**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to complete an accurate minimum data set (MDS) for one of fifteen residents in the survey sample (Resident #32). The findings include: Resident #32's MDS inaccurately documented the resident received hospice services. Resident #32 was admitted to the facility with diagnoses that included Alzheimer's dementia, anxiety, mood disorder, cerebral infarction, pelvic fracture, and depression. The MDS dated [DATE] assessed Resident #32 with severely impaired cognitive skills. Section O. of Resident #32's MDS (minimum data set), dated 12/16/22, documented the resident received hospice services while in the nursing facility. Review of Resident #32's clinical record documented no provision of hospice services. The record documented a physician's order dated 12/14/22 for a Do Not Hospitalize status, in addition to a Do Not Resuscitate/Do Not Intubate order. The record also documented a physician's order dated 12/14/22 for a hospice consult, but there was no order for enrollment in a hospice service. Resident #32's plan of care (initiated 12/20/22) listed that the resident was receiving comfort/palliative care. On 3/8/23 at 1:20 p.m., the registered nurse (RN #1) caring for Resident #32 was interviewed about the MDS indicating the provision of hospice services. RN #1 stated that the resident's family discussed hospice but never elected their services. RN #1 stated the resident was currently with comfort/palliative care orders. RN #1 stated, The family never elected hospice. On 3/8/23 at 1:25 p.m., the MDS coordinator (RN #2) was interviewed about Resident #32's MDS of 12/16/22 listing hospice services. RN #2 reviewed the 12/16/22 MDS and stated there was an order for a hospice consult but that Resident #32 never went on hospice. RN #2 stated that the MDS was inaccurately coded with hospice services for Resident #32. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual on page O-2 concerning section O. for coding special treatments, procedures, and programs, documented .Check all treatments, procedures, and programs received or performed by the resident after admission/entry or reentry to the facility . Page O-5 documented concerning coding for hospice care, .Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. The hospice must be licensed by the state as a hospice provider and/or certified under the Medicare program as a hospice provider . (1) This finding was reviewed with the administrator and director of nursing during a meeting on 3/8/23 at 4:20 p.m. (1) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, Centers for Medicare & Medicaid Services, Revised October 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to develop a comprehensive care plan for one of fifteen residents in the survey sample (Resident #25). The findings include: Resident #25, treated with a hypnotic medication for insomnia, had no plan of care developed addressing sleep problems. Resident #25 was admitted to the facility with diagnoses that included hypothyroidism, insomnia, osteoarthritis, hyperlipidemia, depressed mood, and atrial fibrillation. The minimum data set (MDS) dated [DATE] assessed Resident #25 as cognitively intact. Resident #25's clinical record documented a physician's order dated 2/14/22 for Ambien (zolpidem tartrate) 5 milligrams at each bedtime for insomnia. Resident #25's medication administration record documented nightly administration of the Ambien from 3/1/23 through 3/7/23. Resident #25's plan of care (dated 2/6/23) included no problems, goals and/or interventions regarding insomnia. On 3/8/23 at 4:47 p.m., the director of nursing (DON) was interviewed about a plan of care regarding Resident #25's insomnia treated with nightly Ambien. The DON stated she thought there should be a plan about insomnia since the resident was taking medication for sleep. The DON stated the MDS coordinator was responsible for care plan development. On 3/8/23 at 3:54 p.m., the registered nurse MDS coordinator (RN #2) was interviewed about a plan of care addressing Resident #25's sleeping difficulties. RN #2 stated that the plan listed the resident was prescribed a hypnotic. When asked for assistance in locating the documentation, RN #2 found nothing in the plan of care addressing the resident #25's insomnia/sleeping difficulties. This finding was reviewed with the administrator and director of nursing during meeting on 3/8/23 at 4:20 p.m.

Based on staff interview, clinical record review, and facility policy review, the facility staff failed to ensure professional standards of nursing were followed for one of 15 residents, Resident #4. Findings include: Resident # 4 was admitted to the facility 2/7/23 with diagnoses to include, but were not limited to: orthopedic aftercare, heart failure, and diabetes. The admission MDS (minimum data set) dated 2/13/23 had Resident # 4 assessed as cognitively intact with a score of 13/15. On 3/9/23 at 8:20 a.m., accompanied by licensed practical nurse (LPN) #2, a medication cart on the second floor was inspected. An opened 10 ml (milliliter) vial of Lantus insulin (100 units/ml) was stored in the cart. The vial was marked with an opened date of 2/8/23 and was labeled for a current resident (Resident #4). LPN # 2 stated the insulin should have been discarded 3/7/23. On 3/9/23 at approximately 10:05 a.m., the DON (director of nursing) was made aware of the finding. When asked if it was known if the expired insulin had been administered, the DON stated that she would check. The DON returned a few minutes later and stated Yes, the insulin was administered last night. A copy of the facility policy for medication administration and medication labeling/storage was then requested. On 3/9/23 at approximately 10:25 a.m., the blood sugars for Resident # 4 was reviewed. The blood sugars did not reveal any issues as far as adequate coverage; on 3/8/23 at 10:00 p.m. when the insulin was administered, the blood sugar reading was recorded as 382 mg/dl. At 8:00 a.m. on 3/9/23 the blood sugar was recorded as 204 mg/dl. The resident did not appear to have any negative effect from receiving the expired insulin. On 3/9/23 at approximately 10:40 a.m., the DON stated there was no policy specific to medication administration to include expired medications. She further stated The expectation is that staff is to call the pharmacy at least three (3) days prior to expiration and reorder the medication. If the order has not been received by the time the medication expires, they are to check the cubex (a medication dispenser) or the insulin stat box and pull from there. The open date is put on the label, staff should look at that date and ensure the medication is not expired prior to administration. The facility policy Storage of Drugs directed 13. Drugs shall not be kept on hand after the expiration date on the label . The administrator and DON were informed of the above findings during a meeting with facility staff at 10:45 a.m. 3/9/23. No further information was provided prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to follow physician orders for one of 15 residents, Resident #4. Findings include: Resident # 4 was admitted to the facility on [DATE], with diagnoses to include, but were not limited to: orthopedic aftercare, heart failure, and diabetes. The admission MDS (minimum data set) dated 2/13/23 had Resident # 4 assessed as cognitively intact with a score of 13/15. On 3/8/23 at approximately 1:45 p.m., Resident #4's clinical record was reviewed. A nurses note, dated 2/23/23 at 3:45 a.m., documented Insulin Glargine -Inject 20 units at bedtime for Diabetes Mellitus type 2. Held per nursing judgement. Res noted to not have much of an appetite and refused bedtime snack with BS of 118. On 3/8/23 at approximately 3:05 p.m., the administrator and DON (director of nursing) were asked if they were aware of the above note. The administrator stated that she was not and thought the expectation was to call the doctor prior to a held medication. When asked if the nurse who wrote the note was working, the Administrator stated that nurse was not scheduled to work until tonight, 11-7 shift. On 3/8/23 at approximately 3:15 p.m. during a conversation with LPN (licensed practical nurse) # 2, LPN # 1, identified as the nurse who had written the note, was at the medication cart. She stated she usually worked nights but came in to work the evening shift. LPN # 1 was interviewed about the held insulin. LPN # 1 stated I'm a travel nurse from another state, and we do not have to notify physicians for a nursing judgement; we usually have parameters ordered for when to call the physician, and then use our nursing judgement based on the physician ordered parameters. LPN # 1 was asked about parameters for Resident # 4. LPN # 1 stated, She [Resident #4] has sliding scale orders . the resident was a new admit and had no parameters for when to call the Dr, and since she had not eaten dinner and refused her bedtime snack, her blood sugar was 118 so I held it as had I given it, she would have bottomed out. I did not call the Dr; I did report on it at shift change. On 3/8/23 at approximately 4:20 p.m,. the administrator and DON presented a copy of the education provided to LPN # 1. The education Medication Holds included Nurses are to follow doctors orders for medication administration. If nurse has a concern about medication dosage, holding, resident refusal; nurse must notify doctor for further orders/clarification. This includes insulin orders that are within normal parameters. The administrator further stated that LPN # 1 had been educated immediately, and all nursing staff would be educated for the plan of correction. The end of the day meeting was also held at that time with the administrator and DON. No further information was provided prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, and staff interview, the facility staff failed for one of 15 residents in the survey sample (Resident # 2) to provide pressure ulcer treatment consistent with professional standards of practice. Staff failed to properly clean work surfaces, as well as employ handwashing during a dressing change. The findings were: Resident # 2 in the survey sample was admitted with diagnoses that included epilepsy, anemia, gastroesophageal reflux disease, thyroid disorder, seizure disorder, cataracts, Stage IV sacral pressure ulcer, constipation, dysuria, erythemia intertrigo, pain, urinary retention. Resident #2 was also admitted under palliative care. According to an admission Minimum Data Set with an Assessment Reference Date of 2/15/2023, Resident #2 was assessed under Section C (Cognitive Patterns) as having short and long term memory problems, with severely impaired daily decision making skills. Under Section G (Functional Status), Resident #2 was assessed as totally dependent with one person physical assist for bathing; as needing extensive assistance with two persons physical assist for dressing; as needing extensive assistance with one person physical assist for eating and person hygiene; as transferring and having locomotion on and off the nursing unit with two persons physical assist only once or twice; and, as not walking in the room or unit corridor. Resident # 2 had the following physician's order for wound care: Clean sacral wound with Dakin's or Vashe solution everyday, gently fill wound bed and pack any cavities with Aquacel Ag, then cover with gauze and Allevyn type dressing everyday until healed (measure/document every Wednesday). At approximately 10:30 a.m. on 3/8/2023, LPN # 4 (Licensed Practical Nurse) was observed performing a dressing change to Resident # 2's sacral pressure ulcer. Without cleaning or sanitizing the surface, LPN # 4 placed the dressing change supplies directly on the resident's overbed table. (NOTE: Disinfection and Sterilization .Surface areas to treat. All dirty surfaces and areas must be fully exposed to disinfecting and sterilizing agents. Noncritical items must be disinfected. Some of these items include .Bedside trays and client furniture. Ref. Fundamentals of Nursing, 7th Edition, 2009, [NAME]-[NAME], Chapter 34, pages 658 - 659.) With gloves on, LPN # 4 assisted the resident to turn in bed and then pulled back the resident's incontinence brief. The resident was soiled with bowel movement, which LPN # 4 cleaned using wet washcloths. LPN # 4 removed her gloves, reached in to the supply bag and retrieved a hand sanitizer wipe (towelette) which she then used to wipe her hands. After putting on clean gloves, LPN # 4 removed the soiled pressure ulcer dressing from Resident # 2's sacrum. Upon observation, Resident # 2's sacral pressure ulcer appeared to be clean, and without signs of infection. The wound was approximately two inches in length and one inch wide. There was dark colored slough (necrotic - nonviable tissue) on approximately 25% of the wound bed. LPN # 4 then took off her right glove, retrieved a bottle of Dakin's solution, a tube of Santyl ointment, dressings/gauze, from the supply bag and placed them on the overbed table. LPN # 4 then removed her left glove and put on another pair of gloves. Using a template and a cotton tipped applicator, LPN # 4 measured the size and depth of Resident # 2's pressure ulcer. After removing the template, LPN # 4 removed her gloves and put on another pair of clean gloves. LPN # 4 then obtained a clean pad from the resident's closet, placed it under the resident, cleansed the pressure ulcer with Dakin's solution/gauze, applied Santyl ointment, packed Aquacel gauze into the wound, and then covered the ulcer with a foam border dressing. LPN # 4 then repositioned Resident #2 before removing and discarding her gloves. She then put the dressings/treatments back into the supply bag, discarded the soiled items, and washed her hands prior to leaving the room. The Progress Notes in Resident # 2's Electronic Health Record included the following entry: 3/8/2023 - Sacral wound measures 5cm (centimeters) x (by) 2.5cm x 1.25cm. Tunneling at 12 o'clock measures 2.1cm, has moderate amount of serosanguinous drainage present at this time. Epibole on 9 - 6 o'clock edge. Wound has 75% granulation tissue, 25% slough present. At approximately 10:55 a.m. on 3/8/2023, LPN # 4 was interviewed regarding the dressing change on Resident # 2's sacral pressure ulcer. Asked about placing the supplies on the overbed table without cleaning it first, LPN # 4 stated the supplies were in a plastic bag. Regarding hand hygiene during the dressing change, LPN # 4 said that she should have washed her hands after cleaning the bowel movement, instead of using a sanitizer wipe (towelette). When asked about handwashing, LPN # 4 said that she usually performed hand hygiene between glove changes. The findings during the dressing change observation were discussed at meeting at 4:00 p.m. on 3/8/2023 that included the Administrator, Director of Nursing, and survey team.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, facility document review, and staff interview, the facility staff failed to ensure expired insulin was not available for use on one of two inspected medication carts (second-floor cart). The findings include: A vial of Lantus insulin for a current resident that had been opened beyond 28 days was available for use on a second-floor medication cart. On [DATE] at 8:20 a.m., accompanied by licensed practical nurse (LPN) #2, a medication cart on the second floor was inspected. An opened 10 ml (milliliter) vial of Lantus insulin (100 units/ml) was stored in the cart. The vial was marked with an opened date of [DATE] and was labeled for a current resident (Resident #4). On [DATE] at 8:22 a.m., LPN #2 was interviewed about the opened vial of Lantus and the discard date. LPN #2 stated that the insulin was supposed to be discarded 28 days after opening. LPN #2 stated that the Lantus insulin in the cart was actually past the date for use. LPN #2 stated that the opened vial of Lantus insulin should have been discarded after [DATE]. On [DATE] at 8:36 a.m., the director of nursing (DON) was interviewed about storage time of opened insulin. The DON stated all insulins were to be discarded 28 days after opening. On [DATE] at 9:13 a.m., the DON stated the opened vial of Lantus insulin found in the medication cart should have been discarded on [DATE]. The DON stated nurses were supposed to check and discard any out-of-date insulin prior to their expiration. The DON stated medication expiration dates were posted on a chart in the medication room for reference by nurses as needed. The posting titled Medication Expiration Dates (undated) documented insulin of all types expired 28 days after opening. This protocol documented, .Medications will be discarded according to date open expiration date or according to the manufacturer expiration date, whichever comes first . The facility's policy titled Storage of Drugs (revised [DATE]) documented, .Drugs shall not be kept on hand after the expiration date on the label, and no contaminated or deteriorated drugs shall be available . The Nursing 2022 Drug Handbook on page 790 describes Lantus insulin as a long-acting antidiabetic agent used for the treatment of diabetes. Page 791 of this reference documents regarding administration precautions, .opened vial in use can be kept unrefrigerated for up to 28 days .Opened vials, whether or not refrigerated, must be used within a 28-day period or they must be discarded . (1) This finding was reviewed with the administrator and director of nursing on [DATE] at 10:45 a.m. (1) Woods, [NAME] Dabrow. Nursing 2022 Drug Handbook. Philadelphia: Wolters Kluwer, 2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interview, and review of facility policy and procedure, the facility staff failed for one of 15 residents in the survey sample (Resident # 2) to follow infection control practices during a pressure ulcer dressing change. The staff member performing the dressing change failed to establish a clean surface for supplies, and failed to perform hand hygiene during glove changes. The findings were: Resident # 2 in the survey sample was admitted with diagnoses that included epilepsy, anemia, gastroesophageal reflux disease, thyroid disorder, seizure disorder, cataracts, Stage IV sacral pressure ulcer, constipation, dysuria, erythemia intertrigo, pain, urinary retention. The resident #2 was also admitted under palliative care. According to an admission Minimum Data Set with an Assessment Reference Date of 2/15/2023, Resident #2 was assessed under Section C (Cognitive Patterns) as having short and long term memory problems with severely impaired daily decision making skills. Under Section G (Functional Status), the resident was assessed as totally dependent with one person physical assist for bathing; as needing extensive assistance with two persons physical assist for dressing; as needing extensive assistance with one person physical assist for eating and person hygiene; as transferring and having locomotion on and off the nursing unit with two persons physical assist only once or twice; and, as not walking in the room or unit corridor. Resident # 2 had the following physician's order for wound care: Clean sacral wound with Dakin's or Vashe solution everyday, gently fill wound bed and pack any cavities with Aquacel Ag, then cover with gauze and Allevyn type dressing everyday until healed (measure/document every Wednesday). At approximately 10:30 a.m. on 3/8/2023, LPN # 4 (Licensed Practical Nurse) was observed performing a dressing change to Resident # 2's sacral pressure ulcer. Without cleaning or sanitizing the surface, LPN # 4 placed the dressing change supplies directly on the resident's overbed table. (NOTE: Disinfection and Sterilization .Surface areas to treat. All dirty surfaces and areas must be fully exposed to disinfecting and sterilizing agents. Noncritical items must be disinfected. Some of these items include .Bedside trays and client furniture. Ref. Fundamentals of Nursing, 7th Edition, 2009, [NAME]-[NAME], Chapter 34, pages 658 - 659.) With gloves on, LPN # 4 assisted the resident to turn in bed and then pulled back the resident's incontinence brief. The resident was soiled with bowel movement, which LPN # 4 cleaned using wet washcloths. LPN # 4 removed her gloves, reached in to the supply bag and retrieved a hand sanitizer wipe (towelette) which she then used to wipe her hands. After putting on clean gloves, LPN # 4 removed to soiled pressure ulcer dressing from Resident # 2's sacrum. LPN # 4 then took off her right glove, retrieved a bottle of Dakin's solution, a tube of Santyl ointment, dressings/gauze, from the supply bag and placed them on the overbed table. LPN # 4 remove her left glove and put on another pair of gloves. Using a template and a cotton tipped applicator, LPN # 4 measured the size and depth of Resident # 2's pressure ulcer. After removing the template, LPN # 4 removed her gloves and put on another pair of clean gloves. LPN # 4 then obtained a clean pad from the resident's closet, placed it under the resident, cleansed the pressure ulcer with Dakin's solution/gauze, applied Santyl ointment, packed Aquacel gauze into the wound and then covered the ulcer with a foam border dressing. LPN # 4 then repositioned the resident before removing and discarding her gloves. She then put the dressings/treatments into the supply bag, discarded the soiled items, and washed her hands prior to leaving the room. At approximately 10:55 a.m. on 3/8/2023, LPN # 4 was interviewed regarding the dressing change on Resident # 2's sacral pressure ulcer. Asked about placing the supplies on the overbed table without cleaning it first, LPN # 4 stated the supplies were in a plastic bag. Regarding hand hygiene during the dressing change, LPN # 4 said she should have washed her hands after cleaning the bowel movement instead of using a sanitizer wipe (towelette). When asked about handwashing, LPN # 4 said she usually performed hand hygiene between glove changes. (NOTE: Applying Dry and Moist Dressings: Step 1. Perform hand hygiene Step 13. Fold dressing with drainage inside, and remove gloves inside out. With small dressings, remove gloves inside out over dressing. Dispose of gloves and soiled dressings in disposable bag. Perform hand hygiene. Ref. Fundamentals of Nursing, 7th Edition, 2009, [NAME]-[NAME], Chapter 48, pages 1314 - 1315.) At approximately 8:30 a.m. on 3/9/2023, RN # 5 (Registered Nurse), the Infection Preventionist, was interviewed regarding the dressing change on Resident # 2. RN # 5 said handwashing after cleaning the resident's bowel movement would have been the preferred method of hand cleaning instead of using a sanitizer wipe. RN # 5 also said the overbed table should have been cleaned/sanitized prior to the placement of dressing change supplies, and that infection control protocols require the use of hand sanitizer or hand washing between glove changes. The facility furnished the following policies for review: Hand Washing: .Hand hygiene (using soap and water or alcohol based hand rub) should be performed .Before touching a resident .After touching a resident .After touching a resident('s) surroundings .Hand washing should be performed .Before and after all clean or aseptic techniques/procedures (i.e., before and after changing wound dressing or bandages .After bodily fluid exposure .Before and after removing gloves. Wearing gloves alone is not enough to prevent the spread of infection .When you hands look dirty Hand Rub (Antiseptic): Alcohol based hand sanitizers can quickly reduce the number of germs on hands in some situations, but sanitizers do not eliminate all types of germs. NOTE: HAND(S) SHOULD BE WASHED WITH SOAP AND WATER AFTER DIRECT CONTACT, EXAMPLE .positioning resident with direct contact, dressing changes, etc The findings regarding hand hygiene were discussed at meeting at 4:00 p.m. on 3/8/2023 that included the Administrator, Director of Nursing, and survey team.

Based on observation, facility document review and staff interview, the facility staff failed to ensure proper function of one of two walk-in freezers serving the main kitchen. The findings include: The walk-in freezer in the main kitchen was observed with heavy ice build-up across the ceiling and on the floor with frozen drips noted on the outside of food packaging. Staff reported this frozen condensation build-up had been ongoing for over five months. On 3/7/23 at 11:13 a.m., accompanied by a dining manager (other staff #2) and the registered dietitian (other staff #3), the walk-in freezer in the main kitchen was inspected. Thick, frozen condensation was observed across the entire ceiling. The left ceiling area had heavier ice build-up several inches thick. Dripped condensation was frozen on boxes of food stored on the top shelf of the freezer. Ice approximately one inch thick was observed across the floor of the freezer. On 3/7/23 at 11:20 a.m., the sous chef (other staff #1) was interviewed about the widespread ice build-up on the freezer ceiling and floor. The sous chef stated, That's in work order status. The sous chef stated that there was humidity and when the freezer went into defrost mode, condensation remained frozen, dripped from the ceiling, and resulted in ice accumulation. The sous chef stated a work order was written sometime last year about the ice build-up. The sous chef stated that maintenance worked on the freezer once, but the condition was not repaired. The sous chef stated staff members scraped the ice down occasionally, but the ice accumulated again with time. The sous chef stated packaging protected food from any drips and freezer temperatures had not deteriorated due to the ice. On 3/7/23 at 12:14 p.m., the dining service manager (other staff #4) was interviewed about the ice build-up in the walk-in freezer. The dining service manager stated, That's been back and forth. Right now, it is worse than usual. On 3/7/23 at 4:30 p.m., the facilities director (other staff #5) was interviewed about the ice build-up in the main kitchen's freezer. The facilities director stated that a work order was entered on 9/8/22 regarding the ice/condensation build-up. The facilities director stated that the door and gasket were repaired and he was not aware the ice build-up was not fixed. The facilities director stated that there were no further work orders entered since 9/8/22 to address the continued problems with the freezer. The facilities director presented a copy of work order #90931 dated 9/8/22. This work order documented, . Appliance not working properly .I went to check the freezer and it was frozen up on the coil in the back .had some frost at the top front of the freezer and the door . The work order was marked completed on 9/19/22. This finding was reviewed with the administrator and director of nursing during a meeting on 3/8/23 at 4:20 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and clinical record review, the facility staff failed to review and revise a comprehensive care plan for 1 of 10 in the survey sample, Resident #14. Resident #14's care plan was not reviewed and revised for the discontinuation of psychotropic medication. The findings include: Resident #14 was admitted to the facility on [DATE] with diagnoses that included hyperlipidemia, hypothyroidism, major depressive disorder, dementia with behavioral disturbance, osteoarthritis, chronic obstructive pulmonary disease (COPD), and edema. The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #14 as severely impaired for daily decision making with a score of 7 out of 15. Resident #14's clinical record was reviewed on 06/02/2021. Observed within the progress notes was a Monthly Medication Review dated 05/12/2021 which documented the following: 5/12 d/c (discontinue) am (morning) dose of risperidone and taper down 2pm dose to 0.25 mg (milligrams): gdr (gradual dose reduction) done Observed on Resident #14's care plan was the following: Focus: The resident can be verbally aggressive towards staff r/t (related to) dementia, paranoia, and delusions. Date Initiated: 02/02/2021. Revision on: 02/02/2021. Goal: The resident will demonstrate effective coping skills through the review date. Revision on: 05/18/2021. Target Date: 08/18/2021. Interventions: Administer Risperidone for dementia with behavior disturbance, agitation, and increased confusion per MD (medical director) orders: see MAR (medication administration record) for specific dosage and medication information. Monitor effectiveness and adverse reactions. Notify MD. See also cognition and psychotropic care plans. Revision: 02/17/2021. Monitor behavior and mood: taper risperidone per MD order. Date Initiated 05/17/2021 . A review of Resident #14's physician orders for May 2021 documented the Risperidone was tapered as ordered and ended with the following order: risperiDONE Solution 1 MG/ML Give 0.25 ml by mouth one time a day for behavior disturbance for 7 administrations. Order Date: 05/21/2021. Start Date 05/21/2021. End Date 05/28/2021 . A review of Resident #14's current physician's order summary did not document any active orders for Risperidone. On 06/03/21 at 3:00 p.m. the above findings were reviewed with the administrator and director of nursing. They were asked when should the care plans have been reviewed and revised to reflect the discontinuation of the medication. The administrator stated she would refer this question to [RN #1) who routinely worked with the care plans. 06/03/21 at 3:19 p.m. RN #1 was interviewed regarding the care plan revision to reflect the discontinuation of the Risperidone. RN #1 stated the care plan should have been updated at the time the order was received to taper the medication and when the medication was discontinued the care plan should have been reviewed and revised again because the medication order was complete and discontinued. RN #1 was asked who was responsible for the care plan revision. RN #1 stated the nurse receiving the order and the nurse manager, however it was a group effort with nursing to make sure care plans were updated. No additional information was provided to the survey time prior to exit on 06/03/2021.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #4 was admitted to the facility on [DATE] with diagnoses that included hypercholesterolemia, Alzheimer's dementia, anxiety, depression, and encounters for hospice care. The minimum data set (MDS) dated [DATE] which was a quarterly assessment, assessed Resident #4 as severely cognitively impaired for daily decision making, having long and short term memory problems. On 7/17/19 at 7:30 a.m., Resident #4 was observed sleeping in bed with the bed in a low position and with a fall mat observed beside the bed. Resident #4's electronic medical record was reviewed on 07/17/19 at 7:55 a.m. A progress note dated 4/8/19 documented the following: .Fall interventions are in place: low bed, Dycem pads in WC (wheelchair), and bedside fall mat . A review of the resident's printed care plans did not document the use of the fall mat. On 07/17/19 at 3:45 p.m., the unit manager (RN#1) was interviewed about the Resident #4's care plan. RN #1 reviewed the care plan and stated the fall mat should have been included on the care plan and it must have been overlooked. These findings were reviewed with the administrator and director of nursing on 7/17/19 at 4:30 p.m. Based on observation, staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan for two of 14 residents in the survey sample. Resident #110's care plan was not revised to include the resident's use of a bariatric bed/mattress, recent falls and interventions regarding a significant weight loss. Resident #4's care plan was not revised to include use of a fall mat for fall/injury prevention. The findings include: 1. Resident #110 was admitted to the facility on [DATE] with diagnoses that included heart failure, diabetes, COPD (chronic obstructive pulmonary disease), chronic kidney disease, anemia, atrial fibrillation, lymphedema and constipation. A nursing assessment dated [DATE] assessed Resident #110 with moderately impaired cognitive skills. On 7/16/19 at 12:04 p.m., Resident #110 was observed in bed. A bariatric low air loss mattress was in use on a specialty bed frame. Resident #110 was observed again on 7/16/19 at 3:30 p.m. and on 7/17/19 at 7:38 a.m. and 8:20 a.m. in bed with the bariatric mattress/bed in use. A nursing note dated 7/6/19 documented, .CNA [certified nurses' aide] entered resident's room to provide resident care & observed resident lying on floor .resident lying on floor with top half of her body lying under her bed .Writer attempted to move LLE [left lower extremity] and resident screamed out in pain .resident transferred to [hospital] . A nursing note dated 7/15/19 documented the resident was found in the floor next to her recliner. This note stated, Writer was called to res' [resident's] room .resident lying in fetal position on her R [right] side with her head beside the AC [air conditioning] unit. Her recliner was all the way up in the 'lift' position .no visible injury . The clinical record documented the resident had a significant weight loss (> 10% in 6 months) as of 7/1/19. The resident weighed 203.2 lbs. (pounds) on 1/1/19 and weighed 179.2 lbs. on 7/1/19 indicating an 11.2% weight loss in six months. The resident's weight on 7/15/19 was 168.6 lbs. indicating a 5.9% weight loss since 7/1/19. Resident #110's plan of care (revised 7/15/19) made no mention the resident used a bariatric mattress system or a specialty bed. The care plan listed the resident was at risk of falls due to disease processes, weakness, debility, medication side effects, impaired cognition and limited range of motion but made no reference to the falls occurring on 7/6/19 and 7/15/19. This plan of care listed the resident had nutritional risks due to a history of impaired skin integrity, disease process, diabetes and use of diuretic but made no mention the resident had experienced a significant weight loss. The nutritional care plan interventions had not been revised since November 2018. On 7/17/19 at 10:36 a.m., the registered nurse unit manager (RN #1) was interviewed about updates to Resident #110's plan of care regarding the specialty mattress. RN #1 stated the bariatric mattress was used for pressure relief and prevention of skin breakdown. RN #1 stated the bariatric mattress and specialty bed had been in use with the resident since shortly after her admission. RN #1 stated the resident was bigger when first admitted and had lost weight during her stay. RN #1 stated adding the use of the specialty mattress to the care plan may have been overlooked. On 7/17/19 at 3:50 p.m., the MDS coordinator (RN #2) was interviewed about Resident #110's plan of care. RN #2 stated Resident #110's last care plan meeting was held on 5/22/19 and the specialty bed/mattress had not been discussed or added to the care plan. RN #2 stated a fall mat was added to the care plan on 7/8/19 but the plan did not indicate the resident fell on 7/6/19 or 7/15/19. RN #2 stated the resident's nutritional status was discussed but nothing had been added to the care plan about an actual weight loss. On 7/17/19 at 2:50 p.m., the facility's registered dietitian (RD) was interviewed about any care plan interventions regarding the resident's weight loss. The RD stated she had not performed an additional nutritional assessment since 7/1/19 and was not sure why the significant weight loss was not added and/or addressed in the care plan. These findings were reviewed with the administrator and director of nursing during a meeting on 7/17/19 at 4:20 p.m. and on 7/18/19 at 10:25 a.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, the facility staff failed to assess and implement interventions for significant weight loss for one of 14 residents in the survey sample. Resident #110, assessed with significant weight loss, went 15 days without reassessment of her nutritional status or dietary interventions to prevent further loss. The findings include: Resident #110 was admitted to the facility on [DATE] with diagnoses that included heart failure, diabetes, COPD (chronic obstructive pulmonary disease), chronic kidney disease, anemia, atrial fibrillation, lymphedema and constipation. A nursing assessment dated [DATE] assessed Resident #110 with moderately impaired cognitive skills. This assessment documented the resident required supervision by one person for eating. Resident #110's clinical record documented the resident's body weight on 1/1/19 as 203.2 lbs. (pounds). The resident weighed 179.2 lbs. on 7/1/19 indicating a significant weight loss of 24 lbs. (11.8%) in six months. On 7/15/19, the resident weighed 168.6 lbs. indicating a 10.6 lbs. weight loss (5.9%) in the 15 days since 7/1/19. Resident #110's clinical record documented a physician's order dated 8/22/18 for a regular diet along with a daily multivitamin. An order dated 4/9/19 required one scoop of protein powder with each meal for wound healing. The resident was prescribed daily weight monitoring due to congestive heart failure and daily use of a diuretic. Resident #110's plan of care (revised 7/15/19) listed the resident had nutritional risks due to a need for increased protein, history of impaired skin integrity, disease processes, diabetes, heart failure and diuretic use. Interventions listed to maintain resident's weight between 193 lbs. and 206 lbs. included, multivitamins as ordered, no alcohol use, monitor/report signs of dysphagia, monitor/record/report signs of malnutrition including significant weight loss (defined as loss of 3 lbs. in one week, greater than 5% in one month or greater than 10% in six months), obtain/monitor lab/diagnostic testing, serve diet as ordered including protein powder with meals and supplements per RD (registered dietitian). The resident's plan of care was not revised to indicate the resident's significant weight loss occurring on 7/1/19. There were no dietary interventions implemented in response to the significant weight loss occurring on 7/1/19 and no reassessment of the resident's nutritional status by the facility's RD. The last RD note in the resident's clinical record was dated 10/10/18. The resident's last care plan meeting dated 5/22/19 documented the resident was at high risk for nutritional issues and had unintended weight loss related to diuretic use and varied oral intake. No new interventions were listed to prevent further weight loss. On 7/17/19 at 2:53 p.m., the facility's RD was interviewed about Resident #110's weight loss identified on 7/1/19. The RD stated Resident #110 had been sick in May 2019 with decreased appetite and intake. The RD stated the resident reported she did not feel like eating and declined any supplements other than the protein powder. The RD stated the resident at one time had meal intake of 50% to 75% and now ate from 25% to 50% of her meals. When asked about any other options to maintain the resident's weight goals, the RD stated she knew of no other current interventions. When asked about snacks or other food items, the RD stated the resident's daughter was involved in the resident's food choices. The RD stated she had performed no recent reassessment of Resident #110's nutritional status. The RD stated she normally reassessed residents when a significant weight loss occurred and she was not sure why she had not reassessed Resident #110. The RD stated she participated in weekly weight meetings to review residents with weight loss. The RD stated Resident #110 was on the weight meeting list because she was taking a daily diuretic. The RD stated Resident #110 had not been discussed regarding significant weight loss. The RD did not know why there were no nutrition notes about Resident #110 since October 2018. The facility's policy titled Nutrition Alert Committee (revised 1/19) documented, .The following criteria is used to determine if a resident qualifies for Nutrition Alert .Experienced a significant weight loss/gain - 2% in one week, 5% in one month, 7.5% in 3 months, or 10% in 6 months .Significant change in appetite and/or decrease in usual oral intake in last 7 days .The dietitian provides a list of residents to be discussed at the meeting to all committee members .the following factors may be used to evaluate and determine care for the resident .diet order be modified and/or liberalized to better meet needs .Therapy be requested for screening .supplements and/or fortified foods be introduced, changed or discontinued .dining program be altered .comprehensive nutritional assessment be completed to reassess needs .nutrition-related laboratory values be ordered and assessed .Care plans are updated accordingly . These findings were reviewed with the administrator and director of nursing during a meeting on 7/18/19 at 10:35 a.m.

Based on observation, staff interview, and facility document review, the facility staff failed to ensure expired medications were not available for administration in one of one medication rooms: Healthcare 2. Three bottles of Lorazepam (an antianxiety medication) were observed without an open date in the medication room refrigerator. Findings include: On 7/16/19 at 2:30 p.m. the medication room on HC 2 (Healthcare 2) was inspected with RN (registered nurse) # 1. Three bottles of Lorazepam were located in the narcotic box affixed in the medication refrigerator without an open date. RN # 1 was asked about the bottles, and she stated They should be dated when they are opened. We can look at the authorization code to attempt to find out when that was . RN # 1 was then asked if there was policy for the storage and labeling of medications, and she stated the DON (director of nursing) would have the policy. On 7/16/19 at 2:40 p.m. the DON was asked for the policy for storage and labeling medications. A few minutes after the request, a pharmacy representative, who had made a delivery to the facility, was interviewed. The pharmacy representative (rep) stated she was aware of the issues with the three bottles of Lorazepam stating The Lorazepam sent to the facility has been filled from a large bottle of medication; the facility needs the medication in a small bottle that has the amounts on it; they don't have any smaller bottles to send so the pharmacist fills the smaller bottles from the large bottle. I am not sure when the large bottle was opened, but we can call the pharmacy if you want. The pharmacy rep then called the pharmacy and explained the issue. On 7/16/19 at 3:00 p.m. the pharmacist, identified as OS (other staff) # 5 was interviewed. OS # 5 stated We incorrectly dated the bottle here in the pharmacy; we should have dated it at the time opened, April 9th, 2019, 90 days out, and it was dated out a year. OS # 5 was asked if that information was communicated to the facility staff, and he stated No; but we will have to figure out how we are going to do that. The facility should use the same open date as we have on the bottle here at the pharmacy, but you're right; they don't know that . On 7/17/19 at 7:45 a.m. the DON stated I have a list of the medications that have a shorter expiration date per manufacturer's recommendations, but Lorazepam is not on that list, and never has been. The way it has been sent from the pharmacy, staff here have no idea when the medication was opened, so have no idea when the expiration date is. I had a long discussion with pharmacy last night, and they are going to have to figure out how they are going to communicate those dates to us. The above findings were discussed during an end of the day meeting with the administrator and DON 7/17/19 beginning at 4:30 p.m. No further information was provided prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and staff interview, the facility failed to complete minimum data set (MDS) entry and comprehensive assessments for 6 of 14 residents in the survey sample. This included Resident #109, Resident #110, Resident #112, Resident #113, Resident #208, and Resident #209. Findings include: Residents #109, #110, #112, #113, #208 and #209 were changed from a non-certified bed to a dually certified bed on 07/01/19. There was not an entry and comprehensive MDS assessment completed to reflect the change to the participating bed status. Resident #109 was admitted to the facility on [DATE] with diagnoses that included hypertension, dementia, osteoarthritis, and depression. Resident #110 was admitted to the facility on [DATE] with diagnoses that included constipation, heart failure, type 2 diabetes, chronic obstructive pulmonary disease (COPD), chronic kidney disease stage 4, and hyperlipidemia. Resident #112 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE]. Diagnoses included hypertension, hyperlipidemia, anxiety, bi-polar disorder, gastro-esophageal reflux disease (GERD), and hypothyroidism. Resident #113 was admitted to the facility on [DATE] with diagnoses that included hypertension, Parkinson's disease, anxiety, depression, and quadriplegia. Resident #208 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE]. Diagnoses included hypertension, heart failure, osteoarthritis, hypertension, and gastro-esophageal reflux disease (GERD). Resident #208 was admitted to the facility on [DATE] with diagnoses that included anemia, hypertension, heart failure, orthopedic aftercare (right femur) and urine retention. On 07/17/19 at 7:30 a.m., the MDS coordinator (RN #2) was interviewed regarding the completion of the MDS assessments for residents who were transferred from non-certified beds to dually certified beds effective 07/01/19. RN #1 stated those residents who were in the non-certified beds were just left on the same assessment schedule. RN #1 stated the MDS assessments were completed but not submitted. RN #1 stated she reviewed the RAI (Resident Assessment Instrument) manual, however she did not see any instructions that addressed the facility's situation of changing non-participating beds to a participating bed. RN #1 was asked if there were any entry and comprehensive assessments completed on those residents who were now in certified beds. RN #1 stated no. These findings were reviewed with the administrator and director of nursing on 7/17/19 at 4:30 p.m. No additional information was provided to the survey team prior to the exit on 07/18/19 at 12:00 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to follow physician orders for two of 14 residents in the survey sample: Resident # 161 and # 110. 1. The facility staff failed to obtain and notify the physician of weight gain for Resident # 161 per order. 2. The facility staff failed to obtain and notify the physician of daily weights for Resident # 110. Findings include: 1. Resident # 161 was admitted to the facility 1/9/19 with a readmission date of 7/8/19. Diagnoses for Resident # 161 included, but were not limited to: congestive heart failure, anxiety disorder, and insomnia. The most recent MDS (minimum data set) was the admission assessment dated [DATE] and had the resident coded with moderate impairment in cognition with a total summary score of 10 out of 15. The clinical record was reviewed 7/17/19 beginning at 2:00 p.m. The current POS (physician order summary) included an order with a start date of 7/9/19 to Weigh every day before breakfast; notify MD if 2 pound weight gain in 1 day, or 5 pound gain in 1 week. The weights were then reviewed, and revealed the following: 7/9/19-181.2 7/10/19-180.2 7/11/19- 180.2 7/12/19- 182.6-(2 lbs/1 day) 7/13/19- no weight recorded 7/14/19- 183.7 7/15/19- 182.6 7/16/19- 181.8 7/17/19- 186.7 (5 lbs in 1 day). No information was located in the clinical record that the MD was notified of the 2 pound or the 5 pound weight gain, as per the prder. During an end of the day meeting on 7/17/19 at 4:30 p.m. with the administrator and DON (director of nursing), the DON was asked where documentation would be located of staff notification of the weights. The DON stated notification of weight gain should be in progress notes. The DON was then informed no notification could be located. She stated she would check with the unit manager for the documentation. On 7/18/19 there was no further information provided regarding notification to the physician prior to the exit conference.2. Resident #110 was admitted to the facility on [DATE] with diagnoses that included heart failure, diabetes, COPD (chronic obstructive pulmonary disease), chronic kidney disease, anemia, atrial fibrillation, lymphedema and constipation. A nursing assessment dated [DATE] assessed Resident #110 with moderately impaired cognitive skills. Resident #110's clinical record documented a physician's order dated 8/22/18 requiring a daily body weight before breakfast with notification to the physician of any gain of three or more pounds within a 3-day period. Resident #110's daily weights were reviewed from 7/1/19 through 7/15/19. There were no weights obtained on 7/4/19, 7/6/19, 7/7/19, 7/8/19 or 7/10/19. The resident weighed 171.6 lbs. (pounds) on 7/9/19 and 174.8 lbs. on 7/11/19 indicating a gain of 3.2 lbs. in two days. There was no notification to the physician of the weight gain. On 7/17/19 at 10:38 a.m., the registered nurse unit manager (RN #1) was interviewed about the missing weights and notification of weight gain. RN #1 stated the resident was supposed to be weighed each morning before breakfast. RN #1 stated if notifications were made to the physician, the notification would be in nursing notes. No further information was provided indicating notification to the physician concerning the 3.2 lb. weight gain on 7/11/19. These findings were reviewed with the administrator and director of nursing during a meeting on 7/17/19 at 4:20 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 7/17/19 at 4:00 p.m. during review of the facility's assessment for the water management program, it was noted the therapy hydrocollator was identified as a device requiring water temperature monitoring. On 7/18/19 at 8:00 a.m. the water temperatures from 1/1/19 through 7/18/19 were reviewed. Temperatures were not recorded daily, and ranged from 158 degrees Fahrenheit (F) to 170 degrees (F). From March 2019 through July 2019, temperatures, when recorded, were documented at 170 degrees F. The policy for the hydrocollator was then reviewed and documented 3.4. The temperature of the hydrocollator unit should be monitored per manufacturer guidelines, but no less than monthly .3.4.1. The hydrocollator temperature range should be checked for appropriate temperature range prior to application of moist heat to patients . The safety precautions for the unit was attached to the policy, and directed .The recommended temperature is 160 degrees F to 165 degrees F On 7/18/19 at 10:00 a.m. the therapy director, identified as OS (other staff) # 6, was interviewed. OS # 6 was asked how often the temperature should be recorded/taken, and what the range of the temperature should be. OS # 6 stated The machine was calibrated in February of this year; we were told the temperature should be maintained a little higher than recommended, but I have no documentation of that. We typically take the water temperature prior to the application of the heat pack to a resident. I did some research which indicated the water temperature should be at 170 degrees for bacteria control, but I realize we should be following the manufacturer recommendations and have put a sign over the unit that the temperature range should be maintained at 160-165 degrees F. We have not had any incidents; there are lots of towel layers between the patient skin and the hot pack. The administrator and DON were informed of the above findings 7/18/19 at 11:00 a.m. No further information was provided prior to the exit conference. Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to ensure a safe bed environment and implement safety interventions for one of 14 residents in the survey sample (Resident #110) and failed to ensure safe water temperatures in the therapy department hydrocollator. Resident #110 fell from a specialty bed equipped with a bariatric, low air loss mattress system. There was no physician's order or plan of care regarding use of the specialty mattress and no prior assessment for bed safety regarding the mattress and specialty bed. Resident #110 was observed in bed without a protective floor mat in place as required in her plan of care for injury prevention. The hydrocollator water temperature was checked and maintained above the manufacturer's recommendations. The findings include: 1a). Resident #110 was admitted to the facility on [DATE] with diagnoses that included heart failure, diabetes, COPD (chronic obstructive pulmonary disease), chronic kidney disease, anemia, atrial fibrillation, lymphedema and constipation. A nursing assessment dated [DATE] assessed Resident #110 with moderately impaired cognitive skills. This assessment listed the resident was totally dependent upon one person for transfers, required the extensive assistance of one person for bed mobility and had impaired mobility of both lower extremities. On 7/16/19 at 12:04 p.m., Resident #110 was observed in bed. A bariatric low air loss mattress was in use on a specialty bed frame. The bed was against the wall on one side. A half-length bed rail was installed near the head of the bed on the room side of the bed with the rail in the down position. Resident #110 was observed in bed again on 7/16/19 at 3:30 p.m. and on 7/17/19 at 7:38 a.m. and 8:20 a.m. with the bariatric mattress in use and the bed rail in the lowered position. Resident #110's clinical record documented a fall from the bed on 7/6/19. A nursing note dated 7/6/19 documented, .CNA [certified nurses' aide] entered resident's room to provide resident care & observed resident lying on floor .resident lying on floor with top half of her body lying under her bed .Writer attempted to move LLE [left lower extremity] and resident screamed out in pain .resident transferred to [hospital] . The emergency room report dated 7/6/19 documented, .Xray of the left hip shows an age indeterminate left superior pubic ramus fracture . Non-surgical treatment was recommended because the resident was not ambulatory and the resident returned to the nursing facility on 7/6/19. Resident #110's clinical record documented no physician's order for the bariatric mattress system or the specialty bed. Resident #110's plan of care (revised 7/15/19) made no mention the resident used a bariatric low air mattress system or a specialty bed. The care plan listed the resident was at risk of falls due to disease processes, weakness, debility, medication side effects, impaired cognition and limited range of motion. Interventions to prevent falls prior to 7/6/19 included call bell accessible, educate resident/family about safety reminders and what to do if a fall occurs, appropriate footwear, fall risk assessment, mechanical lift with 2 person assistance for all transfers, uncluttered environment and low bed position. A fall risk assessment dated [DATE] documented the resident was a moderate fall risk due to history of falls, non-ambulatory status, weakness and impaired mobility. There was no assessment regarding the resident's use and/or positioning with the bariatric mattress in combination with the specialty bed. On 7/17/19 at 10:38 a.m., the registered nurse unit manager (RN #1) was interviewed about the resident's fall and use of the bariatric mattress system without a prior assessment for safety. RN #1 stated the resident had been on the bariatric mattress since shortly after her admission in August 2018. RN #1 looked through the clinical record and did not locate the exact date of installation. RN #1 stated she thought the family might have requested the bed/mattress system. RN #1 stated the resident was bigger when admitted and had lost weight during her stay. RN #1 stated the bariatric mattress system was in use for pressure relief and pressure sore prevention. RN #1 stated the resident recently was weaker, leaned to one side at times and was unable to maintain her positioning. RN #1 stated the resident had become more and more dependent upon staff regarding mobility and care needs. When asked how Resident #110 fell from the bed on 7/619, RN #1 stated that she was not sure as the fall was not witnessed. RN #1 stated we concluded that she was possibly leaning and rolled out of the bed. RN #1 was not aware of any assessment regarding Resident #110's use of the bariatric mattress. RN #1 was not aware of any special instructions regarding installation of the bariatric mattress system. RN #1 stated the purchasing manager was responsible for installing the mattresses and bed inspections. On 7/17/19 at 11:45 a.m., the purchasing manager was interviewed about Resident #110's mattress/bed. The purchasing manager stated the facility checked beds/mattresses regarding safety issues and entrapment risks once per year and they spot-checked on occasion. The purchasing manager stated the operating manual for the mattress system used by Resident #110 documented the use of side rails to prevent falls. When asked why the mattress was in use without the use of side rails, the purchasing manager stated that was a suggestion and not a requirement. The bed/mattress checks were requested along with the operating manual for the bariatric mattress system used with Resident #110. On 7/17/19 at 2:15 p.m., the director of nursing (DON), maintenance supervisor and the assistant maintenance supervisor were interviewed about any assessment of Resident #110's specialty mattress/bed. The DON stated they previously checked beds for entrapment risks and safety hazards but the checks had not been performed in over a year. The DON presented a bed check sheet listing beds by room and identification number. The facility beds were last checked during 2017. There was one bed (in room [ROOM NUMBER]) checked in August 2018 but no other bed inspections during 2018. There was no record of any assessment of Resident #110's bariatric mattress system or specialty bed. The maintenance supervisor and assistant supervisor stated they were not trained on bed safety inspections and Resident #110's bariatric mattress/bed was not inspected. The DON, maintenance supervisor and assistant supervisor were not aware of the manufacturer's recommendations regarding installation of Resident #110's mattress system. The bariatric mattress system user's manual (model LS9000B dated 3/25/15) documented, This product is an advance alternating pressure relief replacement system suitable for high risk patients. This low air-loss system is intended to help and reduce the incidence of pressure ulcers while optimizing patient comfort. It is recommended for prevention and treatment of pressure ulcers . Under set up instructions the manual documented, It is recommended to use this mattress system with a bed frame with adequate side rails to prevent falling . The facility's policy titled Bed Inspection Policy (revised 1/18/18) documented, It is the policy .to conduct regular inspections of all bed frames, mattresses, and bed rails, as part of a regular maintenance program to identify areas of potential entrapment or other safety hazards. When bed rails and mattresses are purchased separately from the bed frame .will ensure that bed rails, mattresses, and bed frame are compatible .Before admission, prospective residents will be screened to help determine if care needs may necessitate specialized beds (e.g. bariatric equipment) or accessories .Upon admission, readmission or change of condition, resident will be screened to determine .If the bed meets manufacturers recommendations and specifications pertaining to resident height and weight .The interdisciplinary team will identify resident-specific bed adaptations and pertinent safety risks on the resident care plan . These findings were reviewed with the administrator and director of nursing during a meeting on 7/17/19 at 4:20 p.m. 1b). On 7/16/19 at 11:13 a.m., Resident #110 was observed in bed. There was a protective floor mat positioned at the end of the resident's bed. The over-bed table was positioned on top of the floor mat at the end of the bed. Resident #110's clinical record documented a fall from the bed on 7/6/19. A nursing note dated 7/6/19 documented, .CNA [certified nurses' aide] entered resident's room to provide resident care & observed resident lying on floor .resident lying on floor with top half of her body lying under her bed . Resident #110's plan of care (revised 7/15/19) documented the resident was at risk of falls due to disease processes, weakness, debility, medication side effects, impaired cognition and limited range of motion. Added to the care plan on 7/9/19 in response to the 7/6/19 fall was, Fall mat by bed at all times. On 7/17/19 at 1:53 p.m., the registered nurse unit manager (RN #1) was interviewed about Resident #110's floor mat. RN #1 stated the floor mat was supposed to be in place beside the bed. RN #1 stated positioning wedges and the fall mat were added to the resident's care plan after the fall on 7/6/19. This finding was reviewed with the administrator and director of nursing during a meeting on 7/17/19 at 4:20 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility document review and staff interview, the facility failed to conduct regular inspections of bed frames, mattresses and/or bed rails to identify possible entrapment/safety risks for 26 of 27 beds in the facility. The findings include: On 7/17/19 at 10:38 a.m., the registered nurse unit manager (RN #1) was interviewed about the facility's bed inspections regarding safety and entrapment risks. RN #1 stated the purchasing manager installed mattresses and performed bed/mattress/rail assessments in the facility. On 7/17/19 at 11:45 a.m., the purchasing manager was interviewed about the bed inspection program for the facility. The purchasing manager stated the facility checked beds/mattresses regarding safety issues and entrapment risks once per year and they spot-checked on occasion. The most recent bed/mattress/rail inspections were requested at this time. On 7/17/19 at 2:15 p.m., the director of nursing (DON), maintenance supervisor and the assistant maintenance supervisor were interviewed about the inspection program for beds, mattresses and bed rails in the facility. The DON stated they previously checked beds/mattresses/rails regarding entrapment risks and safety hazards but the checks had not been performed in over a year. The DON stated the previous quality assurance (QA) manager and previous maintenance director developed and implemented the bed/mattress/rail program. The DON stated that after the previous QA manager and maintenance director left, the checks were not completed. The DON presented a bed check sheet listing beds by room number and identification number. The facility beds were last checked in 2017. There was one bed/mattress in room [ROOM NUMBER] checked on 8/27/18. No other bed/mattress/rail assessments were performed in 2018. The maintenance supervisor and assistant supervisor stated they were not trained on bed safety inspections. The maintenance supervisor stated he was not familiar with the facility's bed inspection policy and was not aware of any assessments regarding any specialty mattresses/beds in use. The current maintenance director was not available for interview during the survey. The facility's policy titled Bed Inspection Policy (revised 1/18/18) documented, It is the policy .to conduct regular inspections of all bed frames, mattresses, and bed rails, as part of a regular maintenance program to identify areas of potential entrapment or other safety hazards. When bed rails and mattress are purchased separately from the bed frame .will ensure that bed rails, mattresses, and bed frame are compatible .The DON and Appropriate Maintenance Personnel (or qualified designees) cooperatively will be responsible for completion of bed inspections on a regular basis . These findings were reviewed with the administrator and director of nursing during a meeting on 7/17/19 at 4:20 p.m.