:00 PM, name of Resident #38's hand was partially in name of Resident #13's brief. Both residents were separated and both denied any inappropriate touching. Name of Resident #13 stated she felt safe. LPN (licensed practical nurse) #3's witness statement dated 7/5/19 at 5:43 PM documented, (Name of Resident #13)'s pants were down and (name of Resident #38)'s right hand was in the back of her pull up. (Name of Resident #38) denied touching (name of Resident #13) inappropriately. Both residents were separated. ASM #3, the director of nursing, nurse's note in Resident #13's clinical record dated 7/5/19 at 7:23 PM, documented in part, Noted standing in television room beside another resident, assisted to her bedroom and then with her ADL's (activities of daily living). Resident's son and nurse practitioner made aware of incident. An interview was conducted on 2/13/20 at 7:49 AM with LPN (licensed practical nurse) #6. When asked to define abuse, LPN #6 stated, Abuse is physical, sexual, and inappropriate touching and taking belongings. When asked if LPN #6 remember the 7/5/19 FRI between Resident #13 and Resident #38, LPN #6 stated, I do remember the situation. It was reported to me. He had his hand on her butt and was touching her. When asked if that is abuse, LPN #6 stated, Yes it was inappropriate touching, that is abuse. An interview was conducted on 2/12/20 at 5:01 PM with ASM (administrative staff member) #5, the regional nurse consultant. When asked if inappropriate touching is considered abuse, ASM #5 stated, Yes, this would be considered abuse. ASM #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional nurse consultant, was made aware of the above concern on 2/12/20 at 6:03 PM. No further information was provided prior to exit. References: (1) Cerebral infarction: hemorrhage or blockage of the blood vessels of the brain leading to a lack of oxygen and resulting symptoms-loss of ability to move body part, ability to speak or weakness. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 111. (2) Congestive Heart Failure: abnormal condition characterized by circulatory congestion and retention of salt and water by the kidneys. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 133. (3) Diabetes: altered glucose metabolism caused by the inability of insulin to function normally in the body. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 160. (4) Dementia: progressive state of mental decline. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 154. (5) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 282 Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement the abuse policy for three of 59 residents in the survey sample, (Residents #21, and #24). On 12/22/19, Resident #28 hit Resident #21 in the face. The facility staff failed to implement the abuse policy and report this incident within a two hour time frame. The incident was not reported until 12/23/19. On 2/12/2020 at 4:11 PM the facility administrator was informed of the allegation of verbal abuse stated by Resident #24 on 2/11/2020 at 4:58 PM regarding Resident #41 calling her a bitch. The facility failed implement the abuse policy to report the allegation to the State Agency and other officials. On 7/5/19, per the witness statement at 3:00 PM, Resident #38 was observed with his hand inside Resident #13's brief and was caressing Resident #13's buttocks, the facility staff failed to implement the abuse policy to immediately report the allegation of abuse to the State Agency, the incident was not reported until 6:58 PM, on 7/5/19, three hours and fifty-eight minutes after alleged abuse. The findings include: 1. Resident #21 was admitted to the facility on [DATE]. Resident #21's diagnoses included but were not limited to chronic pain syndrome, muscle weakness and major depressive disorder. Resident #21's quarterly MDS (minimum data set) with an ARD (assessment reference date) of 11/19/19, coded the resident's cognition as severely impaired. Resident #28 was admitted to the facility on [DATE]. Resident #28's diagnoses included but were not limited to repeated falls, muscle weakness and anemia (a blood disorder). Resident #28's quarterly MDS with an ARD of 11/27/19, coded the resident's cognition as severely impaired. The facility abuse policy titled, Reporting Requirements/Investigations documented, POLICY: The Administrator will ensure the timely reporting, investigating, and follow up reporting of incidents of alleged/suspected patient abuse, neglect, mistreatment, exploitation, or crime against a patient to the State Agency and any other appropriate authorities. PROCEDURE: 1. Immediately upon notification of any alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, the Administrator will immediately report to the State Agency, but not later than 2 hours after the allegation is made, if the events that caused the allegation involves abuse or results in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury. Review of Resident #28's clinical record revealed a nurse's note dated 12/22/19 that documented, Staff member reported that resident hit another resident in the dining room. Resident separated from other resident, 1:1 provided as needed . A FRI (facility reported incident) submitted to the state agency on 12/23/19 documented, Report date: 12-23-19. Incident date: 12-22-19. Residents involved: (Name of Resident #21) (Name of Resident #28). Incident reported between (Resident #21) and (Resident #28) in the dining room during lunch. It was about 12:45 pm when (Resident #28) hit (Resident #21) in the face. Residents were separated immediately and (Resident #28) was taken to the unit (illegible word) charge nurse. No injuries noted at this time. Investigation initiated. On 2/12/20 at 4:17 p.m., an interview was conducted with LPN (licensed practical nurse) #4, Resident #28's charge nurse when the incident occurred on 12/22/19. LPN #4 stated she did not witness the incident but she was told by someone from the kitchen that Resident #28 was brought back to the unit because Resident #28 hit Resident #21 in the dining room. LPN #4 stated she texted her unit manager because she did not know what to do. LPN #4 stated her unit manager said she had to complete an incident report and notify the administrator and director of nursing. LPN #4 stated she was getting ready to leave the facility when she received these instructions so she did not report the incident to the administrator or director of nursing. LPN #4 stated she thought she only had to report this incident to the unit manager due to the chain of command. LPN #4 stated the next day, the director of nursing, unit manager and assistant administrator met with her and told her she needed to report a resident to resident incident within an hour to the administrator and director of nursing. On 2/12/20 at 6:10 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #5 (the regional nurse consultant) were made aware of the above concern. No further information was presented prior to exit. 2. Resident #24 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: stroke, diabetes, high blood pressure, depression and hemiplegia (paralysis affecting only one side of the body) (1). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 11/21/19, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating she was cognitively intact to make daily decisions An interview was conducted with Resident #24 on 2/11/2020 at 4:58 p.m. When asked if anyone had ever cursed at her, hit her or abused her, Resident #24 stated that the gentleman across the hall from her (Resident #41) called her a bitch. Resident #24 stated she had reported it. The facility policy documented impart, The Administrator will provide to the State Agency an initial report for occurrences of alleged or reasonably suspected abuse, neglect, exploitation, mistreatment or crime against a patient of the Center .Verbal abuse - Any use of oral, written or gestured language that includes cursing, disparaging, and derogatory terms to other patients or visitor within hearing range, to describe patients, regardless of their age, ability to comprehend or disability. A review was conducted of the Facility reported Incidents (FRIs) and the grievance logs, The review failed to evidence any documentation of Resident #24 being called a bitch by Resident #41. Resident #41 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: dementia, and mild intellectual disability (2). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date coded the resident as scoring a 6 on the BIMS score, indicating the resident was severely impaired to make daily cognitive decisions. A second interview was conducted with Resident #24 on 2/12/2020 at 3:55 p.m. When asked when the incident happened the resident sated just last week. When asked whom she told, she stated she had called the nurse on duty. She stated Resident #24 was sitting in the doorway and his roommate was trying to get into the room. Resident #41 told his roommate to get out of here. Resident #24 told Resident #41 that he didn't have to as it was his room too. Resident #24 stated he then started backing up and said to have it your way bitch. She told him not to call her names like that. The nurse came and got the roommate into the room. Resident #24 told the nurse at that time what he said to her. She stated the nurse told her that the resident had dementia and didn't know what he was saying. Resident #24 stated the same nurse was on duty at this time. I got LPN (licensed practical nurse) #2 and brought her into the room. Resident #24 identified the nurse as the one she told about his calling her a bitch. At 4:01 p.m. LPN #2 was asked if she recalled the resident telling her that Resident #41 called her a bitch, LPN #2 stated she didn't tell me he called her a bitch. On 2/12/2020 at 4:11 p.m. ASM (administrative staff member) #1, the administrator was made aware of the comments made by Resident #24 regarding Resident #41 calling her a bitch. ASM #1 stated she would start their investigation into the matter. On 2/13/2020 at 9:47 a.m., ASM #1 shared the investigation they initiated regarding the above. The file was reviewed and did not evidence documentation that the state agency had been notified. When asked if she had notified the state agency of this allegation of abuse, ASM #1 stated, No. When asked why she hadn't notified the state agency, ASM #1 stated they could not substantiate it as the witness could not recall it. The facility abuse policy was reviewed with ASM #1. When asked if the incident above is an allegation of abuse, ASM #1 stated, Yes. When asked if it should have been filed with the state agency, ASM #1 stated, Yes, Ma'am. ASM #1, ASM #6, the assistant administrator, and ASM # 5, the regional nurse consultant were made aware of the above concern on 2/13/2020 at 1:27 p.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 266. (2) mild intellectual disability: IQ (intelligence quotient) of 60 through 70 and a physical or other mental impairment imposing an additional and significant limitation of function. This information was obtained from the following website: https://www.ncbi.nlm.nih.gov/books/NBK332877/table/tab_9-1/?report=objectonly

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #13 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: cerebral infarction (1), congestive heart failure (2), diabetes (3).Resident #13's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 11/7/19, coded the resident as scoring 5 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. Resident #38 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: dementia (4), diabetes, hypertension (high blood pressure) (5). Resident #38's most recent MDS (minimum data set) assessment, an entry assessment, with an ARD (assessment reference date) of 12/9/19, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the residents cognition was intact. A Facility Reported Incident (FRI) dated 7/5/19, documented in part, Incident date: 7/5/19. Resident's involved (name of Resident #13) and (name of Resident #38). Injuries: (A check mark was documented next to)-No. Incident type: Allegation of abuse/mistreatment. Describe incident: (name of Resident #38) and (name of Resident #13) were in the common are (Television room) on (alphabet letter)-Side unit. (Name of Resident #38) was found caressing (name of Resident #13)'s buttocks. The FRI documented per the witness statement that the incident occurred at 3:00 PM on 7/5/19. The report was faxed to the State Agency on 7/5/19 at 6:58 PM (three hours and fifty-eight minutes after alleged abuse). The Final Report dated, 7/9/19, documented in part, This is follow up report to an initial report filed 7/5/19. Investigation summary: On 7/5/19 at around 3:00 PM, name of Resident #38's hand was partially in name of Resident #13's brief. Both residents were separated and both denied any inappropriate touching. Name of Resident #13 stated she felt safe. LPN (licensed practical nurse) #3's witness statement dated 7/5/19 at 5:43 PM documented, (Name of Resident #13)'s pants were down and (name of Resident #38)'s right hand was in the back of her pull up. (Name of Resident #38) denied touching (name of Resident #13) inappropriately. Both residents were separated. ASM #3, the director of nursing, nurse's note in Resident #13's clinical record dated 7/5/19 at 7:23 PM, documented in part, Noted standing in television room beside another resident, assisted to her bedroom and then with her ADL's (activities of daily living). Resident's son and nurse practitioner made aware of incident. An interview was conducted on 2/13/20 at 7:49 AM with LPN (licensed practical nurse) #6. When asked to define abuse, LPN #6 stated, Abuse is physical, sexual, and inappropriate touching and taking belongings. When asked if LPN #6 remember the 7/5/19 FRI between Resident #13 and Resident #38, LPN #6 stated, I do remember the situation. It was reported to me. He had his hand on her butt and was touching her. When asked if that is abuse, LPN #6 stated, Yes it was inappropriate touching, that is abuse. An interview was conducted on 2/12/20 at 5:01 PM with ASM (administrative staff member) #5, the regional nurse consultant. When asked if inappropriate touching is considered abuse, ASM #5 stated, Yes, this would be considered abuse. The facility policy, Abuse, Neglect, Exploitation & Misappropriation dated 11/28/16, documented in part, Patients of the Center have the legal right to be free from verbal, sexual, mental and physical abuse. Immediately upon notification of any alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, the administrator will immediately report to the state agency, but not later than two hours after the allegation is made, if the events that caused the allegation involve abuse. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional nurse consultant, was made aware of the above concern on 2/12/20 at 6:03 PM. No further information was provided prior to exit. References: (1) Cerebral infarction: hemorrhage or blockage of the blood vessels of the brain leading to a lack of oxygen and resulting symptoms-loss of ability to move body part, ability to speak or weakness. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 111. (2) Congestive Heart Failure: abnormal condition characterized by circulatory congestion and retention of salt and water by the kidneys. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 133. (3) Diabetes: altered glucose metabolism caused by the inability of insulin to function normally in the body. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 160. (4) Dementia: progressive state of mental decline. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 154. (5) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 282 Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to immediately, (but no later than two hours), report allegations of abuse to the State Agency for three of 59 sampled residents, (Residents #21, #24 and #38). On 12/22/19, The facility staff failed to immediately (but not later than 2 hours), report to the State Agency that Resident #28 hit Resident #21 in the face; the incident was not reported until 12/23/19. On 2/12/2020 at 4:11 PM the facility administrator was informed of the allegation of verbal abuse stated by Resident #24 on 2/11/2020 at 4:58 PM regarding Resident #41 calling her a bitch. The facility failed to immediately report the allegation of verbal abuse to the State Agency and other officials. On 7/5/19, per the witness statement at 3:00 PM, Resident #38 was observed with his hand inside Resident #13's brief and was caressing Resident #13's buttocks, the facility staff failed to immediately, report the allegation of abuse to the State Agency, the incident was reported on 7/5/19 at 6:58 PM, three hours and fifty-eight minutes after alleged abuse. The findings include: 1. Resident #21 was admitted to the facility on [DATE]. Resident #21's diagnoses included but were not limited to chronic pain syndrome, muscle weakness and major depressive disorder. Resident #21's quarterly MDS (minimum data set) with an ARD (assessment reference date) of 11/19/19, coded the resident's cognition as severely impaired. Resident #28 was admitted to the facility on [DATE]. Resident #28's diagnoses included but were not limited to repeated falls, muscle weakness and anemia (a blood disorder). Resident #28's quarterly MDS with an ARD of 11/27/19, coded the resident's cognition as severely impaired. Review of Resident #28's clinical record revealed a nurse's note dated 12/22/19 that documented, Staff member reported that resident [Resident #28] hit another resident [Resident #21] in the dining room. Resident [Resident #28] separated from other resident, 1:1 provided as needed . A FRI (facility reported incident) submitted to the state agency on 12/23/19 documented, Report date: 12-23-19. Incident date: 12-22-19. Residents involved: (Name of Resident #21) (Name of Resident #28). Incident reported between (Resident #21) and (Resident #28) in the dining room during lunch. It was about 12:45 pm when (Resident #28) hit (Resident #21) in the face. Residents were separated immediately and (Resident #28) was taken to the unit (illegible word) charge nurse. No injuries noted at this time. Investigation initiated. The facility abuse policy titled, Reporting Requirements/Investigations documented, 1. Immediately upon notification of any alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, the Administrator will immediately report to the State Agency, but not later than 2 hours after the allegation is made, if the events that caused the allegation involves abuse or results in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury. On 2/12/20 at 4:17 p.m., an interview was conducted with LPN (licensed practical nurse) #4, Resident #28's charge nurse when the incident occurred on 12/22/19. LPN #4 stated she did not witness the incident but she was told by someone from the kitchen that Resident #28 was brought back to the unit because Resident #28 hit Resident #21 in the dining room. LPN #4 stated she texted her unit manager because she did not know what to do. LPN #4 stated her unit manager said she had to complete an incident report and notify the administrator and director of nursing. LPN #4 stated she was getting ready to leave the facility when she received these instructions so she did not report the incident to the administrator or director of nursing. LPN #4 stated she thought she only had to report this incident to the unit manager due to the chain of command. LPN #4 stated the next day, the director of nursing, unit manager and assistant administrator met with her and told her she needed to report a resident to resident incident within an hour to the administrator and director of nursing. On 2/12/20 at 6:10 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #5 (the regional nurse consultant) were made aware of the above concern. No further information was presented prior to exit. 2. Resident #24 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: stroke, diabetes, high blood pressure, depression and hemiplegia (paralysis affecting only one side of the body) (1). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 11/21/19, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating she was cognitively intact to make daily decisions An interview was conducted with Resident #24 on 2/11/2020 at 4:58 p.m. When asked if anyone had ever cursed at her, hit her or abused her, Resident #24 stated that the gentleman across the hall from her (Resident #41) called her a bitch. Resident #24 stated she had reported it. A review was conducted of the Facility reported Incidents (FRIs) and the grievance logs, The review failed to evidence any documentation of Resident #24 being called a bitch by Resident #41. Resident #41 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: dementia, and mild intellectual disability (2). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date coded the resident as scoring a 6 on the BIMS score, indicating the resident was severely impaired to make daily cognitive decisions. A second interview was conducted with Resident #24 on 2/12/2020 at 3:55 p.m. When asked when the incident happened the resident sated just last week. When asked whom she told, she stated she had called the nurse on duty. She stated Resident #24 was sitting in the doorway and his roommate was trying to get into the room. Resident #41 told his roommate to get out of here. Resident #24 told Resident #41 that he didn't have to as it was his room too. Resident #24 stated he then started backing up and said to have it your way bitch. She told him not to call her names like that. The nurse came and got the roommate into the room. Resident #24 told the nurse at that time what he said to her. She stated the nurse told her that the resident had dementia and didn't know what he was saying. Resident #24 stated the same nurse was on duty at this time. I got LPN (licensed practical nurse) #2 and brought her into the room. Resident #24 identified the nurse as the one she told about his calling her a bitch. At 4:01 p.m. LPN #2 was asked if she recalled the resident telling her that Resident #41 called her a bitch, LPN #2 stated she didn't tell me he called her a bitch. On 2/12/2020 at 4:11 p.m. ASM (administrative staff member) #1, the administrator was made aware of the comments made by Resident #24 regarding Resident #41 calling her a bitch. ASM #1 stated she would start their investigation into the matter. The facility policy documented impart, The Administrator will provide to the State Agency an initial report for occurrences of alleged or reasonably suspected abuse, neglect, exploitation, mistreatment or crime against a patient of the Center .Verbal abuse - Any use of oral, written or gestured language that includes cursing, disparaging, and derogatory terms to other patients or visitor within hearing range, to describe patients, regardless of their age, ability to comprehend or disability. On 2/13/2020 at 9:47 a.m., ASM #1 shared the investigation they initiated regarding the above. The file was reviewed and did not evidence documentation that the state agency had been notified. When asked if she had notified the state agency of this allegation of abuse, ASM #1 stated, No. When asked why she hadn't notified the state agency, ASM #1 stated they could not substantiate it as the witness could not recall it. The facility abuse policy was reviewed with ASM #1. When asked if the incident above is an allegation of abuse, ASM #1 stated, Yes. When asked if it should have been filed with the state agency, ASM #1 stated, Yes, Ma'am. ASM #1, ASM #6, the assistant administrator, and ASM # 5, the regional nurse consultant were made aware of the above concern on 2/13/2020 at 1:27 p.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 266. (2) mild intellectual disability: IQ (intelligence quotient) of 60 through 70 and a physical or other mental impairment imposing an additional and significant limitation of function. This information was obtained from the following website: https://www.ncbi.nlm.nih.gov/books/NBK332877/table/tab_9-1/?report=objectonly

**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 written notification was provided or sent to the resident and/or responsible party regarding the reasons for a transfer to the hospital for three of fifty nine residents in the survey sample, (Residents #74, #89 and #66). The facility staff failed to evidence written notification was provided to Resident #74 or the responsible party (RP) for the residents 12/12/19, hospital transfer, failed to evidence written notification to Resident #89 or the RP for the residents 12/27/29 hospital transfer and to Resident #66 or the RP for the residents 12/20/19 hospital transfer. The findings include: 1. Resident #74 was admitted to the facility on [DATE]. Resident #74's diagnoses included but were not limited to: chronic obstructive pulmonary disease (chronic, nonreversible lung disease which is a combination of emphysema and chronic bronchitis) (1), left femur fracture (break in the thighbone) (2), atrial fibrillation (rapid and random contraction of the top parts [atria] of the heart) (3). Resident #74's most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 12/23/19, coded the resident as scoring 9 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. Review of Resident #74's clinical record revealed the resident was transferred to the hospital on [DATE] for lethargy, fever, hypotension and hypoxia (unable to wean off supplemental oxygen). A nurse's note dated 12/12/19 documented a report was called to the hospital and Resident #74's history, medications, allergies and reason for transfer was provided. Further review of Resident #74's clinical record failed to reveal documentation to evidence that written notification of the reason for transfer on 12/12/19, was provided to Resident #74 and or the residents representative (RP). On 2/12/20 at 3:14 PM, an interview was conducted with LPN (licensed practical nurse) #1, charge nurse. When asked if written notification was provided to the resident and/or RP for the transfer to the hospital on [DATE], LPN #1 stated, No, we tell them if they are here or call them. On 2/12/20 at 5:15 PM, an interview was conducted with ASM (administrative staff member) #1, the administrator. When asked if a written notice of the reason for transfer is provided to the resident and or RP (responsible party), ASM #1 stated, Our internal process is to call the RP, we don't provide written notice. A review of the facility policy, Notice of Transfer/Discharge, revealed, in part: When the Center initiates a notice of transfer/discharge to a patient and/or responsible party, discharge planning staff will pursue timely and appropriate transfer/discharge notifications as well as discharge planning initiatives to ensure a safe and orderly discharge from the Center. ASM #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional nurse consultant, were made aware of the above concerns on 2/12/20 at 6:03 PM. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 120. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 232. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 54. 2. Resident #89 was admitted to the facility on [DATE] with a recent readmission on [DATE] with diagnoses that included but were not limited to: dementia, quadriplegia (Paralysis affecting all four limbs and the trunk of the body below the level of spinal cord injury. Trauma is the usual cause.) (1), diabetes, gastrointestinal bleed, and high blood pressure. The most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 1/14/2020 coded the resident as unable to answer the question for the BIMS and had both short and long-term memory difficulties. The physician's note 12/27/19 documented in part the resident presented with recurrent episodes of coffee ground emesis and moderate amount of dark brown drainage from the G -tube (gastrostomy tube), and Resident #89 was sent to the emergency room after giving IV (intravenous) fluids and lab [laboratory tests] work. Further review of the clinical record failed to evidence documentation that a written notification was provided to Resident #89 and/or the resident representative (RP). An interview was conducted with ASM (administrative staff member) #1, the administrator on 2/12/2020 at 5:21 p.m. When asked if the facility either provides or sends the resident and/or their responsible party a written notification of why the resident was sent to the hospital, ASM #1 stated, We make phone calls but there is no written notification. ASM #1, the administrator, ASM #2, the director of nursing, ASM #5, the regional nurse consultant and ASM #6, the assistant administrator, were made aware of the above findings on 2/12/2020 at approximately 6:15 p.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 489. 3. Resident #66 was admitted to the facility on [DATE] with a recent readmission on [DATE] with diagnoses that included but were not limited to: fracture of the femur, depression, dementia, diabetes and peripheral vascular disease (any abnormal condition, including atherosclerosis, affecting blood vessels outside the heart) (1). The most recent MDS (minimum data set) assessment, Medicare admission and significant change assessment, with an assessment reference date of 12/30/19 coded the resident as scoring a 3 on the BIMS (brief interview for mental status) score, indicating she was severely impaired to make daily cognitive decisions. A nurse's note dated, 12/20/19 at 7:26 p.m. documented, Resident has a fall in which the x-ray stated that R (right) hip may represent either an acute impacted fracture or a chronic healed fracture. Resident sent out to ER (emergency room) as ordered. Further review of the clinical record failed to evidence documentation that a written notification was provided/sent to the Resident #66 and/or the resident representative. An interview was conducted with ASM (administrative staff member) #1, the administrator on 2/12/2020 at 5:21 p.m. When asked if the facility either provides or sends the resident and/or their responsible party a written notification of why the resident was sent to the hospital, ASM #1 stated, We make phone calls but there is no written notification. ASM #1, the administrator, ASM #2, the director of nursing, ASM #5, the regional nurse consultant and ASM #6, the assistant administrator, were made aware of the above findings on 2/12/2020 at approximately 6:15 p.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 447.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to develop a baseline care plan for one of 59 residents in the survey sample, Resident #318. The facility staff failed to develop a baseline care plan for Resident #318's physician-ordered TED (thromboembolic-deterrent) hose. The findings include: Resident #318 was admitted to the facility on [DATE] with diagnoses of pneumonia, Alzheimer's disease (2), and obstruction of bilateral ureters (3). He had not been a resident at the facility long enough to have a completed MDS (minimum data set) assessment. On the admission nursing assessment dated [DATE], Resident #318 was documented as being alert only to person. 02/12/20 at 8:19 a.m. and at 11:47 a.m., Resident #318 was observed lying in bed; both feet were observed and the resident was not wearing TED (1) hose. On 2/13/20 at 9:07 a.m., Resident #318 was observed sitting in a wheelchair by the nurses' station. The resident was dressed and wearing yellow gripper socks on both feet. CNA (certified nursing assistant) #3 was standing beside Resident #318. When CNA #3 was asked if the resident was wearing no TED hose, CNA #3 wheeled the resident back to his room and checked his legs. CNA #3 stated, No. When asked if Resident #318 should be wearing TED hose, CNA #3 stated, I'm not sure. I will have to ask the nurse. A review of Resident #318's clinical record revealed the following order dated 2/6/2020: Apply TED hose stockings daily and remove in evening. A review of Resident #318's baseline care plan dated 2/9/2020 revealed no information about TED hose. On 2/13/2020 at 11:05 a.m., CNA #3 was interviewed. When asked how she knows whether or not a resident should be wearing TED hose, she stated that there has to be an order. CNA #3 stated if the resident has an order, then the nurse tells her. She stated that until the surveyor asked about Resident #318's TED hose, she was not aware he was supposed to have them. She stated that once she determined Resident #318 had an order for TED hose, she put them on the resident. CNA #3 stated, He has them now. When asked if she knew the importance of TED hose, CNA #3 stated she thought it was for better circulation. When asked if TED hose should be on the resident's care plan, CNA #3 stated she does not see the care plans, and that the nurse tells her what needs to be done. On 2/13/2020 at 11:43 a.m., LPN (licensed practical nurse) #3, a unit manager, was interviewed. When asked if she was aware of an order for Resident #318 to be wearing TED hose, LPN #3 stated she was not sure. When asked if a resident has an order for TED hose, should the resident be wearing them, LPN #3 stated, Yes, absolutely. When asked if TED hose should be included on a resident's care plan, LPN #3 stated, Absolutely. On 2/13/2020 at 1:28 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy Care Planning revealed, in part: The computerized baseline Care Plan is initiated and activated within 48 hours. The Center will provide the patient and representative(s) with a summary of the baseline care plan that includes, but is not limited to: the initial goals of the patient .any services and treatments to be administered by the Center and personnel acting on behalf of the center. No further information was provided prior to exit. References: (1) You wear compression stockings to improve blood flow in your legs. Compression stockings gently squeeze your legs to move blood up your legs. This helps prevent leg swelling and, to a lesser extent, blood clots. This information is taken from the website https://medlineplus.gov/ency/patientinstructions/000597.htm. (2) Alzheimer's disease is an irreversible, progressive brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks. It is the most common cause of dementia in older adults. This information is taken from the website https://www.nia.nih.gov/health/alzheimers/basics.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide treatment and care in accordance with professional standards of practice and the plan of care for one of 59 residents in the survey sample, Resident #318. The facility staff failed to apply TED (thromboembolism deterrent) hose to Resident #318's on 2/12/2020, as ordered by the physician. The findings include: Resident #318 was admitted to the facility on [DATE] with diagnoses of pneumonia, Alzheimer's disease (2), and obstruction of bilateral ureters (3). He had not been a resident at the facility long enough to have a completed MDS (minimum data set) assessment. On the admission nursing assessment dated [DATE], Resident #318 was documented as being alert only to person. 02/12/20 at 8:19 a.m. and at 11:47 a.m., Resident #318 was observed lying in bed; both feet were observed and the resident was not wearing TED (1) hose. On 2/13/20 at 9:07 a.m., Resident #318 was observed sitting in a wheelchair by the nurses' station. The resident was dressed and wearing yellow gripper socks on both feet. CNA (certified nursing assistant) #3 was standing beside Resident #318. When CNA #3 was asked if the resident was wearing TED hose, CNA #3 wheeled the resident back to his room and checked his legs, then stated: No. When asked if Resident #318 should be wearing TED hose, CNA #3 stated, I'm not sure. I will have to ask the nurse. A review of Resident #318's clinical record revealed the following order dated 2/6/2020: Apply TED hose stockings daily and remove in evening. A review of Resident #318's baseline care plan dated 2/9/2020 revealed no information about TED hose. On 2/13/2020 at 11:05 a.m., CNA #3 was interviewed. When asked how she knows whether or not a resident should be wearing TED hose, she stated that there has to be an order. She stated if the resident has an order, then the nurse tells her. She stated that until the surveyor asked about Resident #318's TED hose, she was not aware he was supposed to have them. She stated that once she determined Resident #318 had an order for TED hose, she put them on the resident. She stated: He has them now. When asked if she knew the importance of TED hose, she stated she thought it was for better circulation. On 2/13/2020 at 11:43 a.m., LPN (licensed practical nurse) #3, a unit manager, was interviewed. When asked if she was aware of an order for Resident #318 to be wearing TED hose, she stated she was not sure. When asked if a resident has an order for TED hose, should the resident be wearing them, LPN #3 stated, Yes, absolutely. On 2/13/2020 at 1:28 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy Anti-Embolism Stockings revealed, in part: Licensed nurse will ensure application as ordered and document on TAR (treatment administration record). No further information was provided prior to exit. References: (1) You wear compression stockings to improve blood flow in your legs. Compression stockings gently squeeze your legs to move blood up your legs. This helps prevent leg swelling and, to a lesser extent, blood clots. This information is taken from the website https://medlineplus.gov/ency/patientinstructions/000597.htm. (2) Alzheimer's disease is an irreversible, progressive brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks. It is the most common cause of dementia in older adults. This information is taken from the website https://www.nia.nih.gov/health/alzheimers/basics. (3) The ureters are bilateral thin (3 to 4 mm) tubular structures that connect the kidneys to the urinary bladder, transporting urine from the renal pelvis into the bladder. This information is taken from the website https://www.ncbi.nlm.nih.gov/books/NBK532980/.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #40 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses including, but not limited to persistent vegetative state (1), contractures (2), and multiple sclerosis (3). On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of 12/10/19, she was coded as being in a persistent vegetative state. She was coded as being completely dependent on staff members for all activities of daily living, as having upper and as being impaired on both sides of both upper and lower extremities for range of motion. On 2/11/2020 at 10:51 a.m., at 12:35 p.m., and at 2:55 p.m., Resident #40 was observed lying in bed. At all observations, both arms were contracted at the elbows, and both hands held a white bath cloth. On 2/12/2020 at 4:10 a.m., Resident #40 was observed lying in bed; her eyes were open. Both arms were contracted at the elbows. Observation of Resident #40's hands revealed they were empty. On 2/12/2020 at 10:02 a.m. and at 3:45 p.m., Resident #40 was observed lying in bed; her eyes were closed. Both arms were contracted at the elbows. Observation of Resident #40's hands revealed they were empty. A review of Resident #40's clinical record revealed no orders for palm guards or other skin protection devices for her palms. A review of Resident #40's comprehensive care plan dated 11/22/19 revealed, in part the following documentation: Bilateral palm guards. On 2/13/2020 at 10:59 a.m., CNA (certified nursing assistant) #3 was interviewed. When asked if she was familiar with Resident #40's care, she stated she was. When asked if Resident #40 should have anything in her hands, CNA #3 stated that at one time, Resident #40 had palm guards. She stated she had not seen the guards in a long time, and sometimes, she used bath cloths in place of the palm guards. When asked why these were important, CNA #3 stated, We don't want her to get sores on her palms. She stated the resident should have something in her hands at all times. On 2/13/2020 at 11:09 a.m., LPN (licensed practical nurse) #7 was interviewed. When asked if she was familiar with Resident #40's care, she stated she was. When asked if Resident #40 should have anything in her hands, LPN #7 stated, Usually we have the palm guards. She stated if the palm guards are dirty or cannot be located, the staff roll up something like a bath cloth to put in the resident's hands to absorb moisture and protect her skin from breaking down. She stated the resident should have something in her hands 24 hours a day. When asked who is responsible for making sure the resident has palm guards, LPN #7 stated that ultimately it is her responsibility as nurse, and that it is a team effort. On 2/13/2020 at 11:43, LPN #3, a unit manager was interviewed. When asked if she was familiar with any interventions for Resident #40's hands, LPN #3 stated, She should have some palm guards. When asked the importance of the palm guards, she stated there needed to be something to protect the resident's palms from the resident's fingernails. On 2/13/2020 at 1:28 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A policy on pressure ulcer prevention was requested. A review of the facility policy, Pressure Ulcer Monitoring and Documentation, provided by ASM #1 on 2/13/2020 at 2:15 p.m. revealed no information related to the prevention of pressure ulcers. No further information was provided prior to exit. (1) A coma, sometimes also called persistent vegetative state, is a profound or deep state of unconsciousness. This information is taken from the website https://www.ninds.nih.gov/Disorders/All-Disorders/Coma-Information-Page. (2) A contracture develops when the normally stretchy (elastic) tissues are replaced by nonstretchy (inelastic) fiber-like tissue. This tissue makes it hard to stretch the area and prevents normal movement. This information is taken from the website https://medlineplus.gov/ency/article/003185.htm. (3) Multiple sclerosis (MS) is a disease of the central nervous system. In MS the body's immune system attacks myelin, which coats nerve cells. Symptoms of MS include muscle weakness (often in the hands and legs), tingling and burning sensations, numbness, chronic pain, coordination and balance problems, fatigue, vision problems, and difficulty with bladder control. People with MS also may feel depressed and have trouble thinking clearly. This information is taken from the website https://nccih.nih.gov/health/multiple-sclerosis. Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries, and to promote healing of a pressure injury for two of 59 residents in the survey sample, Residents #267 and #40. The facility staff failed to assess Resident #267's pressure injuries from 1/16/20 until 2/11/20. The facility staff failed to ensure Bilateral palm guards were in place for Resident #40, per the comprehensive plan of care. The findings include: 1. Resident #267 was admitted to the facility on [DATE]. Resident #267's diagnoses included but were not limited to bronchitis, high blood pressure and history of falling. Resident #267's admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 1/21/20, coded the resident's cognition as severely impaired. Section M coded Resident #267 as having two stage two pressure injuries (1) and two deep tissue injury pressure injuries (1) that were present upon admission. Resident #267's care plan created on 1/15/20 documented, The resident admitted with two stage 2 pressure ulcers (injuries) to knees, and bilateral heel SDTI (suspected deep tissue injury). Therefore, there is a potential for further skin integrity, such as pressure ulcer(s) related to limited mobility and incontinence . A Braden scale for predicting pressure sore (injury) risk dated 1/15/20 documented Resident #267 was at moderate risk for pressure injuries. A note signed by the nurse practitioner on 1/15/20 documented, Pt (Patient) admitted to facility s/p (status post) recent hospitalization after sustaining a fall, which caused bilateral knee wounds. Recurrent falls as pt was found x (times) 6 weeks ago in her apt (apartment) on the floor after sustaining a fall, and was unable to get up or call for help. Reported that pt was on the floor of apartment for approximately 2-3 days. Sustained bilateral knee wounds as a result of fall that occurred 6 weeks ago .DTI (Deep tissue injury) noted to R (right) heel . A nurse's note dated 1/15/20 documented, Resident have (sic) wounds on both knees obtained from fall at home. Left knee open area is 100% granulated (pink or red skin tissue) with scanty drainage. Right knee open area is 199% (sic) granulated with no slough (dead skin tissue). The note failed to document measurements of both knee wounds and failed to document information regarding the right heel DTI. A note signed by the physician on 1/16/20 documented Resident #267 presented with a left knee infection but failed to document an assessment of the left knee, right knee and right heel pressure injuries. Further review of Resident #267's clinical record failed to reveal an assessment of the left knee, right knee and right heel pressure injuries until 2/11/20. A skin and wound evaluation regarding the left knee, dated 2/11/20 documented the wound was 3.7 cm (centimeters) length by 1.3 cm width and 100% granulation. A skin and wound evaluation regarding the right knee, dated 2/11/20 documented the wound was 2.3 cm length by 2.0 cm width and 100% granulation. A skin and wound evaluation regarding the right heel, dated 2/11/20 documented the wound was 3.0 cm length by 2.6 cm width and was an intact serum filled blister. A note signed by the wound care physician on 2/12/20 documented a left knee stage two pressure injury measuring 5 cm length by 3 cm width by 0.2 cm depth, a right knee stage two pressure injury measuring 2 cm length by 2 cm width and a right heel DTI measuring 3 cm length by 3.5 cm width. Review of the clinical record revealed treatments were administered to all areas per physician's orders, but failed to evidence documented assessment of the pressure injuries from 1/15/20 until 2/11/20. On 2/12/20 at 3:11 p.m., an interview was conducted with LPN (licensed practical nurse) #1, regarding pressure injury assessments. LPN #1 stated pressure injuries should be assessed, measured and staged every seven days. LPN #1 stated the assessment should consist of the type of wound, any characteristics such as drainage, an assessment of the area around the wound, measurements and staging. LPN #1 was asked to describe the potential impact if assessing, measuring and staging a pressure injury is not done every seven days. LPN #1 stated, There is a potential for the wound to deteriorate or have some type of change; it could become infected; a lot of things that could happen if we don't keep a close watch on it. On 2/12/20 at 3:40 p.m., an interview was conducted with ASM (administrative staff member) #4 (the wound care physician). ASM #4 was asked how often a wound should be measured, assessed, described and staged. ASM #4 stated he follows CMS (Centers for Medicare and Medicaid Services) and state guidelines, and assesses wounds on a weekly basis to assist the outcome of the wounds and determine if the wounds are healing. ASM #4 stated he does not evaluate all resident wounds in the facility and can only do so after he receives a consult from the primary care physician or nurse practitioner. (Note: Resident #267 was not evaluated by ASM #4 until 2/12/20). On 2/12/20 at 6:10 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #5 (the regional nurse consultant) were made aware of the above concern. The facility policy titled, Pressure Ulcer Monitoring & Documentation documented, POLICY: All pressure ulcers will be monitored. PROCEDURE .3. The Skin Wound Evaluation will be completed weekly by a licensed nurse for any patient with pressure ulcers/injuries . No further information was presented prior to exit. Reference: (1) A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface . This information was obtained from the website: https://cdn.ymaws.com/npuap.site-ym.com/resource/resmgr/npuap_pressure_injury_stages.pdf

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide respiratory care consistent with professional standards of practice, and the comprehensive person-centered care plan for one of 59 residents in the survey sample, Resident #318. The facility staff failed to store a nebulizer mask with a protective covering for Resident #318 on 2/12/2020. The findings include: Resident #318 was admitted to the facility on [DATE] with diagnoses of pneumonia, Alzheimer's disease (1), and obstruction of bilateral ureters (3). He had not been a resident at the facility long enough to have a completed MDS (minimum data set) assessment. On the admission nursing assessment dated [DATE], Resident #318 was documented as being alert only to person. 02/12/20 at 8:19 a.m. and at 11:47 a.m., Resident #318 was observed lying in bed. During both observations, a nebulizer mask was lying directly on the bedside table. The mask was uncovered, and in direct contact with the bedside table. A review of Resident #318's clinical record revealed the following order, dated 2/6/2020: Ipratropium-Albuterol Solution (2) 0.5-2.5 mg/3ml (milligrams per three milliliters). Inhale orally every 4 hours as needed for SOB (shortness of breath) or wheezing via nebulizer. A review of Resident #318's February 2020 TARs (treatment administration records) revealed that he received this medication on 2/8/2020 at 11:15 a.m. A review of Resident #318's baseline care plan dated 2/10/2020 revealed, in part: The resident has pneumonia .Give medications as ordered. On 2/13/2020 at 9:53 a.m., LPN (licensed practical nurse) #1 was interviewed. When asked how nebulizer masks are stored when not in use, LPN #1 stated the mask should always be placed in a plastic bag. When asked why the mask should be stored in a plastic bag, LPN #1 stated, For infection control. On 2/13/2020 at 11:01 a.m., CNA (certified nursing assistant) #3 was interviewed. When asked how nebulizer masks should be stored, she stated a mask should be stored in a plastic bag. CNA #3 stated, It should be dated and labeled. When asked why the mask should be stored in a plastic bag, CNA #3 stated, You don't want it to get dirty. That would be bad for the resident. On 2/13/2020 at 11:43 a.m., LPN #3, a unit manager, was interviewed. When asked how a nebulizer mask should be stored, she stated that a nebulizer mask should always be in a plastic bag. When asked why the mask should be in a plastic bag, LPN #3 stated, Bacteria and germs. On 2/13/2020 at 1:28 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Respiratory/Oxygen Equipment, revealed, in part: Rinse out nebulizer reservoir with tap water, dry, and place in a plastic bag when not in use. No further information was provided prior to exit. (1) Alzheimer's disease is an irreversible, progressive brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks. It is the most common cause of dementia in older adults. This information is taken from the website https://www.nia.nih.gov/health/alzheimers/basics. (2) The combination of albuterol and ipratropium is used to prevent wheezing, difficulty breathing, chest tightness, and coughing in people with chronic obstructive pulmonary disease (COPD; a group of diseases that affect the lungs and airways) such as chronic bronchitis (swelling of the air passages that lead to the lungs) and emphysema (damage to the air sacs in the lungs). Albuterol and ipratropium combination is used by people whose symptoms have not been controlled by a single inhaled medication. Albuterol and ipratropium are in a class of medications called bronchodilators. Albuterol and ipratropium combination works by relaxing and opening the air passages to the lungs to make breathing easier. This information is taken from the website https://medlineplus.gov/druginfo/meds/a601063.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 evidence a complete pain management program for one of fifty nine residents in the survey sample, Residents #23 and Resident #4. The facility staff failed to document the location of pain, pain scale and if any non-pharmacological interventions were provided prior to the administration of a narcotic pain medication for Resident #4. The findings include: Resident #4 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: diabetes, high blood pressure, depression, anxiety disorder, peripheral vascular disease - (any abnormal condition, including atherosclerosis, affecting blood vessels outside the heart) (1), and amputation of his toes. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 1/25/2020 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 supervision with set up assistance for all of his activities of daily living. In Section N - Medications, the resident was coded as receiving opioid medications seven days of the look back period. In Section J - Health Conditions, the resident was coded as having pain frequently that makes it hard for him to sleep with a 8 pain level. The physician orders documented, Oxycodone Tablet [used to treat moderate to severe pain (2)] 20 mg (milligrams), give 1 tablet by mouth every 4 hours as needed for pain. Review of the January and February 2020 MAR (medication administration record) revealed the above physician order for Oxycodone was documented. On 1/3/2020 at 7:56 a.m., the Oxycodone was documented as administered. The pain level documented was a zero. Review of the nurse's notes for this date and time revealed no pain scale documentation, no location of the pain and no non-pharmacological interventions provided prior to administration of the medication. On 2/9/2020 at 1:50 a.m. The Oxycodone was documented as administered. The pain level documented was a zero. Review of the nurse's notes for this date and time revealed no pain scale documentation, no location of the pain and no non-pharmacological interventions provided prior to the administration of the medication. The comprehensive care plan dated, 2/1/19 and revised on 9/28/19, documented in part, The resident has actual pain r/t (related to) Medical Procedure Amputation of toes right foot and osteomyelitis to right foot with wound. The Interventions documented in part, Administer analgesia (pain medication) per order and give before treatments or care as needed. Encourage to try different pain relieving methods i.e., positioning, relaxation therapy, progressive relaxation, bathing, heat and cold therapy, muscle stimulation, ultrasound. Monitor/record/report to nurse any s/sx (signs and symptoms) of non-verbal pain. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM (range of motion), withdrawal or resistance to care. An interview was conducted with Resident #4 on 2/11/2020 at 4:16 p.m. When asked what the staff does if he complains of pain, Resident #4 stated they just give him a pain pill. When asked if the staff ask what level the pain is, Resident #4 stated sometimes they ask. When asked if the staff ask the location of his pain, Resident #4 responded, sometimes. When asked if the nurse offers something prior to the administration of the as needed pain medication like repositioning, Resident #4 stated, no, they don't offer anything other the pain pill. An interview was conducted with LPN (licensed practical nurse) #3, on 2/13/2020 at 10:33 a.m. LPN #3 reviewed the order for Oxycodone. When asked if there should be a pain scale with this order, LPN #3 stated at one point we had the pain scale and then they (the pain scales) weren't there. When asked why a nurse would give pain medication for a pain level of zero, LPN #3 stated, if he (Resident #4) asks for it he is very adamant about getting it every four hours. If the nurse practitioner changes his medications, it would be a big issue. I could be a typo error. When asked if the MAR is accurate then, LPN #3 stated no. The nurse's notes for the administration of the Oxycodone for the two dates above were reviewed with LPN #3. When asked if the location of the pain and non-pharmacological interventions were documented, LPN #3 stated, No, you need to put those things in your note. The facility Pain Management Policy dated 11/1/19 revealed in part the following, Patient will be assessed for acute and chronic pain by licensed nurse and a plan of care will be established. Administration of pain medication and effectiveness will be documented. ASM (administrative staff member) #1, the administrator, ASM #5, the regional nurse consultant and ASM #6, the assistant administrator, were made aware of the above concerns. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 447. (2) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a697048.html.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview and clinical record review, it was determined the facility staff failed to ensure a drug regimen free of unnecessary medications for one of 59 residents in the survey sample, (Resident #4). The facility staff administered a physician prescribed as needed narcotic pain medication to Resident #4 for a pain level rating of zero and failed to document non-pharmacological interventions attempted prior to administering the as needed pain medication on 1/13/2020 and 2/9/2020. The findings include. Resident #4 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: diabetes, high blood pressure, depression, anxiety disorder, peripheral vascular disease - (any abnormal condition, including atherosclerosis, affecting blood vessels outside the heart) (1), and amputation of his toes. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 1/25/2020 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 supervision with set up assistance for all of his activities of daily living. In Section N - Medications, the resident was coded as receiving opioid medications seven days of the look back period. In Section J - Health Conditions, the resident was coded as having pain frequently that makes it hard for him to sleep with a 8 pain level. The physician orders documented, Oxycodone Tablet [used to treat moderate to severe pain (2)] 20 mg (milligrams), give 1 tablet by mouth every 4 hours as needed for pain. Review of the January and February 2020 MAR (medication administration record) revealed the above physician order for Oxycodone was documented. On 1/3/2020 at 7:56 a.m., the Oxycodone was documented as administered. The pain level documented was a zero. Review of the nurse's notes for this date and time revealed no pain scale documentation, no location of the pain and no non-pharmacological interventions provided prior to administration of the medication. On 2/9/2020 at 1:50 a.m. The Oxycodone was documented as administered. The pain level documented was a zero. Review of the nurse's notes for this date and time revealed no documentation for the location of the pain and failed to evidence non-pharmacological interventions attempted/provided prior to the administration of the as needed narcotic pain medication. The comprehensive care plan dated, 2/1/19 and revised on 9/28/19, documented in part, The resident has actual pain r/t (related to) Medical Procedure Amputation of toes right foot and osteomyelitis to right foot with wound. The Interventions documented in part, Administer analgesia (pain medication) per order and give before treatments or care as needed. Encourage to try different pain relieving methods i.e., positioning, relaxation therapy, progressive relaxation, bathing, heat and cold therapy, muscle stimulation, ultrasound. Monitor/record/report to nurse any s/sx (signs and symptoms) of non-verbal pain. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM (range of motion), withdrawal or resistance to care. An interview was conducted with Resident #4 on 2/11/2020 at 4:16 p.m. When asked what the staff does if he complains of pain, Resident #4 stated they just give him a pain pill. When asked if the staff ask what level the pain is, Resident #4 stated sometimes they ask. When asked if the staff ask the location of his pain, Resident #4 responded, sometimes. When asked if the nurse offers something prior to the administration of the as needed pain medication like repositioning, Resident #4 stated, no, they don't offer anything other the pain pill. An interview was conducted with LPN (licensed practical nurse) #3, on 2/13/2020 at 10:33 a.m. The physician order for Oxycodone was reviewed with LPN #3. When asked why narcotic pain medication would be administered for a pain level rating of zero, LPN #3 stated, if he asks for it he is very adamant for about getting it every four hours. If the nurse practitioner changes his medications, it would be a big issue. I could be a typo error. LPN #3 was asked if the MAR would be accurate then, LPN #3 stated no. The nurse's notes for the administration of the Oxycodone for the two dates documented above 1/13/2020 and 2/9/2020, were reviewed with LPN #3. When asked if a pain level, location of the pain and non-pharmacological interventions attempted provided prior to the administration of the as needed pain medication documented, LPN #3 stated, No, you need to put those things in your note. The facility Pain Management Policy dated 11/1/19 revealed in part the following, Patient will be assessed for acute and chronic pain by licensed nurse and a plan of care will be established. Administration of pain medication and effectiveness will be documented. ASM (administrative staff member) #1, the administrator, ASM #5, the regional nurse consultant and ASM #6, the assistant administrator, were made aware of the above concerns. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 447. (2) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a697048.html.

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to store food in a safe and sanitary manner. The facility staff failed to store milk in a safe manner in the A unit nourishment room. Two eight ounce cartons of skim milk with a sell by date of 2/4/20 was observed in the refrigerator. The findings include: On 2/12/20 at 12:12 p.m., observation of the A unit nourishment room refrigerator was conducted. Two eight ounce cartons of skim milk with a sell by date of 2/4/20 were observed in the refrigerator. On 2/12/20 at 12:45 p.m., an interview was conducted with OSM (other staff member) #7 (the dining services director). OSM #7 stated the dietary staff checks and restocks the unit refrigerators daily and usually several times a day. OSM #7 was asked if the dietary staff is supposed to check the dates on food and beverages. OSM #7 stated, Uh huh. OSM #7 was made aware of the above concern. OSM #7 stated the cartons of skim milk should not have been in the refrigerator because this date was past the sell by date. On 2/12/20 at 6:10 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #5 (the regional nurse consultant) were made aware of the above concern. The facility policy titled, Unit Pantry/Nourishment Rooms documented, POLICY: Unit pantries/nourishment rooms will be maintained in a sanitary manner. PROCEDURE: 1. A Dining Services staff member will check unit pantry/nourishment room refrigerator/freezer temperatures twice per day. 2. Dining Services will stock unit pantries/nourishment rooms with snacks for patients. 3. Dining Services is responsible for maintaining cleanliness of food storage areas, including freezer, refrigerator, drawers . 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 maintain a complete and accurate clinical record for two of 59 residents in the survey sample, Residents #25 and #21. Resident #31 hit Resident #25 in the chest on 11/15/18 and Resident #28 hit Resident #21 in the face on 12/22/19. The facility staff failed to document these incidents in Resident #25's and Resident #21's clinical records. The findings include: 1. Resident #25 was admitted to the facility on [DATE]. Resident #25's diagnoses included but were not limited to diabetes, chronic kidney disease and repeated falls. Resident #25's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 11/26/19, coded the resident's cognition as moderately impaired. Resident #31 was admitted to the facility on [DATE]. Resident #31's diagnoses included but were not limited to paralysis, heart disease and difficulty swallowing. Resident #31's quarterly MDS assessment with an ARD of 12/3/19, coded the resident as being cognitively intact. A FRI (facility reported incident) submitted to the state agency on 11/15/18 documented, Report date: 11/15/2018. Incident date: 11/15/2018. Residents involved: (Name of Resident #31) (Name of Resident #25). While residents were leaving the dining room, (Resident #31) asked (Resident #25) to speed up. (Resident #31) then backhanded (Resident #25) in the upper chest. Residents were separated. No further interaction was noted between both residents and they continued wheeling themselves through the hallway . Review of Resident #25's clinical record (including nurses' notes dated 11/15/18) failed to reveal documentation that Resident #25 had been hit by another resident. On 2/12/20 at 4:17 p.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated there should be documentation in a resident's clinical record if a resident is hit by another resident. When asked why, LPN #4 stated, Just to have a record of it. On 2/12/20 at 6:08 p.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 confirmed there should be documentation in a resident's clinical record if a resident is hit by another resident, in case the resident presents with injury on a later date. On 2/12/20 at 6:10 p.m., ASM #1 (the administrator), ASM #2 and ASM #5 (the regional nurse consultant) were made aware of the above concern. The facility policy titled, Documentation Summary documented, POLICY: Licensed Nurses and CNAs (certified nursing assistants) will document all pertinent nursing assessments, care interventions, and follow up actions in the medical record. PROCEDURE .12. Document all of the facts and pertinent information related to an event, course of treatment, patient condition, response to care, and deviations from standard treatment along with the reason for the deviation . No further information was presented prior to exit. 2. Resident #21 was admitted to the facility on [DATE]. Resident #21's diagnoses included but were not limited to chronic pain syndrome, muscle weakness and major depressive disorder. Resident #21's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 11/19/19, coded the resident's cognition as severely impaired. Resident #28 was admitted to the facility on [DATE]. Resident #28's diagnoses included but were not limited to repeated falls, muscle weakness and anemia (a blood disorder). Resident #28's quarterly MDS assessment with an ARD of 11/27/19, coded the resident's cognition as severely impaired. A FRI (facility reported incident) submitted to the state agency on 12/23/19 documented, Report date: 12-23-19. Incident date: 12-22-19. Residents involved: (Name of Resident #21) (Name of Resident #28). Incident reported between (Resident #21) and (Resident #28) in the dining room during lunch. It was about 12:45 pm when (Resident #28) hit (Resident #21) in the face. Residents were separated immediately and (Resident #28) was taken to the unit (illegible word) charge nurse. No injuries noted at this time. Investigation initiated. Review of Resident #21's clinical record (including nurses' notes dated 12/22/19) failed to reveal documentation that Resident #21 had been hit by another resident. On 2/12/20 at 4:17 p.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated there should be documentation in a resident's clinical record if a resident is hit by another resident. When asked why, LPN #4 stated, Just to have a record of it. On 2/12/20 at 6:08 p.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 confirmed there should be documentation in a resident's clinical record if a resident is hit by another resident, in case the resident presents with injury on a later date. On 2/12/20 at 6:10 p.m., ASM #1 (the administrator), ASM #2 and ASM #5 (the regional nurse consultant) were made aware of the above concern. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #40 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses including, but not limited to persistent vegetative state (1), contractures (2), and multiple sclerosis (3). On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of 12/10/19, she was coded as being in a persistent vegetative state. A review of Resident #40's clinical record failed to reveal evidence of advance directive documentation. The review also failed to reveal evidence that Resident #40's advance directive information had been reviewed since the last survey conducted on 11/6/2018. On 2/12/2020 at 11:27 a.m., OSM (other staff member) #5, the director of discharge planning, was interviewed. She stated she performs a review of resident rights annually with each resident. She stated advance directives are included in this review. She stated she offers to answer any questions residents might have about executing advance directives. She stated a copy of the resident rights are scanned into the EHR each year. She stated, It doesn't specifically say 'advance directives' on the resident rights document, but it is a part of our [NAME]. OSM #5 was asked if she could provide evidence that Resident #5's resident responsible party had participated in any sort of review of advance directive information since the last survey. OSM #5 stated she could not. On 2/13/2020 at 1:28 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. No further information was provided prior to exit. (1) A coma, sometimes also called persistent vegetative state, is a profound or deep state of unconsciousness. This information is taken from the website https://www.ninds.nih.gov/Disorders/All-Disorders/Coma-Information-Page. (2) A contracture develops when the normally stretchy (elastic) tissues are replaced by nonstretchy (inelastic) fiber-like tissue. This tissue makes it hard to stretch the area and prevents normal movement. This information is taken from the website https://medlineplus.gov/ency/article/003185.htm. (3) Multiple sclerosis (MS) is a disease of the central nervous system. In MS the body's immune system attacks myelin, which coats nerve cells. This information is taken from the website https://nccih.nih.gov/health/multiple-sclerosis. 3. The facility staff failed to periodically review Resident #84's decisions regarding advance directives. Resident #84 was admitted to the facility on [DATE]. Resident #84's diagnoses included but were not limited to major depressive disorder and high blood pressure. Resident #84's quarterly MDS with an ARD of 1/16/20, coded the resident as being cognitively intact. Review of an advance directives acknowledgement dated 1/1/15 revealed Resident #84 had not executed advance medical directives and did not want more information regarding advance directives on that date. Review of Resident #84's clinical record failed to reveal the facility staff had reviewed the resident's decisions regarding advance directives since 1/1/15. Resident #84's comprehensive care plan created on 1/7/15 failed to document information regarding advance directives. On 2/12/20 at 3:04 p.m., an interview was conducted with OSM (other staff member) #5 (the director of discharge planning). OSM #5 stated she completes an annual review with each resident that includes a review of resident rights, the resident's care plan and advance directives. OSM #5 stated this is a general annual review and she does not document everything that is discussed, including advance directives. On 2/12/20 at approximately 4:00 p.m., an interview was conducted with Resident #84 regarding advance directives. Resident #84 stated advance directives were discussed with him upon admission but not since then. On 2/12/20 at 6:10 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #5 (the regional nurse consultant) were made aware of the above concern. No further information was presented prior to exit. Based on resident interview, facility document review and clinical record review, it was determined the facility staff failed to meet the requirements for advanced directives for four of 59 residents in the survey sample, (Residents #24, #116, # 84, and #40). The facility staff failed to obtain a copy of Resident #24's Appointment of Agent to Make Healthcare Decision as documented on the resident's admission paperwork. The facility staff failed to periodically review, Resident 116's, Resident #84's and Resident #40's decisions regarding advance directives. The findings include: 1. Resident #24 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: stroke, diabetes, high blood pressure, depression and hemiplegia (paralysis affecting only one side of the body) (1). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 11/21/19, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating she was cognitively intact to make daily decisions. The resident was coded as requiring extensive assistance to being dependent upon one or more staff members for her activities of daily living. Resident #24 was coded as able to feed herself after set up assistance was provided. The facility policy Advanced Directives documented in part, the resident's advanced directives will be reviewed upon admission and during their stay at the facility. Review of the clinical record failed to evidence any documentation related to advanced directives. On 2/12/2020, a request was made of the administrator (administrative staff member) ASM #1, for documentation upon admission of Resident #24's advanced directive and documentation of the periodic review of the advanced directives. On 2/12/2020 a copy of Resident #24's Business Contract was presented. The contract documented in part, Advanced Directive Acknowledgement. An X was documented next to: I HAVE executed the following portions of an Advance Medical Directive. An X was documented next to: Optional Appointment of Agent to Make Healthcare Decision. An X was documented next to: Yes, I HAVE provided the Health & Rehabilitation Center with a copy verified by the Health & Rehabilitation Center. On 2/12/2020 at 11:27 a.m., OSM (other staff member) #8, the admissions director, and OSM #5, the director of discharge planning, were interviewed. OSM #8 stated that on admission, the facility goes over the contract and offers the resident the right to execute an advance directive, including who the resident chooses to serve as a health care decision maker. She stated the advance directive includes making a decision about anatomical gifts, a health care decision maker, and a living will, in addition to determining code status. OSM #8 stated if the resident already has this documentation, the facility requests a copy for the resident's file. She stated if the resident provides these documents, the documents are scanned into the electronic health record (EHR). OSM #8 stated if the resident does not have the documents, we follow up with them [residents and or resident representative]. OSM #8 stated, we document in the business contract that it exists, but we don't document our efforts to try to get it. It is more of a conversation. OSM #5 stated she performs a review of resident rights annually with each resident. She stated advance directives are included in this review. OSM #5 stated she offers to answer any questions residents might have about executing advance directives. She stated a copy of the resident rights are scanned into the EHR each year. OSM #5 stated, It doesn't specifically say 'advance directives' on the resident rights document, but it is a part of our [NAME]. A request was made on 2/12/2020 at approximately 6:15 p.m. for this above mentioned document. On 2/13/2020 at approximately 9:15 a.m. ASM #1 presented a General Durable Power of Attorney. Review of the document failed to evidence documentation for of an individual appointed as Resident #24's Agent to Make Healthcare Decisions. ASM #1, the administrator, ASM #2, the director of nursing, ASM #5 the regional nurse consultant and ASM #6, the assistant administrator, were made aware of the above findings on 2/12/2020 at approximately 6:30 p.m. No further information was obtained prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 266. 2. Resident #116 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: end stage renal 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), high blood pressure, depression, muscle weakness. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 1/24/2020 coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact to make daily decisions. Review of the clinical record failed to evidence any documentation related to advanced directives. A request was made on 2/12/2020 of the administrator (administrative staff member) ASM #1, for documentation upon admission of the advanced directive and of the periodic review of the advanced directives. On 2/12/2020 a copy of Resident #116's Business Contract was presented. Under the heading of Advanced Directives Acknowledgement, an X was documented next to: I HAVE NOT executed Advance Medical Directive. An X was documented next to: I DO NOT WANT MORE INFORMATION regarding advance directives. Further review of the clinical record failed to evidence documentation of periodic reviews of the Resident #116's selected advanced directive wishes with opportunities to formulate an advanced directive. On 2/12/2020 at 11:27 a.m., OSM (other staff member) #8, the admissions director, and OSM #5, the director of discharge planning, were interviewed. OSM #8 stated that on admission, the facility goes over the contract and offers the resident the right to execute an advance directive, including who the resident chooses to serve as a health care decision maker. She stated the advance directive includes making a decision about anatomical gifts, a health care decision maker, and a living will, in addition to determining code status. OSM #8 stated if the resident already has this documentation, the facility requests a copy for the resident's file. She stated if the resident provides these documents, the documents are scanned into the electronic health record (EHR). OSM #8 stated if the resident does not have the documents, we follow up with them [residents and or resident representative]. OSM #8 stated, we document in the business contract that it exists, but we don't document our efforts to try to get it. It is more of a conversation. OSM #5 stated she performs a review of resident rights annually with each resident. She stated advance directives are included in this review. OSM #5 stated she offers to answer any questions residents might have about executing advance directives. She stated a copy of the resident rights are scanned into the EHR each year. OSM #5 stated, It doesn't specifically say 'advance directives' on the resident rights document, but it is a part of our [NAME]. On 2/12/2020 at 5:08 p.m. an interview was conducted with Resident #116. When asked if the facility staff on a periodic basis reviewed if he wished to have information to initiate an advanced directive, Resident #116 stated the facility talked to him when he first came but no one has asked him anything about advanced directives since he's been at the facility. ASM #1, the administrator, ASM #2, the director of nursing, ASM #5 the regional nurse consultant and ASM #6, the assistant administrator, were made aware of the above findings on 2/12/2020 at approximately 6:30 p.m. No further information was obtained prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 266.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Resident #74 was admitted to the facility on [DATE]. Resident #74's diagnoses included but were not limited to: chronic obstructive pulmonary disease (chronic, nonreversible lung disease which is a combination of emphysema and chronic bronchitis) (1), left femur fracture (break in the thighbone) (2), atrial fibrillation (rapid and random contraction of the top parts [atria] of the heart) (3). Resident #74's most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 12/23/19, coded the resident as scoring 9 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. Review of Resident #74's clinical record revealed the resident was transferred to the hospital on [DATE] for lethargy, fever, hypotension and hypoxia (unable to wean off supplemental oxygen). A nurse's note dated 12/12/19 documented a report was called to the hospital and Resident #74's history, medications, allergies and reason for transfer was provided. Further review of Resident #74's clinical record failed to reveal documentation to evidence that all required information (including comprehensive care plan goals) was provided to the hospital staff. On 2/12/20 at 3:14 PM, an interview was conducted with LPN (licensed practical nurse) #1, a charge nurse. When asked what information is sent with residents' upon transfer to the hospital, LPN #1 stated, We send the face sheet, contact for RP (responsible party), current list of medications, e-Interact change in condition form and transfer form, nurses notes for last 72 hours. When asked if the comprehensive care plan goals are sent to the receiving hospital, LPN #1 stated, Not to my knowledge. On 2/12/20 at 5:15 PM, an interview was conducted with ASM (administrative staff member) #1, the administrator. When asked if care plan goals are provided upon transfer, ASM #1 stated, Yes, they are provided. The staff know to provide them. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional nurse consultant, were made aware of the above concerns on 2/12/20 at 6:03 PM. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 120. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 232. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 54. Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide evidence of required documentation for a transfer to the hospital for six of 59 residents in the survey sample, (Residents #40, #15, #61, #89, #66, and #74). The facility staff failed to provide the comprehensive care plan goals to the receiving hospital for Resident #40 who hospitalized on [DATE], Resident #15 who was hospitalized on [DATE], Resident #61 for transfers to the hospital on [DATE] and 1/2/20, Resident # 89 for transfer to the hospital on [DATE], Resident #66 for transfer to hospital on [DATE], and Resident #74 for transfer to the hospital on [DATE]. The findings include: 1. Resident #40 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses including, but not limited to persistent vegetative state (1), contractures (2), and multiple sclerosis (3). On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of 12/10/19, she was coded as being in a persistent vegetative state. A review of Resident #40's clinical record revealed a Notice of Transfer/discharge date d 1/19/2020. The notice documented: The reason for this notice of your transfer/discharge is you have been sent to the hospital. Further review revealed the following progress note dated 1/18/2020: Spouse was notified of the pt's (patient's) transfer to [name of local hospital] at 1123 (11:23 a.m.) and fax was successful to the pt's nurse at [name of local hospital] of her medications and history to [name of local hospital nurse] at 1113 (11:13 a.m.). Further review of the clinical record revealed no evidence that the resident's comprehensive care plan goals were sent to the receiving hospital when Resident #40 was transferred. On 2/12/20 at 3:11 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 was asked to describe the information that is provided to hospital staff when a resident is transferred to the hospital. LPN #1 stated the nurses send a face sheet, contact information for the resident's representative, a current list of medications, an e-interact change in condition form, hospital transfer form and nurses notes from the last 72 hours. LPN #1 was asked if the resident's comprehensive care plan goals are provided to the hospital staff. LPN #1 stated, Um, not to my knowledge. On 2/12/20 at 5:21 p.m., ASM (administrative staff member) #1 (the administrator) stated the facility staff sends care plan goals with residents to the hospital but this is not documented. On 2/13/2020 at 1:28 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Notice of Transfer/Discharge, revealed, in part: When the Center initiates a notice of transfer/discharge to a patient and/or responsible party, discharge planning staff will pursue timely and appropriate transfer/discharge notifications as well as discharge planning initiatives to ensure a safe and orderly discharge from the Center. A review of the facility policy, Patient Transfer Form revealed, in part: Place a copy of the Patient Transfer Form ., copies of the current face sheet .care plan .in the designated .envelope and send with the patient to the acute care center or hospital. No further information was provided prior to exit. References: (1) A coma, sometimes also called persistent vegetative state, is a profound or deep state of unconsciousness. This information is taken from the website https://www.ninds.nih.gov/Disorders/All-Disorders/Coma-Information-Page. (2) A contracture develops when the normally stretchy (elastic) tissues are replaced by nonstretchy (inelastic) fiber-like tissue. This tissue makes it hard to stretch the area and prevents normal movement. This information is taken from the website https://medlineplus.gov/ency/article/003185.htm. (3) Multiple sclerosis (MS) is a disease of the central nervous system. In MS the body's immune system attacks myelin, which coats nerve cells. This information is taken from the website https://nccih.nih.gov/health/multiple-sclerosis. 2. Resident #15 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses including, but not limited to history of a stroke, paralysis following a stroke, and diabetes (1). On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of 11/13/19, Resident #15 was coded as being moderately impaired for making daily decisions, having scored 12 out of 15 on the BIMS (brief interview for mental status). A review of Resident #15's clinical record revealed a Notice of Transfer/discharge date d 1/19/2020. The notice documented: The reason for this notice of your transfer/discharge is you have been sent to the hospital. Date of transfer/discharge: [DATE]. Further review of the clinical record revealed no evidence that the resident's comprehensive care plan goals were sent to the receiving hospital when Resident #15 was transferred. On 2/12/20 at 3:11 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 was asked if the resident's comprehensive care plan goals are provided to the hospital staff and stated, Um, not to my knowledge. On 2/12/20 at 5:21 p.m., ASM (administrative staff member) #1 (the administrator) stated the facility staff sends care plan goals with residents to the hospital but this is not documented. On 2/13/2020 at 1:28 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. No further information was provided prior to exit. Reference: (1) Diabetes (mellitus) is a disease in which your blood glucose, or blood sugar, levels are too high. This information is taken from the website https://medlineplus.gov/diabetes.html. 3. Resident #61 was admitted to the facility on [DATE]. Resident #61's diagnoses included but were not limited to bladder cancer, diabetes and high blood pressure. Resident #61's five day Medicare MDS (minimum data set) assessment with an ARD (assessment reference date) of 1/23/20, coded the resident as being cognitively intact. Review of Resident #61's clinical record revealed the resident was transferred to the hospital on [DATE] and 1/2/20. Further review of Resident #61's clinical record, including nurses' notes and hospital transfer forms dated 12/17/19 and 1/2/20, and an e-interact form dated 12/17/19, failed to reveal evidence that the resident's comprehensive care plan goals were provided to the hospital staff. On 2/12/20 at 3:11 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 was asked if the staff provides the resident's comprehensive care plan goals to the hospital staff upon transfer of a resident to the hospital. LPN #1 stated, Um, not to my knowledge. On 2/12/20 at 5:21 p.m., ASM (administrative staff member) #1 (the administrator) stated the facility staff sends care plan goals with residents to the hospital but this is not documented. On 2/12/20 at 6:10 p.m., ASM (administrative staff member) #1, ASM #2 (the director of nursing) and ASM #5 (the regional nurse consultant) were made aware of the above concern. No further information was presented prior to exit. 4. Resident #89 was admitted to the facility on [DATE] with a recent readmission on [DATE] with diagnoses that included but were not limited to: dementia, quadriplegia (Paralysis affecting all four limbs and the trunk of the body below the level of spinal cord injury. Trauma is the usual cause.) (1), diabetes, gastrointestinal bleed, and high blood pressure. The most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 1/14/2020 coded the resident as unable to answer the question for the BIMS and had both short and long-term memory difficulties. The physician's note 12/27/19 documented in part the resident presented with recurrent episodes of coffee ground emesis and moderate amount of dark brown drainage from the G -tube (gastrostomy tube), and Resident #89 was sent to the emergency room after giving IV (intravenous) fluids and lab [laboratory tests] work. Further review of the clinical record failed to evidence documentation that Resident #89's comprehensive care plan goals were sent with the patient to the hospital on [DATE]. An interview was conducted with administrative staff member (ASM) #1, the administrator on 2/12/2020 at 5:21 p.m. When asked if the comprehensive care plan goals are sent with residents' upon transfer to the hospital, ASM #1 stated, If it's not in the progress notes, it is our process to send them, it just wasn't documented. An interview was conducted with LPN (licensed practical nurse) #3, on 2/13/2020 at 12:57 p.m. LPN #3 was asked if the comprehensive care plan goals are sent with a resident upon transfer to the hospital. LPN #3 stated, No. We just call the ER (emergency room) with report. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #5, the regional nurse consultant and ASM #6, the assistant administrator, were made aware of the above findings on 2/12/2020 at approximately 6:15 p.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 489 5. Resident #66 was admitted to the facility on [DATE] with a recent readmission on [DATE] with diagnoses that included but were not limited to: fracture of the femur, depression, dementia, diabetes and peripheral vascular disease (any abnormal condition, including atherosclerosis, affecting blood vessels outside the heart) (1). The most recent MDS (minimum data set) assessment, Medicare admission and significant change assessment, with an assessment reference date of 12/30/19 coded the resident as scoring a 3 on the BIMS (brief interview for mental status) score, indicating she was severely impaired to make daily cognitive decisions. A nurse's note dated, 12/20/19 at 7:26 p.m. documented in part, Resident has a fall in which the x-ray stated that R (right) hip may represent either an acute impacted fracture or a chronic healed fracture. Resident sent out to ER (emergency room) as ordered. Further review of the clinical record failed to evidence documentation that Resident #66's comprehensive care plan goals were sent with the patient to the hospital on [DATE]. An interview was conducted with administrative staff member (ASM) #1, the administrator on 2/12/2020 at 5:21 p.m. When asked if the comprehensive care plan goals are sent with residents' upon transfer to the hospital, ASM #1 stated, If it's not in the progress notes, it is our process to send them, it just wasn't documented. An interview was conducted with LPN (licensed practical nurse) #3, on 2/13/2020 at 12:57 p.m. LPN #3 was asked if the comprehensive care plan goals are sent with a resident upon transfer to the hospital. LPN #3 stated, No. We just call the ER (emergency room) with report. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #5, the regional nurse consultant and ASM #6, the assistant administrator, were made aware of the above findings on 2/12/2020 at approximately 6:15 p.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 447.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident #74 was admitted to the facility on [DATE]. Resident #74's diagnoses included but were not limited to: chronic obstructive pulmonary disease (chronic, nonreversible lung disease which is a combination of emphysema and chronic bronchitis) (1), left femur fracture (break in the thighbone) (2), atrial fibrillation (rapid and random contraction of the top parts [atria] of the heart) (3). Resident #74's most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 12/23/19, coded the resident as scoring 9 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. Review of Resident #74's clinical record revealed the resident was transferred to the hospital on [DATE] for lethargy, fever, hypotension and hypoxia (unable to wean off supplemental oxygen). A nurse's note dated 12/12/19 documented a report was called to the hospital and Resident #74's history, medications, allergies and reason for transfer was provided. Further review of Resident #74's clinical record failed to reveal documentation to evidence the resident and or resident representative was provided with written bed hold notice and information upon transfer to the hospital. On 2/12/20 at 3:14 PM, an interview was conducted with LPN (licensed practical nurse) #1, LPN charge nurse. When asked if the provision of the bed hold on transfer to the resident or resident represented is documented, LPN #1 stated, It should be documented, it is not documented on the form. On 2/12/20 at 5:15 PM, an interview was conducted with ASM (administrative staff member) #1, the administrator. When asked if a written notice is provided for the bed hold upon transfer to the hospital, ASM #1 stated, Our internal process is to document it. They did not document the bed hold where they should have. ASM #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional nurse consultant, were made aware of the above concerns on 2/12/20 at 6:03 PM. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 120. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 232. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 54. Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide evidence of required written bed hold notification at the time of a transfer to the hospital for five of 59 residents in the survey sample, (Residents #40, #15, #89, #66, and #74). The facility staff failed to evidence documentation a notice of bed hold was provided to Resident #40 when the resident was hospitalized on [DATE], to Resident #15 when the resident was hospitalized on [DATE], to Resident #89 upon transfer to the hospital on [DATE], to Resident #66 upon transfer to the hospital on [DATE], and to Resident #74 upon transfer to the hospital on [DATE]. The findings include: 1. Resident #40 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses including, but not limited to persistent vegetative state (1), contractures (2), and multiple sclerosis (3). On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of 12/10/19, she was coded as being in a persistent vegetative state. A review of Resident #40's clinical record revealed a Notice of Transfer/discharge date d 1/19/2020. The notice documented: The reason for this notice of your transfer/discharge is you have been sent to the hospital. Further review revealed the following progress note dated 1/18/2020: Spouse was notified of the pt's (patient's) transfer to [name of local hospital] at 1123 (11:23 a.m.) and fax was successful to the pt's nurse at [name of local hospital] of her medications and history to [name of local hospital nurse] at 1113 (11:13 a.m.). Further review of the clinical record revealed no evidence that the resident or resident representative was provided with written bed hold notice information at the time of transfer to the hospital on 1/18/2020. On 2/12/2020 at 3:14 p.m., an interview was conducted with LPN (licensed practical nurse) #1, LPN charge nurse. When asked what information is sent with the resident when transferred to the hospital, LPN #1 stated, We send the face sheet, contact for RP (responsible party), current list of meds (medications), e-Interact change in condition form and transfer form, nurses notes for last 72 hours. When asked if the bed hold is documented, LPN #1 stated, It should be documented, it is not documented on the form. On 2/12/2020 at 5:15 p.m., an interview was conducted with ASM (administrative staff member) #1, the administrator. When asked if a written bed hold notice information is provided upon transfer to the hospital, ASM #1 stated, Our internal process is to document it. They did not document the bed hold where they should have. On 2/13/2020 at 1:28 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Notice of Transfer/Discharge, revealed, in part: When the Center initiates a notice of transfer/discharge to a patient and/or responsible party, discharge planning staff will pursue timely and appropriate transfer/discharge notifications as well as discharge planning initiatives to ensure a safe and orderly discharge from the Center. A review of the facility policy, Patient Transfer Form revealed, in part: Place a copy of the Patient Transfer Form ., copies of the current face sheet .care plan .in the designated .envelope and send with the patient to the acute care center or hospital. The policy contained no information related to the facility's notice of bed hold. No further information was provided prior to exit. Reference: (1) A coma, sometimes also called persistent vegetative state, is a profound or deep state of unconsciousness. This information is taken from the website https://www.ninds.nih.gov/Disorders/All-Disorders/Coma-Information-Page. (2) A contracture develops when the normally stretchy (elastic) tissues are replaced by nonstretchy (inelastic) fiber-like tissue. This tissue makes it hard to stretch the area and prevents normal movement. This information is taken from the website https://medlineplus.gov/ency/article/003185.htm. (3) Multiple sclerosis (MS) is a disease of the central nervous system. In MS the body's immune system attacks myelin, which coats nerve cells. This information is taken from the website https://nccih.nih.gov/health/multiple-sclerosis. 2. Resident #15 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses including, but not limited to history of a stroke, paralysis following a stroke, and diabetes (1). On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of 11/13/19, Resident #15 was coded as being moderately impaired for making daily decisions, having scored 12 out of 15 on the BIMS (brief interview for mental status). A review of Resident #15's clinical record revealed a Notice of Transfer/discharge date d 1/19/2020. The notice documented: The reason for this notice of your transfer/discharge is you have been sent to the hospital. Date of transfer/discharge: [DATE]. Further review of the clinical record revealed no evidence that the resident or resident representative was provided with written bed hold notice information at the time of transfer to the hospital on 1/17/2020. On 2/12/2020 at 3:14 p.m., an interview was conducted with LPN (licensed practical nurse) #1, LPN charge nurse. When asked if staff document that the bed hold notice and information is provided to the resident or RP upon transfer to the hospital, LPN #1 stated, It should be documented, it is not documented on the form. On 2/12/2020 at 5:15 p.m., an interview was conducted with ASM (administrative staff member) #1, the administrator. When asked if a written bed hold notice information is provided upon transfer to the hospital, ASM #1 stated, Our internal process is to document it. They did not document the bed hold where they should have. On 2/13/2020 at 1:28 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. No further information was provided prior to exit. Reference: (1) Diabetes (mellitus) is a disease in which your blood glucose, or blood sugar, levels are too high. This information is taken from the website https://medlineplus.gov/diabetes.html. 3. Resident #89 was admitted to the facility on [DATE] with a recent readmission on [DATE] with diagnoses that included but were not limited to: dementia, quadriplegia (Paralysis affecting all four limbs and the trunk of the body below the level of spinal cord injury. Trauma is the usual cause.) (1), diabetes, gastrointestinal bleed, and high blood pressure. The most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 1/14/2020 coded the resident as unable to answer the question for the BIMS (brief interview for mental status) and had both short and long-term memory difficulties. The physician's note 12/27/19 documented in part the resident presented with recurrent episodes of coffee ground emesis and moderate amount of dark brown drainage from the G -tube (gastrostomy tube), and Resident #89 was sent to the emergency room after giving IV (intravenous) fluids and lab [laboratory tests] work. Further review of the clinical record failed to evidence documentation that a bed hold was sent with the resident upon transfer to the hospital. An interview was conducted with administrative staff member (ASM) #1, the administrator on 2/12/2020 at 5:21 p.m. ASM #1 stated the notice of bed hold is an internal process and it appears the staff did not document in the place as stated in our process. That is our process. An interview was conducted with LPN (licensed practical nurse) #3 on 2/13/2020 at 12:57 p.m. When asked if she does anything with a bed hold when a resident is transferred to the hospital, LPN #3 stated, I don't talk money. We document in the nurse's note that it was sent with the patient. Administration calls the family and discusses the money part, not us. ASM #1, the administrator, ASM #2, the director of nursing, ASM #5, the regional nurse consultant and ASM #6, the assistant administrator, were made aware of the above findings on 2/12/2020 at approximately 6:15 p.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 489. 4. Resident #66 was admitted to the facility on [DATE] with a recent readmission on [DATE] with diagnoses that included but were not limited to: fracture of the femur, depression, dementia, diabetes and peripheral vascular disease (any abnormal condition, including atherosclerosis, affecting blood vessels outside the heart) (1). The most recent MDS (minimum data set) assessment, Medicare admission and significant change assessment, with an assessment reference date of 12/30/19 coded the resident as scoring a 3 on the BIMS (brief interview for mental status) score, indicating she was severely impaired to make daily cognitive decisions. A nurse's note dated, 12/20/19 at 7:26 p.m. documented, Resident has a fall in which the x-ray stated that R (right) hip may represent either an acute impacted fracture or a chronic healed fracture. Resident sent out to ER (emergency room) as ordered. Further review of the clinical record failed to evidence documentation that a bed hold was sent with the resident upon transfer to the hospital. An interview was conducted with administrative staff member (ASM) #1, the administrator on 2/12/2020 at 5:21 p.m. ASM #1 stated the notice of bed hold is an internal process and it appears the staff did not document in the place as stated in our process. That is our process. An interview was conducted with LPN (licensed practical nurse) #3 on 2/13/2020 at 12:57 p.m. When asked if she does anything with a bed hold when a resident is transferred to the hospital, LPN #3 stated, I don't talk money. We document in the nurse's note that it was sent with the patient. Administration calls the family and discusses the money part, not us. ASM #1, the administrator, ASM #2, the director of nursing, ASM #5, the regional nurse consultant and ASM #6, the assistant administrator, were made aware of the above findings on 2/12/2020 at approximately 6:15 p.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 447.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. a. Resident #40 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses including, but not limited to persistent vegetative state (2), contractures (3), and multiple sclerosis (4). On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of 12/10/19, she was coded as being in a persistent vegetative state. On 2/12/2020 at 3:58 p.m., Resident #40 was observed lying in bed. LPN (licensed practical nurse) #1 accompanied the surveyor on this observation. A PICC (peripherally inserted central line) (1) access and dressing was observed on Resident #40's right upper arm. The dressing was peeling off on one side, and the dressing was dated 1/29/2020. A review of Resident #40's clinical record revealed no evidence of orders or directions for PICC care for Resident #40. A review of progress notes, MARs (medication administration records) and TARs (treatment administration records) for February 2020 for Resident #40 revealed no evidence of orders or directions for PICC care for Resident #40. A review of Resident #40's comprehensive care plan dated 5/21/19 revealed no information related to the resident's PICC. On 2/12/2020 at 3:38 p.m., LPN #1 was interviewed. When asked what the facility staff was doing to care for Resident #40's PICC, LPN #1 stated, We are flushing it. When asked to locate the orders for the flushing, she was unable to do so. When asked if there should be orders for maintaining the PICC, LPN #1 stated, Yes, there should, at least some directions. It might just be a nursing thing. When asked how often the dressing should be changed, LPN #1 stated, Every week, at least. When asked if Resident #40's dressing had been changed every week, LPN #1 stated it had not. When asked the reason for changing a PICC dressing weekly, LPN #1 stated that it is easy for these central lines to get infected, and changing the dressing will help prevent infection. When asked if PICC care should be included in the care plan, LPN #1 stated, Yes. Definitely. When asked the process for developing care plans, she stated the floor nurses are responsible for developing and updating care plans. When asked the purpose of the care plan, LPN #1 stated, To provide a plan of care for the resident. When asked how floor staff (nurses and CNAs [certified nursing assistants]) know what a care plan says, she stated nurses have computer access to the care plans, and are able to review them when needed. She stated CNAs do not have computer access to care plans as a whole. However, nurses may add new items to care plans, assign these as tasks to CNAs, and the added items appear as tasks for the CNAs. On 2/13/2020 at 9:08 a.m., LPN #3, a unit manager, was interviewed. When asked how often a PICC dressing should be changed, LPN #3 stated it should be changed weekly or sooner, if soiled. When asked if there should be orders or directions for maintaining a PICC, LPN #3 stated, Absolutely. She stated orders should be in place for flushing with saline and heparin (5), as well as for changing the dressing. When asked if she knew if Resident #40 had orders for any of these interventions, LPN #3 stated, I am already aware that there is nothing. When asked if Resident #40's care plan should include PICC maintenance and care, she stated it should. On 2/13/2020 at 11:11 a.m., LPN #7 was interviewed. When asked how care plans are developed, she stated that care plans are initiated by any nurse, and are updated as needed by any nurse. She stated care plans are overseen by the 24 hour chart review at each day's morning meeting. On 2/13/2020 at 1:28 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. No further information was provided prior to exit. References: (1) A device used to draw blood and give treatments, including intravenous fluids, drugs, or blood transfusions. A thin, flexible tube is inserted into a vein in the upper arm and guided (threaded) into a large vein above the right side of the heart called the superior vena cava. This information is taken from the website https://www.cancer.gov/publications/dictionaries/cancer-terms/def/picc. (2) A coma, sometimes also called persistent vegetative state, is a profound or deep state of unconsciousness. This information is taken from the website https://www.ninds.nih.gov/Disorders/All-Disorders/Coma-Information-Page. (3) A contracture develops when the normally stretchy (elastic) tissues are replaced by nonstretchy (inelastic) fiber-like tissue. This tissue makes it hard to stretch the area and prevents normal movement. This information is taken from the website https://medlineplus.gov/ency/article/003185.htm. (4) Multiple sclerosis (MS) is a disease of the central nervous system. In MS the body's immune system attacks myelin, which coats nerve cells. This information is taken from the website https://nccih.nih.gov/health/multiple-sclerosis. (5) Heparin is used to prevent blood clots from forming in people who have certain medical conditions or who are undergoing certain medical procedures that increase the chance that clots will form. Heparin is also used to stop the growth of clots that have already formed in the blood vessels, but it cannot be used to decrease the size of clots that have already formed. Heparin is also used in small amounts to prevent blood clots from forming in catheters (small plastic tubes through which medication can be administered or blood drawn) that are left in veins over a period of time. Heparin is in a class of medications called anticoagulants ('blood thinners'). It works by decreasing the clotting ability of the blood. This information is taken from the website https://medlineplus.gov/druginfo/meds/a682826.html. 2. b. The facility staff failed to implement the care plan for palm guards for Resident #40. On 2/11/2020 at 10:51 a.m., at 12:35 p.m., and at 2:55 p.m., Resident #40 was observed lying in bed. During each observation both arms were contracted at the elbows, and both hands held a white bath cloth. On 2/12/2020 at 4:10 a.m., Resident #40 was observed lying in bed; her eyes were open. Both arms were contracted at the elbows. Her hands were empty. On 2/12/2020 at 10:02 a.m. and at 3:45 p.m., Resident #40 was observed lying in bed; her eyes were closed. Both arms were contracted at the elbows. Her hands were empty. A review of Resident #40's clinical record revealed no orders for palm guards or other skin protection devices for her palms. A review of Resident #40's comprehensive care plan dated 11/22/19 revealed, in part: Bilateral palm guards. On 2/12/2020 at 3:38 p.m., LPN #1 was interviewed. When asked the purpose of the care plan, LPN #1 stated, To provide a plan of care for the resident. When asked how floor staff (nurses and CNAs [certified nursing assistants]) know what a care plan says, she stated nurses have computer access to the care plans, and are able to review them when needed. She stated CNAs do not have computer access to care plans as a whole. However, nurses may add new items to care plans, assign these as tasks to CNAs, and the added items appear as tasks for the CNAs. On 2/13/2020 at 10:59 a.m., CNA (certified nursing assistant) #3 was interviewed. When asked if she was familiar with Resident #40's care, she stated she was. When asked if Resident #40 should have anything in her hands, CNA #3 stated that at one time, Resident #40 had palm guards. She stated she had not seen the guards in a long time, and sometimes, she used bath cloths in place of the palm guards. When asked why these were important, CNA #3 stated, We don't want her to get sores on her palms. She stated the resident should have something in her hands at all times. When asked if palm guards are included in the resident's care plan, she stated she thought they were. When asked why a care plan should be followed, CNA #3 stated it tells what the resident needs. On 2/13/2020 at 11:09 a.m., LPN (licensed practical nurse) #7 was interviewed. When asked if she was familiar with Resident #40's care, she stated she was. When asked if Resident #40 should have anything in her hands, LPN #7 stated, Usually we have the palm guards. She stated if the palm guards are dirty or cannot be located, the staff roll up something like a bath cloth to put in the resident's hands to absorb moisture and protect her skin from breaking down. She stated the resident should have something in her hands 24 hours a day. When asked who is responsible for making sure the resident has palm guards, LPN #7 stated that ultimately it is her responsibility as nurse, and that it is a team effort. On 2/13/2020 at 11:43, LPN #3, a unit manager was interviewed. When asked if she was familiar with any interventions for Resident #40's hands, LPN #3 stated, She should have some palm guards. When asked the importance of the palm guards, she stated there needed to be something to protect the resident's palms from the resident's fingernails. On 2/13/2020 at 1:28 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A policy on pressure ulcer prevention was requested. No further information was provided prior to exit. 3. Resident #15 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses including, but not limited to history of a stroke, paralysis following a stroke, and diabetes (1). On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of 11/13/19, Resident #15 was coded as being moderately impaired for making daily decisions, having scored 12 out of 15 on the BIMS (brief interview for mental status). On 2/12/2020 at 4:05 p.m., Resident #15 was observed lying in bed. LPN (licensed practical nurse) #1 accompanied the surveyor on this observation. A PICC access and dressing was observed on Resident #15's right upper arm. The dressing was dated 1/30/2020. A review of Resident #15's clinical record revealed the following order dated 2/4/2020: PICC line dressing change on admission, then Q (every) week and prn (as needed) every night shift every Sun (Sunday). A review of resident #15's February 2020 MARs (medication administration records) and TARs (treatment administration records) revealed no evidence that the PICC dressing had been changed. A review of Resident 15's comprehensive care plan dated 2/4/2020 revealed no information related to the resident's PICC. On 2/12/2020 at 3:38 p.m., LPN #1 was interviewed. When asked how often the PICC dressing should be changed, LPN #1 stated, Every week, at least. When asked if Resident #15's dressing had been changed every week, she stated it had not. When asked the reason for changing a PICC dressing weekly, LPN #1 stated that it is easy for these central lines to get infected, and changing the dressing will help prevent infection. When asked if PICC care should be included in the care plan, LPN #1 stated, Yes. Definitely. When asked the process for developing care plans, she stated the floor nurses are responsible for developing and updating care plans. When asked the purpose of the care plan, LPN #1 stated, To provide a plan of care for the resident. When asked how floor staff (nurses and CNAs [certified nursing assistants]) know what a care plan says, she stated nurses have computer access to the care plans, and are able to review them when needed. She stated CNAs do not have computer access to care plans as a whole. However, nurses may add new items to care plans, assign these as tasks to CNAs, and the added items appear as tasks for the CNAs. On 2/13/2020 at 9:08 a.m., LPN #3, a unit manager, was interviewed. When asked how often a PICC dressing should be changed, she stated it should be changed weekly or sooner, if soiled. When asked if Resident #15's care plan should include PICC maintenance and care, she stated it should. On 2/13/2020 at 11:11 a.m., LPN #7 was interviewed. When asked how care plans are developed, she stated that care plans are initiated by any nurse, and are updated as needed by any nurse. She stated care plans are overseen by the 24 hour chart review at each day's morning meeting. On 2/13/2020 at 1:28 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. No further information was provided prior to exit. Reference: (1) Diabetes (mellitus) is a disease in which your blood glucose, or blood sugar, levels are too high. This information is taken from the website https://medlineplus.gov/diabetes.html. 4. Resident #62 was admitted to the facility on [DATE] with diagnoses including, but not limited to diabetes (2) and atrial fibrillation (3). On the most recent MDS (minimum data set), an admission assessment with an assessment reference date of 12/29/19, Resident #62 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). She was coded as having received an anticoagulant medication on four of the seven days of the look back period. A review of Resident #62's clinical record revealed the following order, dated 1/6/2020: Eliquis (1) Tablet 5 mg (milligrams) Apixaban give 1 tablet by mouth two times a day for A-fib (atrial fibrillation). A review of the January and February 2020 MARs (medication administration reports) revealed that Resident #62 had received this medication as ordered. A review of Resident #62's comprehensive care plan dated 12/23/19 revealed no information related to the resident's receiving Eliquis, an anticoagulant. On 2/12/2020 at 3:23 p.m., LPN (licensed practical nurse) #1 was interviewed. When asked how care plans are developed, she stated floor nurses develop, review, and revise the care plans. When asked the purpose of a care plan, she stated the purpose is to provide a plan of care for the resident. On 2/13/2020 at 11:11 a.m., LPN #7 was interviewed. When asked how care plans are developed, she stated that care plans are initiated by any nurse, and are updated as needed by any nurse. She stated care plans are overseen by the 24 hour chart review at each day's morning meeting. When asked if the care plan should include anticoagulant use, LPN #7 stated, Yes. On 2/13/2020 at 1:28 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. No further information was provided prior to exit. Reference: (1) Apixaban is in a class of medications called factor Xa inhibitors. It works by blocking the action of a certain natural substance that helps blood clots to form. This information was taken from the website https://medlineplus.gov/druginfo/meds/a613032.html. (2) Diabetes (mellitus) is a disease in which your blood glucose, or blood sugar, levels are too high. This information is taken from the website https://medlineplus.gov/diabetes.html. (3) Atrial fibrillation is one of the most common types of arrhythmias, which are irregular heart rhythms. Atrial fibrillation causes your heart to beat much faster than normal. Also, your heart's upper and lower chambers do not work together as they should. When this happens, the lower chambers do not fill completely or pump enough blood to your lungs and body. This can make you feel tired or dizzy, or you may notice heart palpitations or chest pain. Blood also pools in your heart, which increases your risk of forming clots and can leads to strokes or other complications. Atrial fibrillation can also occur without any signs or symptoms. Untreated fibrillation can lead to serious and even life-threatening complications. This information is taken from the website https://www.nhlbi.nih.gov/health-topics/atrial-fibrillation. 5. Resident #61 was admitted to the facility on [DATE]. Resident #61's diagnoses included but were not limited to bladder cancer, diabetes and high blood pressure. Resident #61's five day Medicare MDS (minimum data set) assessment with an ARD (assessment reference date) of 1/23/20, coded the resident as being cognitively intact. Section H coded Resident #61 as occasionally incontinent of urine. Review of Resident #61's clinical record revealed a physician's order dated 1/21/2020 for a Foley (urinary) catheter (1)- size 16 French and 10 milliliter balloon. Review of Resident #61's comprehensive care plan created on 12/23/19 failed to reveal documentation regarding the resident's urinary catheter. On 2/11/20 at 1:41 p.m., Resident #61 was observed lying in bed. A urinary catheter was in place. On 2/12/20 at 3:11 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated the purpose of the care plan is to provide a plan of care for a patient. LPN #1 stated the nurses initiate care plans and the MDS coordinator reviews and makes corrections to care plans. LPN #1 was asked if a resident with a urinary catheter should have a care plan developed for that catheter. LPN #1 stated, Yes. They should have a care plan for it so that it can be monitored and so anyone that wants to review the plan of care will know and be aware that they have one. On 2/12/20 at 6:10 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #5 (the regional nurse consultant) were made aware of the above concern. The facility policy titled, Resident Assessment & Care Planning documented, POLICY: A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care, and the necessary health-related care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being of the patient. No further information was presented prior to exit. Reference: (1) A urinary catheter is a tube placed in the body to drain and collect urine from the bladder. This information was obtained from the website: https://medlineplus.gov/ency/article/003981.htm Based on resident interview, 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 five of 59 residents in the survey sample, (Residents #4, #40, #15, #62, and #61). The facility staff failed to implement the comprehensive care plan to offer non-pharmacological interventions prior to the administration of pain medication for Resident #4, failed to develop a comprehensive care plan to address Resident #40's PICC (peripherally inserted central catheter) and failed to implement Resident #40's comprehensive care plan for palm guards. The facility staff failed to develop a comprehensive care plan to address the care of Resident #15's PICC. The facility staff failed to develop a comprehensive care plan to address Resident #62's prescribed anticoagulant medication Eliquis, and failed to develop a comprehensive care plan for Resident #61's use of a urinary catheter. The findings include: 1. Resident #4 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: diabetes, high blood pressure, depression, anxiety disorder, peripheral vascular disease - (any abnormal condition, including atherosclerosis, affecting blood vessels outside the heart) (1), and amputation of his toes. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 1/25/2020 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 supervision with set up assistance for all of his activities of daily living. In Section N - Medications, the resident was coded as receiving opioid medications seven days of the look back period. In Section J - Health Conditions, the resident was coded as having pain frequently that makes it hard for him to sleep with the pain level coded as an 8. The comprehensive care plan dated, 2/1/19 and revised on 9/28/19, documented in part, The resident has actual pain r/t (related to) Medical Procedure Amputation of toes right foot and osteomyelitis to right foot with wound. The Interventions documented in part, Administer analgesia (pain medication) per order and give before treatments or care as needed. Encourage to try different pain relieving methods i.e., positioning, relaxation therapy, progressive relaxation, bathing, heat and cold therapy, muscle stimulation, ultrasound. Monitor/record/report to nurse any s/sx (signs and symptoms) of non-verbal pain. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM (range of motion), withdrawal or resistance to care. The physician orders documented, Oxycodone Tablet [used to treat moderate to severe pain (2)] 20 mg (milligrams), give 1 tablet by mouth every 4 hours as needed for pain. Review of the January and February 2020 MAR (medication administration record) revealed the above physician order for Oxycodone was documented. On 1/3/2020 at 7:56 a.m., the Oxycodone was documented as administered. The pain level documented was a zero. Review of the nurse's notes for this date and time revealed no pain scale documentation, no location of the pain and no non-pharmacological interventions provided prior to administration of the medication. On 2/9/2020 at 1:50 a.m. The Oxycodone was documented as administered. The pain level documented was a zero. Review of the nurse's notes for this date and time revealed no pain scale documentation, no location of the pain and no non-pharmacological interventions provided prior to the administration of the medication. An interview was conducted with Resident #4 on 2/11/2020 at 4:16 p.m. When asked what the staff does if he complains of pain, Resident #4 stated they just give him a pain pill. When asked if the staff ask what level the pain is, Resident #4 stated sometimes they ask. When asked if the staff ask the location of his pain, Resident #4 responded, sometimes. When asked if the nurse offers something prior to the administration of the as needed pain medication like repositioning, Resident #4 stated, no, they don't offer anything other the pain pill. An interview was conducted with LPN (licensed practical nurse) #1 on 2/12/2020 at 3:09 p.m. When asked about the purpose of the care plan, LPN #1 stated it's the plan of care for the patient. An interview was conducted with LPN (licensed practical nurse) #3 on 2/13/2020 at 12:57 p.m. LPN #3 was asked if the care plan is implemented if there is no documentation of attempted non-pharmacological interventions and the care plan documents and directs staff to try non-pharmacological interventions, LPN #3 stated, no. The facility policy, Care Planning, documented in part, A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care and the necessary health-related care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being of the patient. ASM (administrative staff member) #1, the administrator, ASM #5, the regional nurse consultant and ASM #6, the assistant administrator, were made aware of the above concerns. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 447. (2) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a697048.html.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. The facility staff failed to review and revise the care plan for Resident #13 following the 7/5/19 when another resident was found caressing Resident #13's buttocks. Resident #13 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: cerebral infarction (hemorrhage or blockage of the blood vessels of the brain leading to a lack of oxygen and resulting symptoms-loss of ability to move body part, ability to speak or weakness) (1), congestive heart failure (abnormal condition characterized by circulatory congestion and retention of salt and water by the kidneys (2), diabetes (altered glucose metabolism caused by the inability of insulin to function normally in the body) (3). Resident #13's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 11/7/19, coded the resident as scoring 5 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A Facility Reported Incident (FRI) dated 7/5/19, documented in part, Incident date: 7/5/19. Resident's involved (name of Resident #13) and (name of Resident #38). Injuries: (A check mark was documented next to)-No. Incident type: Allegation of abuse/mistreatment. Describe incident: (Resident #38) and (Resident #13) were in the common are (Television room) on (letter of alphabet)-Side unit. (Name of Resident #38) was found caressing (name of Resident #13)'s buttocks. The ASM (administrative staff member) #2, the director of nursing's progress note in Resident #13's clinical record dated 7/5/19 at 7:23 PM, documented in part, Noted standing in television room beside another resident. Assisted to her bedroom and then with her ADL's (activities of daily living). Resident's son and nurse practitioner made aware. Resident #13's care plan dated 5/29/19, documented in part, Focus: Cognition and Communication: The resident has a communication problem and impaired cognition related to disease process. The Interventions documented and dated 5/29/19, Anticipate and meet needs. Be conscious of resident position when in groups, activities, dining room to promote proper communication with other. There was no documentation evidencing Resident #13's care plan was revised to address the 7/5/19 incident. An interview was conducted on 2/12/19 at 3:14 PM with LPN #1. When asked who is responsible for reviewing and revising care plans, LPN #1 stated, The floor nurses develop the care plans. We also review and revise them. When asked the purpose of care plan, LPN #1 stated, To provide the base of care for patient. If we revise the care plan we can assign it to the CNA (certified nursing assistant) so it will show as a daily task and the CNA will be aware of any changes. When asked if the care plan should be reviewed and revised after any allegation of abuse, LPN #1 stated, Yes, if a resident makes physical contact with another resident, it should be documented in clinical record, because it would be classified as agitation, aggression to another resident. Their care plans should be reviewed and revised to ensure their safety. An interview was conducted on 2/13/20 at 7:49 AM with LPN (licensed practical nurse) #6. When asked to define abuse, LPN #6 stated, Abuse is physical, sexual, and inappropriate touching and taking belongings. When asked about the purpose of the comprehensive care plan, LPN #6 stated, The purpose is to identify the care each resident needs. When asked if the comprehensive care plan for Resident #13 should have been revised after the FRI incident on 7/5/19, LPN #6 stated, Yes, it should be updated after any potential abuse. ASM #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional nurse consultant, was made aware of the above concern and validated the concerns on 2/12/20 at 6:03 PM. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 111. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 133. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 160. 8. The facility staff failed to review and revise the comprehensive care plan for Resident #38 after the resident was found caressing Resident #13's buttocks on 7/5/19. Resident #38 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: dementia (progressive state of mental decline) (1), diabetes (altered glucose metabolism caused by the inability of insulin to function normally in the body) (2), hypertension (high blood pressure) (3). Resident #38's most recent MDS (minimum data set) assessment, an entry assessment, with an ARD (assessment reference date) of 12/9/19, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident had intact cognition. The resident was coded as requiring extensive assistance in bed mobility, transfer, dressing, toileting and personal hygiene; independent in eating, and locomotion on/off unit. A Facility Reported Incident (FRI) dated 7/5/19, documented in part, Incident date: 7/5/19. Resident's involved (name of Resident #13) and (name of Resident #38). Injuries: (A check mark was documented next to)-No. Incident type: Allegation of abuse/mistreatment. Describe incident: (name of Resident #38) and (name of Resident #13) were in the common are (Television room) on (letter of the alphabet)-Side unit. (Name of Resident #38) was found caressing (name of Resident #13)'s buttocks. ASM #3, the director or nursing's note in Resident #38's clinical record dated 7/5/19 at 7:37 PM, documented in part, Noted in the television room on (letter of alphabet)-side with his arm around another resident's lower back who was standing beside him. Resident was asked to remove his hands around the other resident's lower back; he was then assisted to the hallway. Resident #38's care plan dated 2/2/14, documented in part, Focus: The resident exhibits adverse behavioral symptoms of history of masturbation in public and taking other resident's food related to dementia. The Interventions documented and dated 2/2/14, Minimize potential for the resident's disruptive behaviors of masturbating in public and taking other resident's food by offering tasks which divert attention, or providing privacy for resident. Resident #38's comprehensive care plan failed to evidence any documentation it was revised after the 7/5/19 incident. An interview was conducted on 2/12/19 at 3:14 PM with LPN #1. When asked who is responsible for reviewing and revising care plans, LPN #1 stated, The floor nurses develop the care plans. We also review and revise them. When asked about the purpose of care plan, LPN #1 stated, To provide the base of care for patient. If we revise the care plan we can assign it to the CNA (certified nursing assistant) so it will show as a daily task and the CNA will be aware of any changes. When asked if the care plan should be revised after any allegation of abuse, LPN #1 stated, Yes, if a resident makes physical contact with another resident, it should be documented in clinical record, because it would be classified as agitation, aggression to another resident. Their care plans should be reviewed and revised to insure their safety. An interview was conducted on 2/13/20 at 11:25 AM with ASM #2, the director of nursing, regarding the process for review and revision of residents' comprehensive care plans. ASM #2 stated, The unit nurses revise the care plan. When asked if the care plan should be revised after any allegation of abuse, ASM #2 stated, Yes, it should be revised after any incident. ASM #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional nurse consultant, was made aware of the above concern and validated the concerns on 2/12/20 at 6:03 PM. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 154. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 160. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 282. 3. The facility staff failed to review and revise Resident #25's comprehensive care plan after the resident was hit in the chest by another resident on 11/15/18. Resident #25 was admitted to the facility on [DATE]. Resident #25's diagnoses included but were not limited to diabetes, chronic kidney disease and repeated falls. Resident #25's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 11/26/19, coded the resident's cognition as moderately impaired. A FRI (facility reported incident) submitted to the state agency on 11/15/18 documented, Report date: 11/15/2018. Incident date: 11/15/2018. Residents involved: (Name of Resident #31) (Name of Resident #25). While residents were leaving the dining room, (Resident #31) asked (Resident #25) to speed up. (Resident #31) then backhanded (Resident #25) in the upper chest. Residents were separated. No further interaction was noted between both residents and they continued wheeling themselves through the hallway . Review of Resident #25's comprehensive care plan created on 7/9/18 failed to reveal the care plan was reviewed or revised after the 11/15/18 incident. On 2/12/20 at 3:11 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated the purpose of the care plan is to provide a plan of care for a patient. LPN #1 stated the nurses initiate care plans and the MDS coordinator reviews and makes corrections to care plans. LPN #1 confirmed a resident's care plan should be reviewed and revised when a resident hits another resident and when a resident is hit by another resident, to ensure the safety of both parties. On 2/12/20 at 6:10 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #5 (the regional nurse consultant) were made aware of the above concern. No further information was presented prior to exit. 4. The facility staff failed to review and revise Resident #31's comprehensive care plan after the resident hit another resident on 11/15/18. Resident #31 was admitted to the facility on [DATE]. Resident #31's diagnoses included but were not limited to paralysis, heart disease and difficulty swallowing. Resident #31's quarterly MDS assessment with an ARD of 12/3/19, coded the resident as being cognitively intact. A FRI (facility reported incident) submitted to the state agency on 11/15/18 documented, Report date: 11/15/2018. Incident date: 11/15/2018. Residents involved: (Name of Resident #31) (Name of Resident #25). While residents were leaving the dining room, (Resident #31) asked (Resident #25) to speed up. (Resident #31) then backhanded (Resident #25) in the upper chest. Residents were separated. No further interaction was noted between both residents and they continued wheeling themselves through the hallway . Review of Resident #31's comprehensive care plan created on 1/28/14 failed to reveal the care plan was reviewed or revised after the 11/15/18 incident. On 2/12/20 at 3:11 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated the purpose of the care plan is to provide a plan of care for a patient. LPN #1 stated the nurses initiate care plans and the MDS coordinator reviews and makes corrections to care plans. LPN #1 confirmed a resident's care plan should be reviewed and revised when a resident hits another resident and when a resident is hit by another resident, to ensure the safety of both parties. On 2/12/20 at 6:10 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #5 (the regional nurse consultant) were made aware of the above concern. No further information was presented prior to exit. 5. The facility staff failed to review and revise Resident #28's comprehensive care plan after the resident hit another resident on 12/22/19. Resident #28 was admitted to the facility on [DATE]. Resident #28's diagnoses included but were not limited to repeated falls, muscle weakness and anemia (a blood disorder). Resident #28's quarterly MDS assessment with an ARD of 11/27/19, coded the resident's cognition as severely impaired. A FRI (facility reported incident) submitted to the state agency on 12/23/19 documented, Report date: 12-23-19. Incident date: 12-22-19. Residents involved: (Name of Resident #21) (Name of Resident #28). Incident reported between (Resident #21) and (Resident #28) in the dining room during lunch. It was about 12:45 pm when (Resident #28) hit (Resident #21) in the face. Residents were separated immediately and (Resident #28) was taken to the unit (illegible word) charge nurse. No injuries noted at this time. Investigation initiated. Review of Resident #28's comprehensive care plan created on 8/14/19 failed to reveal the care plan was reviewed or revised after the 12/22/19 incident. On 2/12/20 at 3:11 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated the purpose of the care plan is to provide a plan of care for a patient. LPN #1 stated the nurses initiate care plans and the MDS coordinator reviews and makes corrections to care plans. LPN #1 confirmed a resident's care plan should be reviewed and revised when a resident hits another resident and when a resident is hit by another resident, to ensure the safety of both parties. On 2/12/20 at 6:10 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #5 (the regional nurse consultant) were made aware of the above concern. No further information was presented prior to exit. 6. The facility staff failed to review and revise Resident #21's comprehensive care plan after the resident was hit in the face by another resident on 12/22/19. Resident #21 was admitted to the facility on [DATE]. Resident #21's diagnoses included but were not limited to chronic pain syndrome, muscle weakness and major depressive disorder. Resident #21's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 11/19/19, coded the resident's cognition as severely impaired. A FRI (facility reported incident) submitted to the state agency on 12/23/19 documented, Report date: 12-23-19. Incident date: 12-22-19. Residents involved: (Name of Resident #21) (Name of Resident #28). Incident reported between (Resident #21) and (Resident #28) in the dining room during lunch. It was about 12:45 pm when (Resident #28) hit (Resident #21) in the face. Residents were separated immediately and (Resident #28) was taken to the unit (illegible word) charge nurse. No injuries noted at this time. Investigation initiated. Review of Resident #21's comprehensive care plan created on 9/21/16 failed to reveal the care plan was reviewed or revised after the 12/22/19 incident. On 2/12/20 at 3:11 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated the purpose of the care plan is to provide a plan of care for a patient. LPN #1 stated the nurses initiate care plans and the MDS coordinator reviews and makes corrections to care plans. LPN #1 confirmed a resident's care plan should be reviewed and revised when a resident hits another resident and when a resident is hit by another resident, to ensure the safety of both parties. On 2/12/20 at 6:10 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #5 (the regional nurse consultant) were made aware of the above concern. No further information was presented prior to exit. Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to review and revise the comprehensive care plan for eight of 59 residents in the survey sample, Resident #24, #4, #25, #31, #28, #21, #13 and #38. The findings include: 1. The facility staff failed to review and revise the comprehensive care plan to address Resident #24's prescribed and administered anti-anxiety medication Xanax. Resident #24 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: stroke, diabetes, high blood pressure, depression and hemiplegia (paralysis affecting only one side of the body) (1). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 11/21/19, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating she was cognitively intact to make daily decisions. The physician order dated, 9/23/19 documented, Xanax [used to treat anxiety (2)] tablet 0.25 MG (milligrams); give 1 tablet by mouth two times a day for anxiety. The January and February 2020 MAR (medication administration record) documented the above physician order for xanax and it is documented as administered as prescribed during both months. The comprehensive care plan dated 3/27/18 and revised on 11/13/19, documented in part, Focus: The resident uses psychotropic medications, anti-depressant - Lexapro r/t disease process. The Goals documented, The resident will be/remain free of psychotropic drug related complications, including movement discords, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairments through review date. The Interventions documented, Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms. Monitor for side effects and effectiveness. An interview was conducted with LPN (licensed practical nurse) #1 on 2/12/2020 at 3:09 p.m., regarding the process staff follows for reviewing and revising resident care plans. LPN #1 stated the care plan is done upon admission by any nurse. Then any nurse can update the care plan as needed. When asked about the purpose of the care plan, LPN #1 stated it the plan of care for the patient. An interview was conducted with LPN (licensed practical nurse) # 6 on 2/12/2020 at 4:44 p.m. When asked if a resident on Xanax would have a care plan addressing the medication, LPN #6 stated, Really, I'm not sure. LPN #6 reviewed Resident #24's comprehensive care plan. When asked if Xanax is a psychotropic medication, LPN #6 stated, I really don't know. An interview was conducted with administrative staff member (ASM) #5, the regional nurse consultant, on 2/12/2020 at 4:57 p.m. When asked if a resident on an antianxiety medication, would have care plan addressing the medication, ASM #5 stated that not the specific medication but the category or we don't care plan antidepressants, antipsychotics, hypnotics or antianxiety medications. When asked if Xanax is an anxiolytic, ASM #5 stated, No, it's an anti-anxiety medication. The care plan was reviewed with ASM #5. ASM #5 stated I don't see the anti-anxiety medication but she is care planned for psychotropic medication, it is technically covered. When asked if the anti-anxiety medication should be care planned, ASM #5 stated since the antidepressant is listed on the care plan then the anti-anxiety medication should be listed also. The facility policy, Resident Assessment & Care Planning, documented in part, 6. Computerized care plans will be updated by each discipline on an ongoing basis as changes in the patient occur, and reviewed quarterly with the quarterly assessment. ASM #1, the administrator, ASM #2, the director of nursing, ASM #5 and ASM #6, the assistant administrator, were made aware of the above findings on 2/12/2020 at approximately 6:15 p.m. No further information was provided prior to exit. References: (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/a684001.html 2. The facility staff failed to review and revise Resident #4's comprehensive care plan to address a physician ordered change in the use of psychotropic medications. Resident #4 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: diabetes, high blood pressure, depression, anxiety disorder and peripheral vascular disease - (any abnormal condition, including atherosclerosis, affecting blood vessels outside the heart) (1). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 1/25/2020 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 supervision with set up assistance for all of his activities of daily living. In Section N - Medications, the resident was coded as receiving seven days of an antidepressant. He was not coded as receiving an antipsychotic or antianxiety medication. The comprehensive care plan dated, 2/12/19 and revised on 9/28/19 documented in part, Focus: The resident uses psychotropic medications (Anti-psychotic & anti-anxiety medications) r/t (related to) disease process (Anxiety/Depression). Review of the physician orders failed to reveal any orders for antipsychotic medications and revealed no orders for anti-anxiety medication. The physician orders did document the order for Sertraline (Zoloft) [used to treat depression (2)]. An interview was conducted with LPN (licensed practical nurse) #3 on 2/13/2020 at 10:31 a.m. The above care plan and physician orders were reviewed with LPN #3. LPN #3 reviewed the electronic medical record and stated that the antipsychotic and anti-anxiety medication was discontinued on 2/6/19. When asked if the care plan should have been updated to reflect the changed orders, LPN #3 stated, Yes, Ma'am. ASM (administrative staff member) #1, the administrator, ASM #5, the regional nurse consultant and ASM #6, the assistant administrator, were made aware of the above concerns. No further in formation was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 447. (2) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a697048.html.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #23 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: systemic lupus erythematosis (chronic autoimmune disease of unknown cause) (1), rheumatoid arthritis (inflammation of a joint that may cause swelling, redness and pain) (2), and diabetes (altered glucose metabolism caused by the inability of insulin to function normally in the body) (3). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/21/19, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. Review of the clinical record revealed the following physician orders for as needed pain medications: - 10/15/18, Oxycodone-Acetaminophen [used to treat moderate to severe pain (4)] tablet 5-325 milligram every six hours as needed for pain. - 1/13/19, Tylenol [used to treat pain and fever (5)] 1000 milligram every six hours as needed for pain or elevated temperature. - 2/27/19, Tylenol [used to treat pain and fever (5)] 650 milligram every four hours as needed for pain or elevated temperature. Review of the January 2020 MAR (medication administration record) for Resident #23, documented the above physician order for as needed pain medications. The Tylenol 650 milligram was documented as given on 1/8/20 at 9:03 AM. Pain level, location and effectiveness was documented. The Tylenol 1000 milligram was documented as given on the following dates and times: -1/1/20 at 10:40 AM, -1/3/20 at 10:37 AM, - 1/4/20 at 3:10 PM, - 1/5/20 at 12:19 PM, - 1/6/20 at 10:21 AM, - 1/7/20 at 10:43 AM, - 1/9/20 at 9:01 AM, - 1/11/20 at 11:01 AM, - 1/12/20 at 9:3 AM, - 1/15/20 at 4:16 PM, - 1/16/20 at 12:22 PM, - 1/17/20 at 11:59 AM, - 1/24/20 at 11:09 AM, - 1/25/20 at 10:51 AM, - 1/26/20 at 9:38 AM, - 1/29/20 at 9:31 AM, - 1/30/20 at 6:00 AM. A pain level, location and effectiveness were documented for all of the above dates and times. The Oxycodone-Acetaminophen 5-325 milligram was documented as given on the following dates and times: on 1/1/20 at 3:04 PM and 1/2/20 at 10:24 AM. A pain level, location and effectiveness were documented for each administration of the medication. Review of the February (1st- 12th) 2020 MAR for Resident #23 documented the above physician order for as needed pain medications. Tylenol 650 milligram was not documented as administered to Resident #23. The Tylenol 1000 milligram was documented as administered on the following dates and times: on 2/3/20 at 4:20 PM, 2/4/20 at 4:44 PM, 2/8/20 at 6:38 PM, 2/9/20 at 10:09 AM, and on 2/12/20 at 11:27 AM. A pain level, location and effectiveness were documented for each administration. The The Oxycodone-Acetaminophen 5-325 milligram was documented as administered on the following dates and times: on 2/5/20 at 9:22 PM, 2/11/20 at 00:54 AM, and 2/11/20 at 5:14 PM. A pain level, location and effectiveness were documented for each administration. The comprehensive care plan dated 3/3/17, documented in part, Problem: The resident has chronic pain related to arthritis, lupus. Revised 10/4/19. The Interventions dated 3/3/17, documented, Administer analgesia per physician order. Given before treatments or care as needed. Encourage to try different pain relieving methods i.e. positioning, relaxation therapy, progressive relaxation, bathing, heat and cold application. Revised 7/26/18. The physician progress note dated, 12/30/19 at 2:28 PM, documented in part, Patient assessed and evaluated. Medications and allergies were reviewed, continue as ordered. Resident #23, was observed on 2/11/20 at 1:28 PM in no apparent pain and denied pain when asked. An interview was conducted on 2/12/20 at 1:51 PM with LPN #3, the unit manager. LPN #3 was asked how the staff decide on which pain medication to administer, when a resident has multiple as needed pain medications prescribed. LPN #3 stated, We should call the nurse practitioner to ask for a pain range for the medications, such as Tylenol for mild (1-4) pain and narcotic for a higher pain level (5-10). I always ask the patient's their pain level and medication they want. When asked if it is within a nurses scope of practice to decide which pain medication to administer, LPN #3 stated, No, it is not in our scope of practice. An interview was conducted on 2/12/20 at 2:10 PM with LPN #2, regarding the process for managing a resident's pain, LPN #2 stated, I ask them the level and location of their pain. Then we try other alternatives like repositioning, meditation, music. If that does not work, then I start with the lowest type of pain medication, a non-narcotic. When asked about the multiple as needed pain medication orders for Resident #23, LPN #2 stated, This resident wants Tylenol first. When asked how LPN #2 determined which pain medication to administer, LPN #2 stated, There should be [pain level] parameters for pain, there are no parameters in this order. When asked about the process staff follows when there are no parameters for pain medications, LPN #2 stated, We should call the nurse practitioner to get ranges [pain level parameters] for the medications. When asked if it is within the nursing scope of practice to determine which pain medication to administer when there are no physician prescribed, pain level parameters, LPN #2 stated, No, it is not in our scope of practice. An interview was conducted on 2/13/20 at 11:25 AM with ASM #2, the director of nursing. When asked what what standard of practice the facility follows, ASM #2, We follow [NAME] and our policies and procedures. Review of the facility's Pain Management Policy dated 11/1/19 revealed in part the following, Patient will be assessed for acute and chronic pain by licensed nurse and a plan of care will be established. Administration of pain medication and effectiveness will be documented. At this time, when ASM #2 was referred to the facility Pain Management Policy and asked about pain levels, ASM #2 stated, Parameters were too difficult to use with residents who couldn't communicate. When asked if the facility had any pain level parameters for mild, moderate or severe pain, ASM #2 stated, No, we don't have that. It's not in our policy. The facility's Physician/Prescriber Authorization and Communication of Orders to Pharmacy dated 12/1/07 with revision of 1/1/12 documents, Orders with missing or incomplete information may not be accepted. Facility should contact Physician/Prescriber when staff is notified of an order requiring clarification. 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. ASM #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional nurse consultant, was made aware of the above concern on 2/12/20 at 6:03 PM. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 553. (2) Barron Dictionary of Medical Terms, 7th edition, Rothenberg and Kaplan, page 47. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 160. (4) 2009 [NAME] Pocket Drug Guide for Nurses, Wolters Kluwer, page 448. (5) 2009 [NAME] Pocket Drug Guide for Nurses, Wolters Kluwer, page 4. (6) Lippincott Manual of Nursing Practice, 11th edition, Wolters Kluwer, page 1508-1509 Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to follow professional standards of practice to clarify physician orders for two of 59 residents in the survey sample, Residents #111 and Resident #23. The facility staff failed to clarify a physician order for Lorazepam for Resident #23, which lead to the resident receiving more than double the prescribed dose of medication. The facility staff failed to clarify physician orders for multiple as needed pain medications for Resident #23 to determine which and when each medication should be administered. The findings include: 1. Resident #111 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: liver cancer, falls, hepatitis C- [inflammation of the liver. similar to hepatitis B, It is spread primarily through blood, though sexual transmission has been described. (1)], high blood pressure, diabetes, fractured hip and cirrhosis of the liver [chronic disease condition of the liver in which fibrous tissue and modules replace normal tissue, interfering with blood flow and normal function of the organ (2)]. The resident is on hospice care. The most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 1/8/2020 coded the resident as scoring a 3 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired to make daily cognitive decisions. The resident was coded as having verbal behavioral symptoms directed towards others and other behavioral symptoms not directed toward others. In Section N - Medications, the resident was coded as having received an antianxiety medication for six of the days during the look back period. The physician orders documented the following medications/dosage and dates ordered: - 1/30/2020 - Lorazepam [used to treat anxiety (3)] tablet 1 MG (milligram) give 1 mg by mouth every 4 hours as needed for anxiety. - 1/30/2020 - Lorazepam tablet 1 MG give 1 mg by mouth two times a day for agitation. - 2/7/2020 - Lorazepam concentrate 2 MG/ML (milligrams per milliliter) give 0.5 ml by mouth three times a day for anxiety. Review of the February 2020 MAR (medication administration record), revealed the above physician orders for Lorazepam were documented. The Lorazepam 1 MG tablets were documented as administered every day, twice a day from 2/1/2020 through 2/11/2020. The MAR also documented a 1 MG Lorazepam dose administered to Resident #111 on 2/12/2020 at 9:00 a.m. The Lorazepam 2 MG/ML concentrate documented 0.5 ml was administered every day, three times a day, from 2/8/2020 through 2/11/2020 and a 0.5 ml dose was administered on 2/12/2020 at 9:00 a.m. From 2/1/2020 through 2/7/2020, the resident was receiving a total of two MG of Lorazepam per day. From 2/8/2020 through 2/12/2020, the resident was receiving 5 mg per day. Almost doubling the physician prescribed dosage. The comprehensive care plan dated 1/2/2020 documented in part, Focus: The resident exhibits adverse behavioral symptoms r/t (related to) itching, picking at skin, restless (agitation), hitting increase in complaints, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucination, psychosis, aggression, refusing care, deliberately sliding unto the floor, crawling on floor, chews tongue and bites his hands/cell phone. The Interventions documented in part, Administer medications as ordered. Monitor/document for side effects and effectiveness. An interview was conducted with LPN (licensed practical nurse) #2; on 2/12/2020 at 12:55 p.m., LPN #2 was asked to review the above physician orders for Lorazepam. Once reviewed, LPN #2 was asked if she thought it was odd that the resident was receiving the same medication in both pill form and tablet form. LPN #2 stated she thought it was related to his aggression toward the staff. LPN #3, the unit manager, was asked to review the physician orders for Lorazepam. LPN #3 stated she felt the orders needed to be clarified. LPN #3 then placed a call to the nurse practitioner (administrative staff member - ASM) #3. An interview was conducted with ASM #3 on 2/12/2020 at 1:08 p.m. When asked why the resident was on pill and liquid doses of the same medication, ASM #3 stated, I believe the order was changed and the previous order was not discontinued. ASM #3 stated she was going to contact the hospice staff and discuss this with them. ASM #3 returned to this surveyor on 2/12/2020 at 1:50 p.m. and stated she had called hospice, they did put the order in for the Ativan (Lorazepam) 1 mg every 4 hours as needed and then put in the order for the 1 mg three times a day. ASM #3 stated that the Ativan tablet was supposed to have been discontinued when the liquid was ordered three times a day. An interview was conducted with ASM #2, the director of nursing, on 02/13/20 at 11:25 a.m , regarding the standard of practice followed by the facility. ASM #2 stated, [NAME] and our policies and procedures. Five Rights of Medication Administration- The right dosage - The third right of administering medications, the right dosage, means that the medication is given in the dose ordered and the dose ordered is appropriate for the client. Incorrect dosages may be given if the prescriber orders a dose that is inappropriate for a client; if the pharmacist dispenses or if the nurse administers an incorrect amount of medication ; or if a pharmacist, nurse or support staff transcribes an order incorrectly onto the client medication record.(4) 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. ASM #1, the administrator, ASM #2, the director of nursing, ASM #5 the regional nurse consultant and ASM #6, the assistant administrator, were made aware of the above findings on 2/12/2020 at approximately 6:30 p.m. No further information was obtained prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 269. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 114. (3) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682053.html (4) Fundamentals of Nursing; [NAME] and [NAME] Hirnle, 5th edition, [NAME], page 564.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide care and services consistent with professional standards of practice and in accordance with physician orders for two of 59 residents in the survey sample with a central venous access, (Residents #40 and #15). Resident #40 had a PICC (peripherally inserted central catheter) (1) in place in her right arm during the time of the survey. There were no orders or documentation for the maintenance and care of the PICC. The dressing on the PICC was dated 1/29/2020, and had not been changed in 14 days. Resident #15 had a PICC in place in her right arm during the time of the survey. The dressing on the PICC was dated 1/30/2020; the dressing had not been changed in 13 days. The findings include: 1. Resident #40 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses including, but not limited to persistent vegetative state (2), contractures (3), and multiple sclerosis (4). On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of 12/10/19, she was coded as being in a persistent vegetative state. She was coded as being completely dependent on staff members for all activities of daily living, as having upper and as being impaired on both sides of both upper and lower extremities for range of motion. On 2/12/2020 at 3:58 p.m., Resident #40 was observed lying in bed. LPN (licensed practical nurse) #1 accompanied the surveyor on this observation. A PICC access and dressing was observed on Resident #40's right upper arm. The dressing was peeling off on one side, and the dressing was dated 1/29/2020. A review of Resident #40's clinical record revealed no evidence of orders or directions for PICC care for Resident #40. A review of progress notes, MARs (medication administration records) and TARs (treatment administration records) for February 2020 for Resident #40 revealed no evidence of orders or directions for PICC care for Resident #40. A review of Resident #40's comprehensive care plan dated 5/21/19 revealed no information related to the resident's PICC. On 2/12/2020 at 3:38 p.m., LPN #1 was interviewed. When asked what the facility staff was doing to care for Resident #40's PICC, LPN #1 stated, We are flushing it. When asked to locate the orders for the flushing, she was unable to do so. When asked if there should be orders for maintaining the PICC, LPN #1 stated, Yes, there should at least be some directions. It might just be a nursing thing. When asked how often the dressing should be changed, LPN #1 stated, Every week, at least. When asked if Resident #40's dressing had been changed every week, she stated it had not. When asked the reason for changing a PICC dressing weekly, LPN #1 stated that it is easy for these central lines to get infected, and changing the dressing will help prevent infection. On 2/13/2020 at 9:08 a.m., LPN #3, a unit manager, was interviewed. When asked how often a PICC dressing should be changed, she stated it should be changed weekly or sooner, if soiled. When asked if there should be orders or directions for maintaining a PICC, LPN #3 stated, Absolutely. She stated orders should be in place for flushing with saline and heparin (5), as well as for changing the dressing. When asked if knew if Resident #40 had orders for any of these interventions, LPN #3 stated, I am already aware that there is nothing. On 2/13/2020 at 1:28 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. When asked what standards of practice the facility follows, ASM #1 stated the facility policies and procedures and [NAME]. Policies regarding central line care were requested. On 2/13/2020 at 2:15 p.m., ASM #1 presented the surveyor with the policy Peripheral IV Site Management. ASM #1 stated, This is all we have. A review of this policy revealed no information related to central venous access devices in general, or PICC lines in particular. Peripherally Inserted Catheter use: A PICC dressing should be changed at least every 7 days. Although a transparent semipermeable dressing is preferred, a gauze dressing should be used if a patient is diaphoretic or the site is bleeding or oozing. A gauze dressing should be changed every 2 days; either dressing should be replaced immediately if it becomes damp, loosened, or visibly soiled to reduce the risk of infection, or further assessment is needed because of drainage, infection or inflammation. Because the immune system's defense against infection declines with age, older patients are more susceptible to infection. Special Considerations: For catheters that are not being use routinely, flush nonvalved catheters at least every 24 hours and valved catheters at least weekly. Flush the catheter with preservative free normal saline solution; lock with heparin (10 units/ml [millimeter]) if the catheter is to be heparin locked. Inspect and palpate the catheter site daily to discern tenderness through the transparent semipermeable dressing. Look at the catheter and cannula pathway, check for bleeding, redness, drainage, and swelling. Lippincott Nursing Procedures Seventh Edition, by [NAME] Kluwer, pages 600-601 and 605. No further information was provided prior to exit. References: (1) A device used to draw blood and give treatments, including intravenous fluids, drugs, or blood transfusions. A thin, flexible tube is inserted into a vein in the upper arm and guided (threaded) into a large vein above the right side of the heart called the superior vena cava. This information is taken from the website https://www.cancer.gov/publications/dictionaries/cancer-terms/def/picc. (2) A coma, sometimes also called persistent vegetative state, is a profound or deep state of unconsciousness. This information is taken from the website https://www.ninds.nih.gov/Disorders/All-Disorders/Coma-Information-Page. (3) A contracture develops when the normally stretchy (elastic) tissues are replaced by nonstretchy (inelastic) fiber-like tissue. This tissue makes it hard to stretch the area and prevents normal movement. This information is taken from the website https://medlineplus.gov/ency/article/003185.htm. (4) Multiple sclerosis (MS) is a disease of the central nervous system. In MS the body's immune system attacks myelin, which coats nerve cells. This information is taken from the website https://nccih.nih.gov/health/multiple-sclerosis. (5) Heparin is used to prevent blood clots from forming in people who have certain medical conditions or who are undergoing certain medical procedures that increase the chance that clots will form. Heparin is also used to stop the growth of clots that have already formed in the blood vessels, but it cannot be used to decrease the size of clots that have already formed. Heparin is also used in small amounts to prevent blood clots from forming in catheters (small plastic tubes through which medication can be administered or blood drawn) that are left in veins over a period of time. Heparin is in a class of medications called anticoagulants ('blood thinners'). It works by decreasing the clotting ability of the blood. This information is taken from the website https://medlineplus.gov/druginfo/meds/a682826.html. 2. Resident #15 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses including, but not limited to history of a stroke, paralysis following a stroke, and diabetes (1). On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of 11/13/19, Resident #15 was coded as being moderately impaired for making daily decisions, having scored 12 out of 15 on the BIMS (brief interview for mental status). On 2/12/2020 at 4:05 p.m., Resident #15 was observed lying in bed. LPN (licensed practical nurse) #1 was present for this observation. A PICC access and dressing was observed on Resident #15's right upper arm. The dressing was dated 1/30/2020. A review of Resident #15's clinical record revealed the following order dated 2/4/2020: PICC line dressing change on admission, then Q (every) week and prn (as needed) every night shift every Sun (Sunday). A review of resident #15's February 2020 MARs (medication administration records) and TARs (treatment administration records) revealed no evidence that the PICC dressing had been changed. A review of Resident 15's comprehensive care plan dated 2/4/2020, revealed no information related to the resident's PICC. On 2/12/2020 at 3:38 p.m., LPN #1 was interviewed. When asked how often the PICC dressing should be changed, LPN #1 stated: Every week, at least. When asked if Resident #15's dressing had been changed every week, she stated it had not. When asked the reason for changing a PICC dressing weekly, LPN #1 stated that it is easy for these central lines to get infected, and changing the dressing will help prevent infection. On 2/13/2020 at 9:08 a.m., LPN #3, a unit manager, was interviewed. When asked how often a PICC dressing should be changed, she stated it should be changed weekly or sooner, if soiled. On 2/13/2020 at 1:28 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. No further information was provided prior to exit. References: (1) Diabetes (mellitus) is a disease in which your blood glucose, or blood sugar, levels are too high. This information is taken from the website https://medlineplus.gov/diabetes.html.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident #55 was admitted to the facility on [DATE] with diagnoses that include but are not limited to: anoxic brain damage (irreversible damage to the brain caused by lack of oxygen) (1), epilepsy (neurological disorder characterized by seizures and impaired consciousness) (2), and persistent vegetative state (condition in which patient is awake without being aware, brainstem is functioning but cerebral cortex is not) (3). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 9/11/19. A review of the MDS Section B-hearing, speech and vision coded the resident as persistent vegetative state. There was no coding of the BIMS (brief interview for mental status) score. A review of the MDS Section G-functional status coded the resident as total dependence for bed mobility, transfer, dressing, eating, toileting and personal hygiene. Resident #55 was observed in bed with bilateral quarter upper rails in raised position on 2/11/20 at 10:50 AM, on 2/11/20 at 1:40 PM and on 2/12/20 at 7:40 AM. Resident #55 is in a persistent vegetative state and was not capable of being interviewed. Review of the clinical record failed to evidence any documentation of alternative measure being attempted prior to the used of bilateral quarter upper bed rails. A list was provided to ASM (administrative staff member) #1, the administrator, on 2/12/20 at 3:00 PM. The list consisted of a request for evidence of the documentation of the assessment for the use of bed rails, the documentation of the risks of entrapment, a consent for the use of the bed rails for each resident listed, attempted prior to the use of bed rails and annual bed safety inspection. Resident #55 was included on this list. The annual bed safety inspection was the only document provided for Resident #55. An interview was conducted on 2/12/2020 at 10:53 AM with ASM #5, the regional nurse consultant. When asked for evidence of assessment for bed rail entrapment, consent and risks/benefits of bed rails, ASM #5 stated, We don't call them bed rails. We refer to them as a grab-bar or assist bar. They are not an extended bed rail. When asked the purpose of the grab bar/assist bars, ASM #5 stated, They are for the resident to either reposition themselves or assist the staff in repositioning them. When asked the purpose of grab bar/assist bars on the bed of a resident in a persistent vegetative state, ASM #5 stated, To assist with care, the caregiver can use it. When asked about the facility's Device Assessment, ASM #5 stated, The purpose of that document is to define if the device is restrictive and would be a restraint. If it were identified as a restraint, then we would get a consent. When asked about performing a risk versus benefit review for the bed rails, ASM #5 stated, Nursing identifies if it is a restraint. Our process explains the benefits of the grab bars and residents are oriented to the grab bars on admission to the facility. ASM #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional nurse consultant, were made aware of the above concern on 2/12/20 at 6:03 PM. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 36. (2) Barron Dictionary of Medical Terms, 7th edition, Rothenberg and Kaplan, page 199. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 446. 6. Resident #8 was admitted to the facility on [DATE] with diagnoses that include but are not limited to: cerebral vascular accident (abnormal condition in which hemorrhage or blockage of blood vessels of the brain leading to lack of oxygen) (1), end stage renal disease (inability of the kidneys to excrete waste or function to maintain electrolyte balance) (2) and diabetes (altered glucose metabolism caused by inability of insulin to function normally in the body) (3). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 1/30/20. A review of the MDS coded the resident as 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as extensive assistance for bed mobility and total dependence for transfer, dressing, toileting and personal hygiene. Resident #8 was observed in bed with bilateral quarter upper rails in raised position on 2/11/20 at 10:50 AM, on 2/11/20 at 1:40 PM and on 2/13/20 at 8:40 AM. Review of the clinical record failed to evidence any documentation of alternative measure being attempted prior to the used of bilateral quarter upper bed rails. An interview was conducted with Resident #8 on 2/13/20 at 8:40 AM. When asked if she utilized the bed rails, Resident #8 stated, Yes, I use them at times to help turn over and shift position. When asked if she remembered signing a consent or receiving information about the risks of entrapment with the use of side rails, Resident #8 stated, No, I don't remember signing a consent or receiving any information. A list was provided to ASM (administrative staff member) #1, the administrator, on 2/12/20 at 3:00 PM. The list consisted of a request for evidence of the documentation of the assessment for the use of bed rails, the documentation of the risks of entrapment, a consent for the use of the bed rails for each resident listed and annual bed safety inspection. Resident #8 was included on this list. The annual bed safety inspection and device assessment were the only documents provided for Resident #8. An interview was conducted on 2/12/2020 at 10:53 AM with ASM #5, the regional nurse consultant. When asked for evidence of assessment for bed rail entrapment, consent and risks/benefits of bed rails, ASM #5 stated, We don't call them bed rails. We refer to them as a grab- bar or assist bar. They are not an extended bed rail. When asked the purpose of the grab bar/assist bars, ASM #5 stated, They are for the resident to either reposition themselves or assist the staff in repositioning them. When asked the purpose of grab bar/assist bars on the bed of a resident in a persistent vegetative state, ASM #5 stated, To assist with care, the caregiver can use it. When asked about the facility's Device Assessment, ASM #5 stated, The purpose of that document is to define if the device is restrictive and would be a restraint. If it were identified as a restraint, then we would get a consent. When asked about performing a risk versus benefit review for the bed rails, ASM #5 stated, Nursing identifies if it is a restraint. Our process explains the benefits of the grab bars and residents are oriented to the grab bars on admission to the facility. ASM #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional nurse consultant, were made aware of the above concern on 2/12/20 at 6:03 PM. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 111. (2) Barron Dictionary of Medical Terms, 7th edition, Rothenberg and Kaplan, page 498. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 160. 7. Resident #317 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses including, but not limited to COPD (chronic obstructive pulmonary disease) (1), UTI (urinary tract infection), and history of falling. On the most recent MDS (minimum data set), an admission assessment dated [DATE], Resident #317 was coded as being severely cognitively impaired for making daily decisions, having scored three out of 15 on the BIMS (brief interview for mental status). She was coded as requiring the limited assistance of one staff member for bed mobility and transfers between surfaces. She was coded as having no impairment in any extremity for range of motion. On 2/11/2020 at 1:42 p.m. and 2/11/2020 at 2:31 p.m., Resident #317's room was observed. On both observations, Resident #317 was not lying in the bed, but bilateral side rails were observed in the up position on the bed. On 2/12/2020 at 4:08 a.m., Resident #317 was observed lying in bed with both side rails up. A review of Resident #317's clinical record revealed a Bed Action Safety Grid dated 1/30/19. The grid indicated the resident was safe from entrapment from the use of bed rails. Further review revealed a Device assessment dated [DATE]. This assessment documented that the bed rails were not considered to be a restraint for Resident #317. Further review of the record revealed no other information related to the use of bed rails for Resident #317, including appropriate alternatives attempted prior to the resident's use of bed rails a consideration of risks/benefits and a signed informed consent. A review of Resident #317's comprehensive care plan dated 1/26/2020 revealed, in part: Bed mobility: The resident uses assist bars to maximize independence with turning and repositioning in bed .Transfer: The resident uses assist bars to maximize independence with transferring. On 2/12/2020 at 10:53 a.m., ASM (administrative staff member) #5, the regional nurse consultant was interviewed. ASM #5 stated, We refer to the rails as a grab-bar or assist bar. He stated these bars are not considered to be an extended bed rail. He stated the rails in use by the facility are different from a more lengthy bed rail. He stated these rails are used for the resident to reposition himself in the bed, or for the resident to assist the staff in repositioning, thereby participating in their own care. When asked if the Device Assessment addresses all the documentation required for bed rail use, ASM #5 stated, No. We see it as a medical support device, not a restraint. He stated the Device Assessment only asks if the rails serve as a restraint. He stated the facility staff do not get a signed consent for the bed rails because they are not considered to be a restraint. ASM #5 was asked about performing a risk vs. benefit review for the bed rails. ASM #5 stated that nursing makes the decision about whether or not the rails are considered a restraint. ASM #5 stated, The process explains the benefits. He stated all the beds in the facility are standard having bed rails. He stated the staff speaks to the resident and explains the use of the bed rails on admission, and considers it part of a resident's orientation. He reiterated that the only assessment documented by the facility is the Device Assessment, which documents only whether or not the device is considered a restraint. On 2/13/2020 at 1:28 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. No further information was provided prior to exit. Reference: (1) COPD is a general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124. 8. Resident #320 was admitted to the facility on [DATE] with a diagnoses of a history of knee replacement. The resident has not been at the facility long enough for an MDS (minimum data set) to be completed. On the admission nursing assessment, dated 2/7/2020, Resident #320 was documented as being oriented to person, place, time, and situation. She was documented as not steady and able to stabilize only with staff assistance for surface to surface transfers. She was documented end as requiring limited assistance of one staff member for bed mobility. On 2/11/2020 at 3:39 p.m., Resident #320's room was observed. The resident was not in the room, and bed rails were observed attached on both sides of the resident's bed. On 2/12/2020 at 4:11 a.m., Resident #320 was observed lying in bed, and her eyes were closed. Both bed rails were up. A review of Resident #320's clinical record revealed a Bed Action Safety Grid dated 1/30/19. The grid indicated the resident was safe from entrapment from the use of bed rails. Further review revealed a Device assessment dated [DATE]. This assessment documented that the bed rails were not considered to be a restraint for Resident #320. Further review of the record revealed no other information related to the use of bed rails for Resident #320, including appropriate alternatives attempted prior to the resident's use of bed rails, a consideration of risks/benefits and a signed informed consent. A review of Resident #320's baseline care plan dated 2/9/2020 revealed, in part: Bed mobility: The resident uses assist device to maximize independence with turning and repositioning in bed. On 2/12/2020 at 10:53 a.m., ASM (administrative staff member) #5, the regional nurse consultant was interviewed. ASM #5 stated, We refer to the rails as a grab-bar or assist bar. He stated these bars are not considered to be an extended bed rail. He stated the rails in use by the facility are different from a more lengthy bed rail. He stated these rails are used for the resident to reposition himself in the bed, or for the resident to assist the staff in repositioning, thereby participating in their own care. When asked if the Device Assessment addresses all the documentation required for bed rail use, ASM #5 stated, No. We see it as a medical support device, not a restraint. He stated the Device Assessment only asks if the rails serve as a restraint. He stated the facility staff do not get a signed consent for the bed rails because they are not considered to be a restraint. ASM #5 was asked about performing a risk vs. benefit review for the bed rails. ASM #5 stated that nursing makes the decision about whether or not the rails are considered a restraint. ASM #5 stated, The process explains the benefits. He stated all the beds in the facility are standard having bed rails. He stated the staff speaks to the resident and explains the use of the bed rails on admission, and considers it part of a resident's orientation. He reiterated that the only assessment documented by the facility is the Device Assessment, which documents only whether or not the device is considered a restraint. On 2/13/2020 at 1:28 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. No further information was provided prior to exit. Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement bed rail requirements for eight of 59 residents in the survey sample, (Residents #267, #21, #24, #116, #55, #8, #317 and #320). The facility staff failed to review risks and benefits, failed to obtain informed consent for the use of bed rails and failed to evidence that appropriate alternatives were attempted prior to the resident's use of bed rails for Resident #267, Resident #21, Resident #24, Resident #116, Resident #55, Resident #8, Resident #317 and Resident #320. The findings include: 1. Resident #267 was admitted to the facility on [DATE]. Resident #267's diagnoses included but were not limited to bronchitis, high blood pressure and history of falling. Resident #267's admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 1/21/20, coded the resident's cognition as severely impaired. Section G coded Resident #267 as requiring extensive assistance of one staff with bed mobility. Review of Resident #267's clinical record revealed a device assessment dated [DATE]. The assessment documented the type of device as assist bars, and documented the device was not considered to be restrictive. The assessment documented the purpose of the device was for assistance of repositioning and documented the resident's representative was notified. The assessment failed to document a review of risks and benefits with Resident #267's representative, failed to document informed consent was obtained from the representative and failed to document appropriate alternatives were attempted prior to the resident's use of the assist bars (bed rails). Resident #267's comprehensive care plan created on 1/15/20 documented, Pad bed rails . On 2/12/20 at 4:34 a.m., Resident #267 was observed lying in bed with bilateral assist bars in use and up. On 2/12/2020 at 10:53 a.m., ASM (administrative staff member) #5, the regional nurse consultant was interviewed. ASM #5 stated, We refer to the rails as a grab bar or assist bar. He stated these bars are not considered to be an extended bed rail. He stated the rails in use by the facility are different from a more lengthy bed rail. He stated these rails are used for the resident to reposition himself in the bed, or for the resident to assist the staff in repositioning, thereby participating in their own care. When asked if the Device Assessment addresses all the documentation required for bed rail use, ASM #5 stated, No. We see it as a medical support device, not a restraint. He stated the Device Assessment only asks if the rails serve as a restraint. He stated the facility staff do not get a signed consent for the bed rails because they are not considered to be a restraint. ASM #5 was asked about performing a risk vs. benefit review for the bed rails. ASM #5 stated that nursing makes the decision about whether or not the rails are considered a restraint. ASM #5 stated, The process explains the benefits. He stated all the beds in the facility are standard having bed rails. He stated the staff speaks to the resident and explains the use of the bed rails on admission, and considers it part of a resident's orientation. He reiterated that the only assessment documented by the facility is the Device Assessment, which documents only whether or not the device is considered a restraint. On 2/12/20 at 6:10 p.m., ASM #1 (the administrator), ASM #2 (the director of nursing) and ASM #5 were made aware of the above concern. The facility policy titled, Device Assessment/Bed Safety documented, POLICY: The Device Assessment will be completed to provide documentation of the needs, and risk factors involved in the use of a restraint or device used by the patient. PROCEDURE: 1. The assessment will also help to determine that all alternatives have been considered and that the lease restrictive restraint or device is being used. 2. The Device Assessment is used to provide documentation that the patient/responsible party has been informed of the purpose, benefits, and potential complications associated with the use of a device(s) . No further information was presented prior to exit. 2. Resident #21 was admitted to the facility on [DATE]. Resident #21's diagnoses included but were not limited to chronic pain syndrome, muscle weakness and major depressive disorder. Resident #21's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 11/19/19, coded the resident's cognition as severely impaired. Section G coded Resident #21 as requiring extensive assistance of one staff with bed mobility. Review of Resident #21's clinical record revealed a device assessment dated [DATE]. The assessment documented multiple devices including assist bars, and documented the device was not considered to be restrictive. The assessment further documented the purpose of the device was to assist with bed mobility and documented the resident's representative was notified. The assessment failed to document a review of risks and benefits with Resident #21's representative, informed consent was obtained from the representative and failed to document appropriate alternatives were attempted prior to the resident's use of the assist bars (bed rails). Resident #21's comprehensive care plan created on 9/21/16 documented, Devices: assist bars for bed mobility . On 2/11/20 at 11:08 a.m. and 2/12/20 at 4:37 a.m., Resident #21 was observed lying in bed with bilateral assist bars in the up position. On 2/12/2020 at 10:53 a.m., ASM (administrative staff member) #5, the regional nurse consultant was interviewed. ASM #5 stated, We refer to the rails as a grab bar or assist bar. He stated these bars are not considered to be an extended bed rail. He stated the rails in use by the facility are different from a more lengthy bed rail. He stated these rails are used for the resident to reposition himself in the bed, or for the resident to assist the staff in repositioning, thereby participating in their own care. When asked if the Device Assessment addresses all the documentation required for bed rail use, ASM #5 stated, No. We see it as a medical support device, not a restraint. He stated the Device Assessment only asks if the rails serve as a restraint. He stated the facility staff do not get a signed consent for the bed rails because they are not considered to be a restraint. ASM #5 was asked about performing a risk vs. benefit review for the bed rails. ASM #5 stated that nursing makes the decision about whether or not the rails are considered a restraint. ASM #5 stated, The process explains the benefits. He stated all the beds in the facility are standard having bed rails. He stated the staff speaks to the resident and explains the use of the bed rails on admission, and considers it part of a resident's orientation. He reiterated that the only assessment documented by the facility is the Device Assessment, which documents only whether or not the device is considered a restraint. On 2/12/20 at 6:10 p.m., ASM #1 (the administrator), ASM #2 (the director of nursing) and ASM #5 were made aware of the above concern. No further information was presented prior to exit. 3. Resident #24 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: stroke, diabetes, high blood pressure, depression and hemiplegia (paralysis affecting only one side of the body) (1). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 11/21/19, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating she was cognitively intact to make daily decisions. The resident was coded as requiring extensive to being dependent upon one or more staff members for her activities of daily living. The resident was coded as being able to feed herself after set up assistance was provided. A Device Assessment, dated 1/8/2020 documented the use of assist bars and lap tray. A check mark was documented next to Device (s) are not considered to be restrictive. The assessment documented, What is the purpose of the device: assist bars to aid in bed mobility. Lap tray, left stump amputee rest, and elevated arm rest for L (left) arm for positioning and comfort measures. Further review of the clinical record failed to evidence documentation of a consent for the use of the assist bars, the acknowledgement of the risk for entrapment and failed to document appropriate alternatives were attempted prior to the resident's use of the assist bars (bed rails). The comprehensive care plan dated, 3/14/17 and revised on 11/13/19, documented in part, Focus: Resident has a actual fall and at risk for further falls r/t (related to) preparing to be transferred from bed to chair, impaired mobility. The Interventions documented in part, Monitor resident closely when rolling in bed as resident is able to roll but d/t (due to) hemiplegia side cannot brace herself or assist in holding onto grab bars to prevent rolling out of bed. On 2/12/2020 at 10:53 a.m., ASM (administrative staff member) #5, the regional nurse consultant was interviewed. ASM #5 stated, We refer to the rails as a grab bar or assist bar. He stated these bars are not considered to be an extended bed rail. He stated the rails in use by the facility are different from a more lengthy bed rail. He stated these rails are used for the resident to reposition himself in the bed, or for the resident to assist the staff in repositioning, thereby participating in their own care. When asked if the Device Assessment addresses all the documentation required for bed rail use, ASM #5 stated, No. We see it as a medical support device, not a restraint. He stated the Device Assessment only asks if the rails serve as a restraint. He stated the facility staff do not get a signed consent for the bed rails because they are not considered to be a restraint. ASM #5 was asked about performing a risk vs. benefit review for the bed rails. ASM #5 stated that nursing makes the decision about whether or not the rails are considered a restraint. ASM #5 stated, The process explains the benefits. He stated all the beds in the facility are standard having bed rails. He stated the staff speaks to the resident and explains the use of the bed rails on admission, and considers it part of a resident's orientation. He reiterated that the only assessment documented by the facility is the Device Assessment, which documents only whether or not the device is considered a restraint. ASM #1, the administrator, ASM #2, the director of nursing, ASM #5 and ASM #6, the assistant administrator, were made aware of the above findings on 2/12/2020 at approximately 6:15 p.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 266. 4. Resident #116 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: end stage renal 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), high blood pressure, depression, muscle weakness. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 1/24/2020 coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact to make daily decisions. The resident was coded as requiring supervision of one staff member for all of his activities of daily living. A Device assessment dated [DATE] documented the use of the assist bars. A check mark was documented next to: Device is not considered to be restrictive. The purpose was documented as: Assist bars to aid in bed mobility, w/c (wheelchair) for mobility, reacher to aid in ADLs (activities of daily living). Further review of the clinical record failed to evidence documentation of a consent for the use of the assist bars, the acknowledgement of the risk for entrapment and failed to document appropriate alternatives were attempted prior to the resident's use of the assist bars (bed rails). An interview was conducted with Resident #116 on 2/11/2020 at 2:28 p.m. Resident #116 was asked if the facility evaluated him for the use of assist bars (bed rails), Resident #116 stated he doesn't t recall them (staff) asking him questions about using the side rails. He also stated he doesn't know why he has them as he really doesn't use or need them anymore. The side rails were observed in the upright position during this interview and the resident was in the bed. The comprehensive care plan dated 6/21/16 and revised on 9/14/18 documented in part, Focus: The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) limited Mobility, and impaired balance, incontinence. The Interventions documented in part, Assistive Device: assist bars, high back wheelchair with cushion on bottom, pillow to residents back when in W/C (wheel chair) per his preference, reacher. On 2/12/2020 at 10:53 a.m., ASM (administrative staff member) #5, the regional nurse consultant was interviewed. ASM #5 stated, We refer to the rails as a grab bar or assist bar. He stated these bars are not considered to be an extended bed rail. He stated the rails in use by the facility are different from a more lengthy bed rail. He stated these rails are used for the resident to reposition himself in the bed, or for the resident to assist the staff in repositioning, thereby participating in their own care. When asked if the Device Assessment addresses all the documentation required for bed rail use, ASM #5 stated, No. We see it as a medical support device, not a restraint. He stated the Device Assessment only asks if the rails serve as a restraint. He stated the facility staff do not get a signed consent for the bed rails because they are not considered to be a restraint. ASM #5 was asked about performing a risk vs. benefit review for the bed rails. ASM #5 stated that nursing makes the decision about whether or not the rails are considered a restraint. ASM #5 stated, The process explains the benefits. He stated all the beds in the facility are standard having bed rails. He stated the staff speaks to the resident and explains the use of the bed rails on admission, and considers it part of a resident's orientation. He reiterated that the only assessment documented by the facility is the Device Assessment, which documents only whether or not the device is considered a restraint. ASM #1, the administrator, ASM #2, the director of nursing, ASM #5 and ASM #6, the assistant administrator, were made aware of the above findings on 2/12/2020 at approximately 6:15 p.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 266.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to ensure a resident was free of unnecessary psychotropic medications for one of 59 residents in the survey sample, Resident #111. Based on the comprehensive assessment the facility staff failed to ensure duplicate antianxiety medication was not administered to Resident #111. The findings include: Resident #111 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: liver cancer, falls, hepatitis C-(inflammation of the liver. similar to hepatitis B, It is spread primarily through blood, though sexual transmission has been described.) (1), high blood pressure, diabetes, fractured hip and cirrhosis of the liver (chronic disease condition of the liver in which fibrous tissue and modules replace normal tissue, interfering with blood flow and normal function of the organ) (2). The resident is on hospice care. The most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 1/8/2020 coded the resident as scoring a 3 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired to make daily cognitive decisions. The resident was coded as having verbal behavioral symptoms directed towards others and other behavioral symptoms not directed toward others. Resident #111 was coded as requiring extensive to total assistance of one or more staff members for all of his activities of daily living except eating in which her required supervision and set up assistance. In Section N - Medications, the resident was coded as having received an antianxiety medication for six of the days during the look back period. The physician orders documented the following medications/dosage and dates ordered: - 1/30/2020 - Lorazepam (used to treat anxiety) (3) tablet 1 MG (milligram) give 1 mg by mouth every 4 hours as needed for anxiety. - 1/30/2020 - Lorazepam tablet 1 MG give 1 mg by mouth two times a day for agitation. - 2/7/2020 - Lorazepam concentrate 2 MG/ML (milligrams per milliliter) give 0.5 ml by mouth three times a day for anxiety. Review of the February 2020 MAR (medication administration record) documented the above medications. The Lorazepam tablets were documented as administered every day, twice a day from 2/1/2020 through 2/11/2020 and received a dose on 2/12/2020 at 9:00 a.m. The Lorazepam concentrate was documented as administered every day, three times a day, from 2/8/2020 through 2/11/2020 and received a dose on 2/12/2020 at 9:00 a.m. From 2/1/2020 through 2/7/2020 the resident was receiving a total of two MG per day. From 2/8/2020 through 2/12/2020 the resident was receiving 5 mg per day. The comprehensive care plan dated 1/2/2020 documented in part, Focus: The resident exhibits adverse behavioral symptoms r/t (related to) itching, picking at skin, restless (agitation), hitting increase in complaints, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucination, psychosis, aggression, refusing care, deliberately sliding unto the floor, crawling on floor, chews tongue and bites his hands/cell phone. The Interventions documented in part, Administer medications as ordered. Monitor/document for side effects and effectiveness. An interview was conducted with LPN (licensed practical nurse) #2; on 2/12/2020 at 12:55 p.m., LPN #2 was asked to review the physician orders for Lorazepam. Once reviewed, LPN #2 was asked if she thought it odd that the resident was receiving the same medication in both pill form and tablet form, LPN #2 stated she thought it was related to his aggression toward the staff. LPN #3, the unit manager, was asked to review the orders for Lorazepam. LPN #3 stated she feels the orders needed to be clarified. LPN #3 placed a call to the nurse practitioner (administrative staff member - ASM) #3. An interview was conducted with ASM #3 on 2/12/2020 at 1:08 p.m. When asked why the resident was on two doses of the same medication, ASM #3 stated I believe the order was changed and the previous order was not discontinued. ASM #3 stated she would like to contact the hospice staff and discuss it with them and would get back with this surveyor. ASM #3 returned to this surveyor on 2/12/2020 at 1:50 p.m. and stated she had called hospice, they did put the order in for the Ativan (Lorazepam) 1 mg every 4 hours as needed and then put in the order for the 1 mg three times a day. The Ativan tablet was supposed to have been discontinued when the liquid was ordered three times a day. The facility policy, Psychopharmacological Medication Use, documented in part, Facility should comply the psychopharmacologic dosage guidelines created by the Centers for Medicare and Medicaid Services, the State Operations Manual and all other applicable Law related to the use of psychopharmacologic medication including gradual dose reduction. ASM #1, the administrator, ASM #2, the director of nursing, ASM #5 the regional nurse consultant and ASM #6, the assistant administrator, were made aware of the above findings on 2/12/2020 at approximately 6:30 p.m. No further information was obtained prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 269. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 114. (3) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682053.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 one resident (Resident #111) of 59 sampled residents was free of a significant medication errors. The facility staff administered both Lorazepam tablet (1 mg) twice daily and Lorazepam concentrate three times a day resulting in Resident #111 receiving a total of two milligrams of Lorazepam per day from 2/1/2020 through 2/7/2020, and a total of 5 mg per day, from 2/8/2020 through 2/12/2020. The findings include: Resident #111 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: liver cancer, falls, hepatitis C-(inflammation of the liver. similar to hepatitis B, It is spread primarily through blood, though sexual transmission has been described.) (1), high blood pressure, diabetes, fractured hip and cirrhosis of the liver (chronic disease condition of the liver in which fibrous tissue and modules replace normal tissue, interfering with blood flow and normal function of the organ) (2). The resident is on hospice care. The most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 1/8/2020 coded the resident as scoring a 3 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired to make daily cognitive decisions. The resident was coded as having verbal behavioral symptoms directed towards others and other behavioral symptoms not directed toward others. Resident #111 was coded as requiring extensive to total assistance of one or more staff members for all of his activities of daily living except eating in which her required supervision and set up assistance. In Section N - Medications, the resident was coded as having received an antianxiety medication for six of the days during the look back period. The physician orders documented the following medications/dosage and dates ordered: 1/30/2020 - Lorazepam (used to treat anxiety) (3) tablet 1 MG (milligram) give 1 mg by mouth every 4 hours as needed for anxiety. 1/30/2020 - Lorazepam tablet 1 MG give 1 mg by mouth two times a day for agitation. 2/7/2020 - Lorazepam concentrate 2 MG/ML (milligrams per milliliter) give 0.5 ml by mouth three times a day for anxiety. Review of the February 2020 MAR (medication administration record) documented the above medications. The Lorazepam tablets were documented as administered every day, twice a day from 2/1/2020 through 2/11/2020 and received a dose on 2/12/2020 at 9:00 a.m. The Lorazepam concentrate was documented as administered every day, three times a day, from 2/8/2020 through 2/11/2020 and received a dose on 2/12/2020 at 9:00 a.m. From 2/1/2020 through 2/7/2020 the resident was receiving a total of two MG per day. From 2/8/2020 through 2/12/2020 the resident was receiving 5 mg per day. Almost double the dosage prescribed. The comprehensive care plan dated 1/2/2020 documented in part, Focus: The resident exhibits adverse behavioral symptoms r/t (related to) itching, picking at skin, restless (agitation), hitting increase in complaints, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucination, psychosis, aggression, refusing care, deliberately sliding unto the floor, crawling on floor, chews tongue and bites his hands/cell phone. The Interventions documented in part, Administer medications as ordered. Monitor/document for side effects and effectiveness. On 2/12/2020 at 12:55 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 was asked to review the physician orders for Lorazepam. Once reviewed, LPN #2 was asked if she thought it odd that the resident was receiving the same medication in both pill form and tablet form, LPN #2 stated she thought it was related to his aggression toward the staff. LPN #3, the unit manager, was asked to review the orders for Lorazepam. LPN #3 stated she feels the orders needed to be clarified. LPN #3 placed a call to the nurse practitioner (administrative staff member - ASM) #3. An interview was conducted with ASM #3 on 2/12/2020 at 1:08 p.m. When asked why the resident was on two doses of the same medication, ASM #3 stated I believe the order was changed and the previous order was not discontinued. ASM #3 stated she would like to contact the hospice staff and discuss it with them. On 2/12/2020 at 1:50 p.m. ASM #3 returned and stated that she had called hospice. ASM #3 stated they did put the order in for the Ativan (Lorazepam) 1 mg every 4 hours as needed and then put in the order for the 1 mg three times a day. The Ativan tablet was supposed to have been discontinued when the liquid was ordered three times a day. An interview was conducted with ASM #2, the director of nursing, on 02/13/20 at 11:25 a.m., regarding what standard of practice the facility uses. ASM #2 stated, [NAME] and our policies and procedures. Five Rights of Medication Administration- The right dosage - The third right of administering medications, the right dosage, means that the medication is given in the dose ordered and the dose ordered is appropriate for the client. Incorrect dosages may be given if the prescriber orders a dose that is inappropriate for a client; if the pharmacist dispenses of if the nurse administers an incorrect amount of medication ; or if a pharmacist, nurse or support staff transcribes an order incorrectly onto the client medication record.(4) A medication error is a mistake that occurs during the medication administration process. If a mistake occurs, it does not matter whether the patient was harmed or not or whether there was only a potential for injury; it is still considered a medication error. Lippincott Nursing Procedures Seventh Edition, by [NAME] Kluwer, page 678. Lorazepam is indicated for the management of anxiety disorders or for the short-term relief of the symptoms of anxiety or anxiety associated with depressive symptoms. WARNINGS: Use of benzodiazepines, including lorazepam, both used alone and in combination with other CNS depressants, may lead to potentially fatal respiratory depression. PRECAUTIONS: Lorazepam should be used with caution in patients with compromised respiratory function (e.g. COPD, sleep apnea syndrome). Elderly or debilitated patients may be more susceptible to the sedative effects of lorazepam. Therefore, these patients should be monitored frequently and have their dosage adjusted carefully according to patient response; the initial dosage should not exceed 2 mg. (5) ASM #1, the administrator, ASM #2, the director of nursing, ASM #5 the regional nurse consultant and ASM #6, the assistant administrator, were made aware of the above findings on 2/12/2020 at approximately 6:30 p.m. No further information was obtained prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 269. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 114. (3) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682053.html (4) Fundamentals of Nursing; [NAME] and [NAME] Hirnle, 5th edition, [NAME], page 564. (5) This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=711b60a3-028d-41d4-aa17-8f976e6df23e#P-Clinically_Significant_Drug_Interactions

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview and clinical record review, it was determined that the facility staff failed to provide food at a palatable temperature. The facility staff failed to provide food at a palatable temperature during lunch on 2/12/20. The findings include: Resident #96 was admitted to the facility on [DATE]. Resident #96's diagnoses included but were not limited to paralysis and diabetes. Resident #96's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 1/23/20, coded the resident as being cognitively intact. On 2/11/20 at 12:52 p.m., an interview was conducted with Resident #96. The resident stated the facility food was cold. Resident #84 was admitted to the facility on [DATE]. Resident #84's diagnoses included but were not limited to major depressive disorder and high blood pressure. Resident #84's quarterly MDS assessment with an ARD of 1/16/20, coded the resident as being cognitively intact. On 2/11/20 at 1:03 p.m., an interview was conducted with Resident #84. The resident stated the facility food was cold. Resident #116 was admitted to the facility on [DATE]. Resident #116's diagnoses included but were not limited to chronic pain syndrome and end stage kidney disease. Resident #116's quarterly MDS assessment with an ARD of 1/24/20, coded the resident as being cognitively intact. On 2/11/20 at 1:43 p.m., an interview was conducted with Resident #116. The resident stated the facility food is only hot fifty percent of the time. Resident #4 was admitted to the facility on [DATE]. Resident #4's diagnoses included but were not limited to heart failure and low back pain. Resident #4's quarterly MDS assessment with an ARD of 1/25/20, coded the resident as being cognitively intact. On 2/11/20 at 4:04 p.m., an interview was conducted with Resident #4. The resident stated the facility food is warm and not hot. Resident #24 was admitted to the facility on [DATE]. Resident #24's diagnoses included but were not limited to diabetes and chronic kidney disease. Resident #24's quarterly MDS assessment with an ARD of 11/21/19, coded the resident as being cognitively intact. On 2/11/20 at 4:58 p.m., an interview was conducted with Resident #24. The resident stated she eats in her room and the facility food is not always hot. On 2/12/20 at 11:35 a.m., the holding temperatures of lunch were obtained from the steam table in the main dining room and were as follows: Meatloaf- 185 degrees Fahrenheit Fish- 168 degrees Fahrenheit Rice- 206 degrees Fahrenheit Spinach- 207 degrees Fahrenheit Mixed vegetables- 195 degrees Fahrenheit After the holding temperatures were obtained, residents in the dining room were served; then plates were prepared, covered with a lid, placed in food carts and taken to units. On 2/12/20 at 1:09 p.m., a test tray was plated and sent to the A unit. On 2/12/20 at 1:23 p.m., when the final meal was served on the A unit, the temperatures of the food on the test tray were obtained by OSM (other staff member) #7 (the dining services director) using a facility thermometer. The test tray food temperatures were as follows: Meatloaf- 119.9 degrees Fahrenheit Fish- 108 degrees Fahrenheit Rice- 114 degrees Fahrenheit Spinach- 118 degrees Fahrenheit Mixed vegetables- 140 degrees Fahrenheit The food on the test tray was sampled by a surveyor who determined the meatloaf, fish and rice were not warm enough to be palatable. OSM #7 confirmed this and stated these food items could be warmer. On 2/12/20 at approximately 3:00 p.m., OSM #7 stated the facility did not have a policy regarding palatable food. On 2/12/20 at 6:10 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #5 (the regional nurse consultant) were made aware of the above concern. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement infection control practices for three of 59 residents in the survey sample, (Residents #40, #15, and #318); and in one of two dining rooms, (Dining Room B); and in two of 62 resident rooms, (Rooms #35 and #36). The facility staff failed to ensure PICC (peripherally inserted central catheter) care was provided including dressing changes, to prevent infection for Resident #40 who had a PICC in place in her right arm, and Resident #15, who had a PICC in place in her right arm. The facility staff failed to store Resident #318's nebulizer mask with a protective covering, to prevent infection on 2/12/2020. The facility staff placed ungloved thumbs on the eating surfaces of dishes being served to the residents in Dining Room B of the facility during lunch on 2/11/2020. The facility staff removed a straight-back chair from room [ROOM NUMBER] and placed it in room [ROOM NUMBER], without first sanitizing the chair. The findings include: 1. Resident #40 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses including, but not limited to persistent vegetative state (2), contractures (3), and multiple sclerosis (4). On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of 12/10/19, she was coded as being in a persistent vegetative state. She was coded as being completely dependent on staff members for all activities of daily living, as having upper and as being impaired on both sides of both upper and lower extremities for range of motion. On 2/12/2020 at 3:58 p.m., Resident #40 was observed lying in bed. LPN (licensed practical nurse) #1 accompanied the surveyor on this observation. A PICC access and dressing was observed on Resident #40's right upper arm. The dressing was peeling off on one side, and the dressing was dated 1/29/2020. A review of Resident #40's clinical record revealed no evidence of orders or directions for PICC care for Resident #40. A review of progress notes, MARs (medication administration records) and TARs (treatment administration records) for February 2020 for Resident #40 revealed no evidence of orders or directions for PICC care for Resident #40. A review of Resident #40's comprehensive care plan dated 5/21/19 revealed no information related to the resident's PICC. On 2/12/2020 at 3:38 p.m., LPN #1 was interviewed. When asked how often the PICC dressing should be changed, LPN #1 stated, Every week, at least. When asked if Resident #40's dressing had been changed every week, she stated it had not. When asked the reason for changing a PICC dressing weekly, LPN #1 stated that it is easy for these central lines to get infected, and changing the dressing will help prevent infection. On 2/13/2020 at 9:08 a.m., LPN #3, a unit manager, was interviewed. When asked how often a PICC dressing should be changed, LPN #3 stated it should be changed weekly or sooner, if soiled. When asked if there should be orders or directions for maintaining a PICC, she stated there should be orders for changing the dressing. When asked if Resident #40 had orders for any PICC dressing changes, LPN #3 stated, I am already aware that there is nothing. On 2/13/2020 at 1:28 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. When asked what standards of practice the facility follows, ASM #1 stated the facility policies and procedures and [NAME]. Policies regarding central line care were requested. On 2/13/2020 at 2:15 p.m., ASM #1 presented the surveyor with the policy Peripheral IV Site Management. She stated: This is all we have. A review of this policy revealed no information related to central venous access devices in general, or PICC lines in particular. Peripherally Inserted Catheter use: A PICC dressing should be changed at least every 7 days. Although a transparent semipermeable dressing is preferred, a gauze dressing should be used if a patient is diaphoretic or the site is bleeding or oozing. A gauze dressing should be changed every 2 days; either dressing should be replaced immediately if it becomes damp, loosened, or visibly soiled to reduce the risk of infection, or further assessment is needed because of drainage, infection or inflammation. Because the immune system's defense against infection declines with age, older patients are more susceptible to infection. Special Considerations: . Inspect and palpate the catheter site daily to discern tenderness through the transparent semipermeable dressing. Look at the catheter and cannula pathway, check for bleeding, redness, drainage, and swelling. Lippincott Nursing Procedures Seventh Edition, by [NAME] Kluwer, pages 600-601 and 605. No further information was provided prior to exit. References: (1) A device used to draw blood and give treatments, including intravenous fluids, drugs, or blood transfusions. A thin, flexible tube is inserted into a vein in the upper arm and guided (threaded) into a large vein above the right side of the heart called the superior vena cava. This information is taken from the website https://www.cancer.gov/publications/dictionaries/cancer-terms/def/picc. (2) A coma, sometimes also called persistent vegetative state, is a profound or deep state of unconsciousness. This information is taken from the website https://www.ninds.nih.gov/Disorders/All-Disorders/Coma-Information-Page. (3) A contracture develops when the normally stretchy (elastic) tissues are replaced by nonstretchy (inelastic) fiber-like tissue. This tissue makes it hard to stretch the area and prevents normal movement. This information is taken from the website https://medlineplus.gov/ency/article/003185.htm. (4) Multiple sclerosis (MS) is a disease of the central nervous system. In MS the body's immune system attacks myelin, which coats nerve cells. Symptoms of MS include muscle weakness (often in the hands and legs), tingling and burning sensations, numbness, chronic pain, coordination and balance problems, fatigue, vision problems, and difficulty with bladder control. People with MS also may feel depressed and have trouble thinking clearly. This information is taken from the website https://nccih.nih.gov/health/multiple-sclerosis. 2. Resident #15 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses including, but not limited to history of a stroke, paralysis following a stroke, and diabetes (1). On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of 11/13/19, Resident #15 was coded as being moderately impaired for making daily decisions, having scored 12 out of 15 on the BIMS (brief interview for mental status). On 2/12/2020 at 4:05 p.m., Resident #15 was observed lying in bed. LPN (licensed practical nurse) #1 accompanied the surveyor on this observation. A PICC access and dressing was observed on Resident #15's right upper arm. The dressing was dated 1/30/2020. A review of Resident #15's clinical record revealed the following order dated 2/4/2020: PICC line dressing change on admission, then Q (every) week and prn (as needed) every night shift every Sun (Sunday). A review of resident #15's February 2020 MARs (medication administration records) and TARs (treatment administration records) revealed no evidence that the PICC dressing had been changed. A review of Resident 15's comprehensive care plan dated 2/4/2020 revealed no information related to the resident's PICC. On 2/12/2020 at 3:38 p.m., LPN #1 was interviewed. When asked how often the PICC dressing should be changed, LPN #1 stated, Every week, at least. When asked if Resident #15's dressing had been changed every week, she stated it had not. When asked the reason for changing a PICC dressing weekly, LPN #1 stated that it is easy for these central lines to get infected, and changing the dressing will help prevent infection. On 2/13/2020 at 9:08 a.m., LPN #3, a unit manager, was interviewed. When asked how often a PICC dressing should be changed, LPN #3 stated it should be changed weekly or sooner, if soiled. On 2/13/2020 at 1:28 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. No further information was provided prior to exit. References: (1) Diabetes (mellitus) is a disease in which your blood glucose, or blood sugar, levels are too high. This information is taken from the website https://medlineplus.gov/diabetes.html. 3. Resident #318 was admitted to the facility on [DATE] with diagnoses of pneumonia, Alzheimer's disease (1), and obstruction of bilateral ureters (3). He had not been a resident at the facility long enough to have a completed MDS (minimum data set). On the admission nursing assessment dated [DATE], Resident #318 was documented as being alert only to person. 02/12/20 at 8:19 a.m. and at 11:47 a.m., Resident #318 was observed lying in bed. At both observations, a nebulizer mask was lying directly on the bedside table. The mask was uncovered, and in direct contact with the bedside table. A review of Resident #318's clinical record revealed the following order, dated 2/6/2020: Ipratropium-Albuterol Solution (2) 0.5-2.5 mg/3ml (milligrams per three milliliters). Inhale orally every 4 hours as needed for SOB (shortness of breath) or wheezing via nebulizer. A review of Resident #318's February 2020 TARs (treatment administration records) revealed that he received this medication on 2/8/2020 at 11:15 a.m. A review of Resident #318's baseline care plan dated 2/10/2020 revealed, in part: The resident has pneumonia .Give medications as ordered. On 2/13/2020 at 9:53 a.m., LPN (licensed practical nurse) #1 was interviewed. When asked how nebulizer masks should be stored, she stated the mask should always be placed in a plastic bag. When asked why the mask should be stored in a plastic bag, LPN #1 stated, For infection control. On 2/13/2020 at 11:01 a.m., CNA (certified nursing assistant) #3 was interviewed. When asked how nebulizer masks should be stored, she stated a mask should be stored in a plastic bag. CNA #3 stated, It should be dated and labeled. When asked why the mask should be stored in a plastic bag, CNA #3 stated, You don't want it to get dirty. That would be bad for the resident. On 2/13/2020 at 11:43 a.m., LPN #3, a unit manager, was interviewed. When asked how a nebulizer mask should be stored, she stated that a nebulizer mask should always be in a plastic bag. When asked why the mask should be in a plastic bag, LPN #3 stated, Bacteria and germs. On 2/13/2020 at 1:28 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Respiratory/Oxygen Equipment, revealed, in part: Rinse out nebulizer reservoir with tap water, dry, and place in a plastic bag when not in use. According to Fundamentals of Nursing [NAME] and [NAME] Eighth Edition 2006, [NAME] Company, page 240, Administering Nebulizer Therapy: Follow up Phase 2. Disassemble and clean nebulizer after each use Each patent has own breathing circuit (nubulizer, tubing, and mouthpiece). Through proper cleaning, .and storage of equipment, organisms can be prevented from entering the lungs. No further information was provided prior to exit. References: (1) Alzheimer's disease is an irreversible, progressive brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks. It is the most common cause of dementia in older adults. This information is taken from the website https://www.nia.nih.gov/health/alzheimers/basics. (2) The combination of albuterol and ipratropium is used to prevent wheezing, difficulty breathing, chest tightness, and coughing in people with chronic obstructive pulmonary disease (COPD; a group of diseases that affect the lungs and airways) such as chronic bronchitis (swelling of the air passages that lead to the lungs) and emphysema (damage to the air sacs in the lungs). Albuterol and ipratropium combination is used by people whose symptoms have not been controlled by a single inhaled medication. Albuterol and ipratropium are in a class of medications called bronchodilators. Albuterol and ipratropium combination works by relaxing and opening the air passages to the lungs to make breathing easier. This information is taken from the website https://medlineplus.gov/druginfo/meds/a601063.html. 4. On 2/11/2020 at 12:07 p.m., observation was made of the lunch food service to residents in Dining Room B. The facility staff transported freshly-served plates from the steam tables to the residents who were seated at tables. OSM (other staff member) #11, a dietary aide, OSM #12, a dietary supervisor, and LPN (licensed practical nurse) #8 delivered plates and bowls to the residents. All three of these staff members consistently handled resident dishware with ungloved hands, and all three consistently placed their thumbs on the eating surfaces of the residents' dishes as they distributed them for the residents to eat lunch. On 2/11/2020 at 2:03 p.m., OSM #11 and OSM #12 were interviewed. When asked if they remembered how they had handled resident dishware as they were distributing it for the residents to eat lunch, both staff members stated they did not recall. When informed that they had both handled the dishware with ungloved hands, and had put their bare thumbs on the surfaces of residents' plates and bowls, they stated they did not remember. When asked if this was the correct way to handle resident dishware, OSM #12 stated it was not. OSM #12 stated, We do not want to touch the plates. We do not want any germs. OSM #11 stated that the bare thumbs could be a source of contamination of the residents' dishes. OSM #13, the registered dietician, accompanied OSMs #11 and #12 on this interview. When asked if resident dishware should be handled in such a way that the servers' bare thumbs come into contact with the eating surfaces of the dishes, OSM #13 stated, Normally we do not touch the eating surface of the plate. On 2/11/2020 at 2:09 p.m., LPN #8 was interviewed. When asked about her handling of the gravy bowls she served to the residents at lunch that day, LPN #8 stated, No, I should not have had my thumbs in them. That was my first time ever in the dining room. She stated she should just have held the bowls on the bottom. She stated there was a risk of getting infection and germs into the bowls. On 2/13/2020 at 1:28 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. No further information was provided prior to exit. 5. On 2/11/20 at 1:08 PM, ASM #1 (Administrative Staff Member), the administrator, was observed entering room [ROOM NUMBER], and then leaving the room, carrying a straight back chair to room [ROOM NUMBER] across the hall. ASM #1 then handed the chair to LPN #1 (Licensed Practical Nurse) who was in room [ROOM NUMBER] assisting the residents. ASM #1 did not sanitize the chair prior to placing it in a different resident room. On 2/11/20 at 1:10 PM, in an interview with ASM #1, she stated that there were two staff members in room [ROOM NUMBER] assisting the two residents in the room with the feeding of the lunch meal. ASM #1 stated that the second staff member needed a chair, to feed one of the two residents. When asked if it was acceptable to take furniture from one resident's room and use it in another resident's room, ASM #1 stated, If you return it. When asked if the chair was sanitized prior to removing it from room [ROOM NUMBER] and placing it in room [ROOM NUMBER], ASM #1 stated that the housekeeper had sanitized it. ASM #1 was asked at what time the housekeeper had sanitized the chair. ASM #1 stated the housekeeper would have gone through around 10:00 AM. When asked if she saw the chair being sanitized, ASM #1 stated that she did not see the chair being cleaned. When asked if it was possible for the chair to become re-contaminated from 10:00 AM when the housekeeper may have cleaned it, to the time of the observation at 1:08 PM when the chair was removed from room [ROOM NUMBER] and placed in room [ROOM NUMBER], ASM #1 stated it was possible. On 2/11/20 at approximately 1:15 PM, an observation was made of room [ROOM NUMBER]. There was one chair immediately inside the door of the room in the corner to the right as you walk into the room. LPN #1 was in another chair at the bedside of one of the residents, assisting them with feeding. On 2/11/20 at 1:45 PM an interview was conducted with LPN #1. LPN #1 stated that she started feeding one of the residents in room [ROOM NUMBER], but that resident was lethargic so she then went to assist the other resident with feeding. When asked about the two chairs that were observed in the room, LPN #1 stated that the one that was observed by the door was the rightful chair for that room and the one she was using at the time of the observation to feed one of the residents was the chair that came from room [ROOM NUMBER]. LPN #1 stated, I thought it would be an issue to use the chair that was already in the room for both residents. She stated, We normally disinfect the chairs before we move them because it would be a contamination issue. I did not see anyone disinfect it. It was an assumption that before they moved it they would have wiped it down. On 2/11/20 at 1:51 PM in an interview with OSM #1 (Other Staff Member, the housekeeper), she stated when she cleans a room, she sprays cleaner in the bathroom and if there is something that needs to be removed from the room she sprays it with the cleaner. She stated that she then wipes down the tables, chairs, window sills, the heater, TV, clocks, anything in there that needs to be wiped she wipes it down. OSM #1 stated she was in room [ROOM NUMBER] sometime between 10:00 AM and 10:30 AM. She stated she wiped down the chair. When asked, if a chair has to be wiped down before being moved to another resident room, OSM #1 stated it did. When asked if a chair could be become re-contaminated between 10:00 and the time of the observation of the chair being moved at 1:08 PM, OSM #1 stated, It can be and has to be cleaned again because it is supposed to be removed immediately after cleaning, if it was being cleaned for the purpose of moving it to another area. A review of the facility policy, Housekeeping Policies and Procedures: Equipment/Utility Areas was provided. This policy documented, Cleaning Schedules: 2. Regular schedules will be established for the cleaning of all patient rooms, offices, utility areas, public restrooms, therapy gyms, and public areas. The policy did not specify sanitizing items for use from one resident to another resident or what to do prior to removing furniture from one resident room to another resident room. On 2/11/20 at approximately 6:15 PM, ASM #5, the Regional Nurse Consultant, was made aware of the findings. No further information was provided.