**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and clinical record review the facility staff failed to ensure 1 resident (Resident #35), in the survey sample of 34 Residents who was unable to carry out activities of daily living receives the necessary services to maintain toenail care. The findings included: Resident #35 was originally admitted to the facility on [DATE]. Diagnosis for Resident #35 included but not limited to other abnormalities of gait and mobility and Chronic Kidney Disease. The most recent Minimum Data Set (MDS) an annual with an Assessment Reference Date (ARD) of 12/04/21 coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 9 which indicated moderate cognitive impairment for daily decision-making. Resident #35 was coded to require limited assistance of one staff with personal hygiene. The Care Plan revealed the following: I have an ADL Self Care Performance Deficit r/t my cognition. Goal: I will maintain current level of function in my adls (Activities of Daily Living) through the review date. Interventions: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. During the initial tour on 1/26/2022 at approximately 10:29 AM., an interview was conducted with Resident #35. The surveyor asked the Resident if his toenails needed to be trimmed. He stated, Yes. The surveyor then asked the resident if she could see his feet. He stated, Yes. The Resident's nurse, LPN (Licensed Practical Nurse) #1 was asked to assist in removing the covers and socks from off of the Resident's feet. An observation of the resident's toenails on the right great toe revealed his toenails were long, thick and jagged. The toenails on the resident's left great toe appeared Jagged and long. His fourth toenail (on the left foot) appeared long and jagged and his second toenail appeared jagged (on the left foot). LPN #1 stated that she will put him on the podiatry list. On 01/26/22 at 12:19 PM. The surveyor was approached by LPN #1. She stated, The Podiatrist comes on a case by case basis. We can put him (Resident #35) on the list. I talked to MDS (Minimum Data Set) staff about getting him on the list for an appointment. Received the podiatry list dated 11/09/21 from the administator via email on 1/28/22. A notation at the bottom of the podiatry list reads: Next earliest appointment date 2/07/22. Resident #35's name was not on the list. On 1/28/22 at 2:15 PM a pre-exit interview was conducted via telephone with the administrator and the DON. The surveyor asked what are your expectations concerning Resident #35 and is your nursing staff allowed to cut residents' toenails if they're non diabetic. The administrator stated, The SW (Social Worker) is notified and schedules ancillary services. Yes. (nurses are allowed to provide toenail care if a resident is not diabetic).

Based on observations, record review and staff interviews, the facility staff failed to ensure one Resident (Resident #45) in the survey sample of 28 residents did not smoke inside the facility. The findings included: Resident #45 had a re-admit date of 12/09/21. Resident #45 was re-admitted with diagnoses which included muscle weakness, paraplegia, neuromuscular dysfunction of bladder, schizoaffective disorder, and adjustment disorder. Resident #45 was assessed as requiring maximum assist with Activities of Daily living. Resident was noted to have a colostomy. Resident #45 had a care plan dated 11/05/21 which indicated: Focus- Smoking paraphernalia no-complaint with smoke free facility; Goal- The resident will have an understanding of the effects of being non complaint with smoke free facility. Interventions- Educate and encourage of the risk verses benefits of not following non-smoking facility policy. Resident #45 was observed on 1/25/22 at 2:35 p.m. in bed. Resident #45 was able to speak and carry on a conversation. Resident #45 was observed in bed on 1/26/22 at 9:15 a.m. in bed. Resident had completed his breakfast meal and ate 100%. A Social Worker's note dated 1/24/22 at 13:29 (1:29 p.m.) indicated: SW spoke with admin who informed resident was smoking again in his room. Guardian was made aware. Non emergent (police) were called out, they were unable to assist in room search but did stand outside the door as backup. Administrator, Unit Manager and SW entered the room to assist in a room search. Resident was informed he wasn't smoking but had a vape pen in his hand. Once pointed out by SW, Administrator informed resident he will need to had over. Resident refused stated that he does not see why he needs to stop doing the things he likes to do. The administrator continued to educate resident that smoking is prohibited in the facility. SW informed resident that the guardian is still working on restoring his rights. SW also informed that multiple group homes and no beds or he is on there do not readmit list because of his behaviors. When requested to hand over his smoking device resident refused and stated he wanted to be sent out to he hospital, when asked why he stated it was his bladder. A call was placed to guardian to make him aware. Resident refused to be sent out. A Social Worker's note dated 1/18/222 at 17:20 (5:20 p.m.) indicated: SW called no emergent police line, per police officers there is nothing that they can do at a state level because marijuana is legal in the state of Virginia. Per officers this would be something that needs to be handled at an administrative level. Cops wouldn't even assist with room search they only stood outside door, while an attempt to search room. Resident informed he was not smoking and he was only burning SAGE. Resident refused search. Social worker requested the red lighter that was on the bed and the sage. Resident handed over both items. SW educated resident that this a non-smoking facility and we will be initiating a 30 day dc notice. SW will issue a 30 day notice once a place for him to go, SW have been working diligently these last couple of days to find placement for this gentlemen but once they see the behavior notes facilities are very apprehensive. Officers suggest if you get into a physical altercation with resident file a police report. Build a case. During an interview on 1/27/22 at 2:36 p.m. with the SW, she stated, the doctor had completed a competency assessment on Resident #45 and resident is competent. SW stated getting full support from Guardian had been troublesome. When asked how resident receive smoking material, the SW stated, they can not figure it out. Resident have wounds and refuse to be treated. They think he has items hidden under his bottom. During an interview on 1/27/22 at 3: 10 p.m. with the administrator she was asked how resident was able to get smoking material into the building since he was not able to get up on his own. The administrator, stated she was not sure because resident did not have that many visitors. During an interview on 1/28/22 at 9:21 a.m. with the Unit Manager she was asked how resident got smoking material into building. the Unit Manager stated, they do not know. Cameras set up out side did not capture the area where Resident #45's room is located. A facility Smoking Policy: indicated- This facility is a non- smoking facility.

Based on observation, resident and staff interviews, clinical record review and during the course of a complaint investigation the facility staff failed to follow the physician order for the oxygen flow rate, monitor the flow rate and failed to label and date the oxygen tubing for 1 of 34 residents (Resident #23) in the survey sample. The findings included: Resident #23 was originally admitted to the nursing facility on 03/11/21. Diagnosis for Resident #23 included but not limited Diabetes Mellitus and Respiratory Failure. Resident #23's Minimum Data Set (MDS-an assessment protocol) a quarterly revision assessment with an Assessment Reference Date (ARD) of 11/17/21 coded Resident #23 an 8 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive skills for daily decision-making. In addition, under respiratory treatments was coded for the use of oxygen therapy. Resident #23's person centered care plan had a focus which read; Resident #23 is on oxygen therapy. The goal read; will be free from signs and symptoms of hypoxia. One of the interventions included; administer oxygen as ordered. The care plan also reads: The resident has a behavior problem: Turns up 02. Goals: Resident #23 will have an understanding of the effects of turning up 02 thru the next review date. 2/13/22. Initiated on 11/19/21. Interventions: Educate and encourage the risk verses the benefits of the 02 setting. Review of Resident #23's Order Summary Report for January 2022 included the following order: Oxygen at 4 LPM Via nasal cannula every 24 hours as needed for Shortness of Breath with a start date of 12/29/21. Change O2 tubing and set-up weekly every night shift every Monday for SOB (Shortness of Breath) Label tubing with date when changed. Order date: 10/14/21. Start Date: 10/18/21. During the initial tour on 1/26/22 at approximately 4:34 PM., Resident #23 was observed lying in bed with oxygen on at 7 liters per minute via nasal cannula (n/c) with humidification. No label/Date seen on O2 tubing On 1/27/22 at approximately 8:51 AM., Resident lying in bed with his oxygen at 7 liters per minute via n/c with humidification. No label/Date seen on O2 tubing. On 1/27/22 at approximately 8:57 AM an interview was conducted with LPN (Licensed Practical Nurse) #3 concerning resident #23's 02 level. He stated, It should be 4 liters. On 1/27/22 at approximately 1:36 PM., an interview was conducted with LPN (Licensed Practical Nurse) #4. She stated, Resident #23 turns up his own O2. He is care planned as being non-compliant with his O2. She was asked by surveyor if Resident's oxygen flow rate should be monitored due to his behavior. She stated, Yes. Policy: Oxygen Administration (all routes) Policy. Department: Clinical: Respiratory. Effective Date: 1/23/2017. Last Revision Date: 12/16/2019. Policy: Licensed clinicians with demonstrated competence will administer oxygen via the specified route as ordered by a provider. In an emergency situation, clinicians may administer oxygen and obtain a provider's order as soon as practicably possible after patient stabilization or transfer. Equipment: Regulator/Flow meter. Procedure: Verify Provider order. Preparation and Equipment: Connect the regulator and flow meter, open set to desired flow. Administration via nasal cannula: Set flow rate. Cleaning: Change tubing, mask, and cannula weekly and document according to facility policy. On 1/28/22 at approximately 9:25 AM a telephone interview was conducted with the administrator and DON concerning the above. The facility staff did not present any further information. This is a complaint deficiency!

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and in the course of a complaint investigation, it was determined that facility staff failed to maintain a complete record for one of 34 residents in the survey sample; Resident #298. During the course of the survey from 1/25/22 through 1/28/22 a surveyor was not able to retrieve records for one closed record resident through the facility's current eMAR (Electronic Medication Administration Records) system called My Unity. The administrator assured the surveyor that she would be able to get the requested records for Resident #298. The records were received upon request. However, when requesting wound care information the records provided by the facility did not contain adequate information. A conclusion was made concerning Resident #298's stage 2 pressure ulcer once hospital records were requested and received by VDH/OLC (Virginia Department of Health/Office of Licensure and Certification). On 1/28/22 at 9:25 AM the administrator stated, With the user rights for the eMAR (Electronic Medication Administration Records) system at each Sentara building was given to one person on sight. They are not able to add additional users. We are not able to do that through my Unity. The findings included: Resident #298 was admitted to the facility on [DATE]. Diagnosis for Resident #298 included but not limited to Hypertension and Atrial Fibrillation. The current Minimum Data Set (MDS), an admission assessment with an Assessment Reference Date (ARD) of 07/20/20 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15.This indicated Resident #298's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as total dependence of two persons with bed mobility, dressing, toilet use and personal hygiene. Resident was coded as Independent with eating-set up help only. In section M (Skin Conditions). Risk of Pressure Ulcers/Injuries? Coded as 1, meaning Yes. The Medical Records Custody Agreement reads: This Medical Records Custody Agreement is entered into to be effective as of November 1, 2020 by and between the entities set forth on the signature page under the heading Saber (Collectively, Saber), and the entities set forth on the signature page under the heading Sentara (Collectively, Sentara). On 1/28/22 at approximately 9:25 AM a telephone interview was conducted with the Administrator and DON concerning the above. The facility did not present any further information.

Based on compliant investigation, staff interviews, clinical record review and facility documentation review, the facility staff failed to follow professional standards of nursing for 1 of 34 residents (Resident #47) in a survey sample. The findings included: The facility staff failed to ensure blood pressures were taken prior to the administration of medication (Zanaflex) as ordered by the physician Resident #47 was admitted to the nursing facility on 06/03/21. Diagnosis for Resident #47 included but not limited to Myasthenia Gravis. Resident #47's Minimum Data Set (an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of 12/10/21 coded the resident's Brief Interview for Mental Status (BIMS) score 08 of a possible 15 with moderate impairment for daily decision-making. In section G (Physical functioning) the MDS coded Resident #47 requiring total dependence of one with bathing, extensive assistance of one with bed mobility, transfer, dressing, toilet use and personal hygiene and set-up help only with eating for Activities of Daily Living (ADL) care. Review of Resident's #47's Order Summary Report for January 2022 revealed the following order: Zanaflex tablet - give 2 mg tablet by mouth three times a day for muscle relaxer; hold for altered mental status/sedation or systolic blood pressure less than 100. During the review of Resident #47's blood pressure for the month of July 2022 revealed blood pressure was not taken three times a day prior to the administration of the medication Zanaflex on the following days: (01/02, 01/03, 01/04, 01/05, 01/06, 01/07, 01/08, 01/09, 01/11, 01/13, 01/14, 01/16, 01/18, 01/19 and 01/22/2022). An interview was conducted with License Practical Nurse (LPN) #5 on 01/26/22 at approximately 3:50 p.m. The LPN reviewed the above mentioned physician order for the administration of Zanaflex, then stated, The resident's blood pressure should be taken three times a day prior to the administration of the medication Zanaflex. On 01/27/22 at approximately 1:10 p.m., an interview was conducted with the Director of Nursing (DON). The DON reviewed the Zanaflex order and stated, Resident #47's blood pressure should have been taken prior to giving each dose of the Zanaflex. On the same day at approximately 3:00 p.m., the DON said she had spoken with Resident #47's physician who stated, Resident #47's blood pressure should have been taken prior to giving each dose of Zanaflex because she was having low blood pressures during that time. A debriefing was held with the Administrator and Director of Nursing on 01/27/22 at approximately 4:50 p.m. The Administration team were informed of the above findings; no further information was provided prior to exit. Definitions: -Zanaflex is used to relieve the spasms and increased muscle tone caused by multiple sclerosis (MS, a disease in which the nerves do not function properly and patients may experience weakness, numbness, loss of muscle coordination and problems with vision, speech, and bladder control), stroke, or brain or spinal injury. Tizanidine is in a class of medications called skeletal muscle relaxants. It works by slowing action in the brain and nervous system to allow the muscles to relax (https://medlineplus.gov/druginfo/meds/a601121.html). -Myasthenia Gravis is a disease that causes weakness in your voluntary muscles. These are the muscles that you control. For example, you may have weakness in the muscles for eye movement, facial expressions, and swallowing. You can also have weakness in other muscles. This weakness gets worse with activity, and better with rest(https://medlineplus.gov/druginfo/meds/a601121.html). Complaint deficiency

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on information gleamed during a complaint investigation, staff interviews, and review of facility documents, the facility staff failed to have a procedure in place to ensure that a presumed Graduate Nurse (GN) had a license or authorization to practice in the state prior to hiring, starting orientation and rendering care to residents in the facility. The findings included: An interview was conducted with the Director of Nursing and Administrator on 1/28/21 at approximately 5:45 p.m. regarding the complaint that they had nurses right out of school without proper credentials working in the facility. The Director of Nursing stated they didn't have anyone working as a nurse who didn't meet the requirements to work as a graduate Nurse. Review of one presumed Graduate Nurse (GN) Personnel record revealed the staff was originally hired 10/18/21 and rehired 12/20/21. Further review of the personnel records didn't reveal a license to practice as a practical Nurse neither a letter from the Department of Health Professions authorizing the individual the right to practice as a Practical Nurse applicant for 180 days or until results were received from the first licensing examination. An interview could not be conducted with the Human Resource Director for she was out of town during the survey. On 1/28/21 at approximately 2:25 p.m., an interview was conducted with the staff who currently held the proper credentials to practice as a practical nurse applicant as of 1/19/22 with a testing date of 3/9/22. The staff member stated he was supposed to complete his nursing classes October 2021 but he hadn't completed all clinical hours necessary for he had been out sick. He stated he had to wait for the specific clinical rotation to come back around therefore; there was a delay in completion of the practical nursing program. The staff stated he completed the graduate practical nurse orientation in the nursing facility and staff taught him to complete wound care, pass medications, obtain vital signs, conduct a fall assessment and other competent nurse duties. The staff stated sometime in November he resumed the practical nurse program to complete the required clinical rotation at which time he stopped working in the nursing facility. The staff stated it was approximately 12/19/21 that he was rehired as a graduate Nurse by the nursing facility and he has worked continuously since then. On 1/28/21 at approximately 2:30 p.m., the above findings were shared with the Director of Nursing. An opportunity was offered to the facility's staff to present additional information but no additional information was provided and no concerns were voiced. The below information was obtain from the following website on 2/7/22: https://law.[NAME].virginia.gov/admincode/title18/agency90/chapter19/section110/ A. The board shall authorize the administration of the (National Council Licensure Examination) NCLEX for registered nurse licensure and practical nurse licensure. B. A candidate shall be eligible to take the NCLEX examination (i) upon receipt by the board of the completed application, the fee, and an official transcript or attestation of graduation from the nursing education program and (ii) when a determination has been made that no grounds exist upon which the board may deny licensure pursuant to § 54.1-3007 of the Code of Virginia. C. To establish eligibility for licensure by examination, an applicant for the licensing examination shall: 1. File the required application, any necessary documentation and fee, including a criminal history background check as required by § 54.1-3005.1 of the Code of Virginia. 2. Arrange for the board to receive an official transcript from the nursing education program that shows either: a. That the degree or diploma has been awarded and the date of graduation or conferral; or b. That all requirements for awarding the degree or diploma have been met and that specifies the date of conferral.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interview, family interview, staff interviews, and clinical record review, the facility staff failed to to ensure a resident exhibiting resistive behaviors secondary to a history of pain related trauma received person-centered services to support and promote mental and physical well-being which resulted escalated behaviors and a significant decline in mental and physical functioning for 1 of 34 residents (Resident #36), in the survey sample. The findings included: Resident #36 was originally admitted to the facility 10/11/21, and readmitted [DATE], after an acute care hospital stay. The current diagnoses included; Cerebral palsy/paraplegia, status post Right hip fracture, Chronic pain, an Adjustment disorder with anxiety and Generalized Weakness. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/9/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #36's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring total care of one person with bathing and locomotion, extensive assistance of two people with bed mobility, transfers, personal hygiene and dressing, extensive assistance of one person with toileting, supervision after set-up with eating. During an interview with Resident #36 on 1/25/22 at approximately 1:35 p.m., the resident began to cry and speak very rapidly because she felt the staff doesn't answer her call bell timely, doesn't speak to her, her friend or parents appropriately The resident also stated the staff is causing her mental anguish because of their attitudes towards her. The resident further stated she came to the facility to strengthen her body so she could return home requiring one person assistance with bed mobility, activities of daily living (ADL) and transfers from the bed to a chair. The resident further stated at some point during the hospitalization prior to admission to the nursing facility she sustained a right hip fracture and later other fractures in which she was unaware of until she experienced excruciating pain during turning and repositioning. The resident also stated on one occasion she was put in the Hoyer lift while she was fractured and the pain was indescribable. The resident expressed since the fractures and the Hoyer lift events she has had great fear of excruciating pain when staff approaches her and often prior to staff touching her to provide any type of care. The resident further stated she occasionally uses the call bell to ask for assistance because she knows she needs ADL care but because of fear of pain she rejects the care when the staff finally arrives. The resident also stated sometimes she requests pain medication prior to receiving care but most of the time she simply rejects care for fear of experiencing great pain. The resident stated her most recent method for dealing with having staff assistance has been to eat very little and decrease her fluid intake so she will not eliminate very often but; as a result she has suffered frequent episodes of constipation. Observations were made on the resident on 1/25/21 at approximately 1:35 p.m., and again on 1/27/28 at approximately 4:45 p.m., the resident appeared unbathed, sweaty, with dishevel hair and the bed linens were notably soiled. The window was opened because the resident stated she was too warm. A care plan had a problem dated 12/7/21 which read; resident has behaviors: as evidenced by; refuses Adl care, turn and reposition, dressing changes, weights, Physician orders, hair facial hairs removed, to be changed when soiled, can be accusatory, skin assessment related to severe anxiety that debilitates her functional status. The goal read; resident will have fewer episodes of refusal by the review date, 5/22/22. The interventions included; Anticipate and meet the resident's needs. Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by. Educate and encourage of the risk verses benefits of skin assessments, of being accusatory, of being changed when soiled of removing facial hairs, of refusing MD orders, encourage and allow the resident to express feelings appropriately. Explain all procedures to the resident before starting and allow the resident to adjust to changes. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Another care plan problem dated 12/7/21 read; resident has potential for acute/chronic pain related to Chronic Physical Disability Cerebral Palsy, and a right femur fracture. The goal read; the resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date 5/22/22. The interventions included; Administer analgesia/medications per orders. Anticipate the resident's need for pain relief and respond to any complaint of pain as needed. Assess/document for probable cause of each pain episode. Remove/limit causes where possible. Assess/record/report to nurse loss of appetite, refusal to eat and weight loss. Assess/record/report to nursing any signs/symptoms of non-verbal pain. Implement non-pharmacological interventions to release the pain like Distraction techniques, Relaxation and Breathing exercises, music therapy, Re-position. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal or resistance to care. Notify MD as needed with changes. Report to Nurse any change in usual activity attendance patterns or refusal to attend activities related to signs/symptoms or complaints of pain or discomfort. Review of the clinical record revealed Resident #36 had rejected care since admission to the facility and when the resident was initially approached by Social Services to receive support from a psychologist the therapy was rejected but agreed upon on at a later date. Further review of the clinical record revealed volumes of documentation of the resident's episodes of rejecting services yet interventions; such as staff education to encourage resident trust and acceptance of services or professional services such as increased psychotherapy with a focus on the resident's indicators of distress using a person-centered approach were not documented, neither were referrals to provide ongoing assessment and symptom management, and emotional/spiritual support documented. The clinical record had a progress note from the Psychological practitioner which indicated on 10/27/21 the resident wasn't available to be seen. Another opportunity to treat the resident wasn't made until 1/26/22. Review of the 1/26/22 notes resulted in no recommendations for changes in therapy, medications of the treatment plan even with the constant rejection of care, screaming, and other indicators of mental distress. An interview was conducted with the Occupational Therapist (OTR) on 1/27/22 at approximately 1:00 p.m. The OTR stated the resident received occupational therapy services 10/11/21 through 10/22/21 and 10/29/21 through 11/8/21 and because the resident was currently long term care she wasn't receiving any type of therapy but could be screened for physical therapy services. The OTR also stated the resident's dad wanted her to roll in bed with one person originally but it wasn't possible for sometimes it required three to four people here to roll the resident. The OTR stated she recognized the resident's greatest obstacle was her anxiety therefore; she talked about techniques to control the her anxiety using singing, praying, the resident offering cues and the resident's anxiety got better but not rolling still wasn't doable with one person. The OTR stated she continued to work with the resident in strengthening to assist with rolling and desensitization related to having the immobilizers in place for the fractures. The OTR finally stated the resident's anxiety prevented further progression in occupational therapy for the resident wasn't capable of getting past her anxiety exhibited as pain to warrant continued therapy services and she stated based on her interactions with the resident she didn't believe as long as the resident was with the level of anxiety she currently exhibits therapy services could be rendered. 01/28/22 07:59 a.m., an interview was conducted with the parents of Resident #36. They expressed their concerns that the facility had plans to discharge the resident and hadn't worked effectively towards their goal of one person assistance for bed mobility and transfers in the community. The parents expressed their desire for their daughter to leave the nursing facility but at the currently level of dependence they didn't have to community resources to meet her needs. They felt the therapist provided the services they felt were appropriate for the resident such as speech therapy instead of physical therapy. On 1/27/22 at approximately 2:55 p.m., an interview was conducted with the primary physician for Resident #36. The physician stated the resident has had great anxiety related to pain when staff touches her resulting in the resident's inability to receive needed care and services. The physician further stated this anxiety had been overshadowing her entire stay at the facility therefore the primary physician stated he would institute a team approach to maximize resident's relief of her pain which seems to be exacerbated by her overall anxious disposition. His plans and options of treatment included treatment of her anxiety by seeking out further assistance from psychological services, in the form of more frequent visits from psychologist as well as the utilize the psychiatric nurse practitioner. The physician also stated he would request input for ongoing chronic pain management from a physician of physical medicine and rehabilitation and he would review the medication for changes. On 1/27/22 at approximately 5:45 p.m., the above findings were shared with the Administrator, Director of Nursing. An opportunity was offered to the facility's staff to present additional information but no additional information was provided and neither were concerns voiced.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interview the facility, the failed to ensure 1 of 34 Residents (#92) in the survey sample was seen by the pharmacist for Medication Regimen Review (MRR) on a monthly basis. The findings included: The facility staff failed to review Resident #92's medication regimen for the month of August 2021. Resident #92 was admitted to the facility on [DATE]. Diagnosis for Resident #92 included but not limited to Major Depressive disorder and Anxiety disorder. Resident #92's Minimum Data Set (MDS), a quarterly Assessment Reference Date (ARD) of 01/09/22 coded the resident with a 09 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The MDS coded Resident #92 requiring extensive assistance of one with bed mobility, transfer, dressing, eating, toilet use, personal hygiene and bathing for Activities of Daily Living (ADL) care. Resident #92's comprehensive care plan documented Resident #92 is on a antipsychotic therapy related to depression. The goal set for the resident by the staff is to remain free from adverse effects of antipsychotic therapy. One of the interventions/approaches the staff would use to accomplish this goal is to consult with the pharmacist, physician and the Medical Director for a gradual dose reduction if appropriate. Review of Resident #92's Order Summary Report revealed the resident was taking 14 scheduled medication to include Klonopin and Seroquel. Review of Resident #92's clinical record did not include a pharmacy progress note for August 2021. The DON said she was not able to locate the pharmacy review for August 2021. A debriefing was held with the Administrator and Director of Nursing (DON) on 01/27/22 at approximately 4:50 p.m. The DON stated, The pharmacist is expected to the resident on a monthly basis. Definitions: Klonopin is used alone or in combination with other medications to control certain types of seizures. It is also used to relieve panic attacks (sudden, unexpected attacks of extreme fear and worry about these attacks). Clonazepam is in a class of medications called benzodiazepines. It works by decreasing abnormal electrical activity in the brain (https://medlineplus.gov/drug). Seroquel tablets and extended-release tablets are also used alone or with other medications to treat episodes of mania (frenzied, abnormally excited or irritated mood) or depression in patients with bipolar disorder (manic depressive disorder; a disease that causes episodes of depression, episodes of mania, and other abnormal moods) (https://medlineplus.gov/drug).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility staff failed to enhance and promote dignity during medication administration for one resident, Resident #57 in a survey sample of 39 residents. The findings included: The facility staff failed to knock upon entering Resident #57's room during medication on the Garden Spring Unit. Resident #57 was admitted to the facility on [DATE] from the community and has never been discharged . Diagnoses included, but not limited to, Vascular Dementia and Type 2 Diabetes Mellitus. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 03/15/19 coded the resident as having short-term and long- term memory problems. Cognitive skills for decision making coded the resident as being severely impaired never/rarely making decisions. On 07/17/19 at approximately 4:30 PM Licensed Practical Nurse (LPN) #3 entered the resident's room to administer medications on two occasions without knocking before entering. On 07/18/19 at approximately 3:44 PM an interview was conducted with Licensed Practical Nurse #5 and she was asked if it was important to knock before entering into a resident's room. She stated Yes, this is considered their home and each room is considered their apartment. On 07/18/19 at approximately 3:58 PM an interview was conducted with Licensed Practical Nurse #3 concerning her entering the resident's room without knocking. Her response was, I should have knocked. It's a dignity issue. It's their home. On 07/18/19 at approximately 4:02 PM an interview was conducted with Certified Nursing Assistant (CNA) #2, when asked if it's important to knock before entering resident's rooms she stated, Yes, because it's a dignity and privacy issue. On 7/18/19 at approximately 4:12 PM, a pre-exit interview was conducted with the Administrator and the Director of Nursing concerning the above. No comments were made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and facility documentation, the facility staff failed to ensure Medicare Beneficiary Notices were issued to 1 of 39 residents (Resident #43) in the survey sample. The facility staff failed to issue an Advanced Beneficiary Notice (ABN) and Notice of Medicare Provider Non-Coverage (NOMNC) letter to Resident #43. Resident #43 was discharged from skilled services who remained in the facility with Medicare days remaining. The findings include: Resident #43 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to, Type 2 diabetes, urinary retention due to neuromuscular dysfunction of bladder, Alzheimer's disease and chronic kidney disease. Resident #43's most recent MDS (minimum data set) assessment was 5 day scheduled assessment with an ARD (assessment reference date) of 5/14/19. Resident #43 was coded as being severely impaired in cognitive function on the Staff Interview for Mental Status Exam. Resident #43 was coded in Section A2400. (Medicare Stay) as receiving skilled services from 5/7/19 through 5/14/19. Review of the facility's list of residents whose Medicare Part A services were discontinued in the last six months with benefit days remaining, revealed that Resident #43's Medicare Part A services were discontinued on 5/15/19. Resident #43 had 92 skilled days remaining at the time of the cut. Evidence that the facility issued an Advanced Beneficiary Notice (ABN) and Notice of Medicare Provider Non-Coverage (NOMNC) letter to Resident #43 was requested from administration. On 7/17/19 at 9:20 a.m., ASM (administrative staff member) #1, the Administrator, stated that staff could not find an ABN and NOMNC letter for Resident #43. When asked who staff were, ASM #1 stated that she was referring to the social worker. ASM #1 stated the social worker could not find the letter and therefore could not determine if the letter was given to the resident's representative. On 7/17/19 at 11:38 a.m., an interview was conducted with OSM (other staff member) #6, the social worker. When asked the process for issuing ABNs and or NOMNC letters to residents being discharged from Medicare Part A services, OSM #6 stated that she will issue both the ABN and NOMNC letters three days prior to discharge so that the resident has sufficient time to appeal the discharge. OSM #6 stated that the other social worker misplaced the ABN and NOMNC for Resident #43 and that she could not provide evidence that they were issued. On 7/17/19 at approximately 5:30 p.m., ASM (administrative staff member) #1, the administrator was made aware of the above concern. Facility policy titled, Generic Notice of Medicare Provider Non-Coverage, documents in part, the following: Skilled Nursing Facilities must provide the Notice of Medicare Provider Non-Coverage (generic notice) to Medicare Beneficiaries No later than 2 days (48 hours) before the effective date of the end of the coverage that their Medicare coverage will be ending.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to send Resident #16's comprehensive care plan goals when discharged to the hospital on [DATE]. Resident #16 was admitted to the facility on [DATE]. Resident #16 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnosis included but were not limited to, Cerebral Palsy and Paraplegia. On 07/18/2019 at approximately 10:00 a.m., documentation was requested evidencing that the comprehensive care plan goals were sent with Resident #16 upon discharge to the hospital on [DATE]. At approximately 2:00 p.m., the facility staff reported that they were unable to provide any documentation evidencing that comprehensive care plan goals were sent with the resident upon discharge to the hospital. On 07/19/2019 at 4:20 p.m., an interview was conducted with the Administrator and she was asked, What information do you expect your nurses to send with the resident's upon discharge to the hospital? The Administrator stated, I expect the nurses to send the Clinical Summary which includes the care plan goals, Bed Hold Notice and Discharge Summary upon discharge to the hospital. The Administrator stated that the facility had conducted an audit and identified a facility issue with staff not sending the Bed Hold Notice and comprehensive care plan goals with the resident's upon discharge to the hospital. The staff were educated to send the Clinical Summary which includes the care plan and the Bed Hold Notice when discharging the resident to the hospital but they did not do it. On 07/19/2019 at approximately 4:00 p.m., at the pre-exit meeting the Administrator and Director of nursing was informed of the finding. The facility did not present any further information about the finding. Based on staff interviews, clinical record review and facility documentation review the facility staff failed to send a copy of the resident's care plan to include their goals for 3 of 39 residents in the survey sample (Residents #85, #16 and #75) upon transfer to the hospital. This deficiency is cited as past non-compliance. The findings included: 1. The facility staff failed to ensure that Resident #85's Plan of Care Summary to include their care plan goals was sent upon transfer/discharge to the hospital on [DATE]. Resident #85 was originally admitted to the facility on [DATE] and was re-admitted to the facility on [DATE]. Diagnosis for Resident #85 included but not limited to Hypertension and Hypothyroidism. A review of nurse's notes dated 4/02/19 reads Phone call to 911 per RP (Responsible Party) would prefer to send resident out to local hospital. Resident resting in bed eyes closed, waiting for arrival of EMT's. MD is aware. At 1820 Resident on LOA (Leave Of Absence) to local hospital. Family will meet resident at the hospital. An action Plan-Discharge and Bed Hold Notice was received from the administrator on this day. It reads as follows: Date Identified: 05/01/19. Date Certain: 07/05/19. Project Team: IDT. Issue/Concern: F622 Transfer Notice and Bed Hold. Goals/Objectives/Expected Outcome: 1. Provide Bed Hold Notice at time of Transfer. 2. Provide Discharge/Transfer notice at time of transfer. 3. Document items provided to resident/significant other. 4. Include information regarding clinical summary (which includes the care plan and goals) at time of discharge. Correction: All residents experiencing a transfer to ED will be provided a copy of the bed hold policy, transfer notice and clinical summary. Responsible person-Staff nurse. Projected Date:7/2/19. Other Potential: All residents have potential to be affected by this deficient practice. System Changes: 1. Educate Staff on discharge process and documentation requirements. Responsible Person: SDC. Projected Completion Date: 7/5/19. Review Date and Status Report: See education Record 2. Review discharges at daily huddle. Responsible Person: DON. Projected Completion Date: 7/01/19 and ongoing. 3. Review nursing documentation to assure required tools were provided at the time of discharge. Responsible Person: Clinical Manager. Projected Completion Date: 7/01/19 and ongoing 4. SW to provide F/U call to family member to assure information is communicated and determine outcome of bed hold decision. Responsible Person: SW (Social Worker) Projected Completion Date: 7/01/19 and ongoing. 5. Bed Hold policy, transfer notice and clinical summary to be uploaded to EMR. Responsible Person: Medical Records. Projected Completion Date: 7/01/19. Monitoring/QA Oversight: 1. DON will audit 100% of resident discharges weekly x 3 months for completion of bed hold notification, transfer notice and provision of clinical summary. 2. Analysis of audit will be by the DON to QAPI committee for additional oversight. Responsible person: DON Review Date and Status Report: QA meeting scheduled for 7/16/19. On 07/18/19 at approximately 3:11 PM an interview was conducted with the Administrator concerning the above issues. The administrator stated that no bed hold notice or care plan summary was sent. She stated that they do have a plan of action in place as of 07/05/19. 3. The facility staff failed to ensure that Resident #75's Plan of Care Summary to include their care plan goals was sent upon transfer/discharge to the hospital. Resident #75 went to Programs of All-Inclusive care for the Elderly (PACE) and was transferred to the local hospital and admitted on [DATE]. Resident #75 was originally admitted to the facility on [DATE]. Resident #75 was re-admitted to the facility on [DATE]. Diagnosis for Resident #75 included but not limited to Dementia with behavioral disturbances. On 04/19/19, according to the facility's documentation, the facility's nursing staff received a phone call from Programs of All-Inclusive care for the Elderly (PACE) on 04/19/19. The documentation read; PACE clinic called at 1:30 p.m., to inform that they were sending Resident #75 to the local hospital due to him sleeping a lot, the podiatrist feels he may be septic. The Resident returned to the facility on [DATE]. On 07/17/19 at approximately 4:10 p.m., the Administrator stated there was no evidence the care plan information was sent upon discharge or shortly after being discharged to the hospital for 4/19/19. An interview was conducted with the clinical manager on 07/18/19 at approximately 10:13 a.m. The surveyor asked, After Resident #75 was sent to the local hospital and admitted on [DATE], was the Resident's care plan to include their goals either faxed or delivered to the hospital. The clinical manager replied, I was unable to locate documentation that the care plan was issued in the resident's clinical record. She said the care plan should have been either faxed or delivered once we realized that Resident #75 was sent to the hospital. The surveyor asked, What is the purpose for sending the resident person-centered care plan, she replied, To maintain continuity of care, that way they know what we are doing here and the same care can be provided at the hospital. On 07/18/19 at approximately 2:20 p.m., the above information was shared with the Administrator and the Director of Nursing. The facility did not present any further information about the finding. The facility's policy titled Life Care-Transfer, Discharge & Room Change (Social Services ) reviewed date of 08/15/18. The discharge care plan is part of the comprehensive care plan and must included but not limited to: -Address goals of care and treatment preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to provide Resident #16 a written Bed Hold Notice when discharged to the hospital on [DATE]. Resident #16 was admitted to the facility on [DATE]. Resident #16 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnosis included but were not limited to, Cerebral Palsy and Paraplegia. Resident #16's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 04/16/2019 was coded with a BIMS (Brief Interview for Mental Status) score of 12 indicating moderate cognitive impairment. In addition, the Minimum Data Set coded Resident #16 as requiring extensive assistance of 1 for bed mobility, transfer, dressing, toilet use and personal hygiene and independent in eating with set up help only. On 07/18/2019 at approximately 10:00 a.m., documentation was requested evidencing that the written Bed Hold Notice was sent with or provide to Resident #16 upon discharge to the hospital on [DATE]. At approximately 2:00 p.m., the facility staff reported that they were unable to provide any documentation evidencing that the written Bed Hold was sent with or provided to the resident upon discharge to the hospital. On 07/19/2019 at 4:20 p.m., an interview was conducted with the Administrator and she was asked, What information do you expect your nurses to send with the resident's upon discharge to the hospital? The Administrator stated, I expect the nurses to send the Clinical Summary which includes the care plan goals, Bed Hold Notice and Discharge Summary upon discharge to the hospital. The Administrator stated that the facility had conducted an audit and identified a facility issue with staff not sending the Bed Hold Notice and comprehensive care plan goals with the resident's upon discharge and the staff had been educated to send them but they did not do it. On 07/19/2019 at approximately 4:00 p.m., at the pre-exit meeting the Administrator and Director of nursing was informed of the finding. The facility did not prevent any further information about the finding. Based on staff interviews, facility documentation review and clinical record review the facility staff failed to provide the resident or resident's representative a copy of the bed hold policy upon discharge/transfer to the hospital for 3 of 39 residents (Resident #85, #16 and #75 after being transferred to the hospital. This deficiency is cited as past non-compliance. The findings included: 1. The facility staff failed to issue the resident/representative with a written copy of bed hold policy for Resident #85. Resident #85 was transferred to the local hospital and admitted on [DATE]. Resident #85 was originally admitted to the facility on [DATE] and was re-admitted to the facility on [DATE]. Diagnosis for Resident #85 included but not limited to Hypertension and Hypothyroidism. Resident #85's current Minimum Data Set (MDS), a quarterly revision with an Assessment Reference Date (ARD) of 02/13/19 coded the resident with a 07 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating cognitive impairment. The Discharge MDS assessment dated [DATE] - discharge return anticipated, resident re-admitted on [DATE]. A review of nurse's notes dated 4/02/19 reads Phone call to 911 per RP (Responsible Party) would prefer to send resident out to local hospital. Resident resting in bed eyes closed, waiting for arrival of EMT's. MD is aware. At 1820 Resident on LOA (Leave Of Absence) to local hospital. Family will meet resident at the hospital. On 07/18/19 at approximately 3:11 PM an interview was conducted with the Administrator concerning the above issues. The Administrator stated that no bed hold notice was sent. She stated that they do have a plan of action in place as of 07/05/19. An action Plan-Discharge and Bed Hold Notice was received from the administrator on this day. It reads as follows: Date Identified: 05/01/19. Date Certain: 07/05/19. Project Team: IDT. Issue/Concern: F622 Transfer Notice and Bed Hold. Goals/Objectives/Expected Outcome: 1. Provide Bed Hold Notice at time of Transfer. 2. Provide Discharge/Transfer notice at time of transfer. 3. Document items provided to resident/significant other. 4. Include information regarding clinical at time of discharge. Correction: All residents experiencing a transfer to ED will be provided a copy of the bed hold policy, transfer notice and clinical summary. Responsible person-Staff nurse. Projected Date:7/2/19. Other Potential: All residents have potential to be affected by this deficient practice. System Changes: 1. Educate Staff on discharge process and documentation requirements. Responsible Person: SDC. Projected Completion Date: 7/5/19. Review Date and Status Report: See education Record 2. Review discharges at daily huddle. Responsible Person: DON. Projected Completion Date: 7/01/19 and ongoing. 3. Review nursing documentation to assure required tools were provided at the time of discharge. Responsible Person: Clinical Manager. Projected Completion Date: 7/01/19 and ongoing 4. SW to provide F/U call to family member to assure information is communicated and determine outcome of bed hold decision. Responsible Person: SW (Social Worker) Projected Completion Date: 7/01/19 and ongoing. 5. Bed Hold policy, transfer notice and clinical summary to be uploaded to EMR. Responsible Person: Medical Records. Projected Completion Date: 7/01/19. Monitoring/QA Oversight: 1. DON will audit 100% of resident discharges weekly x 3 months for completion of bed hold notification, transfer notice and provision of clinical summary. 2. Analysis of audit will be by the DON to QAPI committee for additional oversight. Responsible person: DON Review Date and Status Report: QA meeting scheduled for 7/16/19. On 7/18/19 at approximately 4:12 PM a pre-exit interview was conducted concerning the above issues. The Administrator and Director of Nursing were present. 3. Resident #75 went to Programs of All-Inclusive care for the Elderly (PACE) and was transferred to the local hospital and admitted on [DATE]. Resident #75 was originally admitted to the facility on [DATE]. Resident #75 was re-admitted to the facility on [DATE]. Diagnosis for Resident #75 included but not limited to *Dementia with behavioral disturbances. Resident #75's Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 06/24/19 coded the resident with a 05 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognitive skills for daily decision-making. The Discharge MDS assessments was dated for 04/19/19-discharge return anticipated. On 04/19/19, according to the facility's documentation, the facility's nursing staff received a phone call from Programs of All-Inclusive care for the Elderly (PACE) on 04/19/19. The documentation read; PACE clinic called at 1:30 p.m., to inform that they were sending Resident #75 to the local hospital due to him sleeping a lot, the podiatrist feels he may be septic. On 07/17/19 at approximately 4:10 p.m., the Administrator stated there was no evidence the bed hold information was sent upon discharge or shortly after being discharged to the hospital for 4/19/19. An interview was conducted with the clinical manager on 07/18/19 at approximately 10:13 a.m. The surveyor asked, After Resident #75 was sent to the local hospital and admitted on [DATE], was the bed hold policy either faxed or delivered to the hospital? The clinical manager replied, I am unable to locate documentation that the bed hold policy was ever issued in the resident's clinical record. She said the bed hold policy should have been either faxed or delivered once we realized that Resident #75 was sent to the hospital. The surveyor asked, What is the purpose for issuing the bed hold policy she replied, To see if the family would like to hold the residents bed. On 07/18/19 at approximately 2:20 p.m., the above information was shared with the Administrator and the Director of Nursing. The facility did not present any further information about the finding. The facility's policy titled Life Care - Bed Hold (Last revision: 12/19/18.) -Policy statement: It is the facility policy to inform the resident or resident representative of the durations of the bed-hold policy, if any, during which the resident is permitted to return and resume residence when admitted to an acute care facility or goes on therapeutic leave. -Resident or Resident Representative will be provided a Notice of Bed Hold Policy letter at time of transfer, if not immediately possible, notification will be a first available opportunity. -Notice of bed hold policy will be provided with transfer documents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical review, the facility failed to complete a significant change assessment for 1 of 39 residents (Resident #39), in the survey sample, after being discharged from Hospice services. The findings included: Resident #39 was originally admitted to the facility on [DATE]. Diagnosis for Resident #39 included but not limited to, Alzheimer's disease and Dementia without behavioral disturbances. Resident #39's Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 05/22/19 coded Resident #39 with short and long-term memory problems and cognitive skills severely impaired-never/rarely made decisions. Resident #39 under section O-Special Treatments and Programs was coded for Hospice Care. An interview was conducted with Licensed Practical Nurse (LPN) #1 on 07/17/19 at approximately 1:02 p.m., who said Resident #39 has had a big improvement; she was recently discharged from hospice care on 05/22/19. Review of the clinical record did not show evidence that a significant change assessment was completed. Review of the clinical record showed evidence that Resident #39 was admitted to hospice care on 02/22/19. The resident was discharged from hospice care on 05/22/19. An interview was conducted with the Clinical Manager on 07/18/19 at approximately 10:06 a.m. When asked, When Resident #39 was discharged from hospice services, did that change require a significant change MDS to be completed? The Clinical Manager replied, I'm not sure, check with the MDS Coordinator. On 07/18/19 at approximately 11:10 a.m., an interview was conducted with the MDS Coordinator. The surveyor asked, When a resident is discharged from hospice services, should a significant change assessment be completed. The MDS Coordinator stated, Yes, a significant change MDS should been done within 14 days after the resident was discharged from hospice services. The surveyor asked, What references do you use to determine when a significant change assessment needs to be completed she replied, We go by the Resident Assessment Instrument (RAI) manual. On the same day at 11:53 a.m., the MDS Coordinator presented the surveyor a form titled: CMS's RAI Version 3.0 Manual. The following information was included: On 07/18/19 at approximately 2:20 p.m., the above information was shared with the Administrator and the Director of Nursing. The facility did not present any further information about the finding. 0.3 Significant Change in Status Assessment (SCSA): -A SCSA is required to be performed when a resident is receiving hospice services and then decides to be discontinue those services (known as revoking of hospice care). The ARD must be within 14 days from one of the following but not limited to; The ARD must be less than or equal to 14 days after the IDT's determination that the criteria for a SCSA are met (determination date + 14 calendar days). Definitions: *Hospice Care is a system of family-centered care designated to assist the terminally ill person to the be comfortable and to maintain a satisfactory life-style through the phases of dying (Mosby's Dictionary Medicine, Nursing & Health Professions 7th edition).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility document review and staff interviews the facility staff failed to ensure that the discharge Minimum Data Set Assessment was accurate for 1 of 39 resident in the survey sample, Resident #84. The findings included : Resident #84's discharge Minimum Data Set assessment dated [DATE] was coded as the resident was discharged to the hospital when in fact he was discharged home. Resident #84 was admitted to the facility on [DATE] with diagnoses to include but not limited to Diabetes Mellitus and Hypertension. Resident #84 was discharged home on 4/17/19. The most recent comprehensive Minimum Data Set (MDS) Assessment was an admission 5-Day with an Assessment Reference Date (ARD) of 4/9/19. The Brief Interview for Mental Status for Resident #84 was coded as a 15 out of a possible 15 indicating the resident was cognitively intact and capable of daily decision making. Resident #84's Physician Discharge summary dated [DATE] was reviewed and is documented in part, as follows: NH (Nursing Home) Course: Resident seen for preparation discharge today. He has met goals with therapy and today is discharging to home. Resident #84's Clinical Note dated 4/17/19 was reviewed and is documented in part, as follows: Pt. (patient) discharged with all medications and signed documentation at this time. Transported by wheelchair with sister. Resident #84's Discharge MDS Assessment with an ARD date of 4/17/19 was reviewed and is documented in part, as follows: Section A Identification Information A2000. discharge date : [DATE] A2100. Discharge Status: 03-Acute Hospital On 7/18/19 at 11:38 A.M. an interview was conducted with the MDS Coordinator regarding Resident #84's Discharge MDS with the ARD of 4/17/19. The MDS Coordinator was shown the Physician Discharge Summary, the Clinical Note and the Discharge MDS all dated 4/17/19. The MDS Coordinator stated, The MDS is incorrect the resident did not go tot he hospital, he went home. I will have to do a modification of the MDS to show he went home. The MDS should report the information about the resident accurately. The MDS Coordinator was asked if there was a policy for ensuring that MDS's are accurate. The MDS Coordinator stated, We follow the RAI (Resident Assessment Instrument) 3.0 Manual. On 7/18/19 at approximately 4:00 P.M. a pre-exit debriefing was held with the Administrator and the Director of Nursing where the above information was shared. Prior to exit no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility document review and staff interviews the facility staff failed to ensure a Baseline Care Plan addressed hemo-dialysis for 1 of 39 residents in the survey sample, Resident #237. The findings included: Resident #237 was admitted to the facility on [DATE] with diagnoses to include but not were limited to, Chronic Kidney Disease and Dependence on Renal Dialysis. Resident #237 was a new admission and the comprehensive admission Minimum Data Set Assessment and Comprehensive Care Plan has not yet been completed. The resident's baseline care plan was reviewed, however the resident requiring hemo-dialysis was not included. Resident #237's Hospital Discharge summary dated [DATE] was reviewed and is documented in part, as follows: Discharge Diagnoses: ESRD (end stage renal disease) on PD (peritoneal dialysis) now HD (hemo-dialysis). Resident #237's Treatment Administration Record was reviewed and is documented in part, as follows: Dialysis Three Times Weekly Starting 7/12/19. Order Date: 7/12/19 Notes Monday and Thursday at 9:30 A.M. then Tuesday, Thursdays and Saturdays. Resident was signed off by nursing as going to dialysis on 7/12/19 and 7/16/19. On 7/17/19 at 4:34 P.M. an interview was conducted with the Director of Nursing regarding Resident #237's Baseline Car Plan. The Director of Nursing was asked if hemo-dialysis has been included in Resident #237's Baseline Care Plan and if not should it had been and why. The Director of Nursing stated, No, it was not on the baseline care plan. It should have been included to provide person-centered care for the resident, it was added on 7/16/19. The facility policy titled Baseline Care Plan revised 11/21/17 was reviewed and is documented in part as follows: Policy Statement: It is the policy of the facility to develop and implement a baseline care plan for each resident to include the instructions needs to provide a person-centered care plan. It is the standard of the facility to have developed within 48 hours of the residents' admission the baseline care plan. On 7/18/19 at approximately 4:00 P.M. a pre-exit debriefing was held with the Administrator and the Director of Nursing where the above information was shared. Prior to exit no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interview, staff interview and clinical record review the facility staff failed to include pain management in the comprehensive care plan, for 1 of 39 resident's in the survey sample (Resident #77). The findings included: Resident #77 was admitted to the facility on [DATE]. Diagnoses included but were not limited to, Fracture of Left Femur and Cancer. Resident #77's Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 06/25/2019 coded the resident with a BIMS (Brief Interview for Mental Status) score of 14 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #77 as requiring extensive assistance of 1 for bed mobility and toilet use, extensive assistance of 2 for transfer, limited assistance of 1 for dressing and independent in eating and personal hygiene with set up help only. On 07/17/2019 at 5:50 p.m., an interview was conducted with Resident #77 and she was asked, Do you ever have any pain? Resident #77 stated, Yes, in my left leg and hip where I fractured my hip. Resident #77 was asked, Do you receive pain medication for your pain? Resident #77 stated, Yes. Resident #77 was asked, Is the medication effective? Resident #77 stated, Yes. On 07/18/2019 Resident #77's clinical record was reviewed and revealed the following Physician Orders in June 2019 and July 2019: Robaxin-750 750 mg (milligrams). (1 tablet) three times daily starting on 06/18/2019 for pain; Hydrocodone 5 mg -acetaminophen 325 mg (1 tab) Tablet oral as needed every six hours for pain starting on 06/18/2019 and Hydrocodone 5 mg-acetaminophen 325 mg tablet (2 tab) Tablet oral as needed every six hours for pain starting on 06/18/2019; Gabapentin 100 mg. capsule (1 cap) oral at hour of sleep for pain starting on 07/17/2019. Resident #77's comprehensive care plan was reviewed and failed to evidence that pain management was addressed in the care plan. On 07/18/2019 at approximately 10:32 a.m., an interview was conducted with the MDS Coordinator and she was asked, Is pain management addressed in Resident #77's comprehensive care plan? The MDS Coordinator stated, No, but it should have been care planned. The MDS Coordinator was asked, What is the purpose of the comprehensive care plan? The MDS Coordinator stated, The purpose it to provide an overall picture of the resident's needs. It provides the staff with interventions and how to care for the resident. On 07/19/2019 at approximately 4:00 p.m., at the pre-exit meeting the Administrator and Director of Nursing was informed of the finding. The facility did not present any further information about the finding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review and facility documentation review, the facility staff failed to revise the comprehensive personal centered care plan for 3 (Resident #39, #52 and #5) of 39 residents in the survey sample. The findings included: 1. The facility staff failed to revise Resident #39's comprehensive person centered care plan to include the discontinuation use of the antianxiety medication, Ativan. Resident #39 was originally admitted to the facility on [DATE]. Diagnoses for Resident #39 included but was not limited to, *Anxiety disorder. Resident #39's Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 05/22/19 coded Resident #39 with short and long-term memory problems and cognitive skills severely impaired-never/rarely made decisions. Review of Resident #39's person centered care plan with a revision date of 05/30/19 had a problem which read: resident is receiving antianxiety drugs on a regular basis. The goal read: symptoms of anxiety will be controlled with minimal side effects over the next 90 days. Interventions included monitor for side effects of medication and to notify the physician if side effects noted. Review of Resident #39's current Physician Order Sheet (POS) for July 2019, did not include medication for the treatment of anxiety. An interview was conducted with the Clinical Manager on 07/18/19 at approximately 10:00 a.m. She reviewed Resident #39's discontinued medication. She said Resident #39 was started on Ativan 1 mg tablet as needed four times daily for anxiety with a discontinuation date of 04/26/19. The surveyor asked, Should Resident #39's person-centered care plan still read that she is receiving antianxiety medication, she replied, No, the care plan should have been revised. She said the order was for *Ativan prn (as needed) and not scheduled per the care plan. The surveyor asked, Who is responsible for updating/revising the resident's care plan she replied, The nurses, MDS Coordinator as well as myself. The surveyor asked, What is the purpose of having an accurate care plan she replied, To make sure the resident is receiving the proper care. On 07/18/19 at approximately 2:20 p.m., the above information was shared with the Administrator and the Director of Nursing. The facility did not present any further information about the finding. Definitions: *Anxiety disorder is a mental condition in which you are frequently worried or anxious about many things. Even when there is no clear cause, you are still not able to control your anxiety (https://medlineplus.gov/ency/patientinstructions/000685.htm). *Ativan is used to relieve anxiety (www.nlm.nih.gov/medlineplus/druginfo/meds/a682053.html). 2. The facility staff failed to revise Resident #52's comprehensive person centered care plan to include the discontinuation use of a hypnotic and anti-anxiety medication. Resident #52 was originally admitted to the facility on [DATE]. Diagnosis for Resident #52 included but not limited to *Insomnia and *Anxiety disorder. Resident #52's Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 05/29/19 coded Resident #52 with a 02 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognitive skills for daily decision-making. Review of Resident #52's person centered care plan with a revision date of 06/05/19 had a problem, which read: to receive hypnotic medication to aid with insomnia. The goal read: minimize/avoid harmful side effects during the next review. Interventions included: Administer medication as ordered, notify physician if resident appears to be drowsy or shows decrease in usual functioning and monitor for side effects. The care plan also had a problem, which read: Resident is receiving antianxiety drugs on a needed basis r/t (related to) anxiety. The goal read: symptoms of anxiety will be controlled with minimal side effects. One of the interventions included to monitor for side effects of medication. During the review of Resident #52's current Physician Order Sheet (POS) for July 2019, did not include medication for the treatment of anxiety or insomnia. An interview was conducted with the Clinical Manager on 07/18/19 at approximately 10:00 a.m. She reviewed Resident #52's discontinued medication. She said Resident #52 was started on *Ativan 1 mg tablet every 6 hours as needed for anxiety with a start date of 09/07/16 and a discontinued date of 04/10/17. She also said the resident was started on *Ambien 10 mg daily at bedtime for insomnia with a start date of 09/22/17 with a stop date of 06/26/18. The surveyor asked, Should Resident #52's person-centered care plan still read that she is receiving antianxiety and hypnotic medication, she replied, No, the care plan should have been revised. The surveyor asked, Who is responsible for updating/revising the resident's care plan she replied, The nurses, MDS Coordinator as well as myself. The surveyor asked, What is the purpose of having an accurate care plan she replied, To make sure the resident is receiving the proper care. On 07/18/19 at approximately 2:20 p.m., the above information was shared with the Administrator and the Director of Nursing. The facility did not present any further information about the finding. Definitions: *Insomnia is a common sleep disorder; you may have trouble falling asleep, staying asleep, or both (https://medlineplus.gov/ency/article/007365.htm). *Anxiety disorder is a mental condition in which you are frequently worried or anxious about many things. Even when there is no clear cause, you are still not able to control your anxiety (https://medlineplus.gov/ency/patientinstructions/000685.htm). *Ativan is used to relieve anxiety (www.nlm.nih.gov/medlineplus/druginfo/meds/a682053.html). *Ambien is used to treat insomnia (difficulty falling asleep or staying asleep) (https://medlineplus.gov/ency/article/007365.htm). #3. The facility staff failed to revise the comprehensive care plan for Resident #5 to include an indwelling Foley catheter. Resident #5 was admitted to the facility on [DATE] with diagnoses to include, but not limited to cervical spine (neck) surgery, and generalized weakness. The current MDS (Minimum Data Set) a 5 day admit with an assessment reference date of 7/7/19, coded the resident as scoring a 14 out of a 15, indicating the residents cognition was intact. The resident was coded as always incontinent under section H. Bowel and Bladder and required extensive assistance of two staff for toileting. Review of the clinical notes entered 7/12/19 at 12:15 a.m. evidenced the following, Distended pelvis region reported by CNA (certified nurse assistant), bladder scan completed and reading was 787 ml (milliliters). Pt straight cath and 800 cc was collected. MD made aware and gave new order for Foley to be placed. 18 F (French) with 10 cc balloon in place and anchored to LT (left) thigh. Foley is patent and draining light amber urine . A Foley catheter is a thin, sterile tube inserted into the bladder to drain urine. Reference www.NIH.gov (National Institutes of Health). On 7/16/19 at approximately 5:15 p.m., and on 7/17/19 at 10:45 a.m., the resident was observed to have an indwelling Foley catheter. Resident #5's comprehensive care plan with an effective date of 7/8/19 was reviewed on 7/17/19. The care plan was not revised to include the Foley catheter. On 07/17/19 at 5:08 p.m., an interview with Registered Nurse (RN) #3, Great Bridge Pavilion unit manager, was conducted. He was asked to review the resident's care plan. When asked if there was a care plan for the Foley catheter he stated, I don't see anything here for a Foley. When asked if the care plan should have been revised to include the Foley catheter, he stated, Yes. The unit manager further stated that it is the responsibility of the nurse who implemented the order to have revised the care plan. On 7/19/19 at 2:13 p.m., the above findings was shared with the Administrator and the Director of Nursing. The Administrator agreed that the care plan should have been revised to include the Foley catheter. No additional information was provided to the survey team prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, clinical record review and review of the facility's policy, the facility staff failed to ensure the necessary treatment, care and services were provided to prevent further development or worsening of, a facility acquired *pressure ulcer for 1 of 39 residents (Resident #75) in the survey sample. The facility staff failed to notify the physician of the podiatrist's recommendation written on 07/01/19 for the use of prevalon boots for a resident with an *unstageable left heel pressure ulcer. The findings included: Resident #75 was admitted to the facility on [DATE]. Diagnosis for Resident #75 included but are not limited to *Dementia with behavioral disturbance and Involuntary Mobility (not done by choice; done unwillingly). Resident #75's Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 06/24/19 coded the resident with a 5 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognitive skills for daily decision-making. In addition, the MDS coded Resident #75 as requiring total dependence of one with bathing, extensive assistance of two with bed mobility, transfer and personal hygiene, extensive assistance of one with dressing, eating and toilet use. The MDS with an ARD of 06/24/19 under section M (Skin Condition-M0100) was coded: Resident has a stage 1 or greater pressure ulcer. Under section (M0150) at risk for developing pressure ulcers was coded: yes, under section (M0210) for unhealed pressure ulcers was coded: yes, under section (M0300) for having unstageable (1) pressure ulcer was coded: yes. Under section (M1200) for skin and treatments it was coded for having pressure reducing device for chair and bed, nutrition or hydration intervention to manage skin problems and pressure ulcer care. Resident #75's person-centered comprehensive care plan documented Resident #75 with actual skin breakdown to left heel (ulcer). The goal: ulcer will not worsen during the next 90 days. Some of the intervention/approaches to manage goal included to provide care according to physician orders-see Treatment Administration Record (TAR), use pressure reducing mattress and use pillows, pads, or wedges to reduce pressure on heels and provide care according to physician orders. A Braden Risk Assessment Report was completed on 01/02/19; resident scored a 16 indicating mild risk for the development of pressure ulcers with Friction and Shear as a potential problem. During the initial tour of the facility on 07/16/19 at approximately 4:32 p.m., Resident #75 was observed in bed lying on his right side with his heels position directly on the mattress. A pair of prevalon boots were observed on the floor beside Resident #75's nightstand. On 07/17/19 at approximately 2:05 p.m., Resident #75's bilateral heels were observed positioned directly on the mattress and a pair prevalon boots were observed on the over bed table. Resident #75's progress note written by the podiatrist on 07/01/19 revealed the following documentation: Assessment: [NAME] Stage 1 Ulcer to left heel (Staging the seriousness of a diabetic foot ulcers; Stage 1=ulcer is present but no infection. www.healthline.com). Plan: He needs to wear a Prevalon boot on both feet. Vascular Exam: Within Normal Limits to left foot. Integument/Skin: Ulcer posterior left heel with stable eschar. An interview was conducted with Licensed Practical Nurse (LPN) #1 on 07/17/19 2:10 p.m. The surveyor asked, Since Resident #75 has an unstageable pressure ulcer to his left heel, when should the prevalon boots to be applied? The LPN replied, I cannot answer that; how Resident #75 is to wear the prevalon boots is up to PACE, they approve all orders for Resident #75. The LPN looked in the computer for the order on how and when Resident #75 is to wear the prevalon boots. After the LPN finished looking for the prevalon boot order she replied, I do not see an order for prevalon boots. She said I will call PACE for clarification on when Resident #75 is to wear the prevalon boots and get back with you. An interview was conducted with certified nursing assistant (CNA) #1 on 07/17/19 at approximately 2:20 p.m. The surveyor asked When does Resident #75 wear his prevalon boots she replied , I removed them when he goes to bed but put them back on when I get him out of the bed. The surveyor asked, When is Resident #75 to wear his prevalon boots she replied, I really do not know. The surveyor asked, Were you ever told when to apply the prevalon boots she replied, No. The surveyor asked, What is the purpose of prevalon boots, she replied, To take the pressure of the heels and ankles. The surveyor asked, Is the pressure being relieved when the resident is in bed without his prevalon boots on, she replied No. The Administrator and Director of Nursing (DON) were informed of the finding during a briefing on 07/18/19 at approximately 2:20 p.m. The surveyor informed the Administrator and DON the *podiatrist made a recommendation on 07/01/19 for the use of prevalon boot due to an unstageable left heel pressure but the nursing staff was unable to show evidence that PACE was ever made aware. The DON said, PACE should have received the podiatrist recommendation and they (PACE) should have either approved or declined the recommendation. The surveyor asked, What is the purpose of prevalon boots. The DON stated, To give off load to the heels; the prevalon boots form as a cradle to keep the heels from touching the bed. On the same day at approximately 5:35 p.m., the DON presented a physician order sheet signed by the PACE physician that read: Podiatry note from 07/01/19 reviewed; agree with order for prevalon boots to be worn on both feet. Boots to be worn at all times except for cleaning and care. Definitions: *Pressure Injury: 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 (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/). *Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/). *Dementia with behavioral disturbances is frequently the most challenging manifestations of dementia and are exhibited in almost all people with dementia (https://www.ncbi.nlm.nih.gov/pubmed/22644311). *Prevalon (boots) helps minimize pressure, friction and shear on the feet, heels and ankles of non-ambulatory individuals. By off-loading the heel, it delivers total, continuous heel pressure relief (www.hdis.com/prevalon-boot-heel-protector.html). *Podiatrist is a health professional who diagnoses and treats disorders of the feet (Mosby's Dictionary of Medicine, Nursing & Health Professions).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility documentation review, the facility staff failed to provide one resident, Resident #13, in the survey sample of 39 residents with an assistive device to help prevent further contractures and/or decline in range of motion of hands. The findings included: The facility staff failed to provide Resident #13 with physician ordered hand palm guards to maintain range of motion. Resident #13 was re-admitted to the facility on [DATE] with diagnoses that included, but not limited to, functional quadriplegia, Anoxic Brain injury, Severe flexion contractures of all joints,and failure to thrive in adult. A Quarterly Minimum Data Set (MDS) dated [DATE] assessed the resident in the area of Hearing, Speech and Vision as having no speech, not able to make self understood and not able to understand. This resident was assessed as being severely impaired in the area of Vision. This resident was unable to be assessed in the area of Cognitive Patterns. In the area of Activities of Daily Living this resident was assessed requiring total dependence and one person physical assist in the areas of dressing, toileting and personal hygiene. This resident was not able to be assessed in the areas of transfer, walking, and locomotion. In the area of Functional Limitation in Range of Motion this resident was assessed as being impaired on both sides of the upper and lower extremity. A Care Plan dated 07/03/19 included: palm guard to both hands. A Physician and Occupational Therapy order dated 4/11/19 indicated use for foam palm guard at all times. A palm guard is used as a barrier between the fingers and palmar skin to prevent injury to the palm from severe finger flexion; decreases the risk of skin irritation from involuntary motions. www.medline.com Resident #13 was observed on 07/18/19 with the Rehabilitation Director and the Unit Manager. Resident #13 was observed without palmar guard to hand. Resident #13's hands were contracted with finger nails embedded into hands (no open wounds were observed). The Rehabilitation Director was asked if resident should have palmar guards on. The Rehabilitation Director stated, Yes he should have them on at all times except with bathing. A request was made for a facility policy on Assistive Devices. The facility did not provide the policy prior to the time of exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, medical record review, and facility document review the facility staff failed to ensure ongoing communication and coordination between the nursing home and the dialysis facility on 7/13/19 and 7/16/19 for 1 of 39 residents in the survey sample, Resident #237. The findings included: Resident #237 was admitted to the facility on [DATE] with diagnoses to include but not limited to, Chronic Kidney Disease and Dependence on Renal Dialysis. Resident #237 is a new admission and the comprehensive admission Minimum Data Set Assessment and Comprehensive Care Plan has not yet been completed. The resident's baseline care plan was reviewed, however there was no mention of dialysis noted. Resident #237's Hospital Discharge summary dated [DATE] was reviewed and is documented in part, as follows: Discharge Diagnoses: ESRD (end stage renal disease) on PD (peritoneal dialysis) now HD (hemo-dialysis). Resident #237's Treatment Administration Record was reviewed and is documented in part, as follows: Dialysis Three Times Weekly Starting 7/12/19. Order Date: 7/12/19 Notes Monday and Thursday at 9:30 A.M. then Tuesday, Thursdays and Saturdays. Resident was signed off by nursing as going to dialysis on 7/12/19 and 7/16/19. On 07/17/19 at 11:00 AM Unit Manager Registered Nurse (RN) #3 was asked for Resident #237's Dialysis Communication Log. On 07/17/19 at 2:25 PM Unit Manager RN#3 provided the surveyor with a folder for Resident #237 that included a face sheet and the dialysis patient registration and a Dialysis Post Treatment with a fax date of 7/17/19 which was today. Unit Manager RN#3 was asked when Resident #237's Dialysis Communication Log was started. Unit Manager RN#3 stated, We put it together today after you asked for it we did not have one together when he went out for dialysis on Monday. The Surveyor asked what is the facility/dialysis communication procedure for their residents. Unit Manager RN#3 stated, We should have an ongoing communication log between us and the dialysis center. We should get a set of vital signs and a weight that are done prior to transport, and any medications specific to be given after the treatments are sent as well. The dialysis center sends us back the pre and post weights and vitals. They also send us documentation of any issues they may have occurred with the resident during treatment. The facility policy titled Dialysis-Guidelines of Care revised 1/22/18 was reviewed and is documented in part, as follows: Policy Statement: The facility will provide patients and residents who require dialysis services that are consistent with professional standards of practice. When a resident requires dialysis service, the resident must leave the facility to obtain dialysis. The facility will have an agreement or arrangement with an outside entity providing dialysis services. This agreement will address at least: *Development and implementation of the resident's care plan. *Interchange of information necessary for the resident's care. On 7/18/19 at approximately 4:00 P.M. a pre-exit debriefing was held with the Administrator and the Director of Nursing where the above information was shared. Prior to exit no further information was provided.

Based on staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to ensure medications were provided per physician orders for 1 resident (Resident #84) of 39 residents in the survey sample. The findings include: Resident #84 was admitted to the facility 08/16/2018. Resident #84 left the facility, AMA (Against Medical Advice), on 08/27/2018. Diagnosis included but were not limited to, Left Distal Femur Fracture, Left Distal Radius Fracture and End Stage Renal Disease. Resident #84's admission Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 08/23/2018 was coded with a BIMS (Brief Interview for Mental Status) score of 13 indicating no cognitive impairment. On 07/19/2019 Resident #84's Physician Order's were reviewed and revealed the following medications were ordered on 08/16/2018: Linzess 290 mcg (micrograms) capsule (1 cap) Capsule Oral Two Times Daily Starting 08/17/2018 and Prasugrel 10 mg (milligrams) tablet (1 tab) Tablet Oral One Time Daily Starting 08/17/2018. The brand name for Prasugrel is Effient and is used to help prevent blood clots. Linzess is a prescription medication used in adults to treat irritable bowel syndrome with constipation (IBS-C) and chronic idiopathic constipation (CIC)-www.linzess.com. On 07/19/2019 at 11:30 a.m. the surveyor spoke to the Pharmacy Technician by phone and she said that Linzess and Effient were high cost medications and needed approval to interchange. Medications that cost over $300.00 have to be approved by the facility and they had tried to get the facility to approve. The Pharmacy Technician said Linzess was made available to the resident and sent on 08/22/2018. The pharmacy sent a 15 day supply, 30 tablets, of the Linzess, which cost $447.00. The Pharmacy Technician stated that Effient cost $483.00 for 30 tablets. The Effient was not sent. Review of the Medication Administration Record revealed that Resident #84 was administered Linzess and Prasugrel starting on 08/17/2018. It was determined that Resident #84 provided the medication from home. An interview was conducted with the Administrator on 07/19/2019 at approximately 2:00 p.m. and she was asked, What is your practice when accepting residents that have high cost medications? The Administrator stated, My response to the pharmacy is Please send. The Administrator was asked, Should someone from the facility have responded to the pharmacy? The Administrator stated, Yes. Complaint deficiency.

Based on observation and staff interview of 8 medication carts and 5 medication rooms, the facility staff failed to dispose of expired medications, biologicals and nutritional supplements; and failed to secure a medication cart. The findings include: 1. The facility staff failed to dispose of one Nutritional drink pack. (Prostat) located in the medication cart on unit 300 (Town side). 2. The facility staff failed to discard one unopened bottle of Humulin Insulin located in the refrigerator of the medication room medication on Coastal Unit 400. 3. The facility staff failed to discard an expired bag of multiple urine culture and sensitivity containers/kits. 4. The facility staff failed to lock the medication cart when unattended on the Garden Spring Unit 100. On 07/17/19 at approximately 11:25 AM an inspection of the medication cart was conducted on the Town and Country unit. The cart was located on the Town side of the unit. A packet of Prostat sugar free vanilla liquid protein with an expiration date of 02/21/19 was observed in the cart. LPN #4 (Licensed Practical Nurse) was asked what should have been done with the expired protein pack? She said that the expired Prostat should have been discarded. On 07/17/19 at approximately 12:28 PM an inspection of the Coastal Unit 400 Medication Room was conducted and revealed an unopened bottle of Humulin R insulin 100 unit/ml (milliliter) with an expiration date of 04/2019. Licensed Practical Nurse (LPN) #6 was asked what should have been done? She stated Typically pharmacy should have pulled the expired medicine. On 07/17/19 at approximately 3:40 PM an inspection was conducted in the the Medication room located on the Great Bridge Pavilion Unit 300. During the inspection an expired bag of urine culture and sensitivity containers/kits were located in the cabinet were found. They had an expiration date of 03/2019. (RN) Registered Nurse #2 was asked what should have been done with the expired kits? He stated It should have been dispose of. On 07/17/19 at approximately 4:20 PM, during a medication pass observation. Licensed Practical Nurse #3 left her cart unattended and unlocked with the keys inserted inside of the lock for approximately, 4 minutes. She stated that she was going over to another unit to borrow a glucometer. She was asked by the surveyor what should should have been done when walking away from your medication cart? She stated I should have locked it and taken the keys with me. Policy: Storage of Medications. Revision Date: 02/15/2018. Policy statement: Medications, treatments, and biological's are stored safely, securely, and properly following manufacturer's recommendations or facility policy. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, unlabeled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the pharmacy, if a current order exist. On 07/18/19 at approximately 4:12 PM, a pre-exit interview was conducted with the Administrator and the Director of Nursing (DON). They were debriefed on the above concerns. The DON stated In addition to the Pharmacy Review, it is the nurse's responsibility to discard expired medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility documentation review, the facility staff failed to follow hand hygiene practices consistent with accepted standards of practice while performing wound care for 1 of 39 residents in the survey sample, Resident #6. The findings include: Resident #6 was admitted to the facility on [DATE]. Diagnosis included but were not limited to, Quadriplegia and Neurogenic Bladder. Resident #6's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 04/02/2019 coded Resident #6 with a BIMS (Brief Interview for Mental Status) score of 15 which indicates no cognitive impairment. On 07/18/2019 at 1:06 p.m., the surveyor observed Licensed Practical Nurse (LPN) #6 provide wound care to Resident #6's right gluteal fold wound. LPN #6 washed her hands with soap and water and then proceeded to Resident #6's bedside to begin wound care. LPN #6 stated that she had already been in Resident #6's room and cleaned his overbed table with a germicidal cleaner and placed his wound care supplies on the table. LPN #6 donned clean gloves and removed the resident's soiled dressing from the right gluteal fold. LPN #6 removed the dirty gloves and donned clean gloves without performing hand hygiene between changing of gloves. LPN #6 cleaned the wound with dermal wound cleanser and dried the wound area with a gauze dressing. LPN #6 cut a piece of Xeroform gauze and placed it on the wound and covered it with a 2 X 2 gauze dressing and then covered the gauze dressing with roll stretch. LPN #6 failed to apply clean gloves prior to cutting and handling the Xeroform, placing it on the wound with the gloves used to clean the wound. LPN #6 removed a Sharpie marker hanging on her name badge, removed the cap and wrote the date and her initials on the dressing, replaced the cap on the marker. LPN #6 removed her soiled gloves. LPN #6 failed to clean the Sharpie marker after handling it with her dirty gloves. LPN #6 gathered the left over supplies and placed them in Resident #6's cubby cabinets. LPN #6 then went into the bathroom and washed her hands with soap and water. LPN #6 failed to clean Resident #6's overbed table with a decontaminate after performing wound care. On 07/18/2019 at approximately 4:00 p.m., the surveyor reviewed wound care observations with LPN #6. LPN #6 was asked, Did you sanitize or wash your hands between changing of your gloves? LPN #6 stated, No, I did not want to leave the resident's bedside to wash my hands. LPN #6 stated, I should have removed my dirty gloves and cleansed my hands when going from dirty to clean. LPN #6 was asked, Did you clean the overbed table after completing wound care? LPN #6 stated, No, I should have cleaned the table. I usually clean it with the sani wipes. An interview was conducted with the Administrator and Registered Nurse (RN) #4 on 07/18/2019 at 4:15 p.m. and they were asked, What are your expectations of nurses when performing wound care and going from dirty to clean in a procedure and changing of gloves? RN #4 stated, I expect the nurses to sanitize, wash their hands in between changing their gloves and going from dirty to clean procedures. RN #4 was asked, What are your expectations of the nurse when they have completed wound care treatments? RN #4 stated, I expect the nurse to clean the surface of the table with sani wipes and remove the trash. On 07/19/2019 at approximately 4:00 p.m., at the pre-exit meeting the Administrator and Director of Nursing was informed of the findings. The facility did not present any further information about the finding.

Based on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to maintain an effective antibiotic stewardship program. The findings include: Review of the facility Infection Control Log, from January 2019 until June 2019 revealed the following: On multiple occasions from January of 2019 through June 2019, there was no documentation (left blank) under the column, culture/test obtained Y/N (yes/no), to determine if a test or culture was collected for those residents diagnosed with an infection. On multiple occasions, there was also no documentation under column titled culture, to identify the organism causing the infection. On 7/16/19 at 3:11 p.m., an interview was conducted with the infection control nurse (other staff member) #5. When asked the process for tracking and trending infections, OSM # 5 stated that she tracks infections using a computer program called Vision. OSM #5 stated that she obtains her information from residents charts and documents the following on the infection control log: If the infections were acquired at the facility or present upon admission or re-admission, any cultures/tests obtained, the culture results if indicated, the antibiotic used for treatment and the resolve date of the infection. When asked why there were so many blanks (no documentation) under column culture/test obtained, and culture, OSM #5 stated that most of the columns were blank because when residents were admitted or re-admitted to the facility with infections, she did not have access to any cultures or tests that were obtained in the hospital. When asked if the history and physical and d/c (discharge) summary from the hospital were sent with residents upon admission to facility, OSM #5 stated that at times, the hospital paperwork did not contain that information. When asked if she could call the hospital to obtain that information, OSM#5 stated, I guess we could, yes. When asked why it was important for document if a culture was obtained and the organism causing the infection if a culture/test was obtained; OSM #5 stated that it was important to document that information to ensure the resident was on the appropriate antibiotic. On 7/17/19 at approximately 5:30 p.m., ASM (administrative staff member) #1, the Administrator was made aware of the above concern. Facility policy titled, Infection Prevention and Control Program, documents in part the following: Surveillance: A. The facility tracks infections among residents upon admission and throughout their stay; collecting information necessary for evaluation to determine whether present upon admission or health care associated, analyzing and reporting monthly and quarterly to QAPI as required .C. The facility remains alert for potential outbreaks by the following methods: 1. Daily, weekly and monthly review and analysis of surveillance data, looking for any increase in particular types of infections and any clustering patterns. 2. Review lab findings for the isolation of uncommon or unusual organisms such as opportunistic pathogens and communicable disease agents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, facility document review, and staff interviews the facility staff failed to ensure that 1 of 26 residents were invited to participate in their person-centered plan of care, Resident #10. The facility staff failed to ensure that Resident #10 with a BIMS (Brief Interview for Mental Status) of an 11 and her own Responsible Party was invited to participate in her person-centered plan of care. The findings included: Resident #10 was a 74 year admitted to the facility on [DATE] with diagnoses to include, 1.) Anxiety Disorder, 2.) Major Depression, and 3.) Diabetes Mellitus. A review of Resident #10's current facility Face Sheet indicated that the resident was her own Responsible Party. The most recent comprehensive Minimum Data Set (MDS) assessment was a Annual with an Assessment Reference Date (ARD) of 6/6/17. The Brief Interview for Mental Status (BIMS) was an 11 out of a possible 15 which indicated that Resident #10 was cognitively intact and capable of daily decision making. During the initial tour on 12/4/17 an interview was conducted with Resident #10 and is documented in part, as follows: Resident #10 12/04/17 11:00 AM Resident stated she is only made aware of her care plan meeting on the day of her care plan or right before the meeting is about to start, states her son gets a notice way in advance and he attends. However, the resident stated she would like to attend. Son in to visit resident during interview and stated that he does attend and gets a notice in advance. The resident's son was made aware by this surveyor that his mother expresses she would like to attend her care plan as well. Resident #10's current Comprehensive Care Plan dated 11/24/17 to present was reviewed and documented in part, as follows: Problem: Resident will remain LTC (long term care) related to ADL (activities of daily living) care needs and supervision. Goals: Resident will maintain highest level or psychosocial well being over the next 90 days. Interventions: Invite resident/family to care plans as scheduled, Continuous Starting 11/24/17. Resident #10's Social Service's Note dated 3/28/17 was reviewed and documented in part, as follows: Care plan held family invited but, didn't attend. Resident is able to make her needs known and gets out of her room a little more. Staff to continue to monitor for changes in condition. On 12/8/17 an interview was conducted with the facility Social Worker and is documented in part, as follows: 12/08/17 09:59 AM Interview conducted with the facility Social Worker. The Social Worker was asked who was invited to Resident #10's care plan meetings. SW stated, A copy of the care plan letter invite goes to her son 2 to 3 weeks before the care plan. Surveyor asked if a copy of the invite is also given to the resident at that time as well. The Social Worker stated, No, the son is the only person that gets the invite. The Social Worker was made aware of the residents right and desire to attend her own person-centered care plan meeting and that the resident has a BIMS of 11. The Social Worker stated, From now on I will make sure she also gets one too. The facility policy titled, Life Care-Comprehensive Care Plan revised on 1/17/2017 is documented in part, as follows: Procedure: 2. The facility shall inform the resident of the right to participate in their treatment and shall support the resident in this right, A. Facilitate the inclusion of the resident and/or resident representative. 3. The patient or resident and/or resident representative has the right to participate in the development, implementation, and request changes of their plan of care. This includes but not limited to: A. Right to participate in the planning process, B. Right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care. 14. Social Services will be responsible for notifying the resident and/or resident representative of Care Plan dates in a reasonable timeframe. Care Plan Meeting Schedule Process: 1. Social Services will be responsible for notifying the resident and/or resident representative of Care Plan dates in a reasonable timeframe. On 12/11/17 at 5:50 P.M. a pre-exit conference was held with the Administrator and the Director of Nursing where the above information was shared. Prior to exit no further information was provided. 1.) Anxiety Disorder: a disorder in which anxiety is the most prominent feature. The symptoms range from mild, chronic tenseness, with feelings of timidity, fatigue, apprehension, and indecisiveness, to more intense states of restlessness and irritability that may lead to aggressive acts, persistent helplessness, or withdrawal. 2.) Major Depression: an abnormal emotional state characterized by exaggerated feelings of sadness, melancholy, dejection, worthlessness, emptiness, and hopelessness that are inappropriate and out of proportion to reality. 3.) Diabetes Mellitus: a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion by the beta cells of the pancreas or resistance to insulin. The above definitions are derived from Mosby's Dictionary of Medicine, Nursing, and Health Professions 8th Edition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and facility policy, the facility staff failed to notify One resident (Resident #147) physician of significant medication omissions in the survey sample of 26 residents. The findings included: Resident # 147 was admitted to the facility on [DATE] with diagnoses of multiple closed fractures of pelvis, closed fracture of shaft of right tibia and fibula, rib fractures, coronary artery bypass draft, chronic anticoagulation, asbestosis, COPD, osteoarthritis of knees, cardiovascular disease, sleep apnea, stroke, internal carotid aneurysm, history of renal mass, hypertension, severe obesity, type 2 diabetes mellitus, major depression, hyperlipidemia, and hypertrophy of prostate. Resident #147 was not provided six doses of enoxaparin (Lovenox) 30 mg./0.3 ml subcutaneous via syringe. The Nursing Drug Guide Handbook dated 2016 indicates: Lovenox-Therapeutic class: Anticoagulants ; Pharmacological class: Low-molecular-weight heparin's. Used to prevent PE (pulmonary embolus) and DVT (deep [NAME] thrombosis) after hip or knee replacement surgery. To prevent PE and DVT in patients with acute illness who are at increased risk because of decreased mobility. An Initial Minimum Data Set (MDS) dated [DATE] assessed Resident #147 in the area of Cognitive Patterns - Brief Interview of Mental Status (BIMS) as a (15). In the area of Activities of Daily Living (ADL's) this resident was assessed as a (3/3) in the area of bed mobility, a (7/2) in the area of transfer, a (7/3) in the area of walk in room, (2/2) in the area of dressing, a (0/1) in the area of eating, a (3/3) in the area of toilet use, and a (3/3) in the area of personal hygiene. In the area of Medications this resident was assessed as receiving injections for (7) days. In the area of Insulin this resident was assessed as receiving insulin for (4) days. In the area of Orders for Insulin changes- this resident was assessed for (0) days. In the area of Medications Received - this resident was assessed as receiving Anticoagulant for (7) days. There was no Care Plan for the use of Anticoagulant medications. A Care Plan dated 12/6/17 indicated : Problem- Potential for hypo/hyperglygycemia r/t: DX of DM (resident diagnoses of diabetes mellitus) Goals _ resident will have no s/s (signs or symptoms) of diabetic reaction with blood sugars within normal range of 60/120 mg/dl x (time) 90 d (days). Interventions- Administer medication per MD order, Disciplines -Nursing, Frequency - PRN (as needed). Intervention- monitor for effectiveness of medication, Disciplines- Skilled Nursing, Frequency - PRN. Intervention- monitor for side effects of medication, Disciplines- Skilled Nursing, Frequency - PRN. Intervention- observe for s/s of low blood sugar (sweating, headache, light headed, confusion, slurred speech, drowsiness, Intervention -Observe for s/s pf high blood sugar (polyuria, blurred vision, weakness, headache, anorexia, N & V, abdominal pain, acetone breath, mental changes, hypotension), intervention - Monitor accuchecks per MD order Intervention- serve diet per MD order, Disciplines - Dietary- Licensed Practical Nurse- Registered Nurse, Frequency -PRN. Intervention - Notify MD as needed, Disciplines - Skilled Nursing, Frequency - PRN. A physician's order dated 11/20/17 indicated: enoxaparin (Lovenox) 30 mg/0.3 ml sc syrg - inject 0.3 ml beneath the skin every 12 hours. Lovenox for 3 weeks. A Medication Administration History document with a date range of 11/20/17 to 12/07/17 indicated: enoxaparin 30 mg/0.3 ml, 12/03/17 (06:01) - 12/03/17 (07:05) Not Administered; 12/03/17 (19:01) -12/03/17 (20:33) Not Administered; 12/04/17 (06:01) - 12/04/17 (06:28) Not Administered; 12/04/17 (19:01) - 12/04/17 (20:09); 12/05/17 (06:01) - 12/05/17 (10:07) Not Administered; Not Administered; 12/05/17 (06:01) - 12/05/17 (19:01) - 12/05/17 (18:04) Not Administered. During an interview on 12/4/17 at 1:05 P.M. with Resident #147's wife, she stated, Resident #147 had not received his heparin due to non-availability for several days. During an interview on 12/6/17 at 12:45 P.M. with the 300 Nurse Manager, she stated she was not aware of Resident #147 medications not being available, but would look into it. The 300 Nurse Manager stated, it looks like there was a mix-up in his order. When asked had the doctor been informed of the missed doses, she stated, No. A review of a Facility Policy for Notification of Changes In Condition revised 6/2/17 indicated: The resident, legal representative or family member will be immediately informed and the resident's physician will be consulted when changes defined below occur. 1. The nurse on duty will notify the the Practitioner and resident/legal representative/family member when there is an occurrence of an accident involving the resident which results in injury and has the potential for requiring physician intervention. 3. The nurse on duty will the Practitioner and resident legal representative/family member when there is a need to alter treatments significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatments. A Medication Administration policy revised 2/21/17 indicated: The physician must be promptly notified of omission, or refusal, of any medication which causes the resident discomfort, or jeopardizes health and safety. All other omissions or refusals will be reported to the physician after missing three (3) consecutive doses.

Based on staff interviews and review of facility Medicare Beneficiary Notices, it was determined the facility failed to provide services in accordance with applicable Federal regulations for 2 of 3 discharged resident closed records reviewed, (Residents #62 and #396) . The findings included: On review of the Beneficiary Notification Checklists provided by the facility to surveyors it was noted that no residents were listed for having been issued the SNF ABN(Skilled Nursing Facility-Advanced Beneficiary Notice, form CMS-10055). Each resident had received a NOMNC ((Notice of Medicare Provider Non-Coverage- form CMS-10123), however no copies of the SNF ABN(CMS-10055) were provided. On 12/6/17 at 2:20 PM, the facility Administrator stated during interview that the facility does not issue a SNF ABN when Medicare Part A is discontinued by the provider. She provided a copy of the facility Policy titled Generic Notice of Medicare Provider Non-Coverage, revised 2/21/17. The policy did not reference the SNF ABN. The facility Policy states only that the NOMNC is issued. On 12/6/17 at 3:00 PM, the facility Social Worker was interviewed; she confirmed that only the NOMNC is issued to residents. Resident # 62 started a Medicare Part A stay on 7/31/17, and the last covered day of this stay was 8/14/17. Resident #62 remained in the facility with days remaining in the benefit period, and should have been issued a SNF ABN(CMS-10055) and an NOMNC(CMS-10123). Only an NOMNC was issued, with verbal notification to the family on 8/10/17. Resident #396 started a Medicare Part A stay on 11/10/17, and the last covered day of the stay was 11/19/17. Resident #396 remained in the facility with days remaining in the Medicare benefit period. She should have been issued a SNF-ABN and an NOMNC; only an NOMNC was issued. This NOMNC was signed by the resident representative on 11/15/17. No additional information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, facility staff interview, clinical record review and facility document review the facility staff failed to ensure 1 of 26 residents in the survey sample were free from neglect, Resident #46. On 11/30/17 the facility staff failed to respond to the call bell for Resident #46 in a timely manner. The resident stated she had rang the call bell due to being incontinent of bladder and needed staff to render incontinence care. The call bell was activated at 4:09 AM and was not responded to for two hours. The resident had been left wet for two hours. The findings included: Resident #46 was admitted to the facility on [DATE] with current active diagnosis of Multiple Sclerosis (MS-a chronic, slowly progressive disease of the central nervous system-Taber's Cyclopedic Medical Dictionary). The current MDS (Minimum Data Set) a quarterly with an assessment reference date of 10/11/17 coded the resident as scoring a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating the resident's cognition was intact. The resident required extensive assistance of one staff for toileting and was always incontinent of both bladder and bowel. The resident was wheelchair bound and had range of motion limitations to both lower legs. On 12/05/17 at 11:42 AM, the resident was observed sitting up in a wheelchair in the hallway. A request to conduct an interview was granted by the resident. The resident then propelled herself into her room, During the resident interview Resident #46 stated she had experienced a CNA (Certified Nurse Aide) being argumentative with her during care. When asking the CNA to wipe an area on her buttocks due to it feeling wet the CNA stated it was not wet and swiped the area. The resident stated she had reported her concern to staff and named the person she had reported this to (later identified as the unit manager). The resident continued to state that on 10/30/17 it took the staff two hours to respond to a call bell. She stated she put the call bell on because she was wet and needed incontinence care to be provided. The resident stated she had documented this on a note pad at the bedside. The note pad was reviewed and there was an entry authored by the resident that on 11/30/17 it took two hours for the staff to answer the call bell. Prior to this resident interview the resident had attended the Resident Council meeting facilitated by another inspector. The following notes were obtained from this meeting and read in part: 12/05/17 at 10:13 AM: Resident council meeting. short of staff - concern expressed. two staff on each unit at times. Call bells not answered timely. Resident #46 soaking wet. How do you feel about that. She does not like it. Resident #46 (informs) address the nurse on the floor of her concerns. Residents feel they are under stress if they make a complaint. Night shift staff talk down to-Resident #46- she has reported and it continues to happen. She has documentation and bring {sic} it up during care plan meetings. The Resident Council meeting was attended by 6 residents and one activity staff. Following the Resident council meeting the activity staff immediately reported Resident #46's allegation. On 12/6/17 at 4:36 PM, a request to review of any and all grievances for Resident #46 was made to the Director of Nursing (DON). This same day at 5:52 PM. a grievance form was handed to this inspector. The form titled Incident Abstract Report, report date 12/5/17 read, in part: Event description-Resident stated staff took 2 hours to answer the call bell. When she rendered care, the resident stated the staff member was argumentative. The DON also provided a Facility Reported Incident (FRI) form dated 12/5/17 notifying the State Survey Agency, Adult Protective Agency, the Representative Party and physician of an allegation of abuse/mistreatment. The incident was described as: Resident stated during a Resident Council Meeting that night shift staff argue with her, Clinical Manager followed up immediately and meet with patient. Patient stated that on 11/20/17 at 0500 C.N.A (Certified Nurse Aide#5) was argumentative with her when she needed assistance being cleaned. The staff was identified and immediately suspended pending investigation. On 12/7/17 at 11:20 a.m., an interview was conducted with the unit manager. She stated the resident had expressed that her preference was to be woken up every night at 2:00 a.m., to be changed due to incontinence and history of a rash. The care plan was reviewed and was not revised to include the residence preference for staff to wake her up and check her for incontinence. When asked if this should have been care planned the unit manager stated, I didn't think about it going on the care plan, but it makes sense. The unit manager also stated she was not made aware of the staff taking two hours to answer the call bell. The unit manager was asked if residents had expressed concerns about insufficient staffing and call bells not answered in a timely manner she stated, Yes. The unit manager provided to this inspector a typed note that read: 12/7/17- I spoke with (CNA#5)on Tuesday December 5, 2017 in regard to a complaint from resident in 240. Resident stated she rang the call bell approximately 0310 and no on answered it till about 0513. When (CNA#5) went in the room, she was argumentative per the resident. The resident wanted the top sheet changed because she felt it was wet and (CNA#5) stated it is only water. (CNA#5) said in our conversation on the phone that she does not use wipes on the resident, she uses a washcloth. The sheets could have gotten wet from the washcloth and wet gloves. She did remove the sheet and left the blanket only. She stated she got to her as soon as possible. 12/8/17- I followed up with the resident in 240 on Friday, December 8,2017. The resident was asked if she felt the staff member was being verbally abusive. She stated no she was having trouble with her gown and felt she was not assisting her as she should have. On 12/8/17 and 12/11/18 an attempt to interview the night shift CNA#5 who was assigned to care for Resident #46 on 11/30/17 was made during the survey. The phone number provided when called was answered by a message that stated the phone was not able to receive messages. On 12/8/17 at 11:40 AM, certified nurse aide (CNA) #3 was interviewed. She was asked to give examples of neglect. Two examples she gave were not being changed and being left wet, and not answering call bells in a timely manner. When asked what was timely, she stated, A couple of minutes. When asked if ten minutes was too long to respond to a call bell, she stated, Yes, especially if the patient needs your help. On 12/8/17 at 11:55 AM, CNA #4 was interviewed. She was asked to give examples of neglect. One example she stated was Not answering the call bells. When asked what is the time frame to respond to a call bell she stated, Ideally, immediately .within a few minutes. She was asked if ten to fifteen minutes response time was okay, she stated, That is way too long. A review of the call be system Detailed Patient Activity Report from 11/1/17 through 12/7/17 evidenced on 11/30/17 that at 04:09 am the call bell was placed/activated and the call bell was canceled 2:00:35 hours later. This findings supports the residents allegation that it took two hours for staff to respond to her call bell on 11/30/17. Further investigation of the Detailed Patient Activity Report evidenced frequent long response times to call bells for Resident #46 as follows: 1. On 15 occasions the call bell response time was between 18-20 minutes. 2. On 10 occasions the call bell response time was between 23-30 minutes. 3. On 2 occasions the call bell response time was between 45-50 minutes. On 12/08/17 at 12:53 PM, and interview was conducted with the Director of Nursing (DON). The above response time findings was shared. The DON was asked, What is the expected response time to call bells? She stated, I would expect the call bells to be answered within ten to fifteen minutes. When asked, Is failure to answer a call bell in a timely manner neglect? She stated, Yes, I agree. When asked ,Would you consider waiting two hours for the call bell to be answered to be neglect? She responded That is unacceptable. Review of the facility's Policy and Procedure title Abuse-Freedom From, revised 11/23/16 read, in part: Purpose- Residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The above findings was shared during the pre-exit meeting conducted with the Administrator, the DON and Director of Clinical Services on 12/11/17. No additional information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review the facility staff failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman for 1 of 3 discharged resident closed records reviewed, Resident #97. The findings included: Resident #97 was admitted to the facility on [DATE] for skilled services following a hospitalization. The resident's diagnoses included but not limited to, brain stem cancer and diabetes. The admission MDS (Minimum Data Set) with an assessment reference date of 8/15/17 coded the resident as scoring a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating the resident's cognition was intact. On 12/07/17 at 05:16 PM, the resident's record was reviewed. The nurses notes documented that on 9/6/17 the resident had a change of condition with complaints of abdominal pain. The MD was notified and an order for a KUB (abdominal X-ray) was obtained. The X-ray was positive for an ileus (intestinal obstruction), the resident was transferred to the hospital for further evaluation and admitted . On 12/7/17 at approximately 6:30 PM, a request was made to the Administrator for evidence to support that the ombudsman office was provided a notice of discharge. 12/08/17 10:05 AM, the Administrator provided a copy of the Policy and Procedure titled Transfer, Discharge & Room Change dated 12/31/16. The Administrator stated the facility did not provide a notice of discharge to the Office of the State Long-Term Care (LTC) Ombudsman for Resident #97's discharge to the hospital. The aforementioned policy read, in part: Purpose: To provide patients, residents or resident representative notice of transfer or discharge. Documentation concerning transfer or discharge of a resident must be documented in the clinical record. 5. The facility will send a list of transfers discharges monthly at a minimum to the State Long-Term Care Ombudsman. No additional information was provided prior to exit to support compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review the facility staff failed to send a copy of the Notice of Bed-Hold Policy and return for 1 of 3 discharged resident closed records reviewed, Resident #97. The findings included: Resident #97 was admitted to the facility on [DATE] for skilled services following a hospitalization. The resident's diagnoses included but not limited to,brain stem cancer and diabetes. The admission MDS (Minimum Data Set) with an assessment reference date of 8/15/17 coded the resident as scoring a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating the resident's cognition was intact. On 12/07/17 at 05:16 PM, the resident's record was reviewed. The clinical notes documented that on 9/6/17 the resident had a change of condition with complaints of abdominal pain. The MD was notified and an order for a KUB (abdominal X-ray) was obtained. The X-ray was positive for an ileus (intestinal obstruction), the resident was transferred to the hospital for further evaluation and admitted . On 12/7/17 at approximately 6:30 PM, a request was made to the Administrator for evidence to support that the facility provided written information of the Notice of Bed-Hold Policy to the resident or resident representative prior to transfer to the hospital. 12/08/17 10:05 AM, the Administrator provided a copy of the Policy and Procedure titled Life Care-Bed Hold dated revised on 1/17/17. The Administrator stated the facility did not provide the notice of bed-hold policy to Resident #97 prior to discharge to the hospital. She stated this requirement is part of the new process now, and stated prior to this I'm not sure it was being done. She further stated the Notice of Bed-Hold Policy would have been scanned to the electronic record. The aforementioned policy read, in part: Policy statement: It is the facility policy to inform the resident or resident representative of the durations of the bed-hold policy, If any, during which the resident is permitted to return and resume residence when admitted to an acute care facility or goes on therapeutic leave. 1. Resident or Resident Representative will be provided a Notice of Bed Hold Policy letter at time of transfer; if not immediately possible, notification will be at first available opportunity 2. Notice of bed hold policy will be provided with transfer documents. No additional information was provided prior to exit to support compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility documentation review and clinical record review the facility staff failed to ensure a summary of the base line care plan was received by 1 resident (Resident #351) of 26 residents in the survey sample. The findings included: Resident #351 was admitted to the facility on [DATE]. Diagnoses for Resident #351 included but are not limited to Emphysema* (1) and Diabetes Mellitus* (2). Resident #351's Interim Care Plan documented the following: Resident Need: Oxygenation related to COPD (Chronic Obstructive Pulmonary Disease), Emphysema Start Date: 12/3/17 Approaches included but were not limited to: Evaluate respiratory status every shift and as needed Oxygen per Medical Doctor order Resident #351 current Physician orders included no orders for Resident #351 to have, use and provide care for his personally owned CPAP unit. The Interim Care Plan did not document that Resident #351 was admitted with his own personal owned CPAP (Continuous Positive Airway Pressure) unit and that Resident #351 was performing his own care to his unit. In addition, the Interim Care Plan did not document any specifics related to what type of care the CPAP unit required. On 12/8/17 at approximately 11:50 AM, Social Worker #8 was asked if Residents or Responsible Parties were provided a summary of the Baseline Care plan. She stated, We haven't started that policy. I just heard about the new regulation last week. Currently we will give if asked for it. On 12/8/17 at approximately 12:15 PM, the Director of Admissions Social Services was asked if residents were provided a summary of their care plan. She stated, We have not been giving summaries of the care plan. On 12/8/17 at approximately 4:00 PM, Resident #351 stated, No. when asked if he had received a summary of his baseline carnelian since admission. The Facility Policy and Procedure titled, Baseline Care Plan with a revision date of 1/17/17 documented the following: The facility will provide the resident and/or representative a summary of the baseline care plan to include but not limited to: A. The initial goals of the resident B. Summary of residents medications and dietary instructions C. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility The facility administration was informed of the findings during a briefing on 12/11/17 at approximately 6:10 p.m. The facility did not present any further information about the findings. Definitions: 1. Emphysema: Medline Plus documented: Emphysema is a type of COPD involving damage to the air sacs (alveoli) in the lungs. As a result, your body does not get the oxygen it needs. Emphysema makes it hard to catch your breath. You may also have a chronic cough and have trouble breathing during exercise. 2. Diabetes Mellitus: Medline Plus documented: Diabetes is a disease in which your blood glucose, or blood sugar, levels are too high.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, medical record review, and facility document review the facility staff failed to ensure that 1 of 26 residents were provided activities based on the resident's comprehensive assessment, care plan, and preferences, Resident #13. The facility staff to ensure that Resident #13 was provided activities based on the comprehensive assessment, care plan, and preferences. The findings included: Resident #13 was admitted to the facility on [DATE] with diagnoses to include, 1.) Dementia, 2.) Depression, and 3.) Anxiety Disorder. The most recent comprehensive Minimum Data Set (MDS) assessment was a Significant Change with an Assessment Reference Date (ARD) of 6/8/17. The Brief Interview for Mental Status (BIMS) indicated that Resident #13 had long and short-term memory deficits and was severely impaired in cognitive skills for daily decision making. Under Section D Mood (G.) Trouble concentrating on things, such as reading the newspaper or watching television, Resident #13 was coded Yes for symptoms present and 2-6 days for symptom frequency. In Section F Preferences for Customary Routine and Activities Staff Assessment Resident #13 was coded for all of the following to apply: E. Receiving bed bath, F. Receiving sponge bath, I. Family or significant other involvement in care discussions, K. Place to lock personal belongings, M. Listening to music, O. Keeping up with the news, P. Doing things with groups of people, Q. Participating in favorite activities, and T. Participating in religious activities or practices. Resident #13's Comprehensive Care Plan dated 6/21/17 -9/11/17 was reviewed and is documented in part, as follows: Problems: Name (Resident #13) participation in activities is impaired due to multiple medical problems and confusion. Goals: Name will stimulation and socialization daily in room and verbally reply to visitors. Interventions: Offer Name (Resident #13) distractions including family visits, television, music in room via radio and staff visit during care. Post Activity calendar in room. Resident #13's current Comprehensive Care Plan dated 11/29/17 - Present was reviewed and is documented in part, as follows: Problems: Name (Resident #13) participation in activities is impaired due to multiple medical problems and confusion. Goals: Name will stimulation and socialization daily in room and verbally reply to visitors. Interventions: Offer Name (Resident #13) distractions including family visits, television, music in room via radio and staff visit during care. Post Activity calendar in room. Resident #13 observations while on survey by this surveyor: 12/04/17 12:18 PM Resident lying in bed on right side TV on non religious show. No radio noted in room. 12/05/17 10:24 AM Resident lying in bed on back TV on non-religious show. No radio noted in room. 12/6/17 10:45 AM Resident lying in bed on back TV on show not a music station. No radio noted in room. 12/06/17 02:52 PM Resident lying on right side TV on no radio present in room. TV on a show, non religious not a music station. On 12/06/17 02:11 PM an interview was conducted with RN Unit Manager #2 and was asked by this surveyor if there had bee changes in Name (Resident #13)? RN #2 stated, She was on hospice and came off and they did a significant change assessment on her. Surveyor asked, Does she have family that visit regularly and does she ever get up? RN #2 stated, Yes, her son visits daily usually around 6 in the morning and again in the afternoon. She doesn't get up she stays in her room in the bed. Resident #13's Activity Participation Logs were reviewed from May 2017 through December 2017 and are documented in part, as follows: May 2017 through November 2017 checked for Resident #13: Observed Leisure: 1.) Watching TV, 2.) Family/Friend visit/Visitors. December 2017: 1.) Listening to music (only checked for 1 day December 2nd., 2.) Watching TV, 3.) Family/Friend visit/Visitors. On 12/6/17 03: 00 PM an interview was conducted with the Therapeutic Activities Coordinator after reviewing the Resident #13's most recent comprehensive MDS under activities and preferences and the current comprehensive care plan. This surveyor asked what activities were in place for the resident. The Therapeutic Activities Coordinator stated, her TV and her son visits daily. This surveyor showed the Therapeutic Activities Coordinator Resident #13's Comprehensive MDS and current comprehensive care plan and asked what should have been included in her daily activities based on these documents. The Therapeutic Activities Coordinator stated, we should have included her religious/spiritual preferences, reading of the bible, going out of the room for activities, and having her radio with gospel music playing. We should have been more specific and followed her preferences. On 12/07/17 10:47 AM surveyor observed a radio now present in Resident #13's room on a stand in front of her bed but it is turned off. However, the TV is on and currently on a station with religious preaching heard. Resident #13's current Comprehensive Care Plan dated 11/29/17 - Present was revised on 12/6/17 by the Therapeutic Activities Coordinator and is documented in part, as follows: Problem: Name (Resident #13) is dependent on staff and needs assistance to initiate leisure pursuits. She has strong family support and her son visits daily. She also finds strength in faith. Goals: Name (Resident #13) will have meaningful stimulation daily; demonstrating signs of engagement, comfort, or enjoyment in leisure pursuits at least 75 % of the time by next review date. Interventions: 1. Offer/provide brief social visits as needed for rapport. 2. Offer/provide comforting activities such as playing gospel music for her; reading the Bible to her; devotional stories; musical entertainment; using touch and holding her hand for comfort; sensory stimulation. 3. Assist her so she can enjoy the following TV channels: She enjoys the Christian channels on TV, the gospel music TV channel. 4. Provide 1:1 needs programming for meaningful stimulation. 5. Allow family to spend quality time with Name (Resident #13). 6. Refer to chaplain for spiritual support visits. 7. Provide flowers in her room to promote comfort and relaxing environment when available. The facility policy titled, Life Care-Activity Program revised 3/23/17 was reviewed and is documented in part, as follows: Purpose: The facility will provide for an ongoing program designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental and psychosocial well being of each resident/participant. On 12/11/17 at 5:50 P.M. a pre-exit conference was held with the Administrator and the Director of Nursing where the above information was shared. Prior to exit no further information was provided. 1.) Dementia: a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses. 2.) Major Depression: an abnormal emotional state characterized by exaggerated feelings of sadness, melancholy, dejection, worthlessness, emptiness, and hopelessness that are inappropriate and out of proportion to reality. 3.) Anxiety Disorder: a disorder in which anxiety is the most prominent feature. The symptoms range from mild, chronic tenseness, with feelings of timidity, fatigue, apprehension, and indecisiveness, to more intense states of restlessness and irritability that may lead to aggressive acts, persistent helplessness, or withdrawal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interview, staff interviews, facility documentation review and clinical record reviews the facility staff failed to ensure appropriate respiratory care was provided to 2 residents in the sample of 26, Resident #351 and #64. 1. The facility failed to ensure 1 resident (Resident #351) with respiratory care of a CPAP machine received care consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences. 2. The facility staff failed to ensure the filters on the oxygen concentrator were free of debris for Resident #64. The Findings included: 1. Resident #351 was admitted to the facility on [DATE]. Diagnoses for Resident #351 included but are not limited to Emphysema* (1) and Diabetes Mellitus* (2). Resident #351's Interim Care Plan documented the following: Resident Need: Oxygenation related to COPD (Chronic Obstructive Pulmonary Disease), Emphysema Start Date: 12/3/17 Approaches included but were not limited to: Evaluate respiratory status every shift and as needed Oxygen per Medical Doctor order Resident #351 current Physician orders included no orders for Resident #351 to have, use and provide care for his personally owned CPAP unit. The Interim Care Plan did not document that Resident #351 was admitted with his own personal owned CPAP (Continuous Positive Airway Pressure) unit and that Resident #351 was performing his own care to his unit. In addition, the Interim Care Plan did not document any specifics related to what type of care the CPAP unit required. On 12/4/17 at approximately 1:15 PM, Resident #351's CPAP mask was observed lying on top of his bedside table. The tubing for it was lying in his opened bedside table drawer without a date as to when it was last cleaned or changed. On 12/4/17 at approximately 5:45 PM, Resident #351's CPAP mask was observed lying on top of his bedside table. The tubing for it was lying in his opened bedside table drawer without a date as to when it was last cleaned or changed. 12/06/17 at approximately 03:35 PM, Resident #351 was observed in his Room, oxygen at 2 liters via nasal cannula. Resident stated, Therapy went well. Non dated 1 liter opened bottle of Sterile water observed at bedside. 12/07/17 at approximately 10:02 AM, Resident #351 was observed in his room with the Unit Manager #4 in attendance. 1 Liter opened Sterile Water undated bottle was observed at bedside. The Unit Manager #4 removed the undated bottle of Sterile Water. The Unit Manager #4 and Surveyor looked at CPAP tubing it was dated 12/5/17. The CPAP mask was not with the CPAP tubing. Asked what the practice was for storage of sterile water. The Unit Manager #4 stated that she's only been here a short time, and it is practice to date bottles when open. The Unit Manager #4 stated it should be stored in his locked cabinet in his room which it was not. The Unit Manager #4 stated that she was not sure where the mask is, she stated that she has been teaching staff that night shift usually changes tubing or if someone is in there and sees it needs to be changed at any time. The Unit Manager #4 stated tubing is getting changed Midnight shift on Tuesday nights. When asked what the facility practice is when a resident is admitted with undated tubing, the Unit Manager #4 stated, I guess the admission nurse should change tubing and date so that we know when it was last done and then it would be done on midnight shift every Tuesday after that. Resident #351 was observed on 12/07/17 at approximately 05:27 PM eating in dining room and sitting in a wheel chair. Resident #351 stated I clean my own mask (CPAP). I put the water in the CPAP and sometimes the girls do it. I doubt they even know I clean the mask. I clean it with soap and water every day. On 12/08/17 at approximately 3:00 PM, the Director of Nursing (DON) was asked if it is the expectation that Resident #351's Care Plan be updated/revised to include information that he is independently performing his care for the CPAP unit, and to include the specifics of the care. The DON stated, Yes, it would be the expectation. The Facility's Policy and Procedure titled, Positive Airway Pressure (PAP) Devices: Equipment Cleaning with a revision date of 6/23/16 documented the following: PAP Equipment will be maintained in clean condition. Clean headgear and tubing once a week and as needed. Wash/wipe clean nasal pillows or mask daily as needed. Clean the flow generator once a week and as needed. Clean devise filters once a week and as needed. Empty daily, refill with distilled or sterile water nightly. Clean humidifier reservoir weekly. The Facility Policy and Procedure titled, Life Care-Medications-Prescriber Medication Orders with a revision date of 01/17/17 documented the following: Written Orders - Orders written on the Physician's Order form by the physician must be signed and dated and must be concise regarding the name of the medication, strength, form, method, route, and reason for use. The facility administration was informed of the findings during a briefing on 12/11/17 at approximately 6:10 p.m. The facility did not present any further information about the findings. Definitions: 1. Emphysema: Medline Plus documented: Emphysema is a type of COPD involving damage to the air sacs (alveoli) in the lungs. As a result, your body does not get the oxygen it needs. Emphysema makes it hard to catch your breath. You may also have a chronic cough and have trouble breathing during exercise. 2. Diabetes Mellitus: Medline Plus documented: Diabetes is a disease in which your blood glucose, or blood sugar, levels are too high. 2. The facility staff failed to ensure the oxygen concentrator filters were free from debris for Resident #64. Resident #64 was admitted to the facility on [DATE] with diagnoses to include, but not limited to chronic obstructive pulmonary disease (COPD). The current MDS (Minimum Data Set) a quarterly with an assessment reference date of 10/26/17 coded the resident as scoring a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating the resident's cognition was intact. The Person Centered Comprehensive Plan of Care dated 11/1/17 evidenced as a problem that the resident was not able to maintain oxygen saturation levels and received oxygen at 2 liters/ minute. The goal was that the resident would maintain an oxygen saturation level with in acceptable limits. Interventions included, but not limited to; changing the tubing as ordered, and check/fill the humidifier. The physician order dated 9/11/17 instructed the staff to clean the filter weekly and as needed. The aforementioned plan of care was not revised to include this order. On 12/04/17 at 12:34 PM, the resident was observed in bed and awake. The resident was receiving oxygen via nasal cannula at 2 liters/minute from the oxygen concentrator. The nasal cannula tubing and oxygen humidifier were dated as changed on 11/29/17. Both external filters on the sides of the concentrator were observed coated with a white lint like substance. On 12/06/17 at 03:47 PM, the resident was observed in bed and awake. The resident was receiving oxygen via nasal cannula at 2 liters/minute from the oxygen concentrator. One of two filters remained coated with white lint like substance and in need of cleaning (right side). The Humidifier was dated as changed on 12/6/17. On 12/7/17 at 9:55 AM, the unit manager was interviewed. The observation of the facility staff failure to ensure the oxygen filters were free of debris was shared. She stated it was the responsibility of the staff who orders supplies to change the filters weekly. She states the filters are not rinsed under the water, but instead discarded and replaced with new filters. She stated she had noted approximately a month ago that there was education needed to staff to ensure the filters were being changed. She stated she verbally spoke to the staff person responsible for changing the filters but did not do an inservice. She stated she will make sure that the staff are made aware that some of the concentrators have one filter while others have two. The above findings was shared with the Director of Nursing on 12/11/17 at 1:30 AM, she stated the supply person was responsible for checking the oxygen filters and changing them as needed. No additional information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to have sufficient nursing staff to meet the resident's needs in a manner to promote the resident's rights, physical and mental well-being in accordance to the plan of care for 1 of 26 residents in the survey sample, Resident #46. On 11/30/17 the facility staff failed to respond to the call bell for Resident #46 in a timely manner. The resident stated she had rang the call bell due to being incontinent of bladder and needed staff to render incontinence care. The call bell was activated at 4:09 AM and was not responded to for two hours. The resident had been left wet for two hours. The findings included: Resident #46 was admitted to the facility on [DATE] with current active diagnosis of Multiple Sclerosis (MS-a chronic, slowly progressive disease of the central nervous system-Taber's Cyclopedic Medical Dictionary). The current MDS (Minimum Data Set) a quarterly with an assessment reference date of 10/11/17 coded the resident as scoring a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating the resident's cognition was intact. The resident required extensive assistance of one staff for toileting and was always incontinent of both bladder and bowel. The resident was wheelchair bound and had range of motion limitations to both lower legs. Resident #46's Comprehensive Person Centered Care Plan dated 10/18/17 to present was reviewed. The care plan identified the resident was incontinent of both bladder and bowel. The goal was listed as the resident would not have complications associated with incontinence over the next 90 days. Three interventions listed were to apply protective garments/pads as needed and provide peri-care after each incontinent episode, and keep skin clean and dry as needed. On 12/05/17 at 11:42 AM, the resident was observed sitting up in a wheelchair in the hallway. A request to conduct an interview was granted by the resident. The resident then propelled herself into her room, During the resident interview the resident stated that on 11/30/17 it took the staff two hours to respond to a call bell. She stated she put the call bell on because she was wet and needed incontinence care to be provided. While rendering care the staff were argumentative with her. The resident stated she had documented this on a note pad at the bedside. The note pad was reviewed and there was an entry authored by the resident that on 11/30/17 it took two hours for the staff to answer the call bell. Prior to this resident interview the resident had attended the Resident Council meeting facilitated by another inspector. The following notes were obtained from this meeting and read in part: 12/05/17 at 10:13 AM: Resident council meeting. short of staff - concern expressed. two staff on each unit at times. Call bells not answered timely. Resident # 46 soaking wet. How do you feel about that. She does not like it. (Name of another resident) waited two hours for meds. waiting for pain meds. happened once . Facility staff, Stated we are working on it. Not aware Resident #46 (informs) address the nurse on the floor of her concerns. Residents feel they are under stress if they make a complaint. Night shift staff talk down Resident #46- she has reported and it continue to happens. Six residents were in attendance of this meeting. A review of the call be system Detailed Patient Activity Report from 11/1/17 through 12/7/17 evidenced on 11/30/17 that at 04:09 am the call bell was placed/activated and the call bell was canceled 2:00:35 hours later. This findings supports the residents allegation that it took two hours for staff to respond to her call bell on 11/30/17. Further investigation of the Detailed Patient Activity Report evidenced frequent long response times to call bells for Resident #46 as follows: 1. On 15 occasions the call bell response time was between 18-20 minutes. 2. On 10 occasions the call bell response time was between 23-30 minutes. 3. On 2 occasions the call bell response time was between 45-50 minutes. On 12/7/17 at 11:20 a.m., an interview was conducted with the unit manager. She stated the resident had expressed that her preference was to be woken up every night at 2:00 a.m., to be changed due to incontinence and history of a rash. The unit manager also stated she was not made aware of the staff taking two hours to answer the call bell. The unit manager was asked if residents had expressed concerns about insufficient staffing and call bells not answered in a timely manner she stated, Yes. When asked was there a particular shift that the residents state are not staffed sufficiently she stated, All shifts. The unit manager stated that normal staffing patterns on the Town and Country unit a 40 bed unit, were 2 licensed practical nurses (LPN's) and 4 Certified Nurse Aides (CNA's) for day shift (7am-3pm), 2 LPN's and 4 CNA's for evening shift (3pm-11pm) an 1 LPN and 2 CNA's for night shift (11pm-7am). The unit manager stated that there was supposed to be 2 LPN's for night shift and as of January 2018 more positions will be opened up. She also stated the CNA workload should be 1-10 residents on days and evenings but half the time they have more than 10 residents. The census on the unit was 37 during initial tour of the combined units (Town/Country). On the night of 11/30/17 there were 2 CNA's on the night shift to cover both the Town and Country units. An attempt to interview the night shift CNA who was assigned to care for Resident #46 on 11/30/17 was made during the survey. The phone number provided when called was answered by a message that stated the phone was not able to receive messages. On 12/4/17 a dining room lunch observation was conducted on the Town/Country unit. One CNA was observed distributing lunch trays to residents who ate in their rooms. The CNA would take one tray at a time as they were plated and served and take them individually to the resident room. After the observation the CNA (Certified Nurse Aide #7 was interviewed. She stated that when the staffing is short (3 CNA's) it takes about 45 minutes to pass trays, which also interferes with assisting residents who need to be fed. Review of the day shift daily assignment sheet for 12/4/17 evidenced there were 3 CNA's for a census of 37 residents. On 12/8/17 at 11:15 AM, LPN #10 was interviewed. She was asked about staffing. She stated that the unit is short staffed at least once a week. When asked what short staff was, she stated three CNA's. She stated this makes it more difficult to complete nursing tasks due to nursing having to assist residents with toileting, answering call bells, feeding and passing out water. On 12/8/17 at 11:55 AM, CNA#4 was interviewed. She was asked about staffing. She stated, If there is a call out and we only have three CNA's there is a significant difference. When asked what the significant difference is, she stated answering call bells, feeding residents and passing trays. On 12/08/17 at 12:53 PM, and interview was conducted with the Director of Nursing (DON). The above response time findings was shared. The DON was asked, What is the expected response time to call bells? She stated, I would expect the call bells to be answered within ten to fifteen minutes. When asked, Is failure to answer a call bell in a timely manner neglect? She stated, Yes, I agree. When asked ,Would you consider waiting two hours for the call bell to be answered to be neglect? She responded That is unacceptable. The DON was asked if the failure to answer call bells in a timely manner was due to insufficient staffing. She stated she was not sure and would have to look further into this. Review of the facility's Policy and Procedure title Abuse-Freedom From, revised 11/23/16 read, in part: Purpose- Residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The above findings was shared during the pre-exit meeting conducted with the Administrator, the DON and Director of Clinical Services on 12/11/17. The Administrator was asked what is the expected time frame to answer a call bell, she stated, Ten minutes. No additional information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interviews and clinical record review the facility staff failed to ensure 1 of 26 residents in the survey sample obtained dental services to meet the residents needs, Resident #64. The facility staff failed to make a follow up oral surgery appointment after a referral was obtained from the dentist for Resident #64. The findings included: Resident #64 was admitted to the facility on [DATE] with diagnoses to include, but not limited to chronic obstructive pulmonary disease (COPD). The current MDS (Minimum Data Set) a quarterly with an assessment reference date of 10/26/17 coded the resident as scoring a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating the resident's cognition was intact. The Person Centered Comprehensive Plan of Care dated 11/1/17 identified as a problem that Resident # 64 had a broken front lower tooth. The goal was that the resident would be free of dental pain. One of the intervention listed to achieve the goal was to schedule a dental evaluation and arrange for follow up care as indicated. On 12/04/17 at 12:14 PM, Resident # 64 was observed in bed and awake. She was interviewed about dental care. She stated the dentist came to visit a few months ago after losing a cap. The resident stated the loss of the cap interfered with eating and has to use the other side of her mouth to chew. The resident stated a dental follow up for oral surgery was supposed happen but did not know the status at this time. The resident denied any pain at this time. A review of the clinical record was conducted. The resident's weights indicated no weight loss since the loss of the dental crowns in October 2017. The resident's weight on 10/24/17 was 185 pounds, current weight was 188 pounds. Clinical notes dated 9/28/17 documented that the resident's lower tooth fell out. Resident denies pain. The Resident Representative/ Party (RR/RP) and the physician were notified. Clinical notes dated 9/29/17 documented that the resident's RP was contacted and notified that the dentist who used to come to the facility no longer comes to the facility. A voicemail was left to find out if the RP wants resident to go for a dental appt. (appointment). Clinical notes dated 10/16/17 documented by the unit manager read, Contacted (name of dental surgery group) for resident to be seen for chipped tooth. Indicated we would have to have a referral prior to being seen. Social work contacting facility dentist. Clinical notes dated 10/20/17 documented by the unit manager read, Dentist in to see resident's broken teeth. Contacted (name of dental surgery group) for referral for extraction . The Dental Patient Record dated 10/20/17 note read, #25 & 26 both crowns are broken at the gingival margin the teeth need to be extracted pt. (patient) has no pain needs referral to oral surgeon. The clinical record failed to evidence any further action by the staff to ensure the referral to the oral surgeon was complete and an appointment was made. On 12/7/17 at 9:55 AM, the unit manager was interviewed and asked about the delay and failure to obtain an appointment with the oral surgeon for the resident. She stated, I'm not sure .I made initial contact with (name of oral surgeon group), I sent them a fax .I believe I called them and left a voice mail . She further stated, There probably needs to be a better process between me and the nurses .before we used to have a desk nurse who would make the appointments .I think it got lost in the shuffle . She stated she refaxed the referral this morning to the oral surgeon's office. She spoke to someone at the office to ensure the refaxed referral was received. She was told someone would review it and get back to the nurses on the unit. On 12/08/17 at 12:11 PM, an interview about dental services for Resident #64 was conducted with the Social Worker (SW#2). The SW stated she is responsible for scheduling the dentist visits every quarter. A list of residents to be seen is distributed to the units. The contracted dental services provider sends her the resident list. On the day of the dentist visits she assists with coordinating with staff to ensure the residents on the list are taken to the designated exam room. She stated the business office handles any additional insurance needs. When asked specifically for the status of the referral to the oral surgeon per the dentist on 10/20/17 she stated she was first made aware of this referral two days ago when the unit manager came to her. She stated she used to get the referrals directly from the dentist after the residents were seen. She would then communicate referrals/follow ups to the nursing staff. At that point nursing would be responsible for the recommended follow ups to include making appointments if the resident required outside dental services. She further stated, From now on my part will be to call the families to let them know the resident has been seen by the dentist and a referral was needed. In addition, I will follow up with the nursing staff to make sure an appointment was made and follow up on the status of a referral. The SW stated she will ensure documentation will be done with the follow ups. On 12/11/17 at 1:30 PM, an interview was conducted with the Director of Nursing (DON). The above findings of the facility's failure to obtain an appointment to the oral surgeon per the referral dated 10/20/17 and the staffs failure to follow up was shared. The DON response was that it that this was Not acceptable. No additional information was provided to the survey team prior to exit to support compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review and facility document review the facility staff failed to ensure a speech screen was completed for 1 out of 26 residents (Resident #85) in the survey sample. The facility staff failed to ensure a speech screen was completed for Resident #85 who was having difficulty swallowing. The findings included: Resident #85 was originally admitted to the facility on [DATE]. Diagnosis for Resident #85 included but not limited to *Dysphagia and *Dementia. The Resident was coded with a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15, indicating moderate cognitive impairment. In addition, the MDS coded Resident #85 requiring total dependence of two with transfer, extensive assistance of one with bed mobility, dressing, toilet use, personal hygiene and bathing and set-up help only with eating. *Dysphagia is difficulty in swallowing, commonly associated with obstructive or motor disorders of the esophagus (Mosby's Dictionary of Medicine, Nursing & Health Professions 7th Edition). *Dementia is the name for a group of symptoms caused by disorders that affect the brain. People with dementia may not be able to think well enough to do normal activities, such as getting dressed or eating. They may lose their ability to solve problems or control their emotions. Their personalities may change. They may become agitated or see things that are not there (https://medlineplus.gov/ency/article/007365.htm). The Physician Order Sheet for December 2017 indicated a regular diet. According to clinical documentation written by the social worker (SW) on 11/16/17 at approximately 11:22 a.m., indicated the following: Had a care plan meeting with Resident #85's daughter in which weight loss was discussed. The daughter stated the following: Mom is not wanting to swallow her food, she can't swallow; therapy has been contacted and the clinical manager to put order in for speech therapy (ST) to screen due to her swallowing issues. An interview was conducted with the social worker (SW) on 12/8/17 at approximately 9:15 a.m., who stated During the care plan meeting the daughter voiced concerns related to Residents #85 having difficulty swallowing and that she sent the rehab director an email on 11/16/17, requesting a ST screen. According to clinical documentation, an email was sent from the SW to the Rehab Director on 11/16/17 at approximately 10:47 a.m., the SW requested the following: Can you have ST screen Resident #85 for swallowing issues, we just had a care plan meeting with the residents' daughter and she states that she believes her mom is having a hard time swallowing. During the review of Resident's #85 clinical record; the surveyor was unable to locate if a ST screen was completed. An interview was conducted on 12/8/17 at approximately 10:00 a.m., with the Clinical Manager on Coastal Cottage; the surveyor asked if she had informed ST that Resident #85 needed a speech screen due to swallowing issues that was discussed during her care plan meeting on 11/16/17, she replied, Usually I will tell the therapist verbally and write an order in Vision but because there is no screen form to complete; I guess I slipped on that one. The surveyor asked when should a screen be completed, she relied All screens should be followed through within 24 hours. An interview was conducted with the ST on 12/8/17 at approximately 10:35 a.m., who stated, The ST screen was verbally told to me about 2 weeks ago when I was treating someone else and I totally forgot; it was my fault. The ST proceeded to say we need to work on our communication progress because when I'm treating someone, I shouldn't be verbally told while treating or working with another resident. The ST stated, she was waiting for an order to appear in Vision but one never did, I was informed yesterday, 12/7/17, that a screen was needed on Resident #85 due to swallowing issues; the ST screen was completed on 12/7/17. According to clinical documentation indicated the following note written on 12/7/17 at approximately 2:18 p.m., ST screen completed. Resident #85 was seen in the facility's dining room sitting upright in the wheelchair. Resident consumed regular diet textures without sign/symptoms (s/s) of aspiration. No further ST services needed at this time. On 12/8/17 at approximately 2:40 p.m., an interview was conducted with the Rehab Manager, who stated She verbally informed the ST the same day she received an email from the SW on 11/16/17 to screen resident due to having difficulty swallowing. The facility administration was informed of the findings during a briefing on 12/11/17 at 5:50 p.m. The facility did not present any further information about the findings. The facility's policy: New Patient Referrals/Request for Services (Revision 10/9/17). Exceptions: Therapy screenings may be done without a physician's order to determine need for therapy services. This includes chart review, and interview of the patient/caregivers, as well as general observation of the patient. Therapists may provide community education and wellness/injury prevention training without a physician's orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and facility policy, the facility staff failed to ensure 1 resident (Resident #147) clinical records were accurate and complete in the survey sample of 26 residents. The findings included: Resident # 147 was admitted to the facility on [DATE] with diagnoses of multiple closed fractures of pelvis, closed fracture of shaft of right tibia and fibula, rib fractures, coronary artery bypass draft, chronic anticoagulation, asbestosis, COPD, osteoarthritis of knees, cardiovascular disease, sleep apnea, stroke, internal carotid aneurysm, history of renal mass, hypertension, severe obesity, type 2 diabetes mellitus, major depression, hyperlipidemia, and hypertrophy of prostate. Resident #147 was not provided six doses of enoxaparin (Lovenox) 30 mg./0.3 ml subcutaneous via syringe. facility staff failed to ensure Resident #147 clinical records were accurate and complete for the administration and monitoring of insulin and blood glucose levels. The Nursing Drug Guide Handbook dated 2016 indicates: Lovenox-Therapeutic class: Anticoagulants ; Pharmacological class: Low-molecular-weight heparin's. Used to prevent PE (pulmonary embolus) and DVT (deep [NAME] thrombosis) after hip or knee replacement surgery. To prevent PE and DVT in patients with acute illness who are at increased risk because of decreased mobility. An Initial Minimum Data Set (MDS) dated [DATE] assessed Resident #147 in the area of Cognitive Patterns - Brief Interview of Mental Status (BIMS) as a (15). In the area of Activities of Daily Living (ADL's) this resident was assessed as a (3/30 in the area of bed mobility, a (7/2) in the area of transfer, a (7/3) in the area of walk in room, (2/2) in the area of dressing, a (0/1) in the area of eating, a (3/3) in the area of toilet use, and a (3/3) in the area of personal hygiene. In the area of Medications this resident was assessed as receiving injections for (7) days. In the area of Insulin this resident was assessed as receiving insulin for (4) days. In the area of Orders for Insulin changes- this resident was assessed for (0) days. In the area of Medications Received - this resident was assessed as receiving Anticoagulant for (7) days. There was no Care Plan for the use of Anticoagulant medications. A Care Plan dated 12/6/17 indicated : Problem- Potential for hypo/hyperglygycemia r/t: DX of DM (resident diagnoses of diabetes mellitus) Goals _ resident will have no s/s (signs or symptoms) of diabetic reaction with blood sugars within normal range of 60/120 mg/dl x (time) 90 d (days). Interventions- Administer medication per MD order, Disciplines -Nursing, Frequency - PRN (as needed). Intervention- monitor for effectiveness of medication, Disciplines- Skilled Nursing, Frequency - PRN. Intervention- monitor for side effects of medication, Disciplines- Skilled Nursing, Frequency - PRN. Intervention- observe for s/s of low blood sugar (sweating, headache, light headed, confusion, slurred speech, drowsiness, Intervention -Observe for s/s pf high blood sugar (polyuria, blurred vision, weakness, headache, anorexia, N & V, abdominal pain, acetone breath, mental changes, hypotension, intervention - Monitor accuchecks per MD order Intervention- serve diet per MD order, Disciplines - Dietary- Licensed Practical Nurse- Registered Nurse, Frequency -PRN. Intervention - Notify MD as needed, Disciplines - Skilled Nursing, Frequency - PRN. A physician's order dated 11/20/17 indicated: enoxaparin (Lovenox) 30 mg/0.3 ml sc syrg - inject 0.3 ml beneath the skin every 12 hours. Lovenox for 3 weeks. A Medication Administration History document date range 11/20/17 to 12/07/17 indicated: enoxaparin 30 mg/0.3 ml, 12/03/17 (06:01) - 12/03/17 (07:05) Not Administered; 12/03/17 (19:01) -12/03/17 (20:33) Not Administered; 12/04/17 (06:01) - 12/04/17 (06:28) Not Administered; 12/04/17 (19:01) - 12/04/17 (20:09); 12/05/17 (06:01) - 12/05/17 (10:07) Not Administered; Not Administered; 12/05/17 (06:01) - 12/05/17 (19:01) - 12/05/17 (18:04) Not Administered. During an interview on 12/4/17 at 1:05 P.M. with Resident #147's wife, she stated, Resident #147 had not received his heparin due to non-availability for several days. During an interview on 12/6/17 at 12:45 P.M. with the 300 Nurse Manager, she stated she was not aware of Resident #147 medications not being available, but would look into it. The 300 Nurse Manager later stated, it looks like there was a mix-up in his order. When asked had the doctor been informed of the missed doses, she stated, No. A Medication Administration History print-out with a 11:46 A.M. 12/07 17 run date indicated: Novolin 70/30 100 unit/ml subcutaneous suspension two times daily starting 11/22/17. An Administration History form with a date administered column indicated: 11/22/17 (7:30) date documented (11:22/17 (08:23) Not administered, Notes: resident wife taking BS (blood sugar) and injecting insulin An Administration History form indicated: date administered column 11/22/17 (7:30) - 11/22/17 (8:23) Blood Sugar Site - Value (Blank). 11/22/17 (16:30) -11/22/17 - 11/22/17 (17:34) Blood Sugar value 129, Insulin not administered wife administered. An Administration History form dated 11/23/17 (7:30) - 11/23/17 (8:51) blood sugar site Value (blank) Notes - Resident wife stated she does BS and administer insulin. There is no further documentation of Novolin or Blood Sugar levels being shared or documented by the facility staff. A Medication Administration policy revised 2/21/17 indicated: The physician must be promptly notified of omission, or refusal, of any medication which causes the resident discomfort, or jeopardizes health and safety. All other omissions or refusals will be reported to the physician after missing three (3) consecutive doses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** #3. The facility staff failed to provide dignity during dining services by wearing gloves while assisting/feeding Resident #55. Resident #55 was originally admitted to the nursing facility on 5/5/17. The diagnosis for Resident #55 included but are not limited to *Dementia. Resident's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/19/2017 coded Resident #55 a 00 out of a possible 15 indicating severe cognitive impairment for making decisions. In addition, the MDS coded Resident #55 requiring extensive assistance of one with eating. During dining observation on the Coastal Cottage on 12/4/17 at approximately 11:45 a.m., RN # 1 was feeding Resident #55 while wearing gloves throughout the entire lunch meal. On the same day at approximately 2:00 p.m., an interview was conducted RN #1 who stated, I guess I was nervous and was trying to do the right thing. I was passing out trays and I guess I just forgot to take my gloves off; I felt like I was doing the right thing by wearing gloves but obviously not. On 12/06/17 at approximately 2:38 p.m., an interview was conducted with the Director of Nursing (DON) who stated, The staff should not be wearing gloves while feeding but to use hand sanitizer as well as washing your hands; this can be a dignity issue for that resident to wear gloves while feeding. *Dementia is the name for a group of symptoms caused by disorders that affect the brain. People with dementia may not be able to think well enough to do normal activities, such as getting dressed or eating. They may lose their ability to solve problems or control their emotions. Their personalities may change. They may become agitated or see things that are not there (https://medlineplus.gov/ency/article/007365.htm). #4. The facility staff failed to provide dignity during dining services by wearing gloves while feeding/assisting Resident #83. Resident #83 was originally admitted to the nursing facility on 10/31/17. The diagnosis for Resident #83 included but are not limited to *Alzheimer's. Resident's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/07/2017 coded Resident #83 a 00 out of a possible 15 indicating severe cognitive impairment for making decisions. In addition, the MDS coded Resident #83 requiring extensive assistance of one with eating. During dining observation on the Coastal Cottage on 12/4/17 at approximately 11:45 a.m., Licensed Practical Nurse (LPN) #1 was feeding Resident 83 while wearing gloves throughout the entire lunch meal. On the same day at approximately 12:21 p.m., an interview was conducted with LPN #3 who stated, I was wearing gloves because I was just getting over pneumonia and I was protecting myself. On 12/06/17 at approximately 2:38 p.m., an interview was conducted with the Director of Nursing (DON) who stated, The staff should not be wearing gloves while feeding but to use hand sanitizer as well as washing your hands; this can be a dignity issue for that resident to wear gloves while feeding. The facility administration was informed of the findings during a briefing on 12/11/17 at 5:50 p.m. The facility did not present any further information about the findings. The facility's policy: Life Care-Resident Rights and Responsibilities (Revision - 01/17/17). Policy statement: Prior to, or upon admission to the facility, the patient or resident will be informed of their rights, grievances, procedures, and the rules and regulations governing their conduct and responsibilities while residing in the facility. The patient or resident has the right to respect, dignity, a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility and to be supported by the facility in exercising those rights. *Alzheimer's is the common form of dementia. A progressive disease beginning with mild memory loss possibly leading to loss of the ability to carry on a conversation and respond to the environment (Source: http://www.cdc.gov/aging/aginginfo/alzheimers.htm). 2. The facility staff failed to maintain Resident #353's dignity by allowing the resident to be seen on the commode from the Unit's main hall way. Resident #353 was admitted to the facility on [DATE]. Diagnoses for Resident #353 included but are not limited to Abnormality of gait* (1) and mobility. Resident #353's admission Minimum Data Set (MDS - an assessment protocol) with an Assessment Reference Date of 12/4/17 coded Resident #353 with a BIMS (Brief Interview for Mental Status) score of 15 of 15 indicating no cognitive impairment. In addition the admission MDS coded Resident #353 as requiring limited assistance with 2 staff person assistance for transfer. Resident #353 was coded as requiring limited assistance with one staff person assistance for toilet use. Resident #353 was coded as always continent of urinary and bowel functions. An observation on 12/04/17 at approximately 1:30 p.m. during initial tour, housekeeper #5 was observed standing at Resident #352's doorway with the door half opened. Resident #353 was observed sitting on the commode. The surveyor stated, Oh, she's in the bathroom. waiting to see if housekeeper #5 would close the door. The housekeeper did not close the door, and Resident #353 remained visible to those walking down Household Great Bridge's hallway. On 12/6/17 at approximately 2:20 p.m., an interview was conducted with housekeeper #5. Housekeeper #5 was asked what she felt about Resident #353 being on the commode with the door open. Housekeeper #5 stated, I should have closed the door. I knew when I heard you say, oh she is on the toilet. The housekeeper stated, I was so focused on the wet floor waiting for it to dry. And then a family member came in. When asked how she would feel if someone allowed anyone walking down the hall to see her on the commode, the Housekeeper replied, I'd feel bad. Asked if she felt it was a privacy and dignity issue and the housekeeper stated, Yes. On 12/05/17 at approximately 2:16 PM, Resident #353 was asked how she felt being exposed to anyone walking down the hall way while she was on the commode. Resident #353 stated, Well, I've gotten used to it, but I should be allowed my privacy. I feel bad when others see me in my private moments. Resident #353 continued to state, Some of the staff will close the door allowing for privacy and others will not. On 12/06/17 at approximately 03:58 PM Resident #353's daughter was visiting with her Mother. The daughter was updated on an observation of housekeeper not allowing for privacy for her mother made on 12/4/17. The daughter stated, I'm glad you'll are checking residents. On 12/07/17 at approximately 5:52 PM, the Director of Environmental Services was asked if it was her expectation for Housekeeping staff to stand at a resident's door with it half way open allowing passers in the hall to see a resident sitting on the commode. The Director of Environmental services stated that it was her expectation for staff to provide privacy for the residents to enhance their dignity. The Director of Environmental Services stated that the Housekeeper had stated to her that she was concerned about the floor drying so no one would fall and there had been several people coming in and out of the room. The Director of Environmental Services was asked if the Housekeeper could have closed the door to the bathroom. The Director of Environmental Services stated that she could have closed the door to provide privacy for the resident. On 12/08/17 at approximately 3:00 PM, the Director of Nursing (DON) was asked, Is it your expectation for staff to provide privacy for residents while sitting on the commode? and the DON stated, Yes. The Facility Policy and Procedure titled, Resident Rights and Responsibilities with a revision date of 1/17/17 documented the following: Policy Statement: . The patient or resident has the right to respect, dignity, a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility and to be supported by the facility in exercising those rights. The facility administration was informed of the findings during a briefing on 12/11/17 at approximately 6:10 p.m. The facility did not present any further information about the findings. Definitions: 1. Gait: Medline Plus documented Gait is walking patterns. 4. The facility staff failed to maintain Resident #46's dignity by speaking to the resident in an argumentative/ negative manner. Resident #46 was admitted to the facility on [DATE] with current active diagnosis of Multiple Sclerosis (MS-a chronic, slowly progressive disease of the central nervous system-Taber's Cyclopedic Medical Dictionary). The current MDS (Minimum Data Set) a quarterly with an assessment reference date of 10/11/17 coded the resident as scoring a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating the resident's cognition was intact. The resident required extensive assistance of one staff for toileting and was always incontinent of both bladder and bowel. The resident was wheelchair bound and had range of motion limitations to both lower legs. On 12/05/17 at 11:42 AM, the resident was observed sitting up in a wheelchair in the hallway. A request to conduct an interview was granted by the resident. The resident then propelled herself into her room, During the resident interview Resident # 46 stated she had experienced a CNA (Certified Nurse Aide) being argumentative and making negative remarks. When she asked the CNA to wipe an area on her buttocks due to it feeling wet the CNA stated it was not wet and swiped the area. The resident stated she had reported her concern to staff and named the person she had reported this to. This person was later identified as the unit manager. Just prior to the above resident interview the resident had attended the Resident Council meeting facilitated by another inspector. The following notes were obtained from this meeting and read in part: 12/05/17 at 10:13 AM: Resident council meeting . Night shift staff talk down to Resident #46- she has reported and it continue to happens. She has documentation and bring it up during care plan meetings . Review of the clinical notes evidenced the following to support the resident's allegations. A care plan meeting note dated 10/19/17 authored by Social Worker #2 (SW) read, in part:Care plan held with resident and her son .She did say that their is 1 person who talk(s) so negative and she didn't want to say who it was and her son did say they would let the clinical manager know . On 12/7/17 at 11:20 p.m., an interview was conducted with the unit manager. The above allegation was shared. The unit manager was asked if she was aware of the resident's allegation of the staff talking negatively and argumentative. She stated she was not aware of these allegations prior to the Resident Council meeting conducted on 12/5/17. The unit manager then read the aforementioned care plan note dated 10/19/17. When asked if there should have been a follow up by either the Social Worker who had knowledge of the allegation or herself, she stated, Yes, I would have spoken to her in private and followed up on this. On 12/08/17 at 12:11 PM, an interview was conducted with SW#2. The above care plan meeting note was shared. The SW stated she did not follow up with the unit manager to ensure the allegation of the staff speaking negatively to the resident was addressed. She stated she assumed the resident or son had spoken with the unit manager. The Facility Policy and Procedure titled, Resident Rights and Responsibilities with a revision date of 1/17/17 documented the following: Policy Statement: .The patient or resident has the right to respect, dignity, a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility and to be supported by the facility in exercising those rights. On 12/11/17 at 1:30 PM, an interview was conducted with the Director of Nursing (DON). She stated the allegation of the staff speaking negatively to a resident is considered a dignity issue and should also be reported as potential for abuse. She stated the allegation should have been reported to the State Survey Agency with in 2 hours of the allegation being made. No additional information was provided to the survey team prior to exit to support compliance. Based on observations, clinical record reviews, staff interviews and facility policy reviews, the facility staff failed to ensure they maintained the dignity of 5 out of 26 residents (Resident #50, #353, #55, #83 and #46) in the survey sample. 1. Resident #50 was assessed to require complete assistance to eat during his meals. The facility staff failed to sit while assisting Resident #50 to eat his lunch meal. 2. The facility staff failed to maintain Resident #353's dignity by allowing the resident to be seen on the commode from the Unit's main hall way. 3. The facility staff failed to provide dignity during dining services by wearing gloves while assisting/feeding Resident #55. 4. The facility staff failed to provide dignity during dining services by wearing gloves while feeding/assisting Resident #83. 5. 4. The facility staff failed to maintain Resident #46's dignity by speaking to the resident in an argumentative/ negative manner. The findings include: 1. Resident #50 was admitted to the nursing facility on 10/3/14 with diagnoses that included depression, glaucoma, blindness and Alzheimer's dementia. The most recent Minimum Data Set (MDS) assessment was a quarterly dated 10/5/17 and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 3 out of a possible 15, which indicated the resident was severely impaired in the skills needed for daily decision making. Resident #50 was assessed totally dependent on one staff for assistance with eating. The care plan dated 10/16/17 identified the resident had glaucoma with blindness and required assistance with all Activities of Living (ADL). The resident was identified as not able to initiate eating and the goal set by the nursing staff for the resident was to provide him with assistance with all meals. Some of the interventions to accomplish this goal included to feed the resident if he is unable to feed himself. On 12/4/17 at 12:15 p.m. certified nursing assistant (CNA) #1 was observed feeding Resident #50 while standing. The CNA was observed leaving the resident and coming back consistently throughout the lunch meal. He sat down for a couple of minutes and stated, I am trying to catch my breath, after which he stood and continued to feed Resident #50 forkfuls of food and sips of tea. The CNA handed a sandwich to the resident and proceeded down one of the unit's hallways. The resident dropped the sandwich and the CNA retrieved another one for him. Once the CNA obtained the sandwich, he stood over the resident, placed the sandwich to his mouth and said, Bite it (Resident #50's name), bite it. This process of standing to assist the resident to eat continued throughout the entire lunch meal. A licensed practical nurse (LPN#2) was observed sitting at a table next to Resident #50 assisting another resident with her lunch meal. This LPN did not alert CNA #1 to sit down to assist Resident #50 with his meal. Additionally, the unit's clinical manager, Registered Nurse (RN) #1 walked through the unit while CNA #1 was standing to assist Resident #50 with his meal and did not instruct the CNA to sit while feeding the resident. On 12/11/17 at 1:00 p.m., an interview was conducted with CNA #1. He stated he stood to feed the resident because he had so much to do causing him to go back and forth to give the resident forkfuls of food, sips of liquid and bites of his sandwich. He stated I should have stopped and sat to feed the resident throughout the completion of his meal. On 12/11/17 at 1:30 p.m., an interview was conducted with the unit's clinical manager RN #1. She stated she expected all staff on the unit to remain seated while assisting resident's to eat. RN #1 stated she did not understand why CNA #1 moved about during the lunch meal on 12/4/17. On 12/11/17 at 5:50 p.m., during the pre-exit meeting, the aforementioned issue was brought to the attention of the Administrator and the Director of Nursing (DON). No further information was provided prior to survey exit. The facility's policy and procedure titled Resident Rights and Responsibilities dated as revised on 1/17/17 indicated .The patient or resident has the right to respect, dignity, a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility and to be supported by the facility in exercising those rights.

Based on staff interview, clinical record review and facility document review the facility staff failed to develop a care plan for 1 of 26 residents in the survey sample, Resident #23. The facility staff failed to develop a care plan for Resident #23 who was receiving an anticoagulation medication (Eliquis). The findings included: Resident #23 was originally admitted to the nursing facility on 01/12/16. Diagnosis for included but not limited to *Atrial Fibrillation. The current Minimum Data Set (MDS) a quarterly assessment with an Assessment Reference Date (ARD) of 09/20/17 coded the resident with a 06 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. The residents MDS was coded for the usage of anticoagulant. The section N on the MDS under medications read as follows: Indicate the number of DAYS the resident receiving the medication during the last 7 days, the MDS was coded for receiving an anticoagulant for 7 days. The resident had a Physician order dated 8/15/17: *Eliquis 2.5 mg tablet twice daily upon rising and at bedtime. The review of Resident 23's comprehensive care plan did not include a care plan for the use of an anticoagulation medication. An anticoagulation care plan was given to the surveyor that was created on 12/07/17 at 4:40 p.m., but only created after it was requested by the surveyor from the Administrator on 12/07/17 at 11:35 a.m. The review of the anticoagulation care plan included but not limited to following information: Resident is at risk for adverse bleeding related to anticoagulant secondary to diagnosis of A-Fib. Goal: to prevent and promptly detect and report bleeding. Interventions: Give medication as ordered, report bruising or bleeding to charge nurse, monitor for signs and symptoms (s/s) of bleeding such as: blood in urine, dark/tarry stools and report to nurse, report bruising or bleeding to charge nurse and monitor for nausea/vomiting (n/v), diarrhea, elevated liver function test, rash, fever and headaches. An interview was conducted with RN #3 (MDS Coordinator) on 12/8/17 at approximately 10:55 a.m., who stated she was asked if there was an anticoagulation care plan, but after the review of the care plan she realize there wasn't one, so one was created. The surveyor asked if there should have been an anticoagulation care plan because the resident was taking the medication Eliquis, she replied, Yes, there should have been an anticoagulation care plan. The facility administration was informed of the findings during a briefing on 12/11/17 at 5:50 p.m. The facility did not present any further information about the findings. The facility's policy: Life Care - Comprehensive Care Plan (Revision Date: 01/17/17). Purpose: Establishment periodic review of current patient-centered plan of care for each resident to assure a systematic, comprehensive approach to assessing, planning, and periodic review in meeting the resident's needs. Comprehensive Care Plan have included but not limited to: -Identify problem areas and address associated risk factors. *Atrial Fibrillation is the most common type of arrhythmia. An arrhythmia is a problem with the rate or rhythm of the heartbeat. During an arrhythmia, the heart can beat too fast, too slow, or with an irregular rhythm. (Source: www.Nhlbl.nih.gov) *Eliquis is used help prevent strokes or blood clots in people who have Atrial fibrillation (a condition in which the heart beats irregularly, increasing the chance of clots forming in the body and possibly causing strokes) that is not caused by heart valve disease (https://medlineplus.gov/ency/article/007365.htm).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to revise Resident #351's care plan to include his independence for performing care for his privately owned CPAP unit and failed to specify the specifics of the care of the device. Resident #351 was admitted to the facility on [DATE]. Diagnoses for Resident #351 included but are not limited to Emphysema* (1) and Diabetes Mellitus* (2). Resident #351's Interim Care Plan documented the following: Resident Need: Oxygenation related to COPD (Chronic Obstructive Pulmonary Disease), Emphysema Start Date: 12/3/17 Approaches included but were not limited to: Evaluate respiratory status every shift and as needed Oxygen per Medical Doctor order Resident #351 current Physician orders included no orders for Resident #351 to have, use and provide care for his personally owned CPAP unit. The Interim Care Plan did not document that Resident #351 was admitted with his own personal owned CPAP (Continuous Positive Airway Pressure) unit and that Resident #351 was performing his own care to his unit. In addition, the Interim Care Plan did not document any specifics related to what type of care the CPAP unit required. On 12/4/17 at approximately 1:15 PM, Resident #351's CPAP mask was observed lying on top of his bedside table. The tubing for it was lying in his opened bedside table drawer without a date as to when it was last cleaned or changed. On 12/4/17 at approximately 5:45 PM, Resident #351's CPAP mask was observed lying on top of his bedside table. The tubing for it was lying in his opened bedside table drawer without a date as to when it was last cleaned or changed. 12/06/17 at approximately 03:35 PM, Resident #351 was observed in his Room, oxygen at 2 liters via nasal cannula. Resident stated, Therapy went well. Non dated 1 liter opened bottle of Sterile water observed at bedside. 12/07/17 at approximately 10:02 AM, Resident #351 was observed in his room with the Unit Manager #4 in attendance. 1 Liter opened Sterile Water undated bottle was observed at bedside. The Unit Manager #4 removed the undated bottle of Sterile Water. The Unit Manager #4 and Surveyor looked at CPAP tubing it was dated 12/5/17. The CPAP mask was not with the CPAP tubing. Asked what the practice was for storage of sterile water. The Unit Manager #4 stated that she's only been here a short time, and it is practice to date bottles when open. The Unit Manager #4 stated it should be stored in his locked cabinet in his room which it was not. The Unit Manager #4 stated that she was not sure where the mask is, she stated that she has been teaching staff that night shift usually changes tubing or if someone is in there and sees it needs to be changed at any time. The Unit Manager #4 stated tubing is getting changed Midnight shift on Tuesday nights. When asked what the facility practice is when a resident is admitted with undated tubing, the Unit Manager #4 stated, I guess the admission nurse should change tubing and date so that we know when it was last done and then it would be done on midnight shift every Tuesday after that. Resident #351 was observed on 12/07/17 at approximately 05:27 PM eating in dining room and sitting in a wheel chair. Resident #351 stated I clean my own mask (CPAP). I put the water in the CPAP and sometimes the girls do it. I doubt they even know I clean the mask. I clean it with soap and water every day. On 12/08/17 at approximately 3:00 PM, the Director of Nursing (DON) was asked if it is the expectation that Resident #351's Care Plan be updated/revised to include information that he is independently performing his care for the CPAP unit, and to include the specifics of the care. The DON stated, Yes, it would be the expectation. The Facility's Policy and Procedure titled, Positive Airway Pressure (PAP) Devices: Equipment Cleaning with a revision date of 6/23/16 documented the following: PAP Equipment will be maintained in clean condition. Clean headgear and tubing once a week and as needed. Wash/wipe clean nasal pillows or mask daily as needed. Clean the flow generator once a week and as needed. Clean devise filters once a week and as needed. Empty daily, refill with distilled or sterile water nightly. Clean humidifier reservoir weekly. The Facility's Policy and Procedure titled, Baseline Care Plan with a revision date of 1/17/17 documented the following: Purpose: To establish the minimum health information necessary to properly care for the resident. Action Steps: Within 48 hours the facility to establish baseline care plan necessary to properly care for patient and/or resident. A. Initial goals based on admission orders B. Physician orders C. Dietary order D. Therapy services E. Social Services The facility will provide the resident and/or representative a summary of the baseline care plan to include but not limited to: A. The initial goals of the resident B. Summary of residents medications and dietary instructions C. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. The facility administration was informed of the findings during a briefing on 12/11/17 at approximately 6:10 p.m. The facility did not present any further information about the findings. Definitions: 1. Emphysema: Medline Plus documented: Emphysema is a type of COPD involving damage to the air sacs (alveoli) in the lungs. As a result, your body does not get the oxygen it needs. Emphysema makes it hard to catch your breath. You may also have a chronic cough and have trouble breathing during exercise. 2. Diabetes Mellitus: Medline Plus documented: Diabetes is a disease in which your blood glucose, or blood sugar, levels are too high. 3. The facility staff failed to revise Resident #358's care plan to include her independence in performing the treatment to her orthopedic surgical PINS and surgical incisions, as well as the specifics of the treatment. Resident #358 was admitted to the facility on [DATE]. Diagnoses for Resident #358 included but are not limited to Fracture of lower end of Left Radius* (1), Fracture of Right Tibia* (2), Chronic Pain Syndrome* (3), Anxiety Disorder* (4), Depression* (5), and Manic Depression* (6). Resident #358's admission Minimum Data Set (MDS - an assessment protocol) with an Assessment Reference Date of 12/5/17 coded Resident #358 with a BIMS (Brief Interview for Mental Status) with a 15 of 15 indicating no cognitive impairment. In addition, Resident #358 was coded as requiring limited assistance with one staff person assistance for transfer, toilet use and dressing. Resident #358 was coded as always continent of urinary and bowel functions. Resident #358's Hospital Discharge Instructions included the following: discharge: Pin Care Instructions: page 5 of 6 Once a day wash around the pin sites with warm soapy water and anti bacterial soap and a wash cloth. If pin sites become more red and painful or have increased drainage then wash pin sites twice per day. If the redness/drainage/pain continue please call us. You may take a shower and wash your Ex-fix and/or K-wire sites in the shower with warm soapy water and antibacterial soap. Do not soak your extremity that has an Ex-fix and/or K-wires. No baths or hot tubs. discharge: Wound Care: Daily dry dressing changes to medial and lateral incision/sutures on left lower leg and left arm. From the document December 2017 Physician Order sheet the following were documented: Left leg: dry dressing: Left arm: dry dressing Pin Care to left arm fixator daily: Notes: Pin care to left arm fixator Pin sites daily Pin Care to left arm fixator daily: Notes: Pin care to left arm fixator pin sites daily cover left tibia surgical site with xeroform gauze cover with dry dressing cover with Kerlix daily A 11/29/17 12:22 PM Physician Order documented the following: Pin Care to Left Arm fixator daily Notes: Pin Care to Left arm fixator pin sites daily. A 12/7/17 19:31 (7:31 PM) Clarification Physician Order documented the following: pin care with soap and water daily to left tibia fixator A 12/8/17 5:32 AM Clarification Physician Order documented the following: pin care with soap and water to left arm fixator daily Resident #358's Treatment Administration Record (TAR) for November 2017 documented the following: Left leg One time daily starting 11/28/17 dry dressing and was discontinued on 12/8/17 Left arm one time daily starting 11/28/17 dry dressing and discontinued on 12/8/17 Pin Care to Left arm fixator daily one time daily starting 11/29/17 and discontinued 12/7/17 Notes: Pin Care to left arm fixator Pin sites daily Cover left tibia surgical site with xeroform gauze cover with dry dressing cover with Kerlix daily one time daily starting 11/29/17 and discontinued on 12/7/17 Pin care to left tibia fixator daily one time daily starting 11/29/17 and discontinued 12/7/17 Left leg one time daily starting 11/28/17 dry dressing and discontinued 12/8/17 Left arm one time daily starting 11/28/17 dry dressing and discontinued 12/8/17 Resident #358's 11/28/17 to Present Care Plan documented the following: Problem: Impaired skin integrity related to left leg status post surgical site. External fixator pins Interventions included but were not limited to: Monitor nutrition parameters Assist resident to eat/drink adequate amount of nutrition Follow prescribed treatment regimen. Problem: Impaired skin integrity to left arm status post surgical site with external fixator pins Interventions included but were not limited to: Follow prescribed treatment regimen. On 12/04/17 0 Resident #358 was observed at approximately 1:16 PM. She stated that she had Fracture to Left arm and left leg with pins and rod. The Resident stated the bones were crushed in a car accident a month ago. Resident #358 stated that the Nurses are supposed to do pin care in morning and night. Nurses aren't doing morning pin care always. The resident stated she is in a Bariatric bed. The Resident stated she talked to the Unit Manager #4 about 3 days, and reported that she stated she would talk to somebody. Resident #358 stated that she waits a long time for anyone to come in after I ring bell. Resident #358 stated, I've waited up to 2 hours. Resident stated she can get to potty by herself but she shouldn't. Resident #358 stated that if she waited I would wet her self. On 12/7/17 at approximately 10:30 AM, the Unit Manager #4 and surveyor entered Resident #358's room so that the surveyor could show the Unit Manager #4 Hydrogen Peroxide on the bedside table and Dermal Wound Cleanser in the drawer at the foot of Resident #358's bed. Surveyor informed the Unit Manager #4 that the Resident is performing her own wound care using hydrogen peroxide to pin sites and dermal wound cleanser to incision lines of lower left leg with steri strips. The Unit Manager #4 stated that the Educator Registered Nurse #5 had spoken to the resident about her wound care and attempted to removed the peroxide and the Resident would not allow it to be removed. The Unit Manager #4 was asked as the PIN care orders did not specify what to do, how would she perform pin care and she stated that she would clean with soap and water. On 12/08/17 at approximately 3:00 PM, the Director of Nursing (DON) was asked if it is the expectation that Resident #358's specific PIN care orders should be clarified and issues with the Care Plan be updated on the Resident's care plan. The DON stated, Yes. On 12/8/17 at approximately 4:30 PM, Unit Manager #4 stated that the Doctor had talked with Resident #358 about hydrogen peroxide and the Resident #358 agreed for it to be removed from her room. The Unit Manager was asked if she felt all the issues with Pin Care should be updated on the care plan, and asked if PIN care instructions should be clarified and Unit Manager #4 stated, Yes, and the orders have been clarified. The Unit Manager #4 was asked if the Care Plan was updated to address fact that the Resident had been insistent to perform her own PIN Care and the Unit Manager #4 stated, No. The Facility was asked to provide a Policy and Procedure for PIN Care and the DON on 12/8/17 at approximately 3:00 PM stated, We have no specific PIN Care Policy. The Facility Policy and Procedure titled, Comprehensive Care Plan with a revision date of 1/17/17 documented the following: Comprehensive Care Plan will: 1. Identify problem areas and address associated risk factors. 3. Sound and established goals, timetables, and objectives monitored through measurable objectives and outcomes. The facility administration was informed of the findings during a briefing on 12/11/17 at approximately 6:00 p.m. The facility did not present any further information about the findings. Definitions: 1. Fracture Radius: Fracture or break of the wrist bone 2. Fracture Tibia: Fracture or break of the leg shin bone 3. Chronic Pain Syndrome: Medline Plus documented the following: Pain is a signal in your nervous system that something may be wrong. It is an unpleasant feeling, such as a prick, [NAME], sting, burn, or ache. Pain may be sharp or dull. You may feel pain in one area of your body, or all over. There are two types: acute pain and chronic pain. Acute pain lets you know that you may be injured or a have problem you need to take care of. Chronic pain is different. The pain may last for weeks, months, or even years. The original cause may have been an injury or infection. There may be an ongoing cause of pain, such as arthritis or cancer. In some cases there is no clear cause. Environmental and psychological factors can make chronic pain worse. Many older adults have chronic pain. Women also report having more chronic pain than men, and they are at a greater risk for many pain conditions. Some people have two or more chronic pain conditions. 4. Anxiety Disorder: Medline Plus documented: Fear and anxiety are part of life. You may feel anxious before you take a test or walk down a dark street. This kind of anxiety is useful - it can make you more alert or careful. It usually ends soon after you are out of the situation that caused it. But for millions of people in the United States, the anxiety does not go away, and gets worse over time. They may have chest pains or nightmares. They may even be afraid to leave home. These people have anxiety disorders. 5. Depression: Medline Plus documented: Depression is a serious medical illness. It's more than just a feeling of being sad or blue for a few days. If you are one of the more than 19 million teens and adults in the United States who have depression, the feelings do not go away. They persist and interfere with your everyday life. 6. Manic Depression: Medline Plus documented: Bipolar disorder is a mental condition in which a person has wide or extreme swings in their mood. Periods of feeling sad and depressed may alternate with periods of being very happy and active or being cross or irritable. 4. The facility staff failed to revise Resident #41's current person-centered, comprehensive care plan to include the discontinuation of a Foley catheter on 11/22/17. Resident #41 was admitted to the facility on [DATE] with diagnoses to include, 1.) Chronic Kidney Disease and 2.) Diabetes Mellitus. The most recent comprehensive Minimum Data Set (MDS) assessment was a Quarterly with an Assessment Reference Date (ARD) of 10/5/17. The Brief Interview for Mental Status (BIMS) indicated that Resident #41 had long and short-term memory deficits and was severely impaired in cognitive skills for daily decision making. Under Section H Bladder and Bowel, Urinary Incontinence the resident was coded as a 9 indicating (resident had a catheter (indwelling, condom), urinary ostomy, or no urine output for the entire 7 days. Resident #41's Comprehensive person-centered care plan dated 10/12/17 -Present was reviewed and is documented in part as follows: Problem: Alteration in bladder elimination R/T (related to) Foley catheter STATUS: Active (current) Goals: Elimination will be safely maintained through indwelling Foley catheter without signs/symptoms of UTI (urinary tract infection) through out the next 90 days. Interventions: 1. Check tubing for kinks several times each shift. 2. Assess resident for pain, discomfort due to catheter. 3. Change indwelling catheter every month or per MD (medical doctor ) order. Observations made by surveyor while in facility: 12/04/17 11:14 AM Resident #41 lying in bed on back, no Foley catheter present. 12/06/17 2:00 PM Resident #41 up in chair watching TV no Foley catheter present. 12/07/17 11:46 AM Resident #41 up and dressed in wheelchair in common area listening to seasonal music activity, no Foley catheter observed. Surveyor asked Unit Manager #2 if resident #41 still has a Foley cath. Unit Manager #2 stated, No, her catheter was discontinued. On 12/07/17 01:50 PM Resident #41's Treatment Administration Record was reviewed for November 2017, which indicated that the Foley cath was discontinued on 11/22/17. The Physician's order was reviewed and is documented in part, as follows: Order Date: 11/22/17 COMPLETED, Instructions: 1. Discontinue Foley catheter. 2. Check bladder scan or straight cath after gets back to bed today. 3. Replace catheter if bladder scan/straight cath results greater than 300 milliliters. Resident #41's Nurse's Notes were reviewed and are documented in part, as follows: 11/22/17 at 4:21 P.M.: Per Pace, resident to have Foley d/c'd (discontinued) which was done at 13:30 (1:30 P.M.) today. In and out cath to be administered prior to end of shift to determine the need for reinsertion of catheter. 11/23/17 at 8:25 A.M. Resident continue on voiding trial. CNA (certified Nursing assistant) changed resident wet brief x 2 during shift. No signs/symptoms of pain or discomfort at this time. An interview was conducted with Unit Manager #2 on 12/07/17 at 4:25 PM. The Unit Manager made aware that Foley cath was still on Resident #41's care plan and asked who was responsible for updating this change for the resident on the care plan and when should have it been completed. The Unit Manager stated, The care plan should have been updated by nursing or MDS department depending on the day the change occurred and done with in 24 hours. On 12/08/17 10:18 AM, Resident #41's care plan was reviewed and noted to have been revised on 12/6/17 to show the Foley catheter was discontinued which is documented in part,as follows: Problems: Name (Resident #41) is incontinent of bladder functions (Current) Goals: Skin will remain intact during the next 90 days. Interventions: 1. Check for incontinence; change if wet/soiled. Clean skin with mild soap and water. Apply moisture barrier. 2. Use pads/briefs to manage incontinence. The facility policy titled, Life Care-Comprehensive Care Plan revised on 1/17/2017 is documented in part, as follows: Purpose: Establishment, periodic review of current patient-centered plan of care for each resident to assure a systematic comprehensive approach to assessing, planning, and periodic review in meeting the resident's needs. Interdisciplinary Responsibilities: 2. Care plans will be reviewed and updated as needed to reflect changes. Care plans to be updated within 24 hours. On 12/11/17 at 5:50 P.M. a pre-exit conference was held with the Administrator and the Director of Nursing where the above information was shared. Prior to exit no further information was provided. 1.) Chronic Kidney Disease: any one of a large group of conditions, including infectious, inflammatory, obstructive, vascular, and neoplastic disorders of there kidney. 2.) Diabetes Mellitus: a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion by the beta cells of the pancreas or resistance to insulin. The above definitions are derived from Mosby's Dictionary of Medicine, Nursing, and Health Professions 8th Edition. 5. The facility staff failed to revise Resident #13's current person-centered, comprehensive care plan to include activity preferences based on the comprehensive assessment. Resident #13 was admitted to the facility on [DATE] with diagnoses to include, 1.) Dementia, 2.) Depression, and 3.) Anxiety Disorder. The most recent comprehensive Minimum Data Set (MDS) assessment was a Significant Change with an Assessment Reference Date (ARD) of 6/8/17. The Brief Interview for Mental Status (BIMS) indicated that Resident #13 had long and short-term memory deficits and was severely impaired in cognitive skills for daily decision making. Under Section D Mood (G.) Trouble concentrating on things, such as reading the newspaper or watching television, Resident #13 was coded Yes for symptoms present and 2-6 days for symptom frequency. In Section F Preferences for Customary Routine and Activities Staff Assessment Resident #13 was coded for all of the following to apply: E. Receiving bed bath, F. Receiving sponge bath, I. Family or significant other involvement in care discussions, K. Place to lock personal belongings, M. Listening to music, O. Keeping up with the news, P. Doing things with groups of people, Q. Participating in favorite activities, and T. Participating in religious activities or practices. Resident #13's Comprehensive Care Plan dated 6/21/17 -9/11/17 was reviewed and is documented in part, as follows: Problems: Name (Resident #13) participation in activities is impaired due to multiple medical problems and confusion. Goals: Name will stimulation and socialization daily in room and verbally reply to visitors. Interventions: Offer Name (Resident #13) distractions including family visits, television, music in room via radio and staff visit during care. Post Activity calendar in room. Resident #13's current Comprehensive Care Plan dated 11/29/17 - Present was reviewed and is documented in part, as follows: Problems: Name (Resident #13) participation in activities is impaired due to multiple medical problems and confusion. Goals: Name will stimulation and socialization daily in room and verbally reply to visitors. Interventions: Offer Name (Resident #13) distractions including family visits, television, music in room via radio and staff visit during care. Post Activity calendar in room. Resident #13 observations while on survey by this surveyor: 12/04/17 12:18 PM Resident lying in bed on right side TV on non religious show. No radio noted in room. 12/05/17 10:24 AM Resident lying in bed on back TV on non-religious show. No radio noted in room. 12/6/17 10:45 AM Resident lying in bed on back TV on show not a music station. No radio noted in room. 12/06/17 02:52 PM Resident lying on right side TV on no radio present in room. TV on a show, non religious not a music station. On 12/06/17 02:11 PM an interview was conducted with RN Unit Manager #2 and was asked by this surveyor if there had bee changes in Name (Resident #13)? RN #2 stated, She was on hospice and came off and they did a significant change assessment on her. Surveyor asked, Does she have family that visit regularly and does she ever get up? RN #2 stated, Yes, her son visits daily usually around 6 in the morning and again in the afternoon. She doesn't get up she stays in her room in the bed. Resident #13's Activity Participation Logs were reviewed from May 2017 through December 2017 and are documented in part, as follows: May 2017 through November 2017 checked for Resident #13: Observed Leisure: 1.) Watching TV, 2.) Family/Friend visit/Visitors. December 2017: 1.) Listening to music (only checked for 1 day December 2nd., 2.) Watching TV, 3.) Family/Friend visit/Visitors. On 12/6/17 03: 00 PM an interview was conducted with the Therapeutic Activities Coordinator after reviewing the Resident #13's most recent comprehensive MDS under activities and preferences and the current comprehensive care plan. This surveyor asked what activities were in place for the resident. The Therapeutic Activities Coordinator stated, her TV and her son visits daily. This surveyor showed the Therapeutic Activities Coordinator Resident #13's Comprehensive MDS and current comprehensive care plan and asked what should have been included in her daily activities based on these documents. The Therapeutic Activities Coordinator stated, we should have included her religious/spiritual preferences, reading of the bible, going out of the room for activities, and having her radio with gospel music playing. We should have been more specific and followed her preferences. On 12/07/17 10:47 AM surveyor observed a radio now present in Resident #13's room on a stand in front of her bed but it is turned off. However, the TV is on and currently on a station with religious preaching heard. Resident #13's current Comprehensive Care Plan dated 11/29/17 - Present was revised on 12/6/17 by the Therapeutic Activities Coordinator and is documented in part, as follows: Problem: Name (Resident #13) is dependent on staff and needs assistance to initiate leisure pursuits. She has strong family support and her son visits daily. She also finds strength in faith. Goals: Name (Resident #13) will have meaningful stimulation daily; demonstrating signs of engagement, comfort, or enjoyment in leisure pursuits at least 75 % of the time by next review date. Interventions: 1. Offer/provide brief social visits as needed for rapport. 2. Offer/provide comforting activities such as playing gospel music for her; reading the Bible to her; devotional stories; musical entertainment; using touch and holding her hand for comfort; sensory stimulation. 3. Assist her so she can enjoy the following TV channels: She enjoys the Christian channels on TV, the gospel music TV channel. 4. Provide 1:1 needs programming for meaningful stimulation. 5. Allow family to spend quality time with Name (Resident #13). 6. Refer to chaplain for spiritual support visits. 7. Provide flowers in her room to promote comfort and relaxing environment when available. The facility policy titled, Life Care-Comprehensive Care Plan revised on 1/17/2017 is documented in part, as follows: Purpose: Establishment, periodic review of current patient-centered plan of care for each resident to assure a systematic comprehensive approach to assessing, planning, and periodic review in meeting the resident's needs. Interdisciplinary Responsibilities: 2. Care plans will be reviewed and updated as needed to reflect changes. Care plans to be updated within 24 hours. On 12/11/17 at 5:50 P.M. a pre-exit conference was held with the Administrator and the Director of Nursing where the above information was shared. Prior to exit no further information was provided. 1.) Dementia: a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses. 2.) Major Depression: an abnormal emotional state characterized by exaggerated feelings of sadness, melancholy, dejection, worthlessness, emptiness, and hopelessness that are inappropriate and out of proportion to reality. 3.) Anxiety Disorder: a disorder in which anxiety is the most prominent feature. The symptoms range from mild, chronic tenseness, with feelings of timidity, fatigue, apprehension, and indecisiveness, to more intense states of restlessness and irritability that may lead to aggressive acts, persistent helplessness, or withdrawal. 6. The facility staff failed to revise Resident #46's care plan to include her preference for being awakened at 2:00 am every day to ensure incontinence care is rendered in a timely manner to prevent complications. Resident #46 was admitted to the facility on [DATE] with current active diagnosis of Multiple Sclerosis (MS-a chronic, slowly progressive disease of the central nervous system-Taber's Cyclopedic Medical Dictionary). The current MDS (Minimum Data Set) a quarterly with an assessment reference date of 10/11/17 coded the resident as scoring a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating the resident's cognition was intact. The resident required extensive assistance of one staff for toileting and was always incontinent of both bladder and bowel. The resident was wheelchair bound. Resident #46's Comprehensive Person Centered Care Plan dated 10/18/17 to present was reviewed. The care plan identified the resident was incontinent of both bladder and bowel. The goal was listed as the resident would not have complications associated with incontinence over the next 90 days. The two interventions listed were to apply protective garments/pads as needed and provide peri-care after each incontinent episode as needed. On 12/05/17 at 11:42 AM, the resident was observed sitting up in a wheelchair in the hallway. A request to conduct an interview was granted by the resident. The resident then propelled herself into her room, During the resident interview Resident #46 stated that on 11/30/17 it took the staff two hours to respond to a call bell. The resident stated she had put the call bell on because she was wet and needed incontinent care to be rendered. Prior to this resident interview the resident had attended the Resident Council meeting facilitated by another inspector. The following notes were obtained from this meeting and read in part: 12/05/17 at 10:13 AM: Resident council meeting. short of staff - concern expressed. two staff on each unit at times. Call bells not answered timely. Resident #46 soaking wet. How do you feel about that. She does not like it. She has documentation and bring {sic} it up during care plan meetings. Further investigation and evidence supported the resident's allegation that on 11/30/17 it took the staff two hours to respond to the call bell. On 12/6/17 at 4:36 PM, a request to review of any and all grievances for Resident #46 was made to the Director of Nursing (DON). This same day at 5:52 PM a grievance form was handed to this inspector. The form titled Incident Abstract Report, report date 12/5/17 read, in part: Event description-Resident stated staff took 2 hours to answer the call bell. When she rendered care, the resident stated the staff member was argumentative. The DON also provided a Facility Reported Incident (FRI) form dated 12/5/17 notifying the State Survey Agency, Adult Protective Agency, the Representative Party and physician of an allegation of abuse/mistreatment. The staff was identified and immediately suspended pending investigation. The clinical record evidenced a care plan meeting note dated 7/27/17 authored by the Social Worker. The note read that the resident stated that she would like to be changed around 2 am. On 12/7/17 at 11:20 a.m., an interview was conducted with the unit manager. She stated the resident had expressed that her preference was to be woken up every night at 2:00 a.m., to be changed due to incontinence and history of a rash. The care plan was reviewed and was not revised to include the residence preference for staff to wake her up and check her for incontinence. When asked if this should have been care planned the unit manager stated, I didn't think about it going on the care plan, but it makes sense. The unit manager was asked if the staff are aware of the resident's preference to be woken up at two o'clock each morning to be checked for incontinence and rendered[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The physician failed to write orders for Resident #351's CPAP - use and to perform his own treatments and cleaning of the CPAP (Continuous Positive Airway Pressure). Resident #351 was admitted to the facility on [DATE]. Diagnoses for Resident #351 included but are not limited to Emphysema* (1) and Diabetes Mellitus* (2). Resident #351's Interim Care Plan documented the following: Resident Need: Oxygenation related to COPD (Chronic Obstructive Pulmonary Disease), Emphysema Start Date: 12/3/17 Approaches included but were not limited to: Evaluate respiratory status every shift and as needed Oxygen per Medical Doctor order Resident #351 current Physician orders included no orders for Resident #351 to have, use and provide care for his personally owned CPAP unit. The Interim Care Plan did not document that Resident #351 was admitted with his own personal owned CPAP (Continuous Positive Airway Pressure) unit and that Resident #351 was performing his own care to his unit. In addition, the Interim Care Plan did not document any specifics related to what type of care the CPAP unit required. On 12/4/17 at approximately 1:15 PM, Resident #351's CPAP mask was observed lying on top of his bedside table. The tubing for it was lying in his opened bedside table drawer without a date as to when it was last cleaned or changed. On 12/4/17 at approximately 5:45 PM, Resident #351's CPAP mask was observed lying on top of his bedside table. The tubing for it was lying in his opened bedside table drawer without a date as to when it was last cleaned or changed. 12/06/17 at approximately 03:35 PM, Resident #351 was observed in his Room, oxygen at 2 liters via nasal cannula. Resident stated, Therapy went well. Non dated 1 liter opened bottle of Sterile water observed at bedside. 12/07/17 at approximately 10:02 AM, Resident #351 was observed in his room with the Unit Manager #4 in attendance. 1 Liter opened Sterile Water undated bottle was observed at bedside. The Unit Manager #4 removed the undated bottle of Sterile Water. The Unit Manager #4 and Surveyor looked at CPAP tubing it was dated 12/5/17. The CPAP mask was not with the CPAP tubing. Asked what the practice was for storage of sterile water. The Unit Manager #4 stated that she's only been here a short time, and it is practice to date bottles when open. The Unit Manager #4 stated it should be stored in his locked cabinet in his room which it was not. The Unit Manager #4 stated that she was not sure where the mask is, she stated that she has been teaching staff that night shift usually changes tubing or if someone is in there and sees it needs to be changed at any time. The Unit Manager #4 stated tubing is getting changed Midnight shift on Tuesday nights. When asked what the facility practice is when a resident is admitted with undated tubing, the Unit Manager #4 stated, I guess the admission nurse should change tubing and date so that we know when it was last done and then it would be done on midnight shift every Tuesday after that. Resident #351 was observed on 12/07/17 at approximately 05:27 PM eating in dining room and sitting in a wheel chair. Resident #351 stated I clean my own mask (CPAP). I put the water in the CPAP and sometimes the girls do it. I doubt they even know I clean the mask. I clean it with soap and water every day. On 12/08/17 at approximately 3:00 PM, the Director of Nursing (DON) was asked if it is the expectation that Resident #351's Care Plan be updated/revised to include information that he is independently performing his care for the CPAP unit, and to include the specifics of the care. The DON stated, Yes, it would be the expectation. On 12/11/17 at approximately 3:00 PM, the DON, Unit Manager #4, were questioned by surveyor asking if it was an expectation to have Physician orders for Treatments. The DON stated, Yes. The Facility's Policy and Procedure titled, Positive Airway Pressure (PAP) Devices: Equipment Cleaning with a revision date of 6/23/16 documented the following: PAP Equipment will be maintained in clean condition. Clean headgear and tubing once a week and as needed. Wash/wipe clean nasal pillows or mask daily as needed. Clean the flow generator once a week and as needed. Clean devise filters once a week and as needed. Empty daily, refill with distilled or sterile water nightly. Clean humidifier reservoir weekly. The facility administration was informed of the findings during a briefing on 12/11/17 at approximately 6:10 p.m. The facility did not present any further information about the findings. Definitions: 1. CPAP-Continuous positive airway pressure: .Patients with obstructive sleep apnea treated with CPAP wear a face mask during sleep which is connected to a pump (CPAP machine) that forces air into the nasal passages at pressure high enough to overcome obstructions in the airway and stimulate normal breathing. Source-www.Mayoclinic.org 2. Emphysema: Medline Plus documented: Emphysema is a type of COPD involving damage to the air sacs (alveoli) in the lungs. As a result, your body does not get the oxygen it needs. Emphysema makes it hard to catch your breath. You may also have a chronic cough and have trouble breathing during exercise. 3. Diabetes Mellitus: Medline Plus documented: Diabetes is a disease in which your blood glucose, or blood sugar, levels are too high. Based on record review, family, staff interview and facility policy, the physician failed to review the resident's total program of care to include physician orders for medications and treatments for 2 of 26 residents in the survey sample, Residents #147 and #351. 1. The physician failed to (1) write orders for the administration of insulin, (2) for glucose monitoring, (3) for a family member (Wife) to administer insulin and obtain blood sugars under the supervision of a licensed staff and orders for the wife to provide Pro Air Inhaler treatments for Resident #147. 2. The physician failed to write orders for Resident #351 CPAP - use and to perform his own treatments and cleaning of the CPAP (Continuous Positive Airway Pressure). The findings included: 1. Resident # 147 was admitted to the facility on [DATE] with diagnoses of multiple closed fractures of pelvis, closed fracture of shaft of right tibia and fibula, rib fractures, coronary artery bypass draft, chronic anticoagulation, asbestosis, COPD, osteoarthritis of knees, cardiovascular disease, sleep apnea, stroke, internal carotid aneurysm, history of renal mass, hypertension, severe obesity, type 2 diabetes mellitus, major depression, hyperlipidemia, and hypertrophy of prostate. The facility staff failed to have parameter for the use of insulin and the monitoring of glucose levels. The facility staff were not aware of the dosage of insulin administered or the blood sugar levels form 11/20/17 through 12/8/17. Resident #147 wife stated she had been administering insulin twice a day and obtaining blood sugars levels since admission. She also stated that the facility did not inquire about the dosages administered or the blood sugars levels since admission. An Initial Minimum Data Set (MDS) dated [DATE] assessed Resident #147 in the area of Cognitive Patterns - Brief Interview of Mental Status (BIMS) as a (15). In the area of Activities of Daily Living (ADL's) this resident was assessed as a (3/30 in the area of bed mobility, a (7/2) in the area of transfer, a (7/3) in the area of walk in room, (2/2) in the area of dressing, a (0/1) in the area of eating, a (3/3) in the area of toilet use, and a (3/3) in the area of personal hygiene. In the area of Medications this resident was assessed as receiving injections for (7) days. In the area of Insulin this resident was assessed as receiving insulin for (4) days. In the area of Orders for Insulin changes- this resident was assessed for (0) days. In the area of Medications Received - this resident was assessed as receiving Anticoagulant for (7) days. A Care Plan dated 12/6/17 indicated : Problem- Potential for hypo/hyperglygycemia r/t: DX of DM (resident diagnoses of diabetes mellitus) Goals _ resident will have no s/s (signs or symptoms) of diabetic reaction with blood sugars within normal range of 60/120 mg/dl x (time) 90 d (days). Interventions- Administer medication per MD order, Disciplines -Nursing, Frequency - PRN (as needed). Intervention- monitor for effectiveness of medication, Disciplines- Skilled Nursing, Frequency - PRN. Intervention- monitor for side effects of medication, Disciplines- Skilled Nursing, Frequency - PRN. Intervention- observe for s/s of low blood sugar (sweating, headache, light headed, confusion, slurred speech, drowsiness, Intervention -Observe for s/s pf high blood sugar (polyuria, blurred vision, weakness, headache, anorexia, N & V, abdominal pain, acetone breath, mental changes, hypotension, intervention - Monitor accuchecks per MD order Intervention- serve diet per MD order, Disciplines - Dietary- Licensed Practical Nurse- Registered Nurse, Frequency -PRN. Intervention - Notify MD as needed, Disciplines - Skilled Nursing, Frequency - PRN. A review of the Care Plan did not indicate a Care Plan for the care and treatment and use of Anticoagulant medications. A review of the Care Plan did not indicate the care and treatment for Resident #147's wife to administer Insulin, obtain blood sugar levels or provide Pro Air Albuterol treatments. During an interview on 12/8/17 with Resident #147 doctor he stated, Resident #147 wife had talked with him and the facilities admission team while Resident #147 was in the hospital during discharge planning. Resident #147 wife had express that she would be doing his blood sugars levels and insulin administration at the nursing home due to the up and down levels Resident #147 experienced during his hospital stay. He stated, I was ok with her giving him the insulin and taking his blood sugars. She stated, she did it at home for Resident #147. The doctor was asked, Did he write an order indicating it was ok for Resident #147's wife to give insulin and take his blood sugars while a resident at the facility? The doctor stated, No. The doctor stated he was new to long term care and had been working at the facility for a few weeks. The doctor was asked if Resident #147's wife would have been allowed to give insulin and take blood sugars in the hospital ? The doctor stated, No The doctor was asked, was he aware that nursing staff were not given Blood sugar readings by Resident #147 wife? Also, nursing staff were not aware of how much insulin Resident #147's was receiving? The doctor answered, he was not aware that nursing staff did not know blood sugar readings. The doctor also, answered, he was not aware that nursing staff did not know how much insulin Resident #147's wife was giving him. The doctor was asked, was he aware of Resident #147's blood sugar levels and insulin dosage? The doctor stated, He was not aware. During a meeting on 12/8/17 at 2:47 P.M. with the 300 Unit Nurse Manager, The Director of Nursing and the Administrator, the Nurse Manager was asked if there was a physician's order for Resident #147's wife to administer insulin and obtain blood sugars. The Nurse Manager stated, No. During this interview the Director of Nursing (DON) stated she was not aware of Resident #147's blood sugars were not being monitored by nursing staff. The DON was asked if Resident #147's wife have a physician's order to administer insulin and take his blood sugars? The DON stated, No. During this interview, the Administrator stated, we were trying to be home like and allow the wife to care for her husband as she would at home. When asked was the doctor aware of Resident #147 wife administering insulin and taking his blood sugars, she stated, Yes, he knew, we had talked about the wife providing his care prior to Resident #147's discharge from the hospital. The doctor was ok with it. It is apparent that there is a disconnect. A Clinical Note dated 11/22/17 at 02:48 AM indicated: Lantus and Novolog changed to Novolin 70/30 per resident and wife request. Administration changed to PM on several meds. approved and ordered by physician. A Clinical Note dated 11/23/17 at 9:22 AM indicated: Patient stated, wants wife to administer all insulin and obtain blood sugars for him. Wife and husband educated on risks, Wife signed paperwork to self administer insulin and pro air. inhaler. Wife able to answer correctly all questions regarding insulin and pro air inhaler. A physician order dated 11/20/17 indicated: Enoxaparin (Lovenox) 30 mg. 0.3 ml sc Syrg - inject 0.3 ml beneath the skin every 12 hours. Lovenox for 3 weeks. Insulin glargine (Lantus vial) 100 unit/ml SC soln - inject 25 Units beneath the skin every 24 hours. Indications diabetes mellitus, hyperglycemia. Insulin glargine (lantus vial) 100 unit/ml SC soln - inject 2-14 Units beneath the skin 4 times a day before meals and at bedtime. A physician order dated 12/6/17 indicated: albuterol sulfate 2.5 mg 3 ml (0.083 %) solution for nebulization (3 ml) Vial) order date 11/20/17 - frequency- As needed every four hours starting 11/20/17. Enoxaparin 30 mg/0.3 subcutaneous syringe - Unspecified fracture of left acetabulum, initial encounter for closed fracture, multiple fractures of pelvis without disruption of pelvic ring , initial encounter for closed fracture. unspecified fracture of right lower leg. initial encounter for closed fracture - Frequency - every twelve hours for twenty one days. Schedule- Upon rising - bedtime. A Medication Administration History print-out with a 11:46 A.M. 12/07 17 run date indicated: Novolin 70/30 100 unit/ml subcutaneous suspension two times daily starting 11/22/17. An Administration History form with a date administered column indicated: 11/22/17 (7:30) date documented (11:22/17 (08:23) Not administered, Notes: resident wife taking BS (blood sugar) and injecting insulin An Administration History form indicated: date administered column 11/22/17 (7:30) - 11/22/17 (8:23) Blood Sugar Site - Value (Blank). 11/22/17 (16:30) -11/22/17 - 11/22/17 (17:34) Blood Sugar value 129, Insulin not administered wife administered. An Administration History form dated 11/23/17 (7:30) - 11/23/17 (8:51) blood sugar site Value (blank) Notes - Resident wife stated she does BS and administer insulin. There is no further documentation of Novolin or Blood Sugar levels being shared or documented by the facility staff. A Medication Administration policy revised 2/21/17 indicated: The physician must be promptly notified of omission, or refusal, of any medication which causes the resident discomfort, or jeopardizes health and safety. All other omissions or refusals will be reported to the physician after missing three (3) consecutive doses. A Pharmacy Process Prescriber Medication Orders Policy revised on 1/17/17 indicated: The licensed nurse will read the order. If the order is not clear to the nurse, the physician will be contacted for clarification. The nurse communicates the order to the pharmacy via Vision for fax.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and facility policy, the facility staff failed to ensure medications were available for 1 resident (Resident #147) in the survey sample of 26 residents. The findings included: Resident # 147 was admitted to the facility on [DATE] with diagnoses of multiple closed fractures of pelvis, closed fracture of shaft of right tibia and fibula, rib fractures, coronary artery bypass draft, chronic anticoagulation, asbestosis, COPD, osteoarthritis of knees, cardiovascular disease, sleep apnea, stroke, internal carotid aneurysm, history of renal mass, hypertension, severe obesity, type 2 diabetes mellitus, major depression, hyperlipidemia, and hypertrophy of prostate. Resident #147 was not provided six doses of enoxaparin (Lovenox) 30 mg./0.3 ml subcutaneous via syringe. The Nursing Drug Guide Handbook dated 2016 indicates: Lovenox-Therapeutic class: Anticoagulants ; Pharmacological class: Low-molecular-weight heparin's. Used to prevent PE (pulmonary embolus) and DVT (deep [NAME] thrombosis) after hip or knee replacement surgery. To prevent PE and DVT in patients with acute illness who are at increased risk because of decreased mobility. An Initial Minimum Data Set (MDS) dated [DATE] assessed Resident #147 in the area of Cognitive Patterns - Brief Interview of Mental Status (BIMS) as a (15). In the area of Activities of Daily Living (ADL's) this resident was assessed as a (3/30 in the area of bed mobility, a (7/2) in the area of transfer, a (7/3) in the area of walk in room, (2/2) in the area of dressing, a (0/1) in the area of eating, a (3/3) in the area of toilet use, and a (3/3) in the area of personal hygiene. In the area of Medications Received - this resident was assessed as receiving Anticoagulant for (7) days. A review of the Care Plan did not indicate a Care Plan for the care and treatment and use of Anticoagulant medications. A physician's order dated 11/20/17 indicated: enoxaparin (Lovenox) 30 mg/0.3 ml sc syrg - inject 0.3 ml beneath the skin every 12 hours. Lovenox for 3 weeks. A Medication Administration History document date range 11/20/17 to 12/07/17 indicated: enoxaparin 30 mg/0.3 ml, 12/03/17 (06:01) - 12/03/17 (07:05) Not Administered; 12/03/17 (19:01) -12/03/17 (20:33) Not Administered; 12/04/17 (06:01) - 12/04/17 (06:28) Not Administered; 12/04/17 (19:01) - 12/04/17 (20:09); 12/05/17 (06:01) - 12/05/17 (10:07) Not Administered; Not Administered; 12/05/17 (06:01) - 12/05/17 (19:01) - 12/05/17 (18:04) Not Administered. During an interview on 12/4/17 at 1:05 P.M. with Resident #147's wife, she stated, Resident #147 had not received his heparin due to non-availability for several days. During an interview on 12/6/17 at 12:45 P.M. with the 300 Unit Nurse Manager, she stated she was not aware of Resident #147 medications not being available, but would look into it. The 300 Unit Nurse Manager stated, it looks like there may have been a mix-up in his order. A Medication Administration policy revised 2/21/17 indicated: The physician must be promptly notified of omission, or refusal, of any medication which causes the resident discomfort, or jeopardizes health and safety. All other omissions or refusals will be reported to the physician after missing three (3) consecutive doses. A Pharmacy Process Prescriber Medication Orders Policy revised on 1/17/17 indicated: The licensed nurse will read the order. If the order is not clear to the nurse, the physician will be contacted for clarification. The nurse communicates the order to the pharmacy via Vision for fax. A Medications - Ordering/Receiving medications policy original date 12/8/17 indicated Valid orders for medication and related products are received from the pharmacy on a timely basis. Medication orders must be valid orders for the pharmacy to dispense.

Based on observations, clinical record reviews, staff interviews, family interviews and facility policy review, the facility staff failed to ensure 2 of 26 residents (Resident #60 and #69) were free of unnecessary drugs. 1. The facility staff failed to implement non-pharmacological interventions prior to the administration of antianxiety medication, Ativan to Resident #60. 2. The facility staff failed to implement non-pharmacological interventions prior to the administration of antianxiety medication, Ativan to Resident #69. The findings include: 1. Resident #60 was admitted to the nursing facility on 12/2/14 with diagnoses that included Alzheimer's disease and anxiety disorder. The most recent Minimum Data Set (MDS) assessment was a quarterly dated 10/26/17 and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 3 out of a possible score of 15 which indicated he was severely impaired in the skills for daily decision making. Resident #60 was coded for an Anxiety disorder, and to have received antianxiety medication 7 out of 7 days during the assessment period. The care plan dated as revised on 11/2/17 identified Resident #60 to have an anxiety disorder and received antianxiety medications on a regular basis. The goal set by the staff for the resident was that the resident would not experience adverse side effects due to antianxiety medication use over the next 90 days. Some of the approaches to accomplish this goal included to administer medication as ordered, noting effectiveness and side effects, engage the resident in group/individual activities, provide atmosphere with one-on-one support during periods of increased anxiety, allow the resident to talk about event and causes, if known and record behavior. Resident #60 had physician's orders dated 3/15/17 for *Ativan 0.5 milligrams (mg) every 6 hours as needed (PRN) for agitation. *Ativan is used to treat anxiety disorders. It is also used for short-term relief of the symptoms of anxiety or anxiety caused by depression (https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0001078/). The Medication Administration Record reviewed over the last 6 months, and indicated the following administration of Ativan 0.5 milligram (mg) tablet without documentation in the clinical record that non-pharmacological interventions were implemented prior to administration of the antianxiety medication: July 2017-8 times August 2017-17 times September 2017-11 times October 2017-10 times November 2017-8 times December 2017-4 times An interview was conducted with Licensed Practical Nurse (LPN) #2 on 12/4/17 at 2:50 p.m. She stated the resident was easily agitated and medicated with Ativan to calm her, but could not show where she tried other interventions prior to the medication. An interview was conducted with the unit's clinical manager Registered Nurse (RN) #1 on 12/11/17 at 1:30 p.m. She stated she was sure the staff tried approaches to address Resident #60's agitation before medication, but she could not provide evidence through documentation. On 12/8/17 at 4:30 p.m., the Director of Nursing (DON) said there was no place in the clinical record that showed interventions prior to administration of the Ativan, but the facility was in the process of developing a system to implement policy and training pending review of pharmacy software. Resident #60 was observed by this surveyor on the locked unit's dining room in her wheelchair 12/4/17, 12/5/17, 12/6/17, 12/7/17, 12/8/17 and 12/11/17 throughout the day from 10:15 a.m. to 5:30 p.m. She was confused at all times and many times agitated with other residents, as well as attempting to rise from her wheelchair. On 12/11/17 at 1:45 p.m. she appeared agitated stood and fell on the floor. On 12/11/17 at 5:50 p.m., during the pre-exit meeting, the Administrator and the DON reiterated they did not currently have a process in place to show non-pharmacological measures were tried prior to administration of PRN antianxiety medications. 2. Resident #69 was admitted to the nursing facility on 9/25/13 with diagnoses that included Alzheimer's disease. The most recent Minimum Data Set (MDS) assessment was a quarterly dated 11/7/17 and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 4 out of a possible score of 15 which indicated he was severely impaired in the skills for daily decision making. Resident #69 was not coded for an Anxiety disorder. The care plan dated as revised on 11/14/17 identified Resident #69 to display anxiety symptoms at times. The goal set by the staff for the resident was that the resident would have decreased episodes of anxiety over the next 90 days. Some of the approaches to accomplish this goal included assessment and documentation of the resident's level of anxiety and administer medication if interventions do not relieve anxiety. Resident #69 had physician's orders dated 11/17/17 for Ativan 0.5 milligrams (mg) every 6 hours as needed (PRN) for agitation. The Medication Administration Record reviewed since 11/17/17 indicated the following administration of Ativan 0.5 milligram (mg) tablet without documentation in the clinical record that non-pharmacological interventions were implemented prior to administration of the antianxiety medication: November 2017-3 times on the 11/7 shift December 2017-3 times on the 11/7 shift An interview was conducted with the unit's clinical manager Registered Nurse (RN) #1 on 12/11/17 at 1:30 p.m. She stated Resident #69 was a wanderer with agitation during the night mostly on the 11/7 shift and the Ativan was given to decrease his agitation. She stated she was sure the nursing staff tried other interventions prior to administering the Ativan, but she could not provide evidence through documentation. On 12/8/17 at 4:30 p.m., the Director of Nursing (DON) said there was no place in the clinical record that could show interventions prior to administration of the Ativan, but the facility was in the process of developing a system to implement policy and training pending review of pharmacy software. Resident #69 was observed by this surveyor in bed asleep on the locked unit 12/4/17, 12/5/17, 12/6/17, 12/7/17, 12/8/17 and 12/11/17 throughout most of the day from 10:15 a.m. to 5:30 p.m. He was awakened during mealtime, but slept on and off throughout most of the day. On 12/11/17 at 1:20 p.m., this surveyor and RN #1 went to his room to talk to the resident and found him asleep. The RN stated, He walks the floor most nights and he is tired during the day, so you mostly find him asleep until nighttime. During an interview with Resident #69's Resident Representative on 12/04/17 02:22 PM, she stated she was concerned about the resident walking all night and he had recently fallen with injuries. She stated the resident was use to getting up at 4:00 a.m. because he worked as a farmer. She stated she was told the facility was going to give him medication to decrease his irritability, but hoped it did not increase his fall episodes. On 12/11/17 at 5:50 p.m., during the pre-exit meeting, the Administrator and the DON reiterated they did not currently have a process in place to show non-pharmacological measures were tried prior to administration of PRN antianxiety medications. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and facility policy, the facility staff failed to ensure medications were available for 1 resident (Resident #147) in the survey sample of 26 residents. The findings included: Resident # 147 was admitted to the facility on [DATE] with diagnoses of multiple closed fractures of pelvis, closed fracture of shaft of right tibia and fibula, rib fractures, coronary artery bypass draft, chronic anticoagulation, asbestosis, COPD, osteoarthritis of knees, cardiovascular disease, sleep apnea, stroke, internal carotid aneurysm, history of renal mass, hypertension, severe obesity, type 2 diabetes mellitus, major depression, hyperlipidemia, and hypertrophy of prostate. Resident #147 was not provided six doses of enoxaparin (Lovenox) 30 mg./0.3 ml subcutaneous via syringe. The Nursing Drug Guide Handbook dated 2016 indicates: Lovenox-Therapeutic class: Anticoagulants ; Pharmacological class: Low-molecular-weight heparin's. Used to prevent PE (pulmonary embolus) and DVT (deep [NAME] thrombosis) after hip or knee replacement surgery. To prevent PE and DVT in patients with acute illness who are at increased risk because of decreased mobility. The facility staff failed to have parameter for the use of insulin and the monitoring of glucose levels. The facility staff were not aware of the dosage of insulin administered or the blood sugar levels form 11/20/17 through 12/8/17. Resident #147 wife stated she had been administering insulin twice a day and obtaining blood sugars levels since admission. She also stated that the facility did not inquire about the dosages administered or the blood sugars levels since admission. An Initial Minimum Data Set (MDS) dated [DATE] assessed Resident #147 in the area of Cognitive Patterns - Brief Interview of Mental Status (BIMS) as a (15). In the area of Activities of Daily Living (ADL's) this resident was assessed as a (3/30 in the area of bed mobility, a (7/2) in the area of transfer, a (7/3) in the area of walk in room, (2/2) in the area of dressing, a (0/1) in the area of eating, a (3/3) in the area of toilet use, and a (3/3) in the area of personal hygiene. In the area of Medications this resident was assessed as receiving injections for (7) days. In the area of Insulin this resident was assessed as receiving insulin for (4) days. In the area of Orders for Insulin changes- this resident was assessed for (0) days. In the area of Medications Received - this resident was assessed as receiving Anticoagulant for (7) days. A Care Plan dated 12/6/17 indicated : Problem- Potential for hypo/hyperglygycemia r/t: DX of DM (resident diagnoses of diabetes mellitus) Goals _ resident will have no s/s (signs or symptoms) of diabetic reaction with blood sugars within normal range of 60/120 mg/dl x (time) 90 d (days). Interventions- Administer medication per MD order, Disciplines -Nursing, Frequency - PRN (as needed). Intervention- monitor for effectiveness of medication, Disciplines- Skilled Nursing, Frequency - PRN. Intervention- monitor for side effects of medication, Disciplines- Skilled Nursing, Frequency - PRN. Intervention- observe for s/s of low blood sugar (sweating, headache, light headed, confusion, slurred speech, drowsiness, Intervention -Observe for s/s pf high blood sugar (polyuria, blurred vision, weakness, headache, anorexia, N & V, abdominal pain, acetone breath, mental changes, hypotension, intervention - Monitor accuchecks per MD order Intervention- serve diet per MD order, Disciplines - Dietary- Licensed Practical Nurse- Registered Nurse, Frequency -PRN. Intervention - Notify MD as needed, Disciplines - Skilled Nursing, Frequency - PRN. A review of the Care Plan did not indicate a Care Plan for the care and treatment and use of Anticoagulant medications. A physician's order dated 11/20/17 indicated: enoxaparin (Lovenox) 30 mg/0.3 ml sc syrg - inject 0.3 ml beneath the skin every 12 hours. Lovenox for 3 weeks. A Medication Administration History document date range 11/20/17 to 12/07/17 indicated: enoxaparin 30 mg/0.3 ml, 12/03/17 (06:01) - 12/03/17 (07:05) Not Administered; 12/03/17 (19:01) -12/03/17 (20:33) Not Administered; 12/04/17 (06:01) - 12/04/17 (06:28) Not Administered; 12/04/17 (19:01) - 12/04/17 (20:09); 12/05/17 (06:01) - 12/05/17 (10:07) Not Administered; Not Administered; 12/05/17 (06:01) - 12/05/17 (19:01) - 12/05/17 (18:04) Not Administered. During an interview on 12/4/17 at 1:05 P.M. with Resident #147's wife, she stated, Resident #147 had not received his heparin due to non-availability for several days. During an interview on 12/6/17 at 12:45 P.M. with the 300 Unit Nurse Manager, she stated she was not aware of Resident #147 medications not being available, but would look into it. The 300 Unit Nurse Manager came back and stated, it looks like there may have been a mix-up in his order. A Medication Administration policy revised 2/21/17 indicated: The physician must be promptly notified of omission, or refusal, of any medication which causes the resident discomfort, or jeopardizes health and safety. All other omissions or refusals will be reported to the physician after missing three (3) consecutive doses. A Pharmacy Process Prescriber Medication Orders Policy revised on 1/17/17 indicated: The licensed nurse will read the order. If the order is not clear to the nurse, the physician will be contacted for clarification. The nurse communicates the order to the pharmacy via Vision for fax.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #351 was admitted to the facility on [DATE]. Diagnoses for Resident #351 included but are not limited to Emphysema* (1) and Diabetes Mellitus* (2). Resident #351's Interim Care Plan documented the following: Resident Need: Oxygenation related to COPD (Chronic Obstructive Pulmonary Disease), Emphysema Start Date: 12/3/17 Approaches included but were not limited to: Evaluate respiratory status every shift and as needed Oxygen per Medical Doctor order Resident #351 current Physician orders included no orders for Resident #351 to have, use and provide care for his personally owned CPAP unit. The Interim Care Plan did not document that Resident #351 was admitted with his own personal owned CPAP (Continuous Positive Airway Pressure) unit and that Resident #351 was performing his own care to his unit. In addition, the Interim Care Plan did not document any specifics related to what type of care the CPAP unit required. On 12/4/17 at approximately 1:15 PM, Resident #351's CPAP mask was observed lying on top of his bedside table. The tubing for it was lying in his opened bedside table drawer without a date as to when it was last cleaned or changed. On 12/4/17 at approximately 5:45 PM, Resident #351's CPAP mask was observed lying on top of his bedside table. The tubing for it was lying in his opened bedside table drawer without a date as to when it was last cleaned or changed. 12/06/17 at approximately 03:35 PM, Resident #351 was observed in his Room, oxygen at 2 liters via nasal cannula. Resident stated, Therapy went well. Non dated 1 liter opened bottle of Sterile water observed at bedside. 12/07/17 at approximately 10:02 AM, Resident #351 was observed in his room with the Unit Manager #4 in attendance. 1 Liter opened Sterile Water undated bottle was observed at bedside. The Unit Manager #4 removed the undated bottle of Sterile Water. The Unit Manager #4 and Surveyor looked at CPAP tubing it was dated 12/5/17. The CPAP mask was not with the CPAP tubing. Asked what the practice was for storage of sterile water. The Unit Manager #4 stated that she's only been here a short time, and it is practice to date bottles when open. The Unit Manager #4 stated it should be stored in his locked cabinet in his room which it was not. The Unit Manager #4 stated that she was not sure where the mask is, she stated that she has been teaching staff that night shift usually changes tubing or if someone is in there and sees it needs to be changed at any time. The Unit Manager #4 stated tubing is getting changed Midnight shift on Tuesday nights. When asked what the facility practice is when a resident is admitted with undated tubing, the Unit Manager #4 stated, I guess the admission nurse should change tubing and date so that we know when it was last done and then it would be done on midnight shift every Tuesday after that. Resident #351 was observed on 12/07/17 at approximately 05:27 PM eating in dining room and sitting in a wheel chair. Resident #351 stated I clean my own mask (CPAP). I put the water in the CPAP and sometimes the girls do it. I doubt they even know I clean the mask. I clean it with soap and water every day. On 12/08/17 at approximately 3:00 PM, the Director of Nursing (DON) was asked if it is the expectation that Resident #351's CPAP unit be clean properly to reduce the potential risks for infection. The DON stated, Yes, it would be the expectation. The DON was asked if Resident #351 had been assessed to determine if he was cleaning his equipment as recommended by the Standards of Professional Practice. The DON stated, There is no documentation to show that he was. The Facility's Policy and Procedure titled, Positive Airway Pressure (PAP) Devices: Equipment Cleaning with a revision date of 6/23/16 documented the following: PAP Equipment will be maintained in clean condition. Clean headgear and tubing once a week and as needed. Wash/wipe clean nasal pillows or mask daily as needed. Clean the flow generator once a week and as needed. Clean devise filters once a week and as needed. Empty daily, refill with distilled or sterile water nightly. Clean humidifier reservoir weekly. The Center of Disease Control (https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines.pdf) documented the following: Medical equipment and instruments/devices must be cleaned and maintained according to the manufacturers ' instructions to prevent patient-to-patient transmission of infectious agents86, 87, 325, 849. Cleaning to remove organic material must always precede high level disinfection and sterilization of critical and semi-critical instruments and devices because residual proteinacous material reduces the effectiveness of the disinfection and sterilization processes 836, 848. Non critical equipment, such as commodes, intravenous pumps, and ventilators, must be thoroughly cleaned and disinfected before use on another patient. All such equipment and devices should be handled in a manner that will prevent HCW (Health Care Worker) and environmental contact with potentially infectious material. The facility administration was informed of the findings during a briefing on 12/11/17 at approximately 6:10 p.m. The Facility was specifically asked if they any Infection Control Policy relating to CPAP units and tubing that they wanted to present in addition to care of PAP unit Policy. The facility did not present any further information about the findings. Definitions: 1. CPAP-Continuous positive airway pressure: .Patients with obstructive sleep apnea treated with CPAP wear a face mask during sleep which is connected to a pump (CPAP machine) that forces air into the nasal passages at pressure high enough to overcome obstructions in the airway and stimulate normal breathing. Source-www.Mayoclinic.org 2. Emphysema: Medline Plus documented: Emphysema is a type of COPD involving damage to the air sacs (alveoli) in the lungs. As a result, your body does not get the oxygen it needs. Emphysema makes it hard to catch your breath. You may also have a chronic cough and have trouble breathing during exercise. 3. Diabetes Mellitus: Medline Plus documented: Diabetes is a disease in which your blood glucose, or blood sugar, levels are too high. Based on observations, record review, staff interview and facility document review the facility staff failed to implement appropriate infection control practices for 2 of 26 residents in the survey sample, Residents #148 and #351. 1. The facility staff failed to ensure isolation precaution and oxygen signage were posted for Resident #148. 2. The facility staff failed to ensure an opened bottle of sterile water used to care for Resident #351's CPAP unit tubing and mask was clean and dated. The findings included: 1. Resident #148 was admitted to the facility on [DATE] with diagnoses of Pneumonia, gastrointestinal hemorrhage. The facility staff failed to post infection and oxygen usage signs. A review of the clinical records indicated: Resident #148 was transferred to room [ROOM NUMBER] on 12/04/17. During the initial tour of this unit on 12/4/17 at 10:45 A.M. this room was noted to be unoccupied. On 12/4/17 at 2:15 P.M. the room was observed to be occupied with infection gowns, mask, red waste bags hanging from the door. A physician's order dated 12/01/17 indicated: Isolation precautions MRSA -sputum. An isolation precautions sign was not placed on the door until 12/6/17. Staff and family members were observed entering the room. A physician's order dated 11/18/17 indicated: O2 at 2 L/m via nasal cannula with humidification. During the initial tour of this unit on 12/4/17 at 10:45 A.M. this room was noted to be unoccupied. On 12/4/17 at 2:15 P.M. the room was observed to be occupied with infection gowns, mask, red waste bags hanging from the door. There was no signage indicating contact precautions or oxygen in use. During an interview on 12/7/17 at 10:00 A.M. with the 300 Unit Nurse Manager she stated, it was an over site for the signs not being posted.