**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one Resident (R)141 out of one reviewed for advanced directives was provided written information of the right to accept or refuse medical or surgical treatment and formulate an advance directive. Findings include: On [DATE] at 3:30 PM the facility's policy and procedure was requested regarding Advanced Directives. None was provided by the time of the exit. Review of R141's admission Minimum Data Set (MDS) located in the resident's EMR under the RAI tab with an Assessment Reference Date (ARD) of [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R141 was cognitively intact. Review of R141's clinical record showed no documentation that the facility provided written information to the resident regarding the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. During an interview with R141 on [DATE] at 11:00 AM the resident stated that she was never provided information regarding advanced directives and what treatment, or life sustaining treatment options (such as tube feedings, intravenous fluids, comfort care, etc.) were available for her to choose. She stated that she was just given a piece of paper and she had to decide if she wanted CPR or be a DNR, in the event of a cardiac arrest. During an interview on [DATE] at 4:23 PM, with the Social Services Director, Staff D confirmed no information regarding Advanced Directives were provided or discussed with the resident.

Based on staff interview, facility documentation review and clinical record review, the facility staff failed to ensure written acknowledgement of the Notice of Medicare Non Coverage for two Residents (Resident # 81 and # 123) in a survey sample of 3 Residents reviewed for Beneficiary Notices. The findings included: 1. For Resident # 81, the facility staff failed to have the NOMNC (Notice of Medicare Non Coverage) form signed by the Resident and/or the Resident Representative. A copy of the form was not acknowledged by the beneficiary or beneficiary's representative. Review of the clinical record was conducted on 2/3/2023 and 2/6/2023. Review of the Beneficiary notices revealed the notice stated Skilled Nursing Services would end on 1/16/2023. The form was not signed by Resident or representative. There was documentation in the Additional information section of verbal notification to the beneficiary representative on 1/13/2023 at 4:50 p.m. The bottom of the notice form was not signed or dated in the section that had the statement: Please sign below that you received and understood this notice. I have been notified that the coverage if not services will end on the effective date indicated and I may appeal this decision by contacting my QIO. The signature line and date line were blank. On 2/6/2023 at 12:51 p.m., an interview was conducted with the Social Worker (Employee G) who stated Beneficiary notices should be given to Residents or the Resident Representative by the Social Worker. Employee G stated verbal notices were given if the resident or representative were not available to sign. On 2/7/2023 during the end of day debriefing, the Administrator and Director of Nursing were informed of the findings. The Administrator stated the expectation was that the beneficiary notices would be signed by the Resident or Resident Representative. The Administrator stated that if the Social Worker gave verbal notification, there should have been follow up with attempts to notify the Resident and/or Representative in writing such as a Certified letter. No further information was provided. 2. For Resident # 123, the facility staff failed to have the NOMNC (Notice of Medicare Non Coverage) form signed by the Resident and/or the Resident Representative. A copy of the form was not acknowledged by the beneficiary or beneficiary's representative. Review of the clinical record was conducted on 2/3/2023 and 2/6/2023. Review of the Beneficiary notices revealed the notice stated Skilled Nursing Services would end on 1/19/2023. The form was not signed by Resident or representative. There was documentation in the Additional information section of verbal notification to the beneficiary representative on 1/13/2023 at 1:15 p.m The bottom of the notice form was not signed or dated in the section that had the statement: Please sign below that you received and understood this notice. I have been notified that the coverage if not services will end on the effective date indicated and I may appeal this decision by contacting my QIO. The signature line and date line were blank. On 2/6/2023 at 12:51 p.m., an interview was conducted with the Social Worker (Employee G) who stated Beneficiary notices should be given to Residents or the Resident Representative by the Social Worker. Employee G stated verbal notices were given if the resident or representative were not available to sign. On 2/7/2023 during the end of day debriefing, the Administrator and Director of Nursing were informed of the findings. The Administrator stated the expectation was that the beneficiary notices would be signed by the Resident or Resident Representative. The Administrator stated that if the Social Worker gave verbal notification, there should have been follow up with attempts to notify the Resident and/or Representative in writing such as a Certified letter. No further information was provided.

Based on staff interview, facility documentation review and clinical record review, the facility staff failed to provide ensure that the appropriate information regarding a transfer was communicated to the receiving health care institution or provider for one Resident (Resident # 8) in a survey sample of 73 Residents. The findings included: For Resident # 8, the facility staff failed to document that the reason for the transfer to the hospital was communicated with the hospital staff. Review of the clinical record was conducted 2/3/2023 and 2/6/2023. Review of the Progress Notes revealed Resident # 8 was sent to the hospital on 3/16/2022 due to a change in condition related to involuntary muscle movement and confusion. Review revealed no documentation of the information provided to the receiving hospital. On 2/6/2023 at 12:24 p.m., an interview was conducted with LPN (Licensed Practical Nurse) H, the Unit Manager, who stated when a resident is transferred to the hospital, we print a facesheet, transfer sheet, x-rays, labs, medication list and bed hold to send. When asked where the nurses document the information, the LPN H stated it should be in PCC (Point Click Care-the electronic medical record). Review of the electronic Clinical record revealed no documentation of any information reviewed with the resident and/or the family representative. LPN H stated some documents might be in the hard chart. A copy of the documents sent with Resident #8 to the hospital was requested. The Administrator presented scanned copies of documents that were sent with Resident # 8 during the transfer to the hospital. Review of the scanned documents revealed no evidence of communication with the hospital of the reason for the transfer. On 2/7/2023 during the end of day debriefing, the Administrator and Director of Nursing were informed of the findings The Administrator stated the expectation was that the reason for the transfer to the hospital should be communicated to the hospital and documented. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review and clinical record review, the facility staff failed to provide Notice to the Ombudsman of discharge for one Resident (Resident # 8) in a survey sample of 73 Residents. The findings included: For Resident # 8, the facility staff failed to notify the ombudsman of transfer to the hospital. Resident # 8 was sent to the hospital on 3/16/2022 due to a change in condition related to involuntary muscle movement and confusion. Resident # 8 was readmitted to the facility on [DATE]. On 2/6/2023 at 12:51 p.m., an interview was conducted with the Social Worker (Employee G) who stated she did not notify the Ombudsman. Employee G stated she was unsure of who notified the Ombudsman. On 2/6/2023 at 12:53 p.m., an interview was conducted with the Business Office Manager (Employee K) who stated she did not notify the Ombudsman of the transfer to the hospital. Employee K stated she would check to see if she could find out who would notify the Ombudsman. During the end of day debriefing on 2/6/2023, the Administrator and Director of Nursing were informed of the findings. The Administrator stated the Ombudsman should have been notified. The Administrator stated the Unit Secretary used to do it. The Administrator stated normally, the list of discharges would be printed from PCC (Point Click Care) and faxed to the Ombudsman. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review and clinical record review, the facility staff failed to provide the bed hold policy to the resident and resident representative for one Resident (Resident # 8) in a survey sample of 73 Residents. The findings included: For Resident # 8, the facility staff failed to provide the resident and/or resident representative with the bed hold policy at the time of transfer to the hospital. Resident # 8 was sent to the hospital on 3/16/2022 due to a change in condition related to involuntary muscle movement and confusion. Resident # 8 was readmitted to the facility on [DATE]. Review of the clinical record was conducted 2/3/2023 and 2/6/2023. Review of the Nursing Notes, Social Services Notes, and Physician Progress notes revealed no evidence that Resident # 8 or the resident representative was made aware of the facility's bed hold policy. On 2/6/2023 at 12:24 p.m., an interview was conducted with LPN (Licensed Practical Nurse) H, the Unit Manager, who stated when a resident is transferred to the hospital, we print a facesheet, transfer sheet, x-rays, labs, medication list and bed hold to send. The unit manager stated the nurses should document what was reviewed with the resident and family. When asked where the nurses document the information, the unit manager stated it should be in PCC (Point Click Care-the electronic medical record). Review of the electronic Clinical record revealed no documentation of any information reviewed with the resident and/or the family representative. LPN H stated some documents might be in the hard chart. A copy of the documents sent with Resident #8 to the hospital was requested. Review of the scanned documents from the hard chart presented by the Administrator revealed a Bed Hold Agreement form that was incomplete. The form had Resident # 8's name written in the section that stated I DO wish to hold the bed for ____________ [Resident # 8's name was written on that line], Beginning date 3/16/22 The space for Ending date was blank. There was no amount written in the section to denote the cost of each day. The rest of the form was blank. There was no signature nor any documentation that the information on the form was discussed with Resident # 8 and/or the family representative. On 2/7/2023 during the end of day debriefing, the Administrator and Director of Nursing were informed of the findings that there was no evidence to indicate the facility did communicate with Resident # 8 or Resident # 8's representative about the facility bed hold policy at the time of discharge. The Administrator stated the expectation was that the bed hold policy would explained and signed by the Resident or Resident Representative. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure care plan measures were developed and implemented to prevent skin injury during care for one Resident (Resident #222) in a survey sample of 73 Residents. The findings included: For Resident #222, the facility staff failed to develop a care plan for effective measures to prevent and intervene in skin injuries. Resident #222 had an admission minimum data set assessment dated [DATE] which coded the Resident with a Brief Interview of Mental Status score of 1 indicating severe cognitive impairment. Progress notes, skin evaluation sheets, physician's orders, and Treatment Administration Records (TAR) were reviewed and revealed the following chronology of events; 3-31-21 - On admission Left elbow & Left posterior knee skin tears treated and healed 4-5-23. No further skin tears nor skin problems were documented as having occurred in the clinical records until a room change on 4-21-21 at 2:52 P.m 4-21-21 - 8:50 p.m., Skin tears Left lower leg, & Left outer fore arm. 4-23-21 - Skin tears Right lower leg, Left anterior fore arm, & Right fore arm 4-26-21m - Geri legs & sleeves protection begun on evening shift, and not documented as applied on 4-27-21 during the day shift. 4-30-21 - Skin tears Right shin & Left upper leg. Resident #222's care plan was reviewed and revealed that the Resident was to have daily skin inspections, and baths 2 times per week, and as needed or requested. The Skin Tears care plan was initiated on 4-26-21 after 5 days of known skin tears. On 2-3-23, the DON stated that skin checks were completed during hygiene care. The Administrator was asked for any investigations involving this Resident's skin injuries, and she stated we don't have any. No investigation was conducted to ascertain why so many skin injuries occurred in such a short time for this Resident, and after none had occurred until the transfer to a new room in the facility. The Resident incurred 8 skin injuries in 9 days. The Administrator and Director of Nursing (DON) were notified at the end of day meeting on 2-3-23. No further information was provided by the facility.

Based on staff interview and clinical record review, the facility staff failed to ensure a discharge summary was written for one Residents (# 171) in a survey sample of 73 Residents. The findings included: 1. For Resident # 171, the facility staff failed to document a Discharge Summary. Resident # 171 discharged on 12/12/2022 to an Independent Living apartment on the facility's campus . Review of the clinical record was conducted on 2/6/2023. An interview was conducted on 02/6/2023 at 12:24 p.m. with LPN (Licensed Practical Nurse) H who stated notes should be written in PCC (Point Click Care) in the Progress Notes about discharges. LPN H reviewed the Progress Notes and stated she did not see the information about Resident # 171. On 2/6/2023 at 12:51 p.m., an interview was conducted with the Social Worker (Employee G) who stated she did remember the resident but could not find the information in the clinical record. Employee G stated Resident # 171 chose to move back to the Independent Living apartment on the facility's campus. Employee G stated she would check with the Business Office about dates of the stay. On 2/6/2023 at 12:53 p.m., an interview was conducted with the Business Office Manager (Employee K) who stated Resident # 171 had been in the facility for 4 days from 12/8/2022 until 12/12/2022. Employee K explained how to find the information for Resident # 171 in the electronic clinical record. She stated that since Resident # 171 was still on the campus but in Independent Living, the system had the documentation in a different place. Review of the electronic clinical record revealed no Discharge Summary was written for Resident # 171 upon discharge to the Independent Living apartment. Review of a Social Worker Progress Note revealed the following : 12/12/2022 16:38 Administrator, PT(Physical Therapy) and OT (Occupational Therapy) met with (Resident # 171's name redacted), her son, and her SIL (Son in law) this afternoon. Reviewed ADL (Activity of Daily Living) status and progress. Discussed home health vs. outpatient therapy follow up. The note further stated that Per Resident # 171's and family choice, the resident returned to her (name of facility) apartment this afternoon, with therapy follow up from (name of facility redacted) in-house therapy department. The note was electronically signed by the Social Worker (Employee G). On 2/7/2023 during the end of day debriefing, the Administrator and Director of Nursing were informed of the findings of no recapitulation of the stay at the facility. The Administrator stated the expectation was that the Discharge Summary would be completed after discharge. The Administrator stated that a Discharge Summary should have been documented even though the resident was only in the facility for a few days before returning to the previous living arrangement of an apartment on the facility's campus. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to prevent, and treat timely, a stage 2 pressure ulcer prior to development for one Resident (Resident #222) in a survey sample of 73 residents. The findings included: For Resident #222, the facility staff failed to identify (prior to the development of a stage 2) a pressure ulcer, and failed to treat for 5 further days after identification was documented in the care plan. Resident #222 had a minimum data set assessment dated [DATE] which coded the Resident with a Brief Interview of Mental Status score of 1 indicating severe cognitive impairment. The Resident was incontinent of bladder and bowel. Resident #222's care plan was reviewed and revealed that the Resident was incontinent of bladder and bowel and wore incontinence disposable briefs. The Resident could not feed herself, nor turn and reposition without extensive help from staff. The Resident was to have daily skin inspections, and baths 2 times per week, and as needed or requested. The care plan review also revealed an entry on 4-19-21 indicating the Resident had a stage 2 pressure ulcer on the right buttock which was the first pressure ulcer care plan documented for the Resident. The care plan entry on 4-19-21 was the only documentation of the pressure ulcer until 4-23-21 when it was documented in a progress note, and on a skin sheet document. On 4-24-21 a treatment was ordered for the pressure sore 5 days after the care plan denoted the wound. The Resident was assessed upon admission as at risk for developing pressure sores. Progress notes, skin evaluation sheets, physician's orders, and Treatment Administration Records (TAR) were reviewed and revealed the following chronology of events; 3-31-21 - On admission Left elbow & Left posterior knee skin tears treated and healed 4-5-23. No further skin tears nor skin problems were documented as having occurred in the clinical records until a room change on 4-21-21 at 2:52 P.M. 4-21-21 - 8:50 p.m., Skin tears Left lower leg, & Left outer fore arm. 4-23-21 - Skin tears Right lower leg, Left anterior fore arm, & Right fore arm 4-24-21 - Stage 2 pressure sore right inner buttock On 2-3-23, The DON stated that skin checks were completed during that care. The Administrator and Director of Nursing (DON) were notified at the end of day meeting on 2-3-23. No further information was provided by the facility.

Based on observation, Resident interviews, staff interviews, clinical record reviews, and facility documentation review, the facility staff failed to provide timely pain management measures for 2 Residents (Resident #144, Resident #376) in a sample size of 73 Residents. The findings included: 1) For Resident #144, the facility staff delayed assessment and treatment of Resident #144's left leg pain on 02/01/2023. On 02/01/2023 at 10:10 A.M., Resident #144 was observed in her bed. Resident #144 was grimacing, signing, and restless. When asked about this, Resident #144 stated that her entire left leg was having muscle spasms. When asked to rate the severity of the muscle spasms [0=no pain to 10=worst pain], Resident #144 stated the pain severity was 9. When asked if the nurse was aware, Resident #144 stated she did tell the nurse but didn't know her name because she was new. Resident #144 stated that, many times, she receives her medications late, not as scheduled. On 02/01/2023 at 10:30 A.M., Licensed Practical Nurse E (LPN E) was interviewed. LPN E verified she was Resident #144's nurse and this was her first time working with Resident #144. When asked to share what she knew about Resident #144, LPN E referred to her notes and stated that Resident #144 needed to have her medications crushed. LPN E also stated that she knew Resident #144 was in pain. When asked about this, LPN E stated that Resident #144 told her she was in pain around 9:00 A.M. When asked where Resident #144's pain was located, LPN E stated that Resident #144 couldn't say where the pain was. When asked what happened next, LPN E stated she brought Resident #144 some water and told her she would be back later to assess. This surveyor and LPN E then entered Resident #144's room. LPN E asked Resident #144 if she was in pain. Resident #144 stated her entire left leg was having muscle spasms. LPN E asked Resident #144 to rate the pain severity and Resident #144 stated 9. Upon exiting the room, LPN E stated that Resident #144 has not received her scheduled medications yet and will be given now. LPN E administered the medications that were scheduled for 8:00 A.M. and 9:00 A.M. at 10:39 A.M. which included Robaxin (a muscle relaxer). On 02/01/2023, the facility staff provided a copy of Resident #144's Medication Administration Record (MAR) for January and February 2023 with the exact medication times included as requested. A review of the January 2023 MAR revealed that Robaxin was scheduled to be given at 8:00 A.M., 4:00 P.M., and 12:00 A.M. For the 8:00 A.M. scheduled administration of Robaxin, it was administered late at the following times: 01/01/2023 at 11:23 A.M. 01/02/2023 at 9:33 A.M. 01/04/2023 at 9:45 A.M. 01/06/2023 at 9:46 A.M. 01/07/2023 at 10:26 A.M. 01/08/2023 at 3:20 P.M. 01/14/2023 at 11:20 A.M. 01/15/2023 at 11:59 A.M. 01/21/2023 at 11:36 A.M. 01/22/2023 at 11:23 A.M. 01/25/2023 at 12:55 P.M. 01/28/2023 at 11:09 A.M. 01/29/2023 at 11:10 A.M. 01/30/2023 at 10:27 A.M. 01/31/2023 at 11:47 A.M. On 02/03/2023 at 5:30 P.M., the Administrator and Director of Nursing were notified of the delay in assessment and treatment of Resident #144's left leg pain on 02/01/2023. According to Resident #144's Minimum Data Set with an Assessment Reference Date of 10/21/2022, the Brief Interview for Mental Status was coded as 14 out of 15 indicative of intact cognition. On 02/06/2023, Resident #144's care plan was reviewed. A focus initiated on 11/29/2021 contained goals and interventions for Resident #144's osteoarthritis and low back pain. There was no evidence of goals or interventions addressing Resident #144's left leg pain/muscle spasms. On 02/06/2023 at 3:40 P.M., the Director of Nursing (DON) was interviewed. When asked about Resident #144's left leg pain/muscle spasms, the DON stated that they would have to get a physician in to evaluate why Resident #144 was having muscle spasms in her left leg. The facility staff provided a copy of their policy entitled, Pain Management - Stop the Pain Program. Excerpts in Section 2 entitled, The principles of the STOP program include: documented, prompt and accurate assessment of pain; use of non-drug approaches as important parts of a pain management program; use of pharmacological interventions individualized for each resident . 2) For Resident #376, the facility staff delayed assessment and treatment of Resident #376's chest pain and lower right leg pain on 02/02/2023. On 02/02/2023 at 9:46 A.M., this surveyor observed a therapist (Employee J) approach Licensed Practical Nurse F (LPN F) while she was passing medications to explain that Resident #376's right lower leg was tender and swollen. LPN F asked the therapist if Resident #376 was in pain and the therapist stated, Yes. LPN F did not go to Resident #376 at that time to assess the pain. LPN F did continue with passing medications to three Residents (Resident #378, Resident #379, Resident #166). After completing passing medications at approximately 10:15 A.M. on the three Residents, LPN F called to schedule Resident #376 for a doppler study to rule out deep vein thrombus of the right lower leg. On 02/02/2023 at 10:20 A.M., Resident #376 was interviewed. Resident #376 was observed in her bed. When asked about her right leg pain, Resident #376 stated her right leg had been hurting all night. Resident #376 stated it hurt from her knee to her ankle. Resident #376 was observed to be grimacing and moaning at times. When asked to rate the severity of the pain [0=no pain to 10=worst pain], Resident #144 stated the pain severity was 10. On 02/02/2023 at 10:34 A.M., Certified Nursing Assistant C (CNA C) entered Resident #376's room to assist with Activities of Daily Living (ADL) care. Three times during ADL care, Resident #376 verbalized to the CNA C that my leg hurts my leg is sore and my leg hurts so bad. As CNA C was assisting Resident #376 to her wheelchair at 10:52 A.M., Resident #376 stated, My chest hurts, too. When asked about the severity level of the chest pain, Resident #376 stated, 10. Resident #376 stated she thinks the pain is related to fall she had prior to coming to the facility. At 11:00 A.M., CNA C notified LPN F that Resident #376 complained of chest pain. LPN F did not go to Resident #376 to assess the chest pain or the right lower leg pain as reported to her at 9:46 A.M. At 11:37 A.M., LPN F entered Resident #376's room and assessed Resident #376's right lower leg pain. Resident #376 stated she had pain in leg all night long but now it's not as bad as it was. Resident #376 currently rated the right leg pain severity 5. LPN F administered Tylenol to Resident #376 at 11:41 A.M. and left the room. When asked why it took so long to assess and treat Resident #376's leg pain, LPN F stated that she should've gotten there sooner but was doing other things. At 11:55 A.M., LPN F was asked if she assessed Resident #376 for the chest pain. LPN F indicated she did not assess for chest pain but would do so now. LPN F entered Resident #376's room, listened to her heart and lungs, and asked about current chest pain severity. Resident #376 stated she currently didn't have chest pain so LPN F left the room. When asked about what else would be done concerning Resident #376, LPN F stated she could let the physician know. On 02/02/2023 at 1:55 P.M., LPN F was interviewed. When asked if physician was notified, LPN F stated she put a call out and was waiting for a call back. On 02/02/2023 at approximately 2:00 P.M., this surveyor interviewed Resident #376. When asked chest pain, Resident #376 stated it was better than it was. When asked to rate the pain severity, Resident #376 stated, 2. And that the pain comes and goes. On 02/02/2023 at approximately 2:10 P.M., the Director of Nursing was notified of findings. On 02/02/2023, Resident #376's clinical record was reviewed. A nurse's note dated 02/02/2023 at 2:34 P.M. documented, Resident reassessed s/p [status post] chest pain rates pain 2/10 currently in room participating with therapy, spoke with MD [medical doctor] made aware of change in condition v/s [vital signs] and pain level 97.0 [temperature] 20 [respirations] 126/66 [blood pressure] 82 [pulse] 98% [oxygen saturation]. Received new order from MD to send to ER [emergency room] for further evaluation r/t [related to] pervious [sic] medical history. Rp [responsible party] made aware of change in condition and MD order to send resident to the hospital for further evaluation. According to the physician's admission note dated 01/27/2023, Resident #376 was admitted to the facility having chest pain around where she was caught by her son from her fall. Resident #376's baseline care plan was reviewed. The chest pain was not addressed on the care plan. There was no recent Minimum Data Set completed due to Resident #376's recent admission. According to Resident #376's admission nursing progress note dated 01/26/2023 at 8:52 P.M., Resident #376 was alert and oriented. On 02/02/2023 at 5:30 P.M., the Administrator and Director of Nursing were notified of findings.

Based on record review, resident interview, staff interview, the facility failed to ensure routine dental services were offered to one of one Resident (R)26 reviewed for dental services. Findings include: Review of R26's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/03/23 indicated that R26 had a Brief Interview for Mental Status (BIMS) of 14 out of 15, indicating the resident was cognitively intact. During an interview on 02/02/23 at 10:10 AM, R26 stated that she knew she needed dental work or dentures but was unsure if she could get an appointment with a dentist. She revealed she had been at the facility for two years and has not had seen a dentist. Review of R26's Face Sheet located in the electronic medical record (EMR) under the Profile tab, revealed an admission date in February 2021. During an interview on 02/03/23 at 2:00 PM with the Social Services Director, Staff D, who is responsible for arranging resident dental appointments, with the in house free dental clinic stated, We do not automatically get everyone a dental appointment, unless their family or the resident requests it, or unless they have weight issues. During an interview on 02/03/23 at 3:45 PM with the Director of Nursing, (DON) she stated her expectations of residents being made dental appointments was if the resident or family request an appointment, if the nurse notices a concern (no teeth, broken teeth, or pain), or have dietary issues.

Based on staff interview and facility documentation review, the facility staff failed to ensure Committee Members were present for QAPI meetings for 4 of 4 QAPI meetings. The Findings included: For the QAPI meetings, the facility staff failed to ensure core members were present for each meeting. On 02/06/23 at 2:56 p.m., Meeting with DON and Administrator- Administrator stated the QAA, QAPI meets quarterly, The dates of the meetings in the past year were 11/15/2022, 8/31/2022, 5/18/2022 and 2/9/2022. Those in attendance were: 11/15/2022- The Administrator, Director of Nursing, Medical Director and 3 LPNs. (the Infection Preventionist was not present) 8/31/2022- The Administrator, Director of Nursing, Medical Director and 1 LPN. (the Infection Preventionist was not present and 1 other facility staff was not present) 5/18/2022- There were no signatures. All names were printed in the same penmanship. There were 3 listed on the top section as Healthcare Center Advisory Members on Web-ex. The bottom section listed 6 printed names including the Administrator, Director of Nursing, Chief Executive Officer, Unit Managers, one unidentified position and one via Web ex (The printed names did not document the positions held by each person.) 2/9/2022-The Administrator, Director of Nursing, Medical Director and 1 LPN. the Infection Preventionist was not present and 1 other facility staff was not present) On 2/6/23 at 2:52 p.m., Administrator stated We need to get back on track Post COVID- some members were not present She also stated Core group meets every day. The Administrator stated Clin ops (Clinical Operations) meeting is Campus wide,Transparent with each other and meet daily The Administrator stated Department heads, Certified Nursing Assistants, Rehab, Administrator, DON (Director of Nursing) Staffing, Unit Secretary, Dietary, etc were involved in the daily meeting. The Administrator stated the Infection Preventionist did not attend any of the QAPI meetings. She also stated a Certified Nursing Assistant did not attend the QAPI meetings. No further information was provided.

Based on Resident interviews, facility staff interviews and facility documentation review, the facility staff failed to permit the Resident Council to meet without a staff member being present which had the potential to affect Residents who attend resident council. The findings included: The facility staff attended Resident Council meetings without the approval of the group. On 1/31/23, Surveyor D met with the Resident Council President obtained permission to review the Resident Council meeting minutes. On 2/2/23 at 10:30 AM, the facility Administrator provided Surveyor D the Resident Council meeting minutes which were reviewed. This review revealed that during each meeting held, facility staff were in attendance. The minutes from the September 30, 2022, meeting read, .Questions asked about follow up of a secretary position [Resident # name redacted] asked if she could hold two positions . During the meeting held October 20, 2022, the following notation was made in the minutes, [Activities Director name redacted] followed up about the conversation from last meeting about secretary position. [Activities Director name redacted] explained that we only need a President and [NAME] President position since we have staff member appointed to assist with Resident Council Meetings . On 2/2/23 at 11 AM, Surveyor D met with the Resident Council, 14 Residents were in attendance. During the meeting, the Residents expressed that they were not permitted to meet without facility staff being present. Multiple Residents verbalized this was a concern. When asked if any of them had approved for the facility staff to attend the meeting they responded no. On 2/2/23 at 2:50 PM, an interview was conducted with Employee F, the Activities Director. When asked if she always attends the Resident Council Meetings, Employee F said, Yes. When asked, do they have right to meet without staff present? Employee F said, Yes. When asked if she was aware that the Resident Council didn't want her present she said, Not from a group consensus, No. Review of the facility policy titled; Resident Council Meetings was conducted. This policy read, . 5. The Activity Director shall be designated, if approved by the group, to serve as a liaison between the group and the facility's administration and any other staff members. a. If the Activity Director is not approved by the group, the group's designee shall serve as the liaison, and documentation shall be maintained to reflect the group's designation. b. The designated liaison shall be responsible for providing assistance with facilitating successful group meetings and responding to written requests from the group meetings. 6. The group may appoint a resident to take notes/maintain meeting minutes or may elect that the Activity Director/designated liaison to take notes/maintain minutes. Meeting minutes may include, but are not limited to: a. Names of the residents in attendance. b. Follow up from previous meetings. c. Issues discussed. d. Recommendations from the group to facility staff. e. Names of staff members, speakers, and other guests present in the meeting (as invited by the group to attend) . On 2/2/23, during the afternoon, during an end of day meeting, the facility Administrator confirmed that Resident Council has the right to meet without staff being present. The Administrator was made aware that the Residents desire to hold meetings without staff being present. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #375, the facility staff failed to provide personal hygiene, namely shaving. On 02/03/2023 at 3:00 P.M., Resident #375 was observed sleeping in his bed wearing a white T-shirt and covered with a blanket. It appeared Resident #375's face had not been shaved for several days. On 02/06/2023 at 12:15 P.M., Resident #375 was observed sleeping in his bed wearing a white T-shirt and covered with a blanket. It appeared Resident #375's face had not been shaved for several days. Resident #375's sister was visiting. When asked about Resident #375's preference, the family member stated [Resident #375] would prefer to be clean shaven. According to the nursing admission assessment dated [DATE] in Section M entitled ADL's/Functional Devices and subpart (1)(h) entitled, Personal Hygiene it was documented that [Resident #375] requires assistance of staff with personal hygiene. According to Resident #375's baseline care plan, Resident #375 needed the assistance of staff with grooming and hygiene. A review of Resident #375's Activities of Daily Living flowsheet for January and February 2023 were reviewed. According to the flowsheets, Resident #375 received personal hygiene (which includes shaving) on 01/26/2023, 01/28/2023, 01/29/2023, 01/30/2023, and 02/02/2023 - 02/06/2023. However, observations on 02/03/2023 and 02/06 2023 clearly showed that the resident was not clean shaven. On 02/06/2023 at approximately 4:10 P.M., the Administrator and Director of Nursing were notified of findings. The facility staff provided a copy of their policy entitled, Activities of Daily Living (ADL). Under the header Policy in Sections 1 and 2 it was documented, The capability of each resident to meet the demands of daily living is assessed by a licensed nurse. Assistance and instruction in ADL skills is provided to residents as designated by the individual care plan. Based on Resident Interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide services to maintain personal hygiene for 2 Residents (#222, and #375) in a survey sample of 73 Residents. The Findings included: 1. For Resident #222, the bed ridden and incontinent Resident did not receive bathing nor personal hygiene care on multiple days. Resident #222 had an admission minimum data set assessment dated [DATE] which coded the Resident with a Brief Interview of Mental Status score of 1 indicating severe cognitive impairment. The Resident was incontinent of bladder and bowel, and was totally dependent on staff for transferring, toileting, hygiene and bathing. The Resident's closed record ADL Care sheets documented by certified nursing assistants (CNA's) for Activities of Daily Living care were reviewed on 2-2-23. No ADL (activities of daily living) hygiene care was documented as being provided for the Resident on the following days and shifts. 7a.m. to 3p.m. shift - 4-3-21, 4-4-21, 4-13-21, 4-14-21, 4-15-21, 4-16-21, 4-17-21, 4-18-21, 4-19-21, 4-20-21, 4-23-21, 4-24-21, 4-25-21, 4-26-21, 4-27-21, 4-28-21, 4-30-21. The Resident was only documented as receiving hygiene care 13 times in 30 shifts. 3p.m. to 11p.m. shift - 4-1-21, 4-2-21, 4-4-21, 4-5-21, 4-6-21, 4-7-21, 4-9-21, 4-12-21, 4-13-21, 4-14-21, 4-15-21, 4-16-21, 4-17-21, 4-18-21, 4-21-21, 4-22-21, 4-24-21, 4-25-21, 4-26-21, 4-27-21, 4-28-21, 4-29-21, 4-30-21. The Resident was only documented as receiving hygiene care 7 times in 30 shifts. 11p.m. to 7a.m. shift - none was documented as being given during this shift. A tub bath or shower was documented as given only once during the Resident's 32 day stay, on 4-23-21. The ADL care policy was reviewed and under hygiene read Scheduled showers or baths with assistance are provided. Resident #222's care plan was reviewed and revealed that the Resident was incontinent of bladder and bowel. On 2-3-23 The Director of Nursing and Administrator were asked if the ADL documents should be signed correctly indicating care was given, and they stated if it's not documented, it's not done. The DON stated that the facility policy is to provide incontinence care hygiene per policy. They were asked what the expectation was for numbers of baths or showers per week and they stated 2 per week with daily hygiene as needed. The Administrator and Director of Nursing (DON) were notified of the missing documentation and the complaint allegation, at the end of day meeting on 2-3-23. No further information was provided by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, facility documentation review, and clinical record review, the facility staff failed to assess if a resident was safe to self administer medications for one Resident (Resident #149), in a survey sample of 60 Residents. For Resident #149, the facility staff failed to assess if the resident was safe to self administer prescription medications kept at the bedside. The findings included: Resident #149, was admitted to the facility on [DATE]. Resident #149 diagnoses included, but were not limited to: paroxysmal atrial fibrillation, malignant neoplasm of prostate, secondary malignant neoplasm of bone, hypertension anxiety disorder, and hearing loss. Resident #149's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 4/1/19, was coded as a quarterly assessment. Resident #149 was coded as not being able to be assessed for a BIMS (brief interview for mental status) and staff indicated the resident was severely cognitively impaired. Resident #149 was coded as being totally dependent upon staff for ADL's (activities of daily living) which included: dressing, eating, personal hygiene, and bathing. During initial observation of the facility on 4/28/19 at 3:20pm, Resident #149 was observed to be in bed, a bottle of nystatin powder was at the bedside. The prescription label read, apply to groin/perineum topically BID (twice a day) for redness & rash. A printed date was on the label of: 8/19/18 and the bottle contained 15 grams of medication. On 04/29/19 at 11:25 am, it was observed that the box of nystatin was at the bedside of Resident #149. On 4/30/19 at 10:43 am, nystatin was observed at the bedside of Resident #149. During an interview with Employee Q, Social Worker, on 4/30/19 at 11:52am, the Social Worker stated, we do have confused residents and occasionally they do go in other rooms. Review of Resident #149's entire clinical record revealed no documentation that Resident #149 had been assessed or determined to be safe to self administer medications, or to keep medications at the bedside. Review of facility policy, titled Self-Administration of Medications with an effective date of June 2016, the subheading policy read: In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team as determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. Under the subheading procedure, it read: D. The results of the interdisciplinary team assessment of resident skills and of the determination regarding bedside storage are recorded in the resident's medical record, on the careplan. For each medication authorized for self-administration, the label contains a notation that it may be self-administered. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. For Resident #159, the facility staff failed to provide access to her callbell. Resident #159, a [AGE] year old female who was admitted to the facility on [DATE] with diagnoses to include but not limited to diabetes, chronic kidney disease, high blood pressure, anxiety, and chronic obstructive pulmonary disease (COPD). She was placed in Hospice care at the facility on 03/18/2019. Resident #159's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/01/2019 was coded as re-entry from an acute care hospital. Resident #159 was coded with a Brief Interview of Mental Status (BIMS) score of 12 out of possible 15 indicating moderately impaired cognition. On 04/28/19 at approximately 5:30 PM, Resident #159 was observed lying in her bed and yelling Nurse! She stated that she needed to see her nurse and could not find her callbell. Her callbell was not visible and when prompted, she was unable to locate it. LPN B was observed approximately 2 doors down in the same hallway, at a medication cart. He confirmed that he was the LPN assigned to Resident #159 and stated, she always hollers out, she has already had a lot of attention because we've been in her room at least 3 times in the last hour changing her brief and applying her cream for her itching, I am getting her (scheduled) meds for her in just a minutes. LPN B was informed that Resident #159's could not locate her callbell. LPN B found her callbell to be clipped to the sheet near the head of the bed and down on the side of the mattress near the bed frame, out of view as well as out of reach by Resident #159. When asked where the callbell should be placed for access by the Resident, LPN B replied, it should be clipped where she can get to it. LPN B relocated and secured the callbell on top of the Resident's bedcovers within her reach and showed it to her. She verbalized understanding. On 04/29/19 at approximately 11:15 AM, the Unit Manager (RN A) for Resident #159's assigned unit, was asked what her expectations were with regard to the placement and answering of callbells and she stated, the callbells must always be placed and secured where the Residents can easily find them to be able to call for assistance when needed and I expect them to be answered promptly. On 04/29/19, a review was conducted of Resident #159's clinical record. A copy of Resident #159's current Care Plan to date was requested and received. Resident #159's Care Plan contained a Goal that read, The resident will be free of falls through the review date with a target date of 07/22/2019. One written Intervention for this Goal read, Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. On 04/30/19 at approximately 2:30 PM, the Administrator (Employee A) and Director of Nursing (DON, Employee B) were notified of concerns related to response times and access to callbells. A facility policy with regard to callbells was requested, however the DON (Employee B) stated, there is no specific facility policy related to callbells. A callbell log containing dates and times of callbell activations was requested, however the Administrator (Employee A) stated, we do not have the ability to track callbells like that, I just expect them to be answered immediately, I don't monitor callbell responses. No further information was received. On 04/30/19 at approximately 3:10 PM, the Information Technology (IT) Director (Employee M) was interviewed with regard to the callbell system utilized by the facility. He confirmed callbell log sheets that document date and time of actual callbell activation were available. He provided a callbell history for Resident #159 that showed no activations on 04/28/19 until after 06:53:29 PM, with 10 activations after that time. No further information was received. Based on observation, resident interview, resident representative interview, and staff interview, the facility staff failed to receive reasonable accommodation of needs and preferences for three Residents (Resident #84, Resident #251, and Resident #159) in a survey sample of 60 Residents. 1. For Resident #84, the facility staff failed to provide a wheelchair that was the appropriate height to promote Resident #84's ability to move freely within her room. 2. For Resident #251, the facility staff failed to accommodate her need for an appropriate wheelchair. 3. For Resident #159, the facility staff failed to provide access to her callbell. The findings included: 1. For Resident #84, the facility staff failed to provide a wheelchair that was the appropriate height to promote Resident #84's ability to move freely within her room. Resident #84 was admitted to the facility on [DATE]. Resident #84's diagnoses included but were not limited to: Alzheimer's, allergic rhinitis, anemia, major depressive disorder, acute respiratory failure, hypercapnia, and multiple sclerosis. Resident #84's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 3/4/19 was coded as a quarterly assessment. Resident #84 was coded as having a BIMS (brief interview for mental status) score of 9, which indicated cognition was moderately impaired. Resident #84 was coded as requiring extensive assistance of one staff member for dressing and personal hygiene. For transfers and toileting, Resident #84 required extensive assistance of two staff members. On 04/29/19 at 11:12 AM, during an interview with Resident #84 it was observed that her feet were hanging down and unable to reach the floor. When asked if she could get to her call bell to call staff for assistance she attempted to move but was not able to self propel the chair to get to her call bell to call for assistance if she were to need help. During this interview, Resident #84's daughter came in to visit when asked if she had any concerns she stated Mom (Resident #84) is in a loaner wheel chair and has been for about 2 weeks, her feet don't touch foot pedals and she can't reach the floor. If you can help with this I could appreciate it. On 4/29/19 at 4:12pm, an interview was conducted with LPN Q in Resident #84's room, when asked about the wheelchair LPN Q stated, they are fixing her real wheelchair, it wouldn't turn and would lock up, so she has been in this loaner chair for about a week and a half to two weeks. Usually she moves around a lot when in her chair. When asked about her positioning and if she could move, LPN Q stated, no because her feet are several inches from touching the floor. On 4/30/19 at 2:50pm, an interview was conducted with Employee N, the rehab manager, when asked about wheelchair positioning, the rehab manager said, legs shouldn't be hanging, their feet should touch the floor and if they can't self propel they would have leg rests. When asked if feet should rest on the foot pedals, the rehab manager stated yes. The rehab manager said, we don't have (Resident #84's) wheelchair maybe maintenance has it. On 4/30/19 at 2:54pm an interview was conducted with Employee L, Director of Plant Operations, he explained they have a work order system and any employee is able to enter a work order for items needing repair. For wheel chairs typically a work order isn't completed unless therapy is not able to make the repairs. Employee L stated, maintenance doesn't have Resident #84's wheelchair, Employee L was asked to see if he had a work order for Resident #84's wheelchair. On 4/30/19 at 3:18pm Employee L, Director of Plant Operations returned and stated there is no maintenance work order for Resident #84's wheel chair. On 4/30/19 at approximately 5:15pm Employee N, the rehab manager brought a wheelchair and stated I found the chair (Resident #84's chair), it was in the back. The wheel won't turn so the restorative aide got her the loaner chair and brought this one down. No further information was provided. 2. For Resident #251, the facility staff failed to accommodate her need for an appropriate wheelchair. Resident #251 was an [AGE] year old who was admitted to the facility on [DATE]. Resident #251's diagnoses included Anxiety Disorder, Dementia, Chronic Obstructive Pulmonary Disease, Osteoarthritis, Gout, Heart Failure, and Age-related Nuclear Cataract - Bilateral. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 3/1/19 was reviewed. Resident #251 was coded as having a Brief Interview of Mental Status Score of 9, indicating moderately impaired cognition. Resident #251 was also coded as having impaired vision. In addition, she was coded as being independent in locomotion with a wheelchair. On 4/28/19 at approximately 4:00 P.M., an interview was conducted with Resident #251 at the nurse's station. Resident #251 stated, my wheelchair is shaky I may fall out, it's not safe. It rubs against the wheel. She noted that it was difficult to propel the wheelchair. She stated that the therapy staff knew about her concerns with the wheelchair, but did not address it. On 4/30/19 at 2:00 P.M., an interview was conducted with the Rehabilitation Department Director (Employee N). He stated that he would have a staff member look at Resident #251's wheelchair. At 3:00 P.M. The Rehabilitation Department Director came into the conference room. He stated, The wheelchair had the wrong arm on it. It had an arm built on an angle which was meant for another wheelchair. It rubbed against the wheel. The correct arm is straight. The maintenance guy just changed it to the right one for the Invacare wheelchair. According to the manufacturer's instructions for Resident #251's wheelchair, the model is called Invacare 900 XT Wheelchair. The picture showed the correct armrest, which had a straight design, it was not built on an angle. No further information was received.

Based on observation, staff interview, and facility documentation review, the facility staff failed to ensure residents' right to privacy during a Resident Group Interview. The facility Social Worker (Employee K) interrupted a private meeting and violated the residents right to privacy by walking into and throughout the meeting room uninvited. The Findings included: On 4/29/19 at 10:40 A.M., a private group interview was being conducted. There were two doors that led into the very large double room. Do not Disturb Resident Council Meeting in Progress signs were taped on the outside of both doors to ensure residents' privacy. Seven residents were in attendance and were actively participating. They majority of them voiced concerns about consistent shortages of staff, and stated that call bell response times sometimes took between 30 to 60 minutes. Suddenly, the social worker interrupted the resident group interview by entering the room without knocking on the door. She walked across the large room and looked around at all of the residents. In the meantime, another resident entered the room. The residents were startled, and immediately stopped voicing their concerns. The Social Worker (Employee K) stated that she had read the note on the door stating do not disturb, but she came in anyway because she was looking for a resident. The resident she was looking for was not in the group. The social worker approached and interacted with one of the residents, further disrupting the group. The residents were unable to speak privately with the surveyor. On 4/29/19, a review was conducted of facility documentation, revealing an undated Resident Rights Policy. It read, You understand that the Facility will encourage and assist you to exercise your rights as a resident and a citizen. To this end, you understand that you are entitled to voice your grievances and recommend changes in policies and services to facility staff and/or to outside representatives of your choice, free from restraint, interference, coercion, discrimination or reprisal. On 4/29/19 at 12 P.M., the Administrator was informed of the findings. The Administrator stated that the Social Worker told her that she had only opened the door for another resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to notify the physician and responsible party that medications were available for administration for one Resident (Resident # 128) in a survey sample of 60 residents. For Resident #128, the facility staff failed to notify the physician and responsible party of several medications that were unavailable for administration including, but not limited to: the breathing treatment medication Acetylcysteine Solution 20%, the thyroid medication- Levothyroxine 50 micrograms and the mood disorder medication, Depakote 250 milligrams. The findings included: Resident #128, a [AGE] year old male , was admitted to the facility on [DATE]. Diagnoses included but were not limited to: respiratory failure, hypertension, insomnia, dry eye syndrome, cerebral palsy, major depressive disorder, hypertension and diabetes. The most current Minimum Data Set assessment was a Significant Change assessment with an assessment reference date of 3/27/19. Resident #128 was coded with a Brief Interview of Mental Status score of 15 indicating no cognitive impairment. He required extensive assistance with activities of daily living. Review of the clinical record was conducted on 4/28/2019 and 4/29/2019. Review of the April 2019 Medication Administration Record revealed an order for Acetylcysteine Solution 20%, 4 ml (milliliters) inhale orally every 12 hours for SOB (shortness of breath). Acetylcysteine Solution 20% was not administered on 4/12/19 at 9 PM, 4/13/19 at 9 AM Mirtazapine 7.5 milligrams give one tablet by mouth at bedtime for depression on order Not administered 4/16/19 at 9 PM According to the February 2019 MAR, medications were not administered as ordered due to not being available. Depakote 250 milligrams Delayed Release one tablet by mouth one time a day. Depakote 250 milligrams was not administered on 2/10/2019 and 2/17/2019. Acetylcysteine Solution 20% was not administered on 2/9/19, Levothyroxine/sodium Tablet 50 micrograms give 50 micrograms by mouth one time a day for Thyroid. Not administered on 2/23/19. Review of the Progress Notes (Nurses Notes) revealed documentation of medications not being administered. 4/16/2019 20:40 (8:40 PM)- Orders-Administration Note: Mirtazapine 7.5 milligrams give one tablet by mouth at bedtime for depression on order. 4/13/219 9:58 AM- Orders-Administration Note: 'awaiting delivery from pharmacy. 4/12/2019- 21:48 (9:48 PM)- Orders-Administration Note: Acetylcysteine Solution 20%, 4 ml (milliliters) inhale orally every 12 hours for SOB (shortness of breath) Med unavailable. Pharmacy called awaiting delivery. 3/13/2019 22:16 (10:16 PM) - Orders-Administration Note: Melatonin Capsule 3 MG (milligrams) Give 6 mg (milligrams) by mouth at bedtime for insomnia. On order. 3/13/2019 22:15 (10:15 PM) - Orders-Administration Note: Ascorbic Acid Tablet 500 MG (milligrams) give 1 tablet by mouth at bedtime for supplement On order 3/13/2019 22:15 (10:15 PM) - Orders-Administration Note: Acetylcysteine Solution 20%, 4 ml (milliliters) inhale orally every 12 hours for SOB (shortness of breath) On order 2/23/2019 07:11 (7:11 AM) - Orders-Administration Note:Levothyroxine/sodium Tablet 50 micrograms give 50 micrograms by mouth one time a day for Thyroid. Awaiting pharmacy 2/17/2019 11:37 (11:37 AM)- Orders-Administration Note: Depakote 250 milligrams Delayed Release one tablet by mouth one time a day related Mood Disorder due to known psychological condition, unspecified Not available .will call pharmacy 2/10/2019 11:32 (11:32 AM)- Orders-Administration Note: Depakote 250 milligrams Delayed Release one tablet by mouth one time a day related Mood Disorder due to known psychological condition, unspecified Not available .ordered 2/9/2019 12:21 (12:21 PM)- Orders-Administration Note: Acetylcysteine Solution 20%, 4 ml (milliliters) inhale orally every 12 hours for SOB (shortness of breath) Not available .ordered 2/7/2019 10:50 (10:50 AM)- Orders -Administration Note: unavailable 1/5/2019 1440 (2:40 PM)-Orders - Administration Note: On order per Pharmacy. Pharmacy to deliver this evening. Medication not available in pixus (medication delivery system) 1/10/2019 17:15 (5:15 PM)- Orders -Administration Note: Awaiting pharmacy delivery Review of the Facility policy Unavailable Medications Effective Date: June 2016 stated the facility must make every effort to ensure that medications are available to meet the needs of each resident. Under Procedures: A. The pharmacy staff will: 1) Call or notify nursing staff that the ordered product(s) is/are unavailable. 2) Notify nursing when it is anticipated that the drug (s) will become available. 3) Suggest alternative, comparable drug (s) and dosage of drug (s) that is/are available, which is covered by the resident's insurance. B. Nursing staff shall: 1) Notify the attending physician of the situation and explain the circumstances, expected availability and optional therapy(ies) that are available. a. If the facility nurse is unable to obtain a response from the attending physician, the nurse should notify the nursing supervisor and contact the Facility Medical Director for orders and/or direction. 2) Obtain a new order and cancel/discontinue the order for the non-available medication. 3) Notify the pharmacy of the replacement order. On 4/30/2019 at 5 PM, an interview was conducted with the Unit Manager, Employee R who stated she was unaware of medications being unavailable for Resident # 128. Employee R reviewed the Medication Administration Records and stated that Resident # 128 had one medication (Acetylcysteine Solution 20 %) that was kept in the refrigerator and maybe the nurses did not know where to find the medication. Employee R was informed that the documentation showed that the medication Acetylcysteine Solution 20%, 4 ml (milliliters) inhale orally every 12 hours for SOB (shortness of breath) was not in the refrigerator according to one nurse. Employee R reviewed the nurses notes and stated she did not know why medications were unavailable as ordered by the physician and written in the notes. Employee R was asked to identify the medications that were listed as unavailable but not named in the nurses notes. Employee R reviewed the nurses notes further and stated she was unable to tell which medications were unavailable. Employee R stated the Pharmacy was supposed to deliver medications twice a day. Valid Physicians Orders were evident for the medications documented as not administered due to unavailable from Pharmacy. Thorough review of the clinical record revealed no documentation of the physician or responsible party being notified of medications not being administered due to being unavailable from the Pharmacy. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and staff interview the facility failed to ensure a clean comfortable homelike environment for Residents in the Memory Care Unit, and Resident's # 146, and #14 in a survey sample of 60 Residents. 1. For the memory care Unit the facility staff was checking blood pressures and administering medications during breakfast meal. 2. Resident #146's room smelled strongly of urine and the floors were coated with a sticky dirty film. 3. Resident #14's room smelled strongly of urine and the floors were coated with a sticky dirty film The findings include: 1. For the memory care Unit the facility staff was checking blood pressures and administering medications during breakfast meal. On 4/29/19 at 8:00 AM the following observations were made at breakfast. At 8:35 AM while breakfast was going on observed LPN E was obtaining vital signs from a Resident who had a tray in front of them. At 8:35 AM LPN G was administering medications to a Resident with a tray in front of them. On 4/29/19 at 8:45 AM an interview was conducted with Employee C (Unit Manager). When asked what her expectation was for obtaining vital signs and administering meds she stated that there should be none of that going on in the dining room during meal service. During afternoon meeting on 4/30/19 the Administrator was notified of the meal service issues and no further information was given, 2. Resident #146's room smelled strongly of urine and the floors were coated with a sticky dirty film. Resident #146 was admitted to the facility on [DATE]. Diagnoses included; Congestive heart failure, urine retention, foley catheter, dysphagia, atrial fibrillation, muscle weakness, and osteoporosis. The Resident had a recent hip fracture, and a history of falls. The Minimum Data Set which was a quarterly Assessment with an Assessment Reference Date of 3-25-19, coded Resident #146 as having a Brief Interview of Mental Status score of 13, indicating no impaired cognition. In addition, the Resident was coded as being able to understand and be understood by others. The Resident had a foley catheter for urination, and was coded as occasionally incontinent of bowel. The Resident was fully dependant on staff for hygiene needs, as she had recently had a hip fracture, and a history of falls. On 4-29-19 at 10:55 A.M. an observation was made of Resident #146 laying awake in bed. The room floor was so sticky, that the surveyors shoe stuck to the floor, and created a fall hazard. The room had a foul distinct urine odor that permeated even the hallway. The Resident was cognitively intact, and reported not receiving care from the staff. Her room smelled strongly of urine, and the floors were coated with a sticky dirty film. On 4-30-19, the Administrator, Director of Nursing, and Chief Executive Officer were informed of the findings. The facility staff stated they had no further information to provide. 3. Resident #14's room smelled strongly of urine and the floors were coated with a sticky dirty film Resident #14, was originally admitted to the facility on [DATE]. The Resident was discharged and for this stay was readmitted for a medicaid stay on 7-1-15, according to the most recent (4-19-19) MDS (minimum data set) assessment prepared by the facility. Resident #14 was diagnosed on [DATE] with contracture, unspecified hand during stay in the facility. Other diagnoses for Resident #14 included but were not limited to: Arthritis, dementia, psychosis, hernia, dysphagia, anxiety, and chronic obstructive pulmonary disease. Resident #14's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 4-19-19 was coded as a quarterly assessment. Resident #14 was coded as having severe cognitive impairment based on a staff assessment, a BIMS (brief interview for mental status) was not able to be conducted. Resident #14 was coded as being total care, dependent upon one to two staff members, for assistance with dressing, eating, personal hygiene and bathing. The Resident was coded as having not rejected any care services. During observation of Resident #14 on 4-29-19 at 10:00 a.m., 12:00 p.m., and 3:00 p.m., both of the Resident's hands were severely contracted, and clenched in a fist with her fingernails pressed into her palms. The Resident was in a short sleeve gown in bed and wore no arm skin protectors, nor palm protection. Observations continued on 4-30-19 at 10:04 a.m., in the Resident's room. The Resident's room had a foul odor of strong urine, and it permeated the entire hallway. The floor of the Resident's room was sticky and the surveyors shoe stuck to the floor. The CNA stated she could not tell if the urine odor was from Resident #14, as she agreed that the odor could be from anyone on the unit, as the entire unit smelled strongly of urine. This observation and others proved to be the same throughout the entire unit for this surveyor's observations of 4-29-19 through 4-30-19. The facility Administrator, DON, and Chief Executive Officer were made aware of the findings on 4-30-19, of the facility staff's failure to provide services for Resident #14 They stated no further information was available to be provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident Representative interview, staff interview, facility documentation review and clinical record review, the facility staff failed to ensure that appropriate information was communicated to the hospital for one Resident (Resident #105) in a survey sample of 60 Residents. For Resident #105, the facility staff failed to provide the receiving facility with a list of the resident's current medications at the time of transfer to the hospital. The findings included: Resident #105 was initially admitted to the facility on [DATE], with a readmission date of 4/24/19. Resident #105's diagnoses included but were not limited to: heart failure, atrial fibrillation, hypertension, chronic obstructive pulmonary disease, and chronic pain syndrome. Resident #105's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 2/22/19 was coded as an admission assessment. Resident #105 was coded as having a BIMS (brief interview for mental status) score of 8, which indicated moderate cognitive impairment. Resident #105 was coded as requiring extensive assistance of one staff member for transfers, dressing and personal hygiene. On 04/29/19 at 05:19 PM during a resident interview, Resident #105's daughter was present and said, I need a copy of what medications she is on, when she went to hospital recently they didn't know what med's she was on and I didn't know either. I wasn't able to tell them. They wanted to know if she was on a blood thinner but I didn't know. On 4/30/19 during a clinical record review of nursing notes, physician progress notes, and hospital records there was no evidence that the hospital was made aware of Resident #105's medication regime. On 4/30/19 at 3:46pm an interview was conducted with LPN K, Unit Manager, the unit manager stated when a resident is transferred we print a facesheet, transfer sheet, x-rays, labs, medication list and bed hold to send. When the unit manager was asked where they document what is sent with the resident to the receiving provider, she stated we don't really document that. On 4/30/19 at approximately 10:00am, 12:30pm, 3:46pm a request was made for the emergency room visit records for Resident #105. On 4/30/19 at 7:00pm the only records received were discharge instructions (patient copy) dated 4/23/19, Discharge Summary (patient copy) dated 4/23/19 and a hospital facesheet. Review of the facility policy titled Transfer of Resident From The Facility with a previous editions date of: 1/5/09, 8/7/10, policy number: 800-812.12 read under the subheading Procedure: 4. The following documents will be copied and or printed from the ECS medical record by the Unit Secretary if possible, and sent with the resident at the time of transfer: d. pertinent lab reports, x-ray, consults, current MAR, TAR, non-treatment record, and MD. No further information was provided to indicate the facility did communicate Resident #105's medication regime with the receiving facility at the time of discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review and clinical record review, the facility staff failed to provide the bed hold policy to the resident and resident representative for one Resident (Resident #105) in a survey sample of 60 Residents. For Resident #105, the facility staff failed to provide the resident and resident representative with the bed hold policy at the time of transfer to the hospital. The findings included: Resident #105 was initially admitted to the facility on [DATE], with a readmission date of 4/24/19. Resident #105's diagnoses included but were not limited to: heart failure, atrial fibrillation, hypertension, chronic obstructive pulmonary disease, and chronic pain syndrome. Resident #105's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 2/22/19 was coded as an admission assessment. Resident #105 was coded as having a BIMS (brief interview for mental status) score of 8, which indicated moderate cognitive impairment. Resident #105 was coded as requiring extensive assistance of one staff member for transfers, dressing and personal hygiene. Resident #105 was sent to the hospital on 4/23/19 following a fall the resident sustained at the facility. Resident #105 was readmitted to the facility on [DATE] with a diagnosis of a sprained knee. On 4/30/19 during a clinical record review of nursing notes, social services notes, and physician progress notes, there was no evidence that Resident #105 or the resident representative was made aware of the facility bed hold policy. On 4/30/19 at 3:46pm an interview was conducted with LPN K, Unit Manager, the unit manager stated when a resident is transferred we print a facesheet, transfer sheet, x-rays, labs, medication list and bed hold to send. When the unit manager was asked where they document what is reviewed with the resident and family, the unit manager stated we don't really document that. A copy of the documents sent with Resident #105 to the hospital was requested. A copy of the Bed Hold Policy, policy number 300-05 was provided which had blank signature lines at the bottom and no confirmation that Resident #105 or the responsible representative received a copy. The policy shows no evidence that it is to be provided at the time of transfer or discharge. It read; to ensure residents and responsible parties are aware of current bed hold procedures the bed hold policy will be provided and reviewed with the resident ad or responsible part at the time of admission. A signed copy of the policy will be retained in the business office. Review of the facility policy titled Transfer of Resident From The Facility with a previous editions date of: 1/5/09, 8/7/10, policy number: 800-812.12 read under the subheading Procedure: 2. The responsible party for the resident will be notified prior to transfer or as soon as possible in the event of an emergency. 4. The following documents will be copied and or printed from the ECS medical record by the Unit Secretary if possible, and sent with the resident at the time of transfer: a. the most recent nursing summary, b. the last 24 hours of nursing notes and any recent notes that will facilitate the care of the resident at the time of transfer, c. recent orders, and most recent recertification d. pertinent lab reports, x-ray, consults, current MAR, TAR, non-treatment record, and MD. No further information was provided to indicate the facility did communicate with Resident #105 or Resident #105's representative the facility bed hold policy at the time of discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility documentation and clinical record review the facility failed to ensure Residents had (Pre admission Screening and Resident Review) PASARR Level II screening prior for 1 Resident (#97) in a survey sample of 60 Residents. 1. For Resident #97 the facility staff failed to obtain the required Level II screening done based on results of Level I. The Findings Include: Resident #97 a [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Parkinson's disease, Type II Diabetes, Major Depressive Disorder, Restless Leg Syndrome, Sleep Apnea, and Reflux, Osteoarthritis. According to the admission Record the Resident was diagnosed with Dementia on 12/16/18 and Psychosis on 1/9/18 (a year after admission). According Resident's # 97's most recent (Minimum Data Set) MDS screening coded as a quarterly the Resident has a (Brief Interview of Mental Status) BIMS score of 12 indicating moderately impaired cognition. On 4/29/19 during clinical record review it was discovered that the Resident had a PASARR Level I screening done on 4/12/18. The screening was done a year and 4 months after the Resident was admitted . The PASARR Screening states: 1. Does the individual meet nursing facility criteria? YES 2. Does the individual have a current serious mental illness (MD)? YES a. Is this major mental disorder diagnosable under DSM IV (e.g. Schizophrenia, mood, paranoid panic or other serious anxiety disorder somatoform disorder, personality disorder, other psychotic disorder that may lead to chronic disability? YES b. Has this disorder resulted in functional limitations in major life activities within the past 3-6 months? YES c. Does the treatment history indicate that the individual has experienced psychiatric treatment more intensive than outpatient care more than once in the past two years or the individual has experienced within the last two years a significant disruption to the normal living situation due to the mental illness? Yes However question number 5 was answered as follows. 5. Recommendation: b. No referral for active treatment needs assessment required because individual: Has primary diagnosis of Dementia a secondary diagnosis of serious MI (Mental Illness) According to the admission record the Resident was diagnosed with dementia one year and four months after admission. In summary, Resident #97 should have been referred for a Level 2 PASARR. On 5/1/19 the Administrator was made aware of the issues and no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation and clinical record review the facility failed to ensure Residents had (Pre admission Screening and Resident Review) PASARR for 1 Resident (#169) in a survey sample of 60 Residents. For Resident #169 the facility staff failed to ensure a PASARR was obtained prior to admission. The findings include: Resident #169, a [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Dementia, Diabetes type 2, Delusional Disorder, Glaucoma, Hypertension, and Neuropathy. The Resident's most recent (Minimum Data Set) MDS screening was coded as a Quarterly Review with an (Assessment Reference Date) ARD of 4/3/19 coded the Resident as having a (Brief Interview of Mental Status) BIMS Score of 3 indicating severe cognitive impairment. On 4/30/19 during clinical record review it was noted that Resident #169 had a PASARR with the date of 4/12/19 and the Resident was admitted to the facility on [DATE]. On 4/30/19 at 5:10 in an interview with the DON who stated that the PASARR's that didn't get done on admission were done later. On 5/1/19 the Administrator was made aware of the issues and no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #179, the facility staff failed to identify, assess, or treat a potential bowel elimination problem according to professional standards. Resident #179, an [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses included but are not limited to displaced fracture lateral malleolus right fibula, cerebral infarction without residual deficits, cognitive communication deficit, diabetes, muscle weakness, and dysphagia. Resident #179's most recent Minimum Data Set with an Assessment Reference Date of 04/12/2019 was coded as an admission assessment. The Brief Interview for Mental Status was coded as 11 out of possible 15 indicative of moderate cognitive impairment. Discharge plan was coded as 'yes' meaning there was an active plan in place for Resident #179 to return to the community. Resident #179's overall expectation/goal was not coded. Bowel and bladder was coded as occasionally incontinent. On 04/29/2019 at approximately 11:45 AM, Resident #179 was interviewed. When asked about any concerns with bowel elimination, Resident #179 stated she recently started having a problem with constipation. When asked when she last had a bowel movement, she could not remember. She also stated that Sometimes it's a very small amount. Resident #179 also stated she was not in discomfort currently. On 04/29/2019, the active physician's orders for April 2019 were reviewed. There were no orders for a stool softener, laxative, or other medications to prevent/alleviate constipation. Included on the list of medications ordered, there was an order for, Hydrocodone-acetaminophen (an opioid analgesic which can cause constipation) 5-325 mg oral tab Q6hr PRN (every 6 hours as needed). The Medication Administration Record for April 2019 was reviewed. Resident #179 received 8 doses of hydrocodone in the date range of 04/06/2019 through 04/17/2019. Resident #179 did not receive another dose of hydrocodone until 04/29/2019 at 2:04 AM. On 04/30/2019, the electronic care plan was reviewed. Bowel and bladder continence were not addressed. The paper copy baseline care plan provided by the facility staff documented continent for bowel. The CNA care plan documented incontinent under the header Toileting. On 04/30/2019, a copy of the bowel elimination documentation for April 2019 was requested. The facility provided a flowsheet entitled, Bowel and Bladder Elimination with a date range of 04/01/2019 through 04/29/2019. When asked to interpret the meaning of the coding for daily documentation, the DON looked at the form and stated she would get a staff nurse to assist with answering the question. On 04/30/2019 at approximately 5:45 PM, LPN P was interviewed to explain the meaning of the codes on the bowel and bladder elimination flowsheet. She explained each shift could have up to 4 characters in the space provided. The first character coded bowel continence, the second character coded the size of the bowel movement, the third character coded bowel consistency, and the fourth character coded urinary continence. She also stated that when there were only 2 characters in the space provided, it was because a bowel movement did not occur so only bowel continence and urinary continence would be coded. For the day shift dated 04/20/2019 at 1:30 PM, the coding for bowel and bladder elimination indicated Resident #179 was continent and had a medium-sized, formed/normal bowel movement. All subsequent documentation on the flowsheet ranging from 04/20/2019 at 4:39 PM through 04/29/2019 at 6:59 AM was coded as a 2 meaning No bowel movement according to the legend on the bottom of the page. There were 6 shifts in that time range where documentation did not occur: 04/21/2019 (dayshift), 04/23/2019 (dayshift), 04/26/2019 (dayshift), 04/27/2019 (evening shift), 04/28/2019 (dayshift), and 04/29/2019 (evening shift). When asked when Resident #179 last had a bowel movement, LPN P stated according to the flowsheet, the last bowel occurred on 04/20/2019 (10 days ago) unless it occurred where there are empty spaces in the documentation. On 04/30/2019 at approximately 6:00PM, an interview with LPN G was conducted. When asked when Resident #179 last had a bowel movement, LPN G referred to the electronic health record and stated, She must have had one recently because she did not trigger alert. When asked if she received information in nurse-to-nurse verbal report about it, she did not answer. She stated that sometimes residents have a bowel movement and do not tell staff. LPN G continued to refer to electronic health record and stated, She is a one-person assist so staff would know if Resident #179 had a bowel movement. When asked why it is important to monitor bowel elimination, LPN G stated, Because there might be an obstruction or some medical issue. On 04/30/2019 at approximately 6:05 PM, this surveyor and LPN G entered Resident #179's room. Resident #179 was observed awake and sitting up. When asked if she had concerns with bowel elimination, Resident #179 stated she had problems with constipation. When asked when she last had a bowel movement, Resident #179 stated she had a bowel movement earlier today and that it was normal. LPN G asked Resident #179 if she was having any discomfort and Resident #179 stated, No. On 04/30/2019, the facility provided a copy of the policy entitled, Bowel Protocol for Constipation. Procedures listed are as follows: 1. The licensed nurse will check the bowel record daily to see if the resident has had a bowel movement. 2. If there has been no bowel movement in 2 days, administer Sorbitol 2 tsp. by mouth. 3. If there has been no bowel movement within 24 hours of the administration of Sorbitol, administer Bisacodyl - (Dulcolax) rectal suppository. 4. Document medication interventions on the MAR. 5. Document results on the BM flowsheet. 6. If no bowel movement after the suppository, notify the physician for further orders. 7. Physician order must be obtained before manual removal of firm, immobile stool. If manual removal is required, see policy #838.7 before proceeding. According to Lippincott Manual of Nursing Practice, 10th edition, under the section entitled, Standards of Practice and sub-header Common Departures from the Standards of Care, Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician's orders, follow appropriate nursing measures,= and adhere to facility policy or procedure. In summary, Resident #179 expressed concerns with constipation and , according to the bowel flowsheet, Resident #179 did not have a bowel movement for 10 days. There was no evidence in the physician's orders or the Medication Administration Record that Sorbitol was given as indicated in their policy. At 04/30/2019 at approximately 7:15 PM, the DON stated they had no further information or documentation to offer. Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed for two residents (Resident #113 and Resident #179) of 60 sampled residents to meet professional standards of quality. 1. For Resident #113, the facility staff failed to administer the correct physician ordered dose of oxygen. 2. For Resident #179, the facility staff failed to identify, assess, or treat a potential bowel elimination problem according to professional standards. The Findings included: 1. For Resident #113, the facility staff failed to administer the correct physician ordered dose of oxygen. Resident #113 was an [AGE] year old who was admitted to the facility on [DATE]. Resident #113's diagnoses included Congestive Heart Failure, Hypertension, Chronic Kidney Disease, Anxiety Disorder, Dyspnea (shortness of breath), and Cardiomyopathy (enlarged heart). The Minimum Data Set, which was an Annual Assessment with an Assessment Reference Date of 3/17/19 was reviewed. Resident #113 was coded as having a Brief Interview of Mental Status Score of 8, indicating severe cognitive impairment. In addition, Resident #113 was coded as requiring Oxygen Therapy. On 4/28/19 a review was conducted of Resident #113's clinical record, revealing a care plan. It read, Oxygen therapy r/t (related to) Cardiomyopathy & SOB (shortness of breath). Goal: The resident will have no s/sx (signs/symptoms) of poor oxygen absorption through the review date. Oxygen settings: O2 via nasal cannula. Resident #113's signed physician order read, 4/1/19. O2 via nasal cannula at 2 Lpnc continuous for SOB. Check placement every shift. O2 sats (saturation level) prn (as needed). If less than 90% notify MD. The Treatment Administration Record was reviewed. There were no oxygen saturation levels documented during the month of April, 2019. On 4/28/19 a review was conducted of facility documentation, revealing an Administration of Oxygen Policy with an initial implementation date of 1/1/1999. It read, Oxygen should be delivered by the most comfortable and efficient manner. Obtain a complete physician order. Set flowmeter with desired flow. On 4/29/19 at 8:54 A.M., an observation was conducted of Resident #113, who was asleep in her bed. Her oxygen was set at 3 liters per minute. When asked to confirm the amount of oxygen the resident was receiving, the Unit Manager (LPN V) stated, it's right around 3 liters. When asked to confirm the current physician's order for oxygen therapy, the Unit Manager stated, The order says 2 liters. I just looked at it in a glance I should have looked at it differently. We don't want to over saturate them. I don't think that would make a big difference. Guidance for nursing standards for the administration of medication is provided by Fundamentals of Nursing, 7th Edition, [NAME]-[NAME], p. 705: Professional standards, such as the American Nurses Association's Nursing: Scope and Standards of Nursing Practice (2004) apply to the activity of medication administration. To prevent medication errors, follow the six rights of medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation. On 4/29/19 at approximately 10 A.M., in the conference room, the facility Administrator (Employee A) was informed of the findings. No further information was received.

**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 provide quality of care to 3 Residents (Resident #94, Resident #113, and Resident #179) in a survey sample of 60 Residents. 1. For Resident #94, the facility staff failed to apply adaptive devices as ordered by the physician. 2. For Resident #113, the facility staff failed to ensure that physician ordered continuous oxygen was available prior to transport from her room to the dining room. 3. For Resident #179, the facility staff failed to identify, assess, or treat a potential bowel elimination problem. The Findings included: 1. For Resident #94, the facility staff failed to apply adaptive devices as ordered by the physician. Resident #94, an [AGE] year old female who was admitted to the facility on [DATE] with diagnoses to include but not limited to high blood pressure, diabetes, right-sided paralysis following a stroke, and dementia. Resident #94's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/12/2019 was coded as a quarterly assessment. Resident #94 was coded with a Brief Interview of Mental Status (BIMS) score of 4 out of possible 15 indicating severely impaired cognition. Resident #94 was coded as being totally dependent for all of her ADL's (activities of daily living). On 04/28/2019 at approximately 6:45 PM during General Dining Observation, Resident #94 was observed sitting quietly in her wheelchair in the dining room waiting for meal service. A facility staff secured a clothing protector to Resident #94 and fed her dinner. Resident #94's right upper extremity appeared to be contracted at the elbow, wrist, and hand. No movements were observed in any of her extremities. Her feet were resting on the foot pedals of the wheelchair. No adaptive equipment were noted. On 04/29/2019 at approximately 10:00 AM, a review was conducted of Resident #94's clinical record. Current physician orders included: Apply right hand palm guard to right hand Q(every) AM in the morning for Preventative Measures and Check placement for knee abduction wedge between resident's knees every shift for maintaining separation of knees. Current Care Plan included: Focus: (Resident #94) is at risk for skin breakdown r/t (related to) impaired mobility Interventions: Apply R hand palmar guard Q(every) AM with skin checks. Remove at QHS (bedtime), Knee abduction wedge between resident's knees, check placement every shift, Podus boots as tolerated by resident. On 04/29/2019 at approximately 11:15 AM, Resident #94 was observed sitting in her wheelchair at the scheduled morning activity taking place in the dining room. The right palm guard, knee abduction wedge, and Podus boots were not applied. At approximately 3:50 PM, Resident #94 was observed sitting quietly in her room watching TV without her right palm guard, knee abduction wedge, or Podus boots. On 04/30/2019 at approximately 10:40 AM, Resident #94 was observed sitting quietly in her room without her right palm guard, knee abduction wedge, or Podus boots. LPN A confirmed that he was assigned to Resident #94 and when asked about her adaptive devices he stated, I haven't made my rounds yet, the CNA's are responsible for applying them (adaptive devices) in the morning with the Resident's morning care and dressing. LPN A located and applied Resident #94's right palm guard and her knee abductor wedge. CNA A entered the room while LPN A was applying the devices and confirmed that she had dressed Resident #94 that morning and provided her morning hygiene. When asked about the adaptive devices, CNA A stated, I haven't got to it yet but I did dress her this morning--I should have put it on when I dressed her but I didn't know that she needed anything. LPN A stated, We keep an updated CNA care plan, called 'At A Glance', inside of each Resident's closet so that they (CNA) will know what their needs are. LPN A provided a copy of Resident #94's 'At A Glance' care plan that was located inside her closet door and was dated 4-11-2019. The 'At A Glance' care plan for Resident #94 included her needs for Activities for Daily Living (ADLs) as well as a Special Needs section that read, foot cradle to bed, medium size brief, right hand palm remove QHS (bedtime), apply QAM (every morning), left arm lap tray, wedge between knees, and OOB (out of bed) in w/c (wheelchair) for every meal. On 04/30/2019 at approximately 11:15 AM, RN A (Unit Manager) was notified of the concerns related to the adaptive devices not being utilized for Resident #94 on several observations made since 04/28/2019. RN A stated, I expect my staff to be familiar with the needs of the Residents, we use an 'At A Glance' care plan and update and post it into each Resident's closet, the staff knows this so I don't know why (Resident #94's) palm guard and wedge wasn't applied. RN A was unsure of a specific facility policy with regard to 'At A Glance' but indicated that Residents on each unit have one posted in their closets as a reference tool. No further information was received. 3. For Resident #179, the facility staff failed to identify, assess, or treat a potential bowel elimination problem. Resident #179, an [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses include but not limited to displaced fracture lateral malleolus right fibula, cerebral infarction without residual deficits, cognitive communication deficit, diabetes, muscle weakness, and dysphagia. Resident #179's most recent Minimum Data Set with an Assessment Reference Date of 04/12/2019 was coded as an admission assessment. The Brief Interview for Mental Status was coded as 11 out of possible 15 indicative of moderate cognitive impairment. Discharge plan was coded as 'yes' meaning there was an active plan in place for Resident #179 to return to the community. Resident #179's overall expectation/goal was not coded. Bowel and bladder was coded as occasionally incontinent. On 04/29/2019 at approximately 11:45 AM, Resident #179 was interviewed. When asked about any concerns with bowel elimination, Resident #179 stated she recently started having a problem with constipation. When asked when she last had a bowel movement, she could not remember. She also stated that Sometimes it's a very small amount. Resident #179 also stated she was not in discomfort currently. On 04/29/2019, the active physician's orders for April 2019 were reviewed. There were no orders for a stool softener, laxative, or other medications to prevent/alleviate constipation. Included on the list of medications ordered, there was an order for, Hydrocodone-acetaminophen (an opioid analgesic which can cause constipation) 5-325 mg oral tab Q6hr PRN (every 6 hours as needed). The Medication Administration Record for April 2019 was reviewed. Resident #179 received 8 doses of hydrocodone in the date range of 04/06/2019 through 04/17/2019. Resident #179 did not receive another dose of hydrocodone until 04/29/2019 at 2:04 AM. On 04/30/2019, the electronic care plan was reviewed. Bowel and bladder continence were not addressed. The paper copy baseline care plan provided by the facility staff documented continent for bowel. The CNA care plan documented incontinent under the header Toileting. On 04/30/2019, a copy of the bowel elimination documentation for April 2019 was requested. The facility provided a flowsheet entitled, Bowel and Bladder Elimination with a date range of 04/01/2019 through 04/29/2019. When asked to interpret the meaning of the coding for daily documentation, the DON looked at the form and stated she would get a staff nurse to assist with answering the question. On 04/30/2019 at approximately 5:45 PM, LPN P was interviewed to explain the meaning of the codes on the bowel and bladder elimination flowsheet. She explained each shift could have up to 4 characters in the space provided. The first character coded bowel continence, the second character coded the size of the bowel movement, the third character coded bowel consistency, and the fourth character coded urinary continence. She also stated that when there were only 2 characters in the space provided, it was because a bowel movement did not occur so only bowel continence and urinary continence would be coded. For the day shift dated 04/20/2019 at 1:30 PM, the coding for bowel and bladder elimination indicated Resident #179 was continent and had a medium-sized, formed/normal bowel movement. All subsequent documentation on the flowsheet ranging from 04/20/2019 at 4:39 PM through 04/29/2019 at 6:59 AM was coded as a 2 meaning No bowel movement according to the legend on the bottom of the page. There were 6 shifts in that time range where documentation did not occur: 04/21/2019 (dayshift), 04/23/2019 (dayshift), 04/26/2019 (dayshift), 04/27/2019 (evening shift), 04/28/2019 (dayshift), and 04/29/2019 (evening shift). When asked when Resident #179 last had a bowel movement, LPN P stated according to the flowsheet, the last bowel occurred on 04/20/2019 (10 days ago) unless it occurred where there are empty spaces in the documentation. On 04/30/2019 at approximately 6:00PM, an interview with LPN G was conducted. When asked when Resident #179 last had a bowel movement, LPN U referred to the electronic health record and stated, She must have had one recently because she did not trigger alert. When asked if she received information in nurse-to-nurse verbal report about it, she did not answer. She stated that sometimes residents have a bowel movement and do not tell staff. LPN G continued to refer to electronic health record and stated, She is a one-person assist so staff would know if Resident #179 had a bowel movement. When asked why it is important to monitor bowel elimination, LPN G stated, Because there might be an obstruction or some medical issue. On 04/30/2019 at approximately 6:05 PM, this surveyor and LPN G entered Resident #179's room. Resident #179 was observed awake and sitting up. When asked if she had concerns with bowel elimination, Resident #179 stated she had problems with constipation. When asked when she last had a bowel movement, Resident #179 stated she had a bowel movement earlier today and that it was normal. LPN G asked Resident #179 if she was having any discomfort and Resident #179 stated, No. On 04/30/2019, the facility provided a copy of the policy entitled, Bowel Protocol for Constipation. Procedures listed are as follows: 1. The licensed nurse will check the bowel record daily to see if the resident has had a bowel movement. 2. If there has been no bowel movement in 2 days, administer Sorbitol 2 tsp. by mouth. 3. If there has been no bowel movement within 24 hours of the administration of Sorbitol, administer Bisacodyl - (Dulcolax) rectal suppository. 4. Document medication interventions on the MAR. 5. Document results on the BM flowsheet. 6. If no bowel movement after the suppository, notify the physician for further orders. 7. Physician order must be obtained before manual removal of firm, immobile stool. If manual removal is required, see policy #838.7 before proceeding. In summary, Resident #179 expressed concerns with constipation and , according to the bowel flowsheet, Resident #179 did not have a bowel movement for 10 days. There was no evidence the facility identified this potential bowel elimination problem. At 04/30/2019 at approximately 7:15 PM, the DON stated they had no further information or documentation to offer. 2. For Resident #113, the facility staff failed to ensure that physician ordered continuous oxygen was available prior to transport from her room to the dining room. Resident #113 was an [AGE] year old who was admitted to the facility on [DATE]. Resident #113's diagnoses included Congestive Heart Failure, Hypertension, Chronic Kidney Disease, Anxiety Disorder, Dyspnea (shortness of breath), and Cardiomyopathy (enlarged heart). The Minimum Data Set, which was an Annual Assessment with an Assessment Reference Date of 3/17/19 was reviewed. Resident #113 was coded as having a Brief Interview of Mental Status Score of 8, indicating severe cognitive impairment. In addition, Resident #113 was coded as requiring Oxygen Therapy. On 4/28/19 a review was conducted of Resident #113's clinical record, revealing a care plan. It read, Oxygen therapy r/t (related to) Cardiomyopathy & SOB (shortness of breath). Goal: The resident will have no s/sx (signs/symptoms) of poor oxygen absorption through the review date. Oxygen settings: O2 via nasal cannula. Resident #113's signed physician order read, 4/1/19. O2 via nasal cannula at 2 Lpnc continuous for SOB. Check placement every shift. O2 sats (saturation level) prn (as needed). If less than 90% notify MD. On 4/28/19 a review was conducted of facility documentation, revealing an Administration of Oxygen Policy with an initial implementation date of 1/1/1999. It read, Oxygen should be delivered by the most comfortable and efficient manner. Obtain a complete physician order. Set flowmeter with desired flow. On 4/28/19 at 4:30 P.M., an observation was conducted of Resident #113 in the hallway. She was being transported by a Certified Nursing Assistant (CNA I). Resident #113 had a nasal cannula on her face. Her portable oxygen tank displayed a reading of 0. CNA I stated that the tank was empty. She further stated, I noticed earlier at 3:00 P.M. that she was sitting at the nurse's station with her oxygen tank empty. I put her in bed and, the oxygen concentrator in her room was turned on by the nurse. A little while ago, I let the nurse (LPN L) know that she didn't have portable oxygen, and that it was time to take her to the dining room. She told me to being her to the oxygen storage room. When asked about the importance of Resident #113 receiving her oxygen continuously, CNA I stated, She could pass out. She could lose her breath. When the residents run out of oxygen, the nurses tell us to bring the resident to the oxygen storage room. They don't bring the oxygen to the resident in their room. On 4/29/19 at 4:40 P.M. an interview was conducted with LPN L, who was observed in the oxygen storage room. She replaced Resident #113's empty portable oxygen tank with a full one. When asked how long Resident #113 had gone without oxygen, LPN L stated, I assume it was taken off at the time she left her room. When asked about the possible consequences of Resident # 113 being without her continuous oxygen for 5 minutes, LPN L stated, It's possible to have shortness of breath or anxiety within a 5 minute period of time. LPN L did not obtain a saturation level on Resident #113. On 4/28/19 at 6:10 P.M. the Director of Nurses (DON-Employee B), and Administrator (Employee A) were informed of the findings. When asked about the procedure for providing continuous oxygen, the DON stated, We want the CNA's to tell the nurses that oxygen is needed, and it is brought to the residents room before the oxygen concentrator is removed. No further information was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, facility document review, and staff interview, the facility staff failed to provide services to prevent a decline in ROM (range of motion), and to increase range or motion, or prevent further decrease in ROM for one resident (Resident #14) in a survey sample of 60 Residents. For Resident #14, who was not admitted with contractures, the facility staff failed to provide ongoing assessment, services, equipment, and assistance, to maintain Range of Motion, or to prevent a further decline in ROM. The findings included: Resident #14, was originally admitted to the facility on [DATE]. The Resident was discharged and for this stay was readmitted for a medicaid stay on 7-1-15, according to the most recent (4-19-19) MDS (minimum data set) assessment prepared by the facility. Resident #14 was diagnosed on [DATE] with contracture, unspecified hand during stay in the facility. Other diagnoses for Resident #14 included but were not limited to: Arthritis, dementia, psychosis, hernia, dysphagia, anxiety, and chronic obstructive pulmonary disease. Resident #14's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 4-19-19 was coded as a quarterly assessment. Resident #14 was coded as having severe cognitive impairment based on a staff assessment, a BIMS (brief interview for mental status) was not able to be conducted. Resident #14 was coded as being total care, dependent upon one to two staff members, for assistance with dressing, eating, personal hygiene and bathing. The Resident was coded as having not rejected any care services. Further review of the facility coded MDS document areas revealed the following for Resident #14; G0400 was coded as limited range of motion (ROM) in all 4 extremities. G0600 was coded as having no mobility devices. GG0110 prior device use, no devices were coded. Under active diagnoses, contracture of unspecified hand was coded. J0100 pain management described scheduled pain medication every day. J0200 Resident stated she had no pain. M0100 Resident was at risk for pressure ulcers. Speech, occupational and physical therapy none. O0500 Restorative nursing for ROM or splint/brace assistance were all coded as 0 none. Physical examinations or physician's orders were all coded as 0 none. During observation of Resident #14 on 4-29-19 at 10:00 a.m., 12:00 p.m., and 3:00 p.m., both of the Resident's hands were severely contracted, and clenched in a fist with her fingernails pressed into her palms. The Resident was in a short sleeve gown in bed and wore no arm skin protectors, nor palm protection. Observations continued on 4-30-19 at 10:04 a.m., in the Resident's room. Resident #14 was sitting in a reclined wheel-chair in pants and a short sleeve top, with no palm guards or arm skin sleeves on. CNA L was in the room and was asked to open the Residents hands so we could assess the skin of her palms. CNA L complied and the Resident pulled her hand away. The CNA continued, opening both hands enough, (approximately 1.5 inches), to visualize the finger nails, which had been imbedded in the palms, so as to visualize the skin on the Resident's palms. The Resident's hands had a pervasive lasting foul odor which resembled spoiled milk emitting from them as soon as the hands were opened slightly. The CNA stated, oh that smells bad. The Resident's fingernails were visualized to be 1/2 inch long, jagged/broken, dirty, with a dark brown substance under them, and pressing into the palms of both hands. The nails had left indentations where they had been, and the palms were noted to have dark discolorations and excoriated, scratched, and abraded areas where the nails had been pressed into them both. The CNA was interviewed and stated that the Resident had no palm guards, but it would be a good idea to get some, and also stated that the staff couldn't open the Residents hands to clean them because the Resident wouldn't cooperate because it hurt her. The CNA was asked if therapy was seeing the Resident, or if there was any restorative nursing providing range of motion for the Resident, and she stated no, therapy never told us anything about range of motion or dealing with her hands. She was asked if the Resident could stand, and she stated no, the Resident's feet are contracted. Both feet were noted to be rotated and exhibited foot drop. The Resident was again observed at 11:00 a.m., 12:00 p.m., 2:00 p.m., 3:00 p.m., and 5:00 p.m. on 4-30-19, and at no time were protective sleeves nor palm protectors, or foot splints applied to the Resident. Review of the physician's orders from February 2018 through April 2019 revealed no orders for palm guards, or foot splints, no evaluation of contractures by therapy, nor geri-skin sleeves to upper extremities. Physician visits progress notes from January 2019 to the time of survey were reviewed. There were only 2 visits by the doctor. The visits occurred on 1-26-19, and 2-24-19. The visits documented by the doctor stated no new rashes or lesions noted, No deformities or edema noted in lower extremities, contracture unspecified hand. The physician's notes document no deformities in lower extremities, and contracture of hand. However, both hands were observed to be severely contracted, and both feet were rotated and exhibited foot drop deformities. All disciplines of Therapy notes were reviewed and revealed the following; No Speech therapy had ever occurred until 4-20-19 when an evaluation was ordered for aspiration. No physical therapy had been ordered from February 2018 to the time of survey. Occupational therapy was ordered for treatment of positioning in a wheel chair on 8-10-18, and the Resident was discharged from therapy on 8-29-18 with a Pommel cushion and calf pad for positioning in tilt in space wheel chair. The next encounter for an Occupational Therapy evaluation was on 4-17-19 for positioning in wheel chair, again by nursing, and the Resident was provided a new calf pad for her wheel chair. The note described; Patient also gets agitated when attempted to move or touched. Patient will not benefit from skilled OT services at present. If required patient will be evaluated later as need arises. In the document the Occupational therapist describes a medical history of hand contracture, and Precautions of skin integrity, and hand contractures, however, does not evaluate these nor make any recommendations for care and services. The Residents care plan with all revisions was reviewed and revealed only the following 3 care plan areas related to the Residents upper extremities/hand contractures in chronological order; 1. A care plan area documented as potential for pressure ulcers, which stated as interventions, follow facility policy/protocols for the prevention/treatment of skin breakdown initiated 11-27-15, and gerisleeves to bilateral upper extremities, initiated 10-27-16. 2. A second care plan area documented as ADL (activities of daily living) self care performance deficit related to contracture as one impediment, which stated as interventions, unable to grasp with bilateral hands, and, Contractures to bilateral hands. Provide skin care frequently to keep clean and prevent skin breakdown. all initiated 11-11-16. 3. The document also had a third care plan area for Skin Tears with an intervention for The Resident needs their nails kept short to reduce the risk of scratching or injury from picking at skin. initiated 9-18-17. The Resident was diagnosed with contractures on 8-10-15, (3 months prior to this care plan), and no documented interventions were found to be initiated for the diagnosis of contractures until the current care plan which was initiated on 11-27-15, and it was a quarterly care plan revision. The only 3 interventions for this Resident from the 11-27-15 care plan until the time of survey on 4-29-19, which could apply to the Resident's hand contractures, are in the above 3 entries in the current care plan. No palm protection from fingernail pressure injury and abrasions from fingernails was afforded the Resident. No intervention from therapy was sought, and no restorative nursing therapy for range of motion was in place. The facility Administrator, DON, and Chief Executive Officer were made aware of the findings on 4-30-19, of the facility staff's failure to provide services and to prevent a decline in ROM for Resident #14. They stated no further information was available to be provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident # 65 the facility failed to prevent weight loss of 10.5% in two months. Resident #65 a [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Alzheimer's, Dermatitis, Persistent mood [Affective] disorder, Dysphagia, Major Depressive Disorder, Anxiety Disorder, Pseudobulbar Affect, and Bipolar Disorder. Most recent (Minimum Data Set) MDS coded as (Brief Interview of Mental Status) BIMS Score of 99 indicating severe cognitive impairment. The Resident's most recent (Minimum Data Set) MDS coded as a quarterly assessment, coded the Resident as having a (Brief Interview of Mental Status) BIMS score of 99 indicating severe cognitive impairment. Resident is also coded as being totally dependent on staff for meals, a physical assist of 1 person. On 4/28/19 at 6:15 PM during meal observation Resident was noted to have tray in front of her and staff came over to assist Resident with meal. Resident had to be fed by staff due to cognitive status. The Resident ate slowly and had puree diet with nectar thickened liquids and no supplements noted on the tray. On 4/30/19 upon clinical record review it was found that the Resident had an order for monthly weights and had a 10.5% weight loss from her weight in February 2019 of 132.3 lbs. to her April 2019 weight of 118.4 lbs. Upon review of her care plan it was noted that she had been care planned for weight loss as follows: [Resident name redacted] has nutritional problem or potential for weight loss r/t multiple disease processes including Alzheimer's disease h/o [history of] wt. loss. On mechanically altered diet per dysphagia. Interventions: Family is against feeding tube. Monitor / document / report PRN any s/sx [signs or symptoms] of dysphagia Monitor/record/ report to MD s/sx of malnutrition including >5% weight loss in 1 month Obtain and monitor labs/diagnostic work as ordered OT to screen and provide adaptive equipment Promote additional intake and hydration Provide and serve supplements as ordered Provide serve diet as ordered Puree Nectar, larger portions, Provide maximum assist for eating monitor intake. RD to evaluate and make diet changes PRN Resident needs calm quiet setting and interaction with table mates during meals Weigh monthly per protocol. A review of the clinical record showed the following note from dietician. 2/21/19 4:21 PM Resident addressed in IDT [interdisciplinary team] meeting for weight loss. Previous hospital admission for UTI. Psych meds d/c'd [discontinued] . Resident eats slowly however po's [by mouth intake] reported to be improving. Family aware of weight decline. No tube feeding desired going forward. RD following as needed. On 4/30/19 at 5:10 PM in an interview with the DON she was asked about the supplements mentioned in the care plan. She stated I cannot find them in the MAR or the TAR or the Diet orders so she must not be getting supplements. When asked who is responsible for not following up on weight loss she stated, I am. When asked why it is important she stated for the wellbeing of the Resident. 3. For Resident #11 the facility staff failed to provide fluids in the amounts ordered by physician. Resident #11 is an [AGE] year old man who was admitted to the facility on [DATE] with diagnoses of but not limited to Alzheimer's Disease, Chronic Pain Syndrome, Benign Prostatic Hyperplasia, Vascular Dementia with Behavioral Disturbance, Major Depressive Disorder, Cognitive Communication Deficit, and unspecified Psychosis. The Resident's most recent (Minimum Data Set) MDS coded as a quarterly assessment, coded the Resident as having a (Brief Interview of Mental Status) BIMS score of 3 indicating severe cognitive impairment. The Resident is also coded as needing assistance of 1 person for meals. On 4/28/19 Resident # 11 was observed at 6:20 PM in the dining area on the Memory Care Unit. He was sitting in his wheelchair alone at the table waiting for his tray. When his food arrived he ate by himself but quickly lost interest and left the dining room before he finished 1/2 of his food. On 4/30/19 during clinical record review it was noted that the Resident has orders that state: Give 400 ml of fluid at each meal with meals for hydration For the April (Medication Administration Record) MAR there are the following: 4/1/19 8:00 AM under AMT [amount] there is an X. 12:00 PM under AMT there is an X 5:00 PM under AMT. there is 240 ml 4/2/19 8:00 AM under AMT there is an X. 12:00 PM under AMT there is 240 ml 5:00 PM under AMT. there is 240 ml 4/4/19 8:00 AM under AMT there is an X. 4/5/19 12:00 PM under AMT there is an X 5:00 PM under AMT. there is 240 ml 4/7/19 & 4/8/19 8:00 AM under AMT there is 240 ml 12:00 PM under AMT there is 240 ml 5:00 PM under AMT. there is 240 ml 4/9/19 8:00 AM under AMT there is 240 ml 12:00 PM under AMT there is 240 ml 4/10/19 5:00 PM under AMT. there is 240 ml 4/11/19 &4/12/19 8:00 AM under AMT there is 240 ml 12:00 PM under AMT there is 240 ml 5:00 PM under AMT. there is 240 ml 4/13/19 8:00 AM under AMT there is 240 ml 12:00 PM under AMT there is 240 ml 5:00 PM under AMT. there is 180 ml 4/14/19 8:00 AM under AMT there is 180 ml 5:00 PM under AMT. there is 180 ml 4/15/19 8:00 AM under AMT there is 180 ml 12:00 PM under AMT there is an X 5:00 PM under AMT. there is 240 ml 4/16/19 8:00 PM under AMT there is an X 5:00 PM under AMT. there is 240 ml 4/17/19 8:00 AM under AMT there is 240 ml 12:00 PM under AMT there is 240 ml 5:00 PM under AMT. there is 240 ml 4/18/19 8:00 AM under AMT there is 240 ml 12:00 PM under AMT there is 240 ml 5:00 PM under AMT. there is 200 ml 4/19/19 8:00 PM under AMT there is an X 5:00 PM under AMT. there is 240 ml 4/20/19 - 4/26/19 8:00 AM under AMT there is 240 ml 12:00 PM under AMT there is 240 ml 5:00 PM under AMT. there is 240 ml 4/27/19 8:00 AM under AMT there is 240 ml 12:00 PM under AMT there is 240 ml 5:00 PM under AMT. there is 180 ml 4/28/19 8:00 AM under AMT there is 180 ml 5:00 PM under AMT. there is 180 ml 4/29/19 5:00 PM under AMT. there is 240 ml 4/30/19 8:00 AM under AMT there is 240 ml 12:00 PM under AMT there is 240 ml On 4/30/19 at 5:15 PM in an interview with the DON she was asked what the X means and she looked up on the last page of the MAR to where the codes are and stated there is no code for X. I can only assume it means it was not given. She explained the codes as follows: 7= Resident Asleep 2= Refused On 4/30/19 the Administrator was notified of the issues and no further information was provided. Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to prevent a Significant Weight Loss for 2 (Resident #192 and #65) of 60 residents and maintain fluids for 1 (Resident #11) of 60 residents. 1. The facility staff failed to prevent a Significant Weight Loss of 10.59% within 34 days. In addition, the facility staff failed to recognize, evaluate and address Resident #192's nutritional needs in a timely manner. 2. For Resident # 65 the facility failed to prevent wt. loss of 10.5% in two months. 3. For Resident #11 the facility staff failed to provide fluids in the amounts ordered by physician. The Findings included: 1. The facility staff failed to prevent a Significant Weight Loss of 10.59% within 34 days. In addition, the facility staff failed to recognize, evaluate and address Resident #192's nutritional needs in a timely manner. Resident #192 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #192's diagnoses included Alzheimer's Disease, Gastronomy Status, Major Depressive Disorder, Insomnia, Hypertension, Dysphasia, Oropharyngeal Phase, Vitamin Deficiency Unspecified, and Folate Deficiency Anemia. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 4/11/19 was reviewed. Resident #192 was coded as having a Brief Interview of Mental Status Score of 12, indicating mild cognitive impairment. On 4/28/19 at approximately 5:00 P.M., Resident # 192 was observed sitting at the nurse's station. She was dressed appropriately. On 4/29/19 a review was conducted of Resident #192's clinical record. According to the Monthly Weight Report, Resident #192 had a 10.56% decrease in weight between December 10/2018, and January 14/2019. The weights were as follows: November 11/5/2018 - 154.2 December 12/10/2018 - 153.1 January 1/14/2019 - 136.8 February, 2019 - 137.2 March, 2019 - 135.4 April, 2019 - 132.0 Resident #192's physician order read, 4/19/19. Jevity 1.5 240 ML Via peg tube four times a day. The Registered Dietician's notes stated that Resident #192 was seen on 12/6/2018, and subsequently not seen again until 1/22/19, when the regularly scheduled interdisciplinary team meeting was scheduled. On 12/6/18 the note read: Resident noted to have decline in intakes by mouth. Most meals recently reported to be less that 50% overall. Resident also noted not to be snacking as often. Weight stable at this time. Adding Ensure Plus daily at this time to supplement. According to the clinical record, after the Significant Weight Loss documented on 1/14/19, neither the Registered Dietician, Medical Doctor, nor the Responsible Party were notified of the change in condition. In addition, the Weight Variance Committee was not notified of the 10.56 % decrease in weight. On 1/22/19 the Registered Dietician's note read: Resident addressed in IDT meeting due to weight loss. Resident had previously been receiving bolus tube feedings to supplement oral diet. Reported intakes have been good for most meals, however weight loss noted. At this time adding Bolus Jevity 1.5 twice daily to supplement. On 4/30/19 at 5:10 P.M. an interview was conducted with the Director of Nursing (Employee B). When asked about the importance of following- up in a timely manner regarding an unplanned Significant Weight Loss, the DON stated, I'm responsible for not following up with that weight. For the well-being of the resident the Registered Dietician should be contacted so that interventions can be done. The Registered Dietician was not available for an interview. On 4/30/19 a review was conducted of facility documentation, revealing a Significant Weight Changes Policy dated 9/23/2011. It read, To care for residents who are unable, nutritionally challenged, or refuse to consume adequate nutrition and hydration. The goal is to avoid unplanned weight changes which may lead to risk of malnutrition, dehydration, morbid obesity and other complications. Identify residents with significant weight changes. To be defined as 5% weight change in 1 month, 10% weight change in 6 months. Nursing to notify MD, POA (responsible party), and Dietician regarding significant weight changes and document the notification in the resident record. Update plan of care as necessary, Place resident on weekly weights for 1 month or length of time determined by the weight variance committee. The Registered Dietician will assess residents with significant weight changes and make recommendations as needed. Resident #192's care plan was reviewed. It read: 1/23/19. Requires tube feeding related to supplementation of oral diet. Check for tube placement. Head of Bed elevated 45 degrees. The care plan did not address Significant Weight Loss. On 4/30/19 the DON was notified of the findings. No further information was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, Resident interview and clinical record and facility documentation the facility staff failed to ensure Resident are provided adequate behavioral health services for 1 Residents (#180) in a survey sample of 60 Residents. For Resident # 180 the facility failed to provide adequate behavioral health services to prevent or manage behaviors exhibited by Resident #180. The findings included: Resident # 180 is an [AGE] year old man who was admitted to the facility on [DATE] with diagnoses of but not limited to Parkinson's disease, Hypertension, and Dementia without behavioral disturbance, Anxiety Disorder, Major Depressive Disorder, and unspecified Psychosis not due to a substance or known physiological condition. On 4/29/19 during a clinical record review the following was discovered in the Progress Notes: 11/5/18 at 2:40 AM -Behavior Note At about 0215 Resident from room [redacted] approached this writer and said Resident from room [redacted] was in her room trying to get into bed with her and she literally had to push him out. This writer went to room [redacted] to check it out but the Resident from RM [redacted] had already gone to his room and was assisted to bed without incident. We will continue to monitor. According to the clinical record, Resident #180 was originally on the long term care unit however, he was moved to the Memory care unit in January of 2018 due to increasing sexually inappropriate behaviors. In March of 2018 he was moved again to long term care related to an incident of sexually inappropriate behavior. He was then returned to the unit in June of 2018. He was not moved after the incident in 11/5/19. Another progress note after the 11/5/19 incident states: 1/18/19 3:51 PM - Behavior Note Resident is alert to name and place and time. He can usually locate his room but occasionally he will be found in other rooms. Ambulates with a walker, or sometimes walks behind the wheelchair. Sometimes to waits [sic] by the exit door on the secure unit. He will occasionally ask a female if he can kiss her, but is easily redirected. Resident #180 was receiving psychology services at the time of the incident in November 2018 but the behavior continued. He was receiving services due to an incident earlier that year involving inappropriate sexual behaviors. According to psych notes in Resident #180's chart dated 4/3/18 Medication appears to be beneficial but does not prevent inappropriate behavior. On 4/30/19 at 7:25 PM in an interview with the Administrator when asked about the resident room changes, she stated the resident was moved due to inappropriate behaviors. She also stated that he was returned to the Memory Care (secure) unit in June of 2018 due wandering and the need for a more secure environment. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, facility documentation and clinical record review the facility staff failed address psychosocial concerns for 1 Resident (#194) in a survey sample of 60 Residents. For Resident #194 the facility staff failed to provide adequate behavioral health services after a traumatic experience, leaving Resident #194 feeling unsafe at night. The findings include: Resident #194 a [AGE] year old woman was admitted to the facility on [DATE] with diagnoses of but not limited to Dementia without behavioral disturbance, Anxiety disorder, (Chronic Kidney Disease) CKD stage III, Major Depressive Disorder, Type II Diabetes, and Glaucoma. The Resident's most recent (Minimum Data Set) MDS coded as a quarterly assessment, coded the Resident as having a (Brief Interview of Mental Status) BIMS score of 11 indicating moderate cognitive impairment. On 4/30/19 during clinical record review for another Resident the following was found in the nurse's note: 11/5/18 at 2:40 AM -Behavior Note At about 0215 Resident from room [redacted] approached this writer and said Resident from room [redacted] was in her room trying to get into bed with her and she literally had to push him out. This writer went to room [redacted] to check it out but the Resident from RM [redacted] had already gone to his room and was assisted to bed without incident. We will continue to monitor. On 4/30/19 at 7:10 PM during an interview with Resident #194 she stated that several times Resident #180 came into her room uninvited. She said she used to be able to get him to leave but not always. Resident #194 related a story of how a friend had taken her shopping and when she came back her door was open and she knew she had closed it. When she came into room he [Resident #180] was in her bed. She related that she had made attempts to get Resident #180 out of her bed however she was unsuccessful and had to get the Nurse to get him out. On 4/30/19 at 7:15 PM LPN F stated that Resident #180 knows how to shut off the bed alarm when he gets out so we don't know when he is out of bed. I have had to get him out of other resident's rooms and beds plenty of times. When asked about the incident in November of 2018 when Resident #180 got in her bed at 2:15 in the morning Resident #194 stated that he got in the bed and she woke up and couldn't get him out. She again stated she was afraid of him coming in her room in the middle of the night. She further stated, I would stay awake worried because several times I have woke up with him in my room. I was afraid I might have to hit someone, I was jittery and nervous all the time afraid he would come back. She also stated I didn't feel safe for a while there. On 4/30/19 during clinical record review it is noted that the Resident was started on Anti Anxiety medication (Ativan) 1/4/19 the care plan was updated as follows: [Resident name redacted] uses anti-anxiety medication r/t [related to] Anxiety Disorder -Date initiated 1/23/1 Interventions: Administer Anti-Anxiety medications as ordered by physician. Monitor for side effects and effectiveness Monitor / Document/ Report PRN any adverse reactions to Anti-Anxiety therapy. On 4/29/19 at 10:30 AM the Administrator provided a file with any (Facility Reported Incidents) and or Investigations involving Resident #180 since last survey. There was not mention of the 11/5/18 incident. There was no investigation, FRI, the Residents involved were not interviewed. and they were not questioned in spite of this being in Resident #180's clinical Record. On 4/30/19 the Administrator was made aware of the issues during end of day conference and no additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure medications were available for administration for one Resident (Resident # 128) in a survey sample of 60 residents. For Resident #128, several medications were unavailable for administration including, but not limited to: the breathing treatment medication Acetylcysteine Solution 20%, the thyroid medication- Levothyroxine 50 micrograms and the mood disorder medication, Depakote 250 milligrams. The findings included: Resident #128, a [AGE] year old male , was admitted to the facility on [DATE]. Diagnoses included but were not limited to: respiratory failure, hypertension, insomnia, dry eye syndrome, cerebral palsy, major depressive disorder, hypertension and diabetes. The most current Minimum Data Set assessment was a Significant Change assessment with an assessment reference date of 3/27/19. Resident #128 was coded with a Brief Interview of Mental Status score of 15 indicating no cognitive impairment. He required extensive assistance with activities of daily living. Review of the clinical record was conducted on 4/28/2019 and 4/29/2019. Resident #128 had a physician order dated 1/16/18 for Acetylcysteine Solution 20%, 1 vial inhale orally every 12 hours for SOB (shortness of breath) related to Respiratory Failure. According to the January 2018 MAR, the Acetylcysteine Solution 20% was not administered on 1/20/18, 1/21/18 and the morning dose on 1/22/18, a total of five doses. Review of the April 2019 Medication Administration Record revealed an order for Acetylcysteine Solution 20%, 4 ml (milliliters) inhale orally every 12 hours for SOB (shortness of breath). Acetylcysteine Solution 20% was not administered on 4/12/19 at 9 PM, 4/13/19 at 9 AM Mirtazapine 7.5 milligrams give one tablet by mouth at bedtime for depression on order Not administered 4/16/19 at 9 PM According to the February 2019 MAR, Depakote 250 milligrams Delayed Release one tablet by mouth one time a day. Depakote 250 milligrams was not administered on 2/10/2019 and 2/17/2019. Acetylcysteine Solution 20% was not administered on 2/9/19, Levothyroxine/sodium Tablet 50 micrograms give 50 micrograms by mouth one time a day for Thyroid. Not administered on 2/23/19. Review of the Progress Notes (Nurses Notes) revealed documentation of medications not being administered. 4/16/2019 20:40 (8:40 PM)- Orders-Administration Note: Mirtazapine 7.5 milligrams give one tablet by mouth at bedtime for depression on order. 4/13/219 9:58 AM- Orders-Administration Note: 'awaiting delivery from pharmacy. 4/12/2019- 21:48 (9:48 PM)- Orders-Administration Note: Acetylcysteine Solution 20%, 4 ml (milliliters) inhale orally every 12 hours for SOB (shortness of breath) Med unavailable. Pharmacy called awaiting delivery. 3/13/2019 22:16 (10:16 PM) - Orders-Administration Note: Melatonin Capsule 3 MG (milligrams) Give 6 mg (milligrams) by mouth at bedtime for insomnia. On order. 3/13/2019 22:15 (10:15 PM) - Orders-Administration Note: Ascorbic Acid Tablet 500 MG (milligrams) give 1 tablet by mouth at bedtime for supplement On order 3/13/2019 22:15 (10:15 PM) - Orders-Administration Note: Acetylcysteine Solution 20%, 4 ml (milliliters) inhale orally every 12 hours for SOB (shortness of breath) On order 2/23/2019 07:11 (7:11 AM) - Orders-Administration Note:Levothyroxine/sodium Tablet 50 micrograms give 50 micrograms by mouth one time a day for Thyroid. Awaiting pharmacy 2/17/2019 11:37 (11:37 AM)- Orders-Administration Note: Depakote 250 milligrams Delayed Release one tablet by mouth one time a day related Mood Disorder due to known psychological condition, unspecified Not available .will call pharmacy 2/10/2019 11:32 (11:32 AM)- Orders-Administration Note: Depakote 250 milligrams Delayed Release one tablet by mouth one time a day related Mood Disorder due to known psychological condition, unspecified Not available .ordered 2/9/2019 12:21 (12:21 PM)- Orders-Administration Note: Acetylcysteine Solution 20%, 4 ml (milliliters) inhale orally every 12 hours for SOB (shortness of breath) Not available .ordered 2/7/2019 10:50 (10:50 AM)- Orders -Administration Note: unavailable 1/5/2019 1440 (2:40 PM)-Orders - Administration Note: On order per Pharmacy. Pharmacy to deliver this evening. Medication not available in pixus (medication delivery system) 1/10/2019 17:15 (5:15 PM)- Orders -Administration Note: Awaiting pharmacy delivery Review of the Facility policy Unavailable Medications Effective Date: June 2016 stated the facility must make every effort to ensure that medications are available to meet the needs of each resident. Under Procedures: A. The pharmacy staff will: 1) Call or notify nursing staff that the ordered product(s) is/are unavailable. 2) Notify nursing when it is anticipated that the drug (s) will become available. 3) Suggest alternative, comparable drug (s) and dosage of drug (s) that is/are available, which is covered by the resident's insurance. B. Nursing staff shall: 1) Notify the attending physician of the situation and explain the circumstances, expected availability and optional therapy(ies) that are available. a. If the facility nurse is unable to obtain a response from the attending physician, the nurse should notify the nursing supervisor and contact the Facility Medical Director for orders and/or direction. 2) Obtain a new order and cancel/discontinue the order for the non-available medication. 3) Notify the pharmacy of the replacement order. Review of the facility Emergency Box contents revealed the Medications Acetylcysteine Solution 20 %) and Depakote were not included in the contents listed. The medication Levothyroxine 50 micrograms was listed in the contents. On 4/30/2019 at 5 PM, an interview was conducted with the Unit Manager, Employee R who stated she was unaware of medications being unavailable for Resident # 128. Employee R reviewed the Medication Administration Records and stated that Resident # 128 had one medication (Acetylcysteine Solution 20 %) that was kept in the refrigerator and maybe the nurses did not know where to find the medication. Employee R was informed that the documentation showed that the medication Acetylcysteine Solution 20%, 4 ml (milliliters) inhale orally every 12 hours for SOB (shortness of breath) was not in the refrigerator according to one nurse. Employee R reviewed the nurses notes and stated she did not know why medications were unavailable as ordered by the physician and written in the notes. Employee R was asked to identify the medications that were listed as unavailable but not named in the nurses notes. Employee R reviewed the nurses notes further and stated she was unable to tell which medications were unavailable. Employee R stated the Pharmacy was supposed to deliver medications twice a day. Valid Physicians Orders were evident for the medications documented as not administered due to unavailable from Pharmacy. The Administrator and DON were notified of the issue at the end of day meeting on 4/30/2019. Both stated medications should be available for administration. No further information was provided.

**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 a nourishing, well-balanced diet for three Residents (Resident #108, Resident #140, Resident #105) in a survey sample of 60 Residents. 1. For Resident #108, the facility staff ran out of food and failed to provide a well-balanced meal. 2. For Resident #140, the facility staff ran out of food and failed to provide a well-balanced meal. 3. For Resident #105, the facility staff ran out of food and failed to provide a well-balanced meal. The findings included: 1. For Resident #108, the facility staff ran out of food and failed to provide a well-balanced meal. Resident #108's diagnoses included but were not limited to: hypertension, Gastro-esophageal reflux disease, arthritis, anxiety and depression. Resident #108 was admitted to the facility on [DATE]. Resident #108's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 3/20/19, was coded as an annual assessment. Resident #108 was coded as having a BIMS (brief interview for mental status) score of 10, which indicated moderate cognitive impairment. The resident required extensive assistance of two staff members for bed mobility, transfers, dressing, and toileting. On 4/28/19 from 5:55pm until 7:26pm the evening meal was observed in the Midlothian dining room. It was observed that the kitchenette was running low on food, Employee P, the dietary aide started serving half portions to residents. Resident #108 received a half serving of chicken salad, a full serving of potato salad, and a serving of peaches. Employee P was asked about the serving size, the dietary aide said ,we are running low on some stuff. When asked what size serving had been plated and the dietary aide wouldn't answer. CNA J stated, that's a half a scoop, oh, you didn't ask me [looked at the dietary aide] and said just tell the lady. Review of the facility policy titled Accuracy and Quality of Tray Line Services read: each meal will be checked for: proper portion size. On 4/28/19 at 7:42pm the Administrator, DON (Director of Nursing), and Assistant Food Services Director were made aware of the lack of food to serve Resident #108 a full serving. When asked about quantity to prepare, the Administrator stated, they have production sheets downstairs, they know what resident, how many and their perspective diets to ensure enough food is prepared. When asked what happens if the kitchenette where food is being served runs out of food, the Administrator stated if they don't have enough food they would call down to dietary to get what they wanted. This is not our expectation and is not acceptable. The Assistant Food Services Director stated, the dietary aide (Employee P) only works weekends. It is not acceptable to receive a half scoop, the kitchen should have been notified. Additional plates were prepared and delivered to the Midlothian Unit by the Assistant Food Services Director on 4/28/19 at approximately 8pm. No further information was provided. 2. For Resident #140, the facility staff ran out of food and failed to provide a well-balanced meal. Resident #140's diagnoses included but were not limited to: heart failure, hypertension, diabetes, hyperlipidemia, and parkinsons disease. Resident #140 was admitted to the facility on [DATE]. Resident #140's most recent MDS with an ARD of 3/29/19 was coded as a quarterly assessment. Resident #140 had a BIMS score of 11, which indicated moderately impaired cognitive skills. Resident #140 required extensive assistance of one staff member for ADL's (activities of daily living). On 4/28/19 from 5:55pm until 7:26pm the evening meal was observed in the Midlothian dining room. It was observed that the kitchenette was running low on food, Employee P, the dietary aide started serving half portions to residents. Resident #140 received a half serving of chicken salad, a full serving of potato salad, a roll and a 4 oz cup of ice cream. Employee P was asked about the serving size, the dietary aide said ,we are running low on some stuff. When asked what size serving had been plated and the dietary aide wouldn't answer. CNA J stated, that's a half a scoop, oh, you didn't ask me [looked at the dietary aide] and said just tell the lady. Review of the facility policy titled Accuracy and Quality of Tray Line Services read: each meal will be checked for: proper portion size. On 4/28/19 at 7:42pm the Administrator, DON (Director of Nursing), and Assistant Food Services Director were made aware of the lack of food to serve Resident #140 a full serving. When asked about quantity to prepare, the Administrator stated, they have production sheets downstairs, they know what resident, how many and their perspective diets to ensure enough food is prepared. When asked what happens if the kitchenette where food is being served runs out of food, the Administrator stated if they don't have enough food they would call down to dietary to get what they wanted. This is not our expectation and is not acceptable. The Assistant Food Services Director stated, the dietary aide (Employee P) only works weekends. It is not acceptable to receive a half scoop, the kitchen should have been notified. Additional plates were prepared and delivered to the Midlothian Unit by the Assistant Food Services Director on 4/28/19 at approximately 8pm. No further information was provided. 3. For Resident #105, the facility staff ran out of food and failed to provide a well-balanced meal. Resident #105's diagnoses included but were not limited to: Atrial fibrillation, heart failure, hypertension, geastroesophageal reflux disease, and asthma. Resident #105 was admitted to the facility on [DATE]. Resident #105's most recent MDS with an ARD of 2/22/19 was coded as an admission assessment. Resident #105 had a BIMS score of 8, which indicated moderate cognitive impairment. Resident #105 was coded as requiring extensive assistance of one staff member for bed mobility, transfers, locomotion on and off of the unit, dressing, toileting and personal hygiene. On 4/28/19 from 5:55pm until 7:26pm the evening meal was observed in the Midlothian dining room. It was observed that the kitchenette was running low on food, Employee P, the dietary aide started serving half portions to residents. Resident #105 received a serving of potato salad and a roll. Employee P was asked about the serving size, the dietary aide said ,we are running low on some stuff. When asked what size serving had been plated and the dietary aide wouldn't answer. CNA J stated, that's a half a scoop, oh, you didn't ask me [looked at the dietary aide] and said just tell the lady. Review of the facility policy titled Accuracy and Quality of Tray Line Services read: each meal will be checked for: proper portion size. On 4/28/19 at 7:42pm the Administrator, DON, and Assistant Food Services Director were made aware of the lack of food to serve Resident #105 a full serving. When asked about quantity to prepare, the Administrator stated, they have production sheets downstairs, they know what resident, how many and their perspective diets to ensure enough food is prepared. When asked what happens if the kitchenette where food is being served runs out of food, the Administrator stated if they don't have enough food they would call down to dietary to get what they wanted. This is not our expectation and is not acceptable. The Assistant Food Services Director stated, the dietary aide (Employee P) only works weekends. It is not acceptable to receive a half scoop, the kitchen should have been notified. Additional plates were prepared and delivered to the Midlothian Unit by the Assistant Food Services Director on 4/28/19 at approximately 8pm. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to provide food that accommodated resident needs for one resident (Resident #451) in a sample size of 60 residents. The facility staff served eggs to Resident #451 and she had an egg allergy. The findings included: Resident #451, an [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses included but not limited to fracture left distal humerus, osteoporosis, hypertension, vitamin D deficiency, hyperlipidemia, and gastroesophageal reflux disease. Resident #451 was admitted to the facility on [DATE] and therefore a Minimum Data Set assessment was not yet initiated. On 04/29/2019 at 9:15 AM, Resident #451 was observed sitting up in her wheelchair, dressed, and eating breakfast. When asked if she had any concerns, Resident #451 stated that she had to send the tray back this morning because the facility served her eggs for breakfast and she has an allergy to eggs. Resident #451 stated, If I eat an egg, I have vomiting and diarrhea for three days. She also stated she does not tolerate milk and needs Lactaid. Resident #451 was currently eating a biscuit with gravy. The tray card had Resident #451's name on it, the date, the unit, the room number, and three headers entitled Allergies/Dislikes, Beverages/Equipment, Preferences and the spaces under the headers were blank. Resident #451's ordered diet, allergies, needs, and preferences were not listed on the tray card. On 04/29/2019 at approximately 10:35 AM, an interview with Employee E, a certified dietary manager, was conducted. Employee E was asked about the process for assessing new admissions and their dietary needs. Employee E stated dietary services receives yellow sheets from nursing services and then the information is entered into [electronic system] to generate tray cards. The yellow sheet was entitled, Change of Diet and had subheaders entitled Name, Date, Room Number, Bed Number, Medical Record Number, Present Diet Order, and New Diet Order. There was not a subheader for allergies. When asked if there was a yellow sheet for Resident #451, Employee E provided a copy of the yellow sheet for Resident #451. It contained her name, room number, and it was dated 04/28/2019. Under Present Diet Order, it was documented, Regular diet. Allergies were not listed. When asked how the information about resident allergies is communicated, Employee E stated, I confirm allergies in [electronic health record] and also look at the yellow sheet and also by asking the resident. When asked about Resident #451's allergies, Employee E accessed the electronic health record of Resident #451 and stated, She's allergic to eggs. She also stated that Resident #451 just arrived recently and stated, I didn't talk with her yet. On 04/29/2019 at approximately 10:40 AM, an interview with LPN I was conducted. When asked about the process for communicating resident diets to the dietary staff, LPN I stated, We fill out a dietary communication form. She also stated that dietary gets the yellow copy. When asked about how to communicate resident allergies, LPN I stated that allergies are also written on the communication slip that gets sent to dietary. On 04/30/2019, the physician's orders were reviewed. An order dated 04/28/2019 documented, Allergies: Eggs, Diet: Regular. On 04/30/2019 at approximately 6:30 PM, a policy for communicating dietary needs was requested. On 04/30/2019 at approximately 7:15 PM, the DON stated they had no further information or documentation to offer. A policy regarding communication of dietary needs was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview, and facility documentation review the facility staff failed to provide a dignified dining experience in 1 of 6 dining rooms (involving multiple residents) and for two Residents (Resident #29, Resident #82) in a survey sample of 60 Residents. 1. The facility staff failed to serve meals to all residents at the same table, at the same time, in 1 of 6 dining rooms. 2. For Resident #29, the facility staff stood over resident while feeding and after feeding the resident three bites, left to go assist a different resident . 3. For Resident #82, the facility staff failed to serve meals at the same time as her table mates. The findings included: 1. The facility staff failed to serve meals to all residents at the same table, at the same time in 1 of 6 dining rooms. On 4/28/19 at 6:00pm during observation of the meal in the Midlothian dining room it was observed that there were 7 tables in the dining room and 26 residents were present, for the meal. The first plate was served at 6:31pm. The second plate distributed went to a separate table, and the third plate was served at the first table. Throughout the meal distribution, which took place from 6:31pm until 7:07pm in the dining room, at no point did all residents sitting at a table get served at the same time. The time lapse between tablemates receiving their meal was approximately 15 minutes. The facility Administrator, Director of Nursing and Assistant Dining Services Director were made aware of the findings. No further information was provided. 2. For Resident #29, the facility staff stood over resident while feeding and after feeding the resident three bites, left to go assist a different resident . Resident #29, was admitted to the facility 5/4/17. Resident #29's diagnoses included but were not limited to: anemia, hypertension, diabetes, anxiety and depression. Resident #29's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 2/1/19 was coded as a quarterly assessment. Resident #29 was coded as having a BIMS (brief interview for mental status) score of 3, which indicated severe cognitive impairment. Resident #29 was also coded as requiring extensive assistance of one staff member for her activities of daily living (ADL's) which included, dressing, eating and personal hygiene. For transfers and toileting Resident #29 required the assistance of two staff members. On 4/28/19 during the evening meal, it was observed that Resident #29 received her meal plate at 6:53pm which was left on the table in front of her with a lid on it. At 7:07pm, LPN M walked over to Resident #29, removed the cover, and stood over Resident #29, fed her three bites of food and then returned to the opposite side of the table to resume assisting another resident. In approximately 10 minutes, LPN M returned to Resident #29, gave her a few bites and then walked back over to the tablemate and resumed feeding her. This feeding method continued throughout the meal. The facility Administrator, Director of Nursing and Assistant Dining Services Director were made aware of the findings. No further information was provided. 3. For Resident #82, the facility staff failed to serve meals at the same time as her table mates. Resident #82 was admitted to the facility on [DATE]. Resident #82's diagnoses included but were not limited to: vascular dementia without behavioral disturbance, orthostatic hypotension, personal history of transient ischemic attack and cerebral infarction without residual deficits, gastro-esophageal reflux disease, severe protein calorie malnutrition, and type 2 diabetes. Resident #82's most recent MDS with an ARD of 3/1/19 was coded as a quarterly assessment. Resident #82 was coded as having a BIMS of 11, which indicated moderate cognitive impairment. Resident #82 was coded as being totally dependent on one staff member for dressing and bathing. For eating, Resident #82 required supervision. On 4/28/19 during the evening meal, it was observed that Resident #82 was sitting with seven other residents at the table. The first resident sitting at this table received their plate at 6:31pm. At 6:38pm a staff member, CNA K, walked by and CNA K, stated to Resident #82, we are working on it, we aren't going to forget you. At 6:40pm Resident #82 stated, I think they did forget me. Resident #82 received her plate at 6:43pm, as many of her tablemate's were finishing their meal. The facility Administrator, Director of Nursing and Assistant Dining Services Director were made aware of the findings. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. For Resident #105, the facility staff identified the resident was at high risk for falls on 2/15/19 and failed to develop a comprehensive careplan to include interventions to prevent falls until 3/21/19. Resident #105 was initially admitted to the facility on [DATE], with a readmission date of 4/24/19. Resident #105's diagnoses included but were not limited to: heart failure, atrial fibrillation, hypertension, chronic obstructive pulmonary disease, and chronic pain syndrome. Resident #105's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 2/22/19 was coded as an admission assessment. Resident #105 was coded as having a BIMS (brief interview for mental status) score of 8, which indicated moderate cognitive impairment. Resident #105 was coded as requiring extensive assistance of one staff member for transfers, dressing and personal hygiene. During clinical record review on 4/29/19 it was noted that facility staff completed a fall risk assessment for Resident #105 on 2/15/19. The fall risk assessment score was recorded as 65, the form read that any score of 45 and higher is considered high risk. Another fall risk assessment was completed on 3/21/19 for Resident #105, and the score was 35, which indicated a moderate risk for falling. On 4/29/19 a review was conducted of Resident #105's careplan. A fall risk careplan was initiated on 3/25/19 and it read: the resident is at risk for falls r/t (related to) reduced physical function, weakness. On 4/30/19 during facility documentation review of the policy entitled Fall Risk Assessment and Fall Prevention policy number 800-821.24, under the subheading policy statement, it read: It is the policy of (facility name) nursing staff in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document risk factors for falls. The subheading purpose, read: to provide an environment that is safe and that minimizes the potential for resident injury due to falls. To identify fall risk factors particular to the individual resident that may be reduced through care planning, implementation of individualized interventions and staff awareness. Under the subheading procedure it read: 3. Risk factors and fall prevention measures for individual residents will be documented on the resident's comprehensive careplan and communicated to the direct care staff for implementation. No further information was provided. 4. For Resident #180 the facility failed to identify specific inappropriate behavior being care planned in order to monitor measure and evaluate for effectiveness. Resident # 180 is an [AGE] year old man who was admitted to the facility on [DATE] with diagnoses of but not limited to Parkinson's disease, Hypertension, and Dementia without behavioral disturbance, Anxiety Disorder, Major Depressive Disorder, and unspecified Psychosis not due to a substance or known physiological condition. He was originally admitted to the long-term care unit however, he was moved to the Memory care unit in January of 2018 due to increasing sexually inappropriate behaviors. The Resident's most recent (Minimum Data Set) MDS coded as a quarterly assessment, coded the Resident as having a (Brief Interview of Mental Status) BIMS score of 10 indicating moderate cognitive impairment. The Resident is also coded as having wandering behaviors. On 4/28/19 during clinical record review the progress note for 11/5/18 stated: 11/5/18 2:40 AM -Behavior Note At about 2:15 AM the resident from room [redacted] approached this writer and said that the resident from room [redacted] was in her room trying to get into her bed and 'literally had to force him out' [sic] This writer went down to room [redacted] check it out [sic], but resident from rm [redacted] had already gone to his room and was assisted back to bed without incident. We will continue to monitor. 1/18/19 3:51 PM -Behavior Note Resident is alert to name and place and time. He can usually locate his room but occasionally he will be found in other rooms. Ambulates with a walker, or sometimes walks behind the wheelchair. Sometimes to waits [sic] by the exit door on the secure unit. He will occasionally ask a female if he can kiss her, but is easily redirected. On 4/28/19 during clinical record review it was noted that the Residents care plan stated: [Resident name redacted] is noted to exhibit inappropriate behaviors - date initiated 3/5/18 revision 1/30/19 Interventions: Administer Medications as ordered monitor for side effects and effectiveness. - 3/5/18 Anticipate and meet resident needs- 3/5/18 Caregivers to provide [sic] opportunity for positive interaction, attention. Stop and talk with him when passing by. 3/5/18 Explain all procedures to the resident before starting and allow the resident time to adjust to changes- 3/5/18 If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and unacceptable to the resident. 3/5/18 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 an alternate location as needed.-3/5/18 Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved and situations. Document behavior and potential causes. 3/5/18 Praise indication of the resident's progress /improvement. Psych consult PRN [as needed] - 3/5/18 On 4/29/19 in an interview with LPN F he stated Resident # 180 knows how to shut off the bed alarm when he gets out so we don't know when he is out of bed. LPN F stated, I have had to get him out of other resident's rooms and beds plenty of times. On 4/30/19 at 5:15 PM the DON was asked if the care plan was effective with the interventions in place since 3/5/2018 she stated yes. She was then asked if the another incident happened after the 3/5/18 care plan interventions should the care plan have been evaluated for effectiveness and new interventions put into place and she stated yes. On 4/30/19 at the end of day meeting the Administrator was notified of the findings and no further information was provided. 5. For Resident # 49 the facility failed to address Oxygen use in her care plan. Resident #49 is an [AGE] year old woman who was admitted to the facility on [DATE] with diagnoses of but not limited to Neuropathy, Hypertension, Gastric Reflux, Dementia, Hypothyroidism, and history of falls. The Resident's most recent (Minimum Data Set) MDS coded as a quarterly assessment, coded the Resident as having a (Brief Interview of Mental Status) BIMS score of 3 indicating severe cognitive impairment. On 4/28/19 at 4:00 PM during initial tour it was observed that Resident # 49 had an oxygen concentrator in her room. Resident #49 was then observed in the day room without Oxygen. In an interview with LPN D she was asked why the Resident had a concentrator in her room but was not using the oxygen while she was in the day room in her wheelchair, she stated the order for O2 was only for nighttime use. On 4/29/19 during clinical record review it was noted that Resident #49 had an order that stated: Administer O2 [oxygen] at 2 L [liters per minute] via nasal cannula at bedtime at bedtime for wheezing [sic] Resident care plan was reviewed and found to have no reference to Oxygen therapy. In an interview with the DON she was asked if there was anything in the care plan about Oxygen use and she stated no there is not. When asked if something like Oxygen orders should be in the care plan she stated yes it should. On 4/20/19 during the end of day meeting this was brought to the attention of the Administrator and no further information was provided. Based on observations, resident interviews, staff interviews, clinical record review, and facility documentation review, the facility staff failed to develop comprehensive, resident-centered care plans for 6 residents (Resident #146, Resident #14, #105, #180, #49, and #192) in a sample of 60 residents. 1. For Resident #146, the facility staff failed to complete a comprehensive care plan for bathing & foley catheter care. 2. For Resident #14, the facility staff failed to complete a comprehensive care plan for contracture care. 3. For Resident #105, the facility staff identified the resident was at high risk for falls on 2/15/19 and failed to develop a comprehensive careplan to include interventions to prevent falls until 3/21/19. 4. For Resident #180 the facility failed to adequately identify specific inappropriate behavior being care planned in order to monitor measure and evaluate for effectiveness. 5. For Resident # 49 the facility failed to address Oxygen use in her care plan. 6. For Resident #192, the facility staff failed to develop a comprehensive plan of care to include a Significant Weight Loss of 10.56% within 34 days. The findings included: 1. For Resident #146, the facility staff failed to complete a comprehensive care plan for bathing & foley catheter care. Resident #146 was admitted to the facility on [DATE]. Diagnoses included; Congestive heart failure, urine retention, foley catheter, dysphagia, atrial fibrillation, muscle weakness, and osteoporosis. The Resident had a recent hip fracture, and had a history of falls. The Minimum Data Set which was a quarterly Assessment with an Assessment Reference Date of 3-25-19, coded Resident #146 as having a Brief Interview of Mental Status score of 13, indicating no impaired cognition. In addition, the Resident was coded as being able to understand and be understood by others. The Resident had a foley catheter for urination, and was coded as occasionally incontinent of bowel. The Resident was fully dependant on staff for hygiene needs, as she had recently had a hip fracture. On 4-29-19 at 10:55 A.M. an observation was made of Resident #146 laying awake in bed. The Resident's fingernails were observed to be soiled with a black substance underneath the nails, which were approximately one half inch long and jagged. There was one Certified Nursing Assistant (CNA) in the room. The Resident was interviewed, and stated that she Haven't had a real bath, or had my nails done since (the previous month) March. She stated that staff used that awful hospital soap which drys my skin so badly it itches for days. She went on to say the staff here are so short that they routinely have 20 people to take care of, so they tell me, and I am lucky if I see them once a day. She went on to say It's never the same staff member, always a different one, and they tell me that they come from a business that provides traveling staff. I don't understand why they don't just hire their own staff like other places do, then we would at least recognize them. The CNA in the Resident's room was immediately interviewed, and asked for anonymity. She was asked to describe the Resident's nails, she stated, There is dirt underneath them on both hands, the CNA's (Certified Nursing Assistants) are supposed to assess the nails every day, especially if they are giving ADL (Activities of Daily Living) care. They should be cleaned as needed. They need to be filed a little bit. The CNA was asked who bathes the Resident, she stated CNA's do all the bathing, nurses have treatments and medications and stuff, and they can't do the bathing too. She was asked if the Resident refused baths, and she stated She never refused me, but I know she likes her certain soap and stuff. On 4-29-19 a review was conducted of Resident #146's clinical record, revealing a care plan. It read; ADL self care performance deficit related to generalized weakness and reduced physical mobility and function, initiated 10-9-18. Interventions included; Resident is totally dependant on (1) staff to provide bath/shower on shower days and as necessary. Resident does often refuse showers, family suggest to use personal bathing products to encourage her to shower. No risks to refusal, assessed refusal triggers, Resident goals, or description of services to be provided by staff were included in the care plan. The 2 interventions (1. provide bath/shower on shower days and as necessary, 2. family suggests use personal bathing products) had no measurable objectives, and were not resident centered. The Resident was cognitively intact, however, none of her preferences, or goals are included. On 3-18-19, the Resident was readmitted to the facility after a hip fracture with a foley catheter. The care plan was updated on 3-29-19, and there is no mention of care, nor care plan for her foley catheter, which was discontinued on 4-3-19. On 4-29-19 a review was conducted of facility ADL documentation, by CNA's. That document revealed no refusals documented by the CNA's who provide all resident ADL care. It was noted that hygiene and bathing were not documented as given every shift. On 4-29-19 a review of physician progress notes revealed only one visit from 12-12-18 to the time of survey. The Administrator stated when asked for all physician progress notes from 2019, there are at least 90 days (3 months) of current records in all of the hard charts. Older records are purged and we will have to get those out of medical records for you. The one progress note found in the clinical record dated 12-12-18 documented 60 day recertification (for skilled nursing care) visit. That note follows; The doctor documented; There is a an element of lack of motivation on patient's part. Has been evaluated by psych as well, refused care (showers) on multiple occasions. Sometimes slow to respond, prefers to stay in her room.Has been cooperative, but still refused baths, says she prefers that way appears to be make up (sic) things at times, says it's the staff, but no other resudents (sic) having any issues. The Resident was cognitively intact, and reported not receiving care from the staff to her doctor. The doctor's note reveals that the doctor assumes the Resident is not credible, but regards her as cooperative. No indication exists in the clinical record that any member of the facility attempted to ascertain triggering factors, or why the Resident would refuse baths, if indeed it occurred. On 4-30-19, the Administrator, Director of Nursing, and Chief Executive Officer were informed of the findings. The facility staff stated they had no further information to provide. 2. For Resident #14, the facility staff failed to complete a comprehensive care plan for contracture care. Resident #14, was originally admitted to the facility on [DATE]. The Resident was discharged and for this stay was readmitted for a medicaid stay on 7-1-15, according to the most recent (4-19-19) MDS (minimum data set) assessment prepared by the facility. Resident #14 was diagnosed on [DATE] with contracture, unspecified hand during stay in the facility. Other diagnoses for Resident #14 included but were not limited to: Arthritis, dementia, psychosis, hernia, dysphagia, anxiety, and chronic obstructive pulmonary disease. Resident #14's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 4-19-19 was coded as a quarterly assessment. Resident #14 was coded as having severe cognitive impairment based on a staff assessment, a BIMS (brief interview for mental status) was not able to be conducted. Resident #14 was coded as being total care, dependent upon one to two staff members, for assistance with dressing, eating, personal hygiene and bathing. The Resident was coded as having not rejected any care services. Further review of the facility coded MDS document areas revealed the following for Resident #14; G0400 was coded as limited range of motion (ROM) in all 4 extremities. G0600 was coded as having no mobility devices. GG0110 prior device use, no devices were coded. Under active diagnoses, contracture of unspecified hand was coded. J0100 pain management described scheduled pain medication every day. J0200 Resident stated she had no pain. M0100 Resident was at risk for pressure ulcers. Speech, occupational and physical therapy none. O0500 Restorative nursing for ROM or splint/brace assistance were all coded as 0 none. Physical examinations or physician's orders were all coded as 0 none. During observation of Resident #14 on 4-29-19 at 10:00 a.m., 12:00 p.m., and 3:00 p.m., both of the Resident's hands were severely contracted, and clenched in a fist with her fingernails pressed into her palms. The Resident was in a short sleeve gown in bed and wore no arm skin protectors, nor palm protection. Observations continued on 4-30-19 at 10:04 a.m., in the Resident's room. Resident #14 was sitting in a reclined wheel-chair in pants and a short sleeve top, with no palm guards or arm skin sleeves on. CNA L was in the room and was asked to open the Residents hands so we could assess the skin of her palms. CNA L complied and the Resident pulled her hand away. The CNA continued, opening both hands enough, (approximately 1.5 inches), to visualize the finger nails, which had been imbedded in the palms, so as to visualize the skin on the Resident's palms. The Resident's hands had a pervasive lasting foul odor which resembled spoiled milk emitting from them as soon as the hands were opened slightly. The CNA stated, oh that smells bad. The Resident's fingernails were visualized to be 1/2 inch long, jagged/broken, dirty, with a dark brown substance under them, and pressing into the palms of both hands. The nails had left indentations where they had been, and the palms were noted to have dark discolorations and excoriated, scratched, and abraded areas where the nails had been pressed into them both. The CNA was interviewed and stated that the Resident had no palm guards, but it would be a good idea to get some, and also stated that the staff couldn't open the Residents hands to clean them because the Resident wouldn't cooperate because it hurt her. The CNA was asked if therapy was seeing the Resident, or if there was any restorative nursing providing range of motion for the Resident, and she stated no, therapy never told us anything about range of motion or dealing with her hands. She was asked if the Resident could stand, and she stated no, the Resident's feet are contracted. Both feet were noted to be rotated and exhibited foot drop. The Resident was again observed at 11:00 a.m., 12:00 p.m., 2:00 p.m., 3:00 p.m., and 5:00 p.m. on 4-30-19, and at no time were protective sleeves nor palm protectors, or foot splints applied to the Resident. Review of the physician's orders from February 2018 through April 2019 revealed no orders for palm guards, or foot splints, no evaluation of contractures by therapy, nor geri-skin sleeves to upper extremities. Physician visits progress notes from January 2019 to the time of survey were reviewed. There were only 2 visits by the doctor. The visits occurred on 1-26-19, and 2-24-19. The visits documented by the doctor stated no new rashes or lesions noted, No deformities or edema noted in lower extremities, contracture unspecified hand. The physician's notes document no deformities in lower extremities, and contracture of hand. However, both hands were observed to be severely contracted, and both feet were rotated and exhibited foot drop deformities. All disciplines of Therapy notes were reviewed and revealed the following; No Speech therapy had ever occurred until 4-20-19 when an evaluation was ordered for aspiration. No physical therapy had been ordered from February 2018 to the time of survey. Occupational therapy was ordered for treatment of positioning in a wheel chair on 8-10-18, and the Resident was discharged from therapy on 8-29-18 with a Pommel cushion and calf pad for positioning in tilt in space wheel chair. The next encounter for an Occupational Therapy evaluation was on 4-17-19 for positioning in wheel chair, again by nursing, and the Resident was provided a new calf pad for her wheel chair. The note described; Patient also gets agitated when attempted to move or touched. Patient will not benefit from skilled OT services at present. If required patient will be evaluated later as need arises. In the document the Occupational therapist describes a medical history of hand contracture, and Precautions of skin integrity, and hand contractures, however, does not evaluate these nor make any recommendations for care and services. The Residents care plan with all revisions was reviewed and revealed only the following 3 care plan areas related to the Residents upper extremities/hand contractures in chronological order; 1. A care plan area documented as potential for pressure ulcers, which stated as interventions, follow facility policy/protocols for the prevention/treatment of skin breakdown initiated 11-27-15, and gerisleeves to bilateral upper extremities, initiated 10-27-16. 2. A second care plan area documented as ADL (activities of daily living) self care performance deficit related to contracture as one impediment, which stated as interventions, unable to grasp with bilateral hands, and, Contractures to bilateral hands. Provide skin care frequently to keep clean and prevent skin breakdown. all initiated 11-11-16. 3. The document also had a third care plan area for Skin Tears with an intervention for The Resident needs their nails kept short to reduce the risk of scratching or injury from picking at skin. initiated 9-18-17. The Resident was diagnosed with contractures on 8-10-15, (3 months prior to this care plan), and no documented interventions were found to be initiated for the diagnosis of contractures until the current care plan which was initiated on 11-27-15, and it was a quarterly care plan revision. The only 3 interventions for this Resident from the 11-27-15 care plan until the time of survey on 4-29-19, which could apply to the Resident's hand contractures, are in the above 3 entries in the current care plan. No gerisleeves were ever observed as being applied to the Resident while on survey. Staff stated, and it was observed, that the Resident's hands were not being cleansed and assessed as needed, and the Resident's finger nails were long and jagged, leaving indentations and abrasions in the Resident's palms. No palm protection from fingernail pressure injury and abrasions from fingernails was afforded the Resident. No intervention from therapy was sought, and no restorative nursing therapy for range of motion was in place. The facility Administrator, DON, and Chief Executive Officer were made aware of the findings on 4-30-19, of the facility staff's failure to complete a comprehensive care plan for contracture care for Resident #14 They stated no further information was available to be provided. 6. For Resident #192, the facility staff failed to develop a comprehensive plan of care to include a Significant Weight Loss of 10.56% within 34 days. Resident #192 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #192's diagnoses included Alzheimer's Disease, Gastronomy Status, Major Depressive Disorder, Insomnia, Hypertension, Dysphasia, Oropharyngeal Phase, Vitamin Deficiency Unspecified, and Folate Deficiency Anemia. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 4/11/19 was reviewed. Resident #192 was coded as having a Brief Interview of Mental Status Score of 12, indicating mild cognitive impairment. On 4/28/19 at approximately 5:00 P.M., Resident # 192 was observed sitting at the nurse's station. She was dressed appropriately. On 4/29/19 a review was conducted of Resident #192's clinical record. According to the Monthly Weight Report, Resident #192 had a 10.56% decrease in weight between December 10/2018, and January 14/2019. The weights were as follows: November 11/5/2018 - 154.2 December 12/10/2018 - 153.1 January 1/14/2019 - 136.8 February, 2019 - 137.2 March, 2019 - 135.4 April, 2019 - 132.0 Resident #192's care plan was reviewed. It read: 1/23/19. Requires tube feeding related to supplementation of oral diet. Check for tube placement. Head of Bed elevated 45 degrees. The care plan did not address the Significant Weight Loss. Resident #192's physician order read, 4/19/19. Jevity 1.5 240 ML Via peg tube four times a day. The Registered Dietician's notes stated that Resident #192 was seen on 12/6/2018, and subsequently not seen again until 1/22/19, when the regularly scheduled interdisciplinary team meeting was scheduled. On 12/6/18 the note read: Resident noted to have decline in intakes by mouth. Most meals recently reported to be less that 50% overall. Resident also noted not to be snacking as often. Weight stable at this time. Adding Ensure Plus daily at this time to supplement. According to the clinical record, after the Significant Weight Loss documented on 1/14/19, neither the Registered Dietician, Medical Doctor, nor the Responsible Party were notified of the change in condition. In addition, the Weight Variance Committee was not notified of the 10.56 % decrease in weight. On 1/22/19 the Registered Dietician's note read: Resident addressed in IDT meeting due to weight loss. Resident had previously been receiving bolus tube feedings to supplement oral diet. Reported intakes have been good for most meals, however weight loss noted. At this time adding Bolus Jevity 1.5 twice daily to supplement. On 4/30/19 at 5:10 P.M. an interview was conducted with the Director of Nursing (Employee B). When asked about the importance of care planning and following- up in a timely manner regarding an unplanned Significant Weight Loss, the DON stated, I'm responsible for not following up with that weight. For the well-being of the resident the Registered Dietician should be contacted so that interventions can be done. The Registered Dietician was not available for an interview. On 4/30/19 a review was conducted of facility documentation, revealing a Significant Weight Changes Policy dated 9/23/2011. It read, To care for residents who are unable, nutritionally challenged, or refuse to consume adequate nutrition and hydration. The goal is to avoid unplanned weight changes which may lead to risk of malnutrition, dehydration, morbid obesity and other complications. Identify residents with significant weight changes. To be defined as 5% weight change in 1 month, 10% weight change in 6 months. Nursing to notify MD, POA (responsible party), and Dietician regarding significant weight changes and document the notification in the resident record. Update plan of care as necessary, Place resident on weekly weights for 1 month or length of time determined by the weight variance committee. The Registered Dietician will assess residents with significant weight changes and make recommendations as needed. On 4/30/19 the DON was notified of the findings. No further information was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. For Resident #51, the facility staff failed to provide timely assistance with ADL's (Activities of Daily Living) and in accordance with plan of care. Resident #51, a [AGE] year old female who was admitted to the facility on [DATE] with diagnoses to include but not limited to high blood pressure, diabetes, paraplegia, and obesity. Resident #51's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/09/2019 was coded as a quarterly review. Resident #51 was coded with a Brief Interview of Mental Status (BIMS) score of 15 out of possible 15 indicating intact cognition. Resident 51 was coded as total dependence with required 2+ persons to provide physical assistance with regard to bed mobility (how the Resident moves to and from lying position, turns side to side, and positions body while in bed). On 04/28/2019 at approximately 5:00 PM, during the initial unit tour, Resident #51 voiced a concern regarding the lack of assistance she received earlier that morning. She stated, About 5:30 or 6:00 (AM), I rang (callbell) for assistance to pull my bottom out of this dip in the bed, I cannot move myself and I was really uncomfortable--the aide (CNA B) said she would be back but I never saw anyone again until the dayshift came in around 7 (AM) and helped move me. On 04/29/2019, a review was conducted of Resident #51's clinical record. A copy of Resident #51's current Care Plan to date was requested and received. This Care Plan included: Focus: (Resident #51) is at risk for falls r/t (related to) Paralysis Interventions: Be sure the resident's call pendant is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance and Focus: (Resident #51) has potential for pressure ulcer r/t (related to) disease process paraplegia, DM (diabetes) & Immobility and history of chronic pressure wound Interventions: Assist to turn/re-position frequently while in the bed and as needed. On 04/29/2019 at approximately 3:00 PM, the Director of Nursing (DON, Employee B) was notified of Resident #51's concerns and she stated, I'll look into it and a facility policy regarding callbells was requested. On 04/30/2019 at approximately 2:30 PM, the Administrator (Employee A) and Director of Nursing (DON, Employee B) were notified of concerns related to response times to callbells. A facility policy with regard to callbells was again requested, however the DON (Employee B) stated, there is no specific facility policy related to callbells. The Administrator (Employee A) stated, I expect callbells to be answered immediately, I know you are looking at (Resident #51) and I called (CNA B) at home, here is her statement. Administrator A provided a copy of a Witness Statement obtained from CNA B that read: On April 28 at 11:40 am [sic] I checked on [Resident #51] got her situated. Then I checked on her at 2:00 am. She was dry but deep sleeping and I finally went there again changet [sic] her make sure she was dry at 4:15 am. No further information was received. 3. For Resident #86, the facility staff failed to provide assistance with eating. Resident #86 was admitted to the facility on [DATE]. Resident #86's diagnoses included but were not limited to: hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side, low back pain, major depressive disorder, atrial fibrillation, seizures, osteoarthritis, heart failure, and dementia without behavioral disturbance. Resident #86's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 3/6/19, was coded as a quarterly assessment. Resident #86 had a BIMS (brief interview for mental status) score of 99, which indicated staff was not able to assess for this. Staff reported that Resident #86's cognitive skills were moderately impaired. Resident #86 was coded as being totally dependent on staff for ADL's (Activities of Daily Living), except eating, which the resident required extensive assistance of one staff member. During observation of the evening meal on 4/28/19 at 6:45pm Resident #86 was served her plate. Staff then walked away from the resident and continued serving plates to other residents. Resident #86 was observed attempting to feed herself using her fingers and had spilled food on her clothing and had food around her mouth. Dining observation continued until 7:26pm and at no point did staff offer Resident #86 any assistance. Review of Resident #86's clinical record, to include careplan, which had a revision date of 1/25/18 states the resident is dependent on staff for eating. On 4/30/19 at approximately 11:50am, an interview was conducted with LPN N, MDS Nurse . When asked about Resident #86, LPN N stated, they feed her. When asked if the resident were sitting attempting to feed herself with her fingers what would take place, LPN N stated, we would need to find someone, a CNA or nurse to feed her. No further information was provided. Based on observation, resident interview, facility documentation review, and clinical record review, the facility staff failed to provide adequate ADL (activities of daily living) care for four residents (Resident #146, #14, #86, and Resident #51) in the survey sample of 60 Residents. 1. For Resident #146, the facility staff failed to provide adequate fingernail and incontinence care. 2. For Resident #14, the facility staff failed to provide adequate nail care, and skin care. 3. For Resident #86, the facility staff failed to provide assistance with eating. 4. For Resident #51, the facility staff failed to provide timely assistance with ADL's (Activities of Daily Living) and in accordance with plan of care. The Findings included: 1. For Resident #146, the facility staff failed to provide adequate fingernail and incontinence care. Resident #146 was admitted to the facility on [DATE]. Diagnoses included; Congestive heart failure, urine retention, foley catheter, dysphagia, atrial fibrillation, muscle weakness, and osteoporosis. The Resident had a recent hip fracture, and had a history of falls. The Minimum Data Set which was a quarterly Assessment with an Assessment Reference Date of 3-25-19, coded Resident #146 as having a Brief Interview of Mental Status score of 13, indicating no impaired cognition. In addition, the Resident was coded as being able to understand and be understood by others. The Resident had a foley catheter for urination, and was coded as occasionally incontinent of bowel. The Resident was fully dependant on staff for hygiene needs, as she had recently had a hip fracture. On 4-29-19 at 10:55 A.M. an observation was made of Resident #146 laying awake in bed. The Resident's fingernails were observed to be soiled with a black substance underneath the nails, which were approximately one half inch long and jagged. There was one Certified Nursing Assistant (CNA) in the room. The Resident was interviewed, and stated that she Haven't had a real bath, or had my nails done since (the previous month) March. She stated that staff used that awful hospital soap which drys my skin so badly it itches for days. She went on to say the staff here are so short that they routinely have 20 people to take care of, so they tell me, and I am lucky if I see them once a day. She went on to say It's never the same staff member, always a different one, and they tell me that they come from a business that provides traveling staff. I don't understand why they don't just hire their own staff like other places do, then we would at least recognize them. The CNA in the Resident's room was immediately interviewed, and asked for anonymity. She was asked to describe the Resident's nails, she stated, There is dirt underneath them on both hands, the CNA's (Certified Nursing Assistants) are supposed to assess the nails every day, especially if they are giving ADL (Activities of Daily Living) care. They should be cleaned as needed. They need to be filed a little bit. The CNA was asked who bathes the Resident, she stated CNA's do all the bathing, nurses have treatments and medications and stuff, and they can't do the bathing too. She was asked if the Resident refused baths, and she stated She never refused me, but I know she likes her certain soap and stuff. On 4-29-19 a review was conducted of Resident #146's clinical record, revealing a care plan. It read: ADL self care performance deficit related to generalized weakness and reduced physical mobility and function, initiated 10-9-18. Interventions included; Resident is totally dependant on (1) staff to provide bath/shower on shower days and as necessary. Resident does often refuse showers, family suggest to use personal bathing products to encourage her to shower. No risks to refusal, assessed refusal triggers, Resident goals, or description of services to be provided by staff were included in the care plan. The 2 interventions (1. provide bath/shower on shower days and as necessary, 2. family suggests use personal bathing products) had no measurable objectives, and were not resident centered. The Resident was cognitively intact, however, none of her preferences, or goals are included. On 3-18-19, the Resident was readmitted to the facility after a hip fracture with a foley catheter. The care plan was updated on 3-29-19, and there is no mention of care, nor care plan for her foley catheter, which was discontinued on 4-3-19. On 4-29-19 a review was conducted of facility ADL documentation, by CNA's. That document revealed no refusals documented by the CNA's who provide all resident ADL care. It was noted that hygiene and bathing were not documented as given every shift. On 4-30-19, the Administrator, Director of Nursing, and Chief Executive Officer were informed of the findings. The facility staff stated they had no further information to provide. 2. For Resident #14, the facility staff failed to provide adequate nail care, and skin care. Resident #14, was originally admitted to the facility on [DATE]. The Resident was discharged and for this stay was readmitted for a medicaid stay on 7-1-15, according to the most recent (4-19-19) MDS (minimum data set) assessment prepared by the facility. Resident #14 was diagnosed on [DATE] with contracture, unspecified hand during stay in the facility. Other diagnoses for Resident #14 included but were not limited to: Arthritis, dementia, psychosis, hernia, dysphagia, anxiety, and chronic obstructive pulmonary disease. Resident #14's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 4-19-19 was coded as a quarterly assessment. Resident #14 was coded as having severe cognitive impairment based on a staff assessment, a BIMS (brief interview for mental status) was not able to be conducted. Resident #14 was coded as being total care, dependent upon one to two staff members, for assistance with dressing, eating, personal hygiene and bathing. The Resident was coded as having not rejected any care services. Further review of the facility coded MDS document areas revealed the following for Resident #14; G0400 was coded as limited range of motion (ROM) in all 4 extremities. G0600 was coded as having no mobility devices. GG0110 prior device use, no devices were coded. Under active diagnoses, contracture of unspecified hand was coded. J0100 pain management described scheduled pain medication every day. J0200 Resident stated she had no pain. M0100 Resident was at risk for pressure ulcers. Speech, occupational and physical therapy none. O0500 Restorative nursing for ROM or splint/brace assistance were all coded as 0 none. Physical examinations or physician's orders were all coded as 0 none. During observation of Resident #14 on 4-29-19 at 10:00 a.m., 12:00 p.m., and 3:00 p.m., both of the Resident's hands were severely contracted, and clenched in a fist with her fingernails pressed into her palms. The Resident was in a short sleeve gown in bed and wore no arm skin protectors, nor palm protection. Observations continued on 4-30-19 at 10:04 a.m., in the Resident's room. Resident #14 was sitting in a reclined wheel-chair in pants and a short sleeve top, with no palm guards or arm skin sleeves on. CNA L was in the room and was asked to open the Residents hands so we could assess the skin of her palms. CNA L complied and the Resident pulled her hand away. The CNA continued, opening both hands enough, (approximately 1.5 inches), to visualize the finger nails, which had been imbedded in the palms, so as to visualize the skin on the Resident's palms. The Resident's hands had a pervasive lasting foul odor which resembled spoiled milk emitting from them as soon as the hands were opened slightly. The CNA stated, oh that smells bad. The Resident's fingernails were visualized to be 1/2 inch long, jagged/broken, dirty, with a dark brown substance under them, and pressing into the palms of both hands. The nails had left indentations where they had been, and the palms were noted to have dark discolorations and excoriated, scratched, and abraded areas where the nails had been pressed into them both. The CNA was interviewed and stated that the Resident had no palm guards, but it would be a good idea to get some, and also stated that the staff couldn't open the Residents hands to clean them because the Resident wouldn't cooperate because it hurt her. The CNA was asked if therapy was seeing the Resident, or if there was any restorative nursing providing range of motion for the Resident, and she stated no, therapy never told us anything about range of motion or dealing with her hands. She was asked if the Resident could stand, and she stated no, the Resident's feet are contracted. Both feet were noted to be rotated and exhibited foot drop. The Resident was again observed at 11:00 a.m., 12:00 p.m., 2:00 p.m., 3:00 p.m., and 5:00 p.m. on 4-30-19, and at no time were protective sleeves nor palm protectors, or foot splints applied to the Resident. The Residents care plan with all revisions was reviewed and revealed only the following 3 care plan areas related to the Residents upper extremities/hand contractures in chronological order; 1. A care plan area documented as potential for pressure ulcers, which stated as interventions, follow facility policy/protocols for the prevention/treatment of skin breakdown initiated 11-27-15, and gerisleeves to bilateral upper extremities, initiated 10-27-16. 2. A second care plan area documented as ADL (activities of daily living) self care performance deficit related to contracture as one impediment, which stated as interventions, unable to grasp with bilateral hands, and, Contractures to bilateral hands. Provide skin care frequently to keep clean and prevent skin breakdown. all initiated 11-11-16. 3. The document also had a third care plan area for Skin Tears with an intervention for The Resident needs their nails kept short to reduce the risk of scratching or injury from picking at skin. initiated 9-18-17. Staff stated, and it was observed, that the Resident's hands were not being cleansed and assessed as needed, and the Resident's finger nails were long and jagged, leaving indentations and abrasions in the Resident's palms. No palm protection from fingernail pressure injury and abrasions from fingernails was afforded the Resident. No intervention from therapy was sought, and no restorative nursing therapy for range of motion was in place. The facility Administrator, DON, and Chief Executive Officer were made aware of the findings on 4-30-19, of the facility staff's failure to provide necessary services to maintain grooming for Resident #14 They stated no further information was available to be provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. For Resident #149, the facility staff failed to mitigate an accident hazard by storing medication at the bedside. Resident #149, was admitted to the facility on [DATE]. Resident #149 diagnoses included, but were not limited to: paroxysmal atrial fibrillation, malignant neoplasm of prostate, secondary malignant neoplasm of bone, hypertension anxiety disorder, and hearing loss. Resident #149's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 4/1/19, was coded as a quarterly assessment. Resident #149 was coded as not being able to be assessed for a BIMS (brief interview for mental status) and staff indicated the resident was severely cognitively impaired. Resident #149 was coded as being totally dependent upon staff for ADL's (activities of daily living) which included: dressing, eating, personal hygiene, and bathing. During initial observation of the facility on 4/28/19 at 3:20pm, Resident #149 was observed to be in bed, a bottle of nystatin powder was at the bedside. The prescription label read, apply to groin/perineum topically BID (twice a day) for redness & rash. A printed date was on the label of: 8/19/18 and the bottle contained 15 grams of medication. On 04/29/19 at 11:25 AM it was observed that the box of nystatin was at the bedside of Resident #149. On 4/30/19 at 10:43am nystatin was observed at the bedside of Resident #149. During an interview with Employee Q, Social Worker, on 4/30/19 at 11:52am, the Social Worker stated, we do have confused residents and occasionally they do go in other rooms. Review of Resident #149's entire clinical record revealed no documentation that Resident #149 had been assessed or determined to be safe to self administer medications, or to keep medications at the bedside. Review of the facility policy titled Medication Storage in the Facility with an effective date of June 2016 the Policy statement read, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. 5. The facility staff failed to lock a medication cart on one of 5 units, which allowed access from residents, staff, and visitors in the hallway. On 4/29/19 at 4:38pm a medication cart on the 400 wing was observed outside of room [ROOM NUMBER] in the hallway and was unlocked. The cart was approximately 4 feet tall, 2 feet deep and 6 feet wide, with multiple drawers that held blister packs of 30 days worth of medication in each blister pack. Blister packs were filed by dividers for residents who resided on that unit. Observation of the cart revealed hundreds of medications, insulin syringes, alcohol prep pads, and other supplies such as bandages in the cart and accessible to anyone walking by. During this observation LPN S opened the door and came out of room [ROOM NUMBER]. When LPN S was asked about the cart, LPN S stated, I forgot to lock it. Review of the facility policy titled Medication Storage in the Facility with an effective date of June 2016 the Policy statement read, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. No further information was provided 6. The facility staff failed to ensure medications were not accessible to residents, staff and visitors, the keys were left in an unattended medication cart on one of five units. On 4/30/19 at 9:31am, cart 2 on the 100 hall a medication cart was observed to be unattended, sitting mid-way down the hall with keys left hanging in the narcotic box. LPN I was observed to be down the hall and returned to the cart. LPN I was asked, do you always leave your keys in your cart? LPN I stated, no, I lock the cart and put the keys in my pocket. The cart was approximately 4 feet tall, 2 feet deep and 6 feet wide, with multiple drawers that held blister packs of 30 days worth of medication in each blister pack. Blister packs were filed by dividers for residents who resided on that unit. Observation of the cart revealed hundreds of medications. These medications were accessible to staff, residents and visitors in the hallway. Review of the facility policy titled Medication Storage in the Facility with an effective date of June 2016 the Policy statement read, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. No further information was provided. 7. The facility staff failed to secure medications on one of two medication carts on the 300 wing. On 4/30/19 at 10:00am on Dale Unit, on Cart 1 (a medication cart) albuterol sulfate inhale solution 2.5 mg 3ml concentrate was observed to be on top of the cart. LPN R was asked about the medication and asked if she always leaves medications on top of her cart, LPN R stated, oh no, I meant to put it in the drawer. Review of the facility policy titled Medication Storage in the Facility with an effective date of June 2016 the Policy statement read, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Administrator and staff were notified of the facility staff's failure to secure medications on 4/30/19. No further information was provided. Based on observation, staff interview, facility documentation and clinical record review the facility staff failed to ensure residents were free from accidents and hazards. This includes 4 of 60 sampled residents (#79, #180, #251, and #149) and multiple medication carts. 1. For Resident #79 the facility staff failed to ensure Resident chair alarm was functional, allowing the Resident to get out of her wheelchair unassisted. 2. For Resident # 180 the facility failed to supervise and ensure he did not wander into other Resident's rooms. 3. For Resident #251, the facility failed to ensure that she was free of a malfunctioning wheelchair related accident hazard. 4. For Resident #149, the facility staff failed to mitigate an accident hazard by storing medication at the bedside. 5. The facility staff failed to lock a medication cart on one of 5 units, which allowed access from residents, staff, and visitors in the hallway. 6. The facility staff failed to ensure medications were not accessible to residents, staff and visitors, the keys were left in an unattended medication cart on one of five units. 7. The facility staff failed to secure medications on one of two medication carts on the 300 wing. The findings include: 1. For Resident #79 the facility staff failed to ensure Resident chair alarm was functional, allowing the Resident to get out of her wheelchair unassisted. Resident #79, an [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Alzheimer's disease, Major Depressive Disorder, Hypertension, Muscle Weakness, Chronic Embolism and Thrombosis. According to the latest (Minimum Data Set) MDS with an (Assessment Reference Date) ARD of 3/10/19 the Resident has a (Brief Interview of Mental Status) score of 99 indicating she is unable to be assessed due to severe cognitive impairment. On 4/28/19 at 6:45 PM, Resident #79 was observed wheelchair in the day room of the Memory Care Unit. The wheelchair was equipped with a chair alarm which was not ringing, there were no staff in dayroom area all staff were in the dining area. At 6:46 PM found LPN D in the dining area and asked her to come and look at the wheelchair. She identified the wheelchair as belonging to Resident #79. She stated that Resident #79 was in the dining room. When asked how the Resident got to the dining room she stated that the Resident gets out of her chair and walks sometimes. When asked why the wheelchair has an alarm on it she stated that the Resident is a fall risk. When asked how the chair alarm works LPN D indicated there is a sensor pad under the chair cushion and when the weight is lifted off the pad (as when a Resident stands up) the alarm sounds. LPN D was asked if she heard the alarm sound when the Resident got up from the chair. She stated that she had not. LPN D was then asked to test the chair alarm. LPN D pressed on the seat cushion and then released the pressure no sound emitted from the alarm. She then checked to ensure it was not turned off and that it didn't need new batteries. She pressed down on the cushion again and once again no sound emitted. She then lifted the cushion and adjusted the wire that goes to the alarm, and put the cushion back in place and once again applied pressure to the cushion and this time there as a 20-30 second delay and the alarm sounded. LPN D then stated that it needed a new alarm pad. When asked how often the alarms were tested she stated every shift however she admitted to not having checked the alarm yet for that shift. According to the Residents care plan: (Resident name redacted) is at risk for falls r/t [related to] confusion gait/balance problems, wandering and use of psychotropic med Resident uses wheelchair for primary mode of locomotion Uses walker intermittently with staff assistance Wheelchair alarm, check for placement and functioning every shift. On 4/29/19 spoke with Unit Manager who stated that she had been made aware and the alarm issue had been fixed, the pad was replaced. On 4/30/19 the Administrator was made aware during the end of day meeting and no further information was provided. 2. For Resident # 180 the facility failed to supervise and ensure he did not wander into other Resident's rooms. Resident # 180 is an [AGE] year old man who was admitted to the facility on [DATE] with diagnoses of but not limited to Parkinson's disease, Hypertension, and Dementia without behavioral disturbance, Anxiety Disorder, Major Depressive Disorder, and unspecified Psychosis not due to a substance or known physiological condition. On 4/28/19 during clinical record review it was noted that Resident #180 was originally admitted to long term care but was moved to the Memory care unit in January of 2018 due to increasing sexually inappropriate behaviors. After an incident on the memory care unit in 3/2018 he was moved back to the long term care unit and 3 months later June of 2018 returned to memory care due to wandering and need for increased supervision. The Resident's most recent (Minimum Data Set) MDS coded as a quarterly assessment, coded the Resident as having a (Brief Interview of Mental Status) BIMS score of 10 indicating moderate cognitive impairment. The Resident is also coded as having wandering behaviors. On 4/28/19 during clinical record review the progress note for 11/5/18 stated: 11/5/18 2:40 AM -Behavior Note At about 2:15 AM the resident from room [redacted] approached this writer and said that the resident from room [redacted] was in her room trying to get into her bed and 'literally had to force him out' [sic] This writer went down to room [redacted] check it out [sic], but resident from rm [redacted] had already gone to his room and was assisted back to bed without incident. We will continue to monitor. 1/18/19 3:51 PM -Behavior Note Resident is alert to name and place and time. He can usually locate his room but occasionally he will be found in other rooms. Ambulates with a walker, or sometimes walks behind the wheelchair. Sometimes to waits [sic] by the exit door on the secure unit. He will occasionally ask a female if he can kiss her, but is easily redirected. On 4/28/19 during clinical record review it was noted that the Residents care plan stated: [Resident name redacted] is noted to exhibit inappropriate behaviors - date initiated 3/5/18 revision 1/30/19 Interventions: Administer Medications as ordered monitor for side effects and effectiveness. - 3/5/18 Anticipate and meet resident needs- 3/5/18 Caregivers to provide [sic] opportunity for positive interaction, attention. Stop and talk with him when passing by. 3/5/18 Explain all procedures to the resident before starting and allow the resident time to adjust to changes- 3/5/18 If reasonable, discuss the president's behavior. Explain/reinforce why behavior is inappropriate and unacceptable to the resident 3/5/18 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 an alternate location as needed.-3/5/18 Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved and situations. Document behavior and potential causes. 3/5/18 Praise indication of the resident's progress /improvement. Psych consult PRN [as needed] - 3/5/18 The Administrator was made aware of the situation on 4/30/19 and no further information was provided 3. For Resident #251, the facility failed to ensure that she was free of a malfunctioning wheelchair - related accident hazard. Resident #251 was an [AGE] year old who was admitted to the facility on [DATE]. Resident #251's diagnoses included Anxiety Disorder, Dementia, Chronic Obstructive Pulmonary Disease, Osteoarthritis, Gout, Heart Failure, and Age-related Nuclear Cataract - Bilateral. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 3/1/19 was reviewed. Resident #251 was coded as having a Brief Interview of Mental Status Score of 9, indicating moderately impaired cognition. Resident #251 was also coded as having impaired vision. In addition, she was coded as being independent in locomotion with a wheelchair. On 4/28/19 at approximately 4:00 P.M., an interview was conducted with Resident #251 at the nurse's station. Resident #251 stated, my wheelchair is shaky I may fall out, it's not safe. It rubs against the wheel. She noted that it was difficult to propel the malfunctioning wheelchair. She stated that the therapy staff knew about her concerns with the wheelchair, but had not addressed it. On 4/30/19 at 2:00 P.M. an interview was conducted with the Rehabilitation Department Director (Employee N). He stated that he would have a staff member look at Resident #251's wheelchair. At 3:00 P.M. The Rehabilitation Department Director came into the conference room. He stated, The wheelchair had the wrong arm on it. It had an arm built on an angle which was meant for another wheelchair. It rubbed against the wheel. The correct arm is straight. The maintenance guy just changed it to the right one for the Invacare wheelchair. According to the manufacturer's instructions for Resident #251's wheelchair, the model is called Invacare 900 XT Wheelchair. The picture showed the correct armrests, which had a straight design, and were not built on an angle. No further information was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #28, the facility staff failed to provide continuous oxygen treatment as ordered by the physician. Resident #28, a [AGE] year old male who was admitted to the facility on [DATE] with diagnoses to include but not limited to high blood pressure, heart failure, chronic obstructive pulmonary disease (COPD), shortness of breath with exertion, anxiety, and depression. He was placed in Hospice care at the facility on 01/18/2019. Resident #28's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/30/2019 was coded as a significant change in status assessment. Resident #28 was coded with a Brief Interview of Mental Status (BIMS) score of 7 out of possible 15 indicating severely impaired cognition. Resident #28 was coded as requiring extensive assistance with locomotion with the use of a wheelchair. On 04/29/2019 at approximately 11:50 AM, Resident #28 was observed sitting in his wheelchair slowly propelling himself down the hallway. There was an oxygen tank with a nasal cannula (a device that consists of a lightweight tube that splits into 2 prongs which are placed in the nostrils to deliver oxygen from the tank) attached and hanging from the back of his wheelchair. The nasal cannula tubing was rolled up in a clear plastic back which was also hanging from the back of his wheelchair. Inspection of the oxygen tank level indicator showed the oxygen volume arrow in the red zone at 0 which indicated that the oxygen tank was empty. At approximately 11:55 AM, CNA C observed Resident #28 in the hallway and assisted him to the storage room located near the Nursing Station. CNA C reported to LPN C that Resident #28 needed a new oxygen tank which LPN C provided from the storage room. LPN C assisted Resident #28 with putting on his nasal cannula and setting the rate of oxygen at 8 liters per minute. LPN C stated, He (Resident #28) is supposed to be on continuous oxygen, the doctor just decreased the amount from 10 (liters per minute) to 8. CNA C stated, He (Resident #28) usually rolls himself up here and waits by the storage room when he is ready for a new tank, that's how we know it needs changed out. No humidification was observed or provided. On 04/29/2019, a review was conducted of Resident #28's clinical record. A physician's order placed on 04/16/2019 read, D/C (discontinue) O2 (oxygen) @ 10 L/min (liters per minute) via NC (nasal cannula); start O2 @ 8 L/min via NC. A facility policy regarding the administration of oxygen was requested and received from the Director of Nursing (DON, Employee B). The facility policy entitled, Administration of Oxygen dated 11/11/2002, contained a subheading, Policy which read, Oxygen should be delivered by the most comfortable and efficient manner. The subheading, Procedure, line 4, read, Attach humidifier bottle filled with sterile water to source (i.e. wall flowmeter, concentrator or oxygen tank), if the flow is more than or equal to 4L/min (liters per minute) or if the resident complains of dry mucous membranes. On 04/29/2019 at approximately 3:30 PM, the Director of Nursing (Employee B) was notified of these findings. No further information was provided. Based on observation, staff interview, clinical record review, and facility documentation review the facility staff failed to ensure four Resident's (Resident #84, Resident #28, Resident #452, and Resident #113) received oxygen as ordered, in a survey sample of 60 Residents 1. For Resident #84, the facility staff failed to ensure that physician ordered continuous oxygen was administered in accordance with the plan of care. 2. For Resident #28, the facility staff failed to provide continuous oxygen treatment as ordered by the physician. 3. For Resident #452, the facility staff failed to ensure she received continuous oxygen therapy. 4. For Resident #113, the facility staff failed to ensure that physician ordered continuous oxygen was administered in accordance with the plan of care. The findings included: 1. For Resident #84, the facility staff failed to ensure that physician ordered continuous oxygen was administered in accordance with the plan of care. Resident #84 was admitted to the facility on [DATE]. Resident #84's diagnoses included but were not limited to: Alzheimer's, allergic rhinitis, anemia, major depressive disorder, acute respiratory failure, hypercapnia, and multiple sclerosis. Resident #84's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 3/4/19 was coded as a quarterly assessment. Resident #84 was coded as having a BIMS (brief interview for mental status) score of 9, which indicated cognition was moderately impaired. Resident #84 was coded as requiring extensive assistance of one staff member for dressing and personal hygiene. For transfers and toileting, Resident #84 required extensive assistance of two staff members. During initial observation of Resident #84, on 4/28/19 at approximately 4:08pm, Resident #84 was observed to be sitting in a wheel chair, at her bedside, with a nasal cannula in her nose. The nasal cannula was connected to an oxygen tank on the back of the wheelchair. The gauge on the tank was observed to be in the red zone, which denoted the tank was empty. An interview was conducted on 4/28/19 at 4:02pm with LPN M, when asked if Resident #84 is to wear oxygen LPN M stated, yes, she is supposed to be on it all the time. LPN M accompanied the surveyor to Resident #84's room and said yeah it's empty. Usually when the CNA brings her to her room, they are supposed to let the nurse know so we can change it over to the concentrator. On 04/29/19 at 11:13 AM an interview was conducted with Resident #84's representative, who was her daughter. The daughter stated, the tank on her chair is empty all most every time I come, I just took her up there to get another one. On 4/29/19 at 4:10pm Resident #84 was observed in her room, sitting in a wheelchair at her bedside and the tank of oxygen she was connected to by way of a nasal cannula, was empty again. The gauge on the tank was observed to be in the red zone, which denoted the tank was empty. An interview was conducted with LPN Q on 4/29/19 at 4:12pm. LPN Q stated Resident #84 is on oxygen continuously at 4 liters for acute respiratory failure. When asked what could happen if a resident doesn't get the oxygen they need, LPN Q stated ,they get hypoxia, where oxygen is not going to the body, it can cause organ failure, cognitive impairments, and death. LPN Q went to Resident #84's room and looked at the oxygen tank and stated, it's empty. We check it periodically, I think people forget she is on 4 liters and it runs out quick. Review of Resident #84's physician orders with an effective date of 3/26/19 stated, oxygen @ (at) 4 Liters continuous every shift for SOB (shortness of breath). Review of Resident #84's careplan initiated on 9/7/16 read, [Resident #84's name] has oxygen therapy r/t (related to) respiratory failure. The intervention read, Oxygen settings: O2 via nasal cannula @ 4L continuous. No further information was provided. 3. For Resident #452, the facility staff failed to ensure she received continuous oxygen therapy. Resident #452, an [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses include but not limited to non-displaced fracture posterior wall of right acetabulum, congestive heart failure, obstructive sleep apnea, hypertension, and peripheral vascular disease. There was no Minimum Data Set information available. On 04/29/2019 at approximately 11:55 AM, Resident #452 was observed laying in her bed, fully dressed, watching TV. Resident #452 had a nasal cannula applied and the end of the tubing was attached to an oxygen tank on the back of her wheelchair. Resident #452 explained that she got into her wheelchair when she went to breakfast and then returned to her room and got myself in bed awhile ago. The oxygen tank was empty. Resident #452 stated she did not feel short of breath. On 04/29/2019 at approximately 12:00 PM, CNA F was asked how frequently she makes rounds and she stated, I don't have a watch so I don't know. When asked if she checks the oxygen as a part of her rounds, CNA F stated, The nurses do that. This surveyor and CNA F entered Resident #452's room and CNA F looked at the oxygen tubing/tank, saw it was empty, and switched it to concentrator on oxygen source in room. An oxygen saturation value was requested and CNA F obtained Resident #452's oxygen saturation and the reading was 98% on room air. CNA F then turned the concentrator on to 2 liters/minute via nasal cannula from the room oxygen source. On 04/29/2019 at approximately 4:40 PM, Resident #452 was observed seated in her wheelchair at the bedside speaking with visitors. The oxygen tubing was attached to the tank on her wheelchair. The gauge needle was just above the red zone (approaching empty). On 04/29/2019 at approximately 4:45 PM, LPN H was asked how often nurses check portable oxygen tanks for residents. She stated it depends on the flow rate and gave the example oxygen at 2 liters/minute may need to be changed within 4 hours. This surveyor and LPN H entered Resident #452's room. LPN H approached the oxygen tank on the wheelchair and was asked about the reading. LPN H stated there were no numbers but it was just about the red zone So I'll change the tank. After this surveyor and LPN H left the room, LPN H was asked why it is important Resident #452 receives continuous oxygen, she stated, She has a cardiac history. On 04/30/2019, the active physician's orders (including telephone orders) were reviewed. An order for oxygen could not be located. A pre-typed sentence that documented, ____O2 via nasal cannula @ ____LPM/HS/PRN (liters per minute/at bedtime/as needed) but it was not checked as selected and the blank to fill in the amount of liters was also blank. The Medication Administration Record was reviewed. An entry dated 04/27/2019 documented, O2 (oxygen) via nasal cannula @ 2LPM (liters per minute) continuous for shortness of breath. Every shift. It was signed off as administered every shift beginning on night shift 04/27/2019 through the night shift on 04/29/2019 with the exception of the evening shift on 04/29/2019 where the administration field is blank. On 04/30/2019, the facility provided a copy of their policy entitled, Administration of Oxygen. Section 1 documented, Obtain a complete physician order. There was not a procedure listed that specifically addressed monitoring oxygen levels in the portable oxygen tanks. On 04/30/2019 at approximately 7:15 PM, the DON stated they had no further information or documentation to offer. 4. For Resident #113, the facility staff failed to that Oxygen Therapy was administered in accordance with the plan of care. Resident #113 was an [AGE] year old who was admitted to the facility on [DATE]. Resident #113's diagnoses included Congestive Heart Failure, Hypertension, Chronic Kidney Disease, Anxiety Disorder, Dyspnea (shortness of breath), and Cardiomyopathy (enlarged heart). The Minimum Data Set, which was an Annual Assessment with an Assessment Reference Date of 3/17/19 was reviewed. Resident #113 was coded as having a Brief Interview of Mental Status Score of 8, indicating severe cognitive impairment. In addition, Resident #113 was coded as requiring Oxygen Therapy. On 4/28/19 a review was conducted of Resident #113's clinical record, revealing a Care Plan. It read, Oxygen therapy r/t (related to) Cardiomyopathy & SOB (shortness of breath). Goal: The resident will have no s/sx (signs/symptoms) of poor oxygen absorption through the review date. Oxygen settings: O2 via nasal cannula. Resident #113's signed physician order read, 4/1/19. O2 via nasal cannula at 2 Lpnc continuous for SOB. Check placement every shift. O2 sats (saturation level) prn (as needed). If less than 90% notify MD. On 4/28/19 a review was conducted of facility documentation, revealing an Administration of Oxygen Policy with an initial implementation date of 1/1/1999. It read, Oxygen should be delivered by the most comfortable and efficient manner. Obtain a complete physician order. Set flowmeter with desired flow. On 4/29/19 at 8:54 A.M., an observation was conducted of Resident #113, who was asleep in her bed. Her oxygen was set at 3 liters per minute. When asked to confirm the amount of oxygen the resident was receiving, the Unit Manager (LPN V) stated, it's right around 3 liters. When asked to confirm the current physician's order for oxygen therapy, the Unit Manager stated, The order says 2 liters. I just looked at it in a glance I should have looked at it differently. We don't want to over saturate them. I don't think that would make a big difference. On 4/29/19 at approximately 10 A.M., in the conference room, the facility Administrator (Employee A) was informed of the findings. No further information was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident interview, staff interview, facility documentation and clinical record review the facility staff failed to ensure sufficient staff for adequate care. 1. The facility staff failed to provide sufficient staff to answer calls bells in a timely manner. 2. The facility staff failed to provide sufficient staff to feed Residents in timely manner. 3. For Resident #146, the facility failed to provide sufficient staff to maintain bathing and hygiene cleanliness. The findings include: 1. The facility staff failed to provide sufficient staff to answer calls bells in a timely manner. On 04/29/2019 at approximately 10:55 AM, Surveyor E interviewed Resident #174. When asked if staff overall answers call bell promptly, Resident #174 stated It takes a long time to get any help and From 3-11 is a problem. Resident #174 stated that in the evenings, he needs help getting transferred into bed, getting his bed clothes on, and getting off the toilet. On 4/29/19 at 10:40 A.M., Surveyor A conducted a private group interview. Seven residents were in attendance and were actively participated. The majority of them voiced concerns about consistent shortages of staff, and stated that call bell response times sometimes took between 30 to 60 minutes. 2. The facility staff failed to provide sufficient staff to feed Residents in timely manner On 4/28/19 Surveyor F observed the following during the evening meal, Resident #29 received her meal plate at 6:53 pm which was left on the table in front of her with a lid on it. At 7:07 pm, LPN M walked over to Resident #29, removed the cover, and stood over Resident #29, fed her three bites of food and then returned to the opposite side of the table to resume assisting another resident. During observation of the evening meal on 4/28/19 at 6:45 pm Resident #86 was served her plate. Staff then walked away from the resident and continued serving plates to other residents. Resident #86 was observed attempting to feed herself using her fingers and had spilled food on her clothing and had food around her mouth. The dining observation continued until 7:26 pm and at no point did staff offer Resident #86 any assistance. Review of Resident #86's clinical record, to include care plan, which had a revision date of 1/25/18 states the resident is dependent on staff for eating. On 4/30/19 at approximately 11:50 am, an interview was conducted with LPN N, MDS Nurse. When asked about Resident #86, LPN N stated, They feed her. When asked if the resident were sitting attempting to feed herself with her fingers what would take place, LPN N stated, we would need to find someone, a CNA or nurse to feed her. On 4/30 19 during the end of day meeting the Administrator was notified of the staffing issues and no further information was provided 3. For Resident #146, the facility failed to provide sufficient staff to maintain bathing and hygiene cleanliness. Resident #146 was admitted to the facility on [DATE]. Diagnoses included; Congestive heart failure, urine retention, foley catheter, dysphagia, atrial fibrillation, muscle weakness, and osteoporosis. The Resident had a recent hip fracture, and had a history of falls. The Minimum Data Set which was a quarterly Assessment with an Assessment Reference Date of 3-25-19, coded Resident #146 as having a Brief Interview of Mental Status score of 13, indicating no impaired cognition. In addition, the Resident was coded as being able to understand and be understood by others. The Resident had a foley catheter for urination, and was coded as occasionally incontinent of bowel. The Resident was fully dependant on staff for hygiene needs, as she had recently had a hip fracture. On 4-29-19 at 10:55 A.M. an observation was made of Resident #146 laying awake in bed. The room floor was so sticky, that the surveyors shoe stuck to the floor, and was a fall hazard. The room had a foul distinct urine odor that permeated even the hallway. The Resident's fingernails were observed to be soiled with a black substance underneath the nails, which were approximately one half inch long and jagged. There was one Certified Nursing Assistant (CNA) in the room. The Resident was interviewed, and stated that she Haven't had a real bath, or had my nails done since (the previous month) March. She stated that staff used that awful hospital soap which drys my skin so badly it itches for days. She went on to say the staff here are so short that they routinely have 20 people to take care of, so they tell me, and I am lucky if I see them once a day. She went on to say It's never the same staff member, always a different one, and they tell me that they come from a business that provides traveling staff. I don't understand why they don't just hire their own staff like other places do, then we would at least recognize them. The CNA in the Resident's room was immediately interviewed, and asked for anonymity. She was asked to describe the Resident's nails, she stated, There is dirt underneath them on both hands, the CNA's (Certified Nursing Assistants) are supposed to assess the nails every day, especially if they are giving ADL (Activities of Daily Living) care. They should be cleaned as needed. They need to be filed a little bit. The CNA was asked who bathes the Resident, she stated CNA's do all the bathing, nurses have treatments and medications and stuff, and they can't do the bathing too. She was asked if the Resident refused baths, and she stated She never refused me, but I know she likes her certain soap and stuff. On 4-29-19 a review was conducted of Resident #146's clinical record, revealing a care plan. It read: ADL self care performance deficit related to generalized weakness and reduced physical mobility and function, initiated 10-9-18. Interventions included; Resident is totally dependant on (1) staff to provide bath/shower on shower days and as necessary. Resident does often refuse showers, family suggest to use personal bathing products to encourage her to shower. No risks to refusal, assessed refusal triggers, Resident goals, or description of services to be provided by staff were included in the care plan. The 2 interventions (1. provide bath/shower on shower days and as necessary, 2. family suggests use personal bathing products) had no measurable objectives, and were not resident centered. The Resident was cognitively intact, however, none of her preferences, or goals are included. On 3-18-19, the Resident was readmitted to the facility after a hip fracture with a foley catheter. The care plan was updated on 3-29-19, and there is no mention of care, nor care plan for her foley catheter, which was discontinued on 4-3-19. On 4-29-19 a review was conducted of facility ADL documentation, by CNA's. That document revealed no refusals documented by the CNA's who provide all resident ADL care. It was noted that hygiene and bathing were not documented as given every shift. On 4-29-19 a review of physician progress notes revealed only one visit from 12-12-18 to the time of survey. The Administrator stated when asked for all physician progress notes from 2019, there are at least 90 days (3 months) of current records in all of the hard charts. Older records are purged and we will have to get those out of medical records for you. The one progress note found in the clinical record dated 12-12-18 documented 60 day recertification (for skilled nursing care) visit. That note follows; The doctor documented; There is a an element of lack of motivation on patient's part. Has been evaluated by psych as well, refused care (showers) on multiple occasions. Sometimes slow to respond, prefers to stay in her room.Has been cooperative, but still refused baths, says she prefers that way appears to be make up (sic) things at times, says it's the staff, but no other residents (sic) having any issues. On 4-30-19, the Administrator, Director of Nursing, and Chief Executive Officer were informed of the findings. The facility staff stated they had no further information to provide.

2. In three of five medication rooms the facility staff failed to provide a separately locked, permanently affixed compartment for storage of refrigerated controlled drugs. 04/29/19 at 09:07am during observation of the Midlothian medication room, it was observed that the refrigerator in the medication room was not locked. Inside the refrigerator was a black box, which was secured to the removable shelf and the box was locked. The shelf containing the box was able to be removed with ease. On 4/30/19 at 12:15pm during an inspection of the medication room on the Bermuda wing it was observed that the refridgerator in the medication room was not locked. Inside the refridgerator was a black box, which was secured to the removable shelf and the box was locked. When RN B was asked what is kept in the box, RN B stated, liquid ativan if we have it. Surveyor F then removed the shelf containing the locked box and RN B, stated oh, my, I get what you are saying now. On 4/30/19 at 12:35pm during an inspection of the medication room on the Cloverhill unit, it was observed that the refridgerator in the medication room was not locked. Inside the refridgerator was a black box, which was secured to the removable shelf and the box was locked. LPN E stated we only put Ativan for hospice patients in there. When asked why medications are secured, LPN E stated, so people won't get them, they are a danger and hazard to people. When surveyor F removed the shelf containing the locked box, LPN E stated true, it's not secure, I never thought about that. I will let them know! Review of the facility policy titled Medication Storage in the Facility with an effective date of June 2016 the Policy statement read, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Based on observation, staff interview, and facility documentation review, the facility staff failed to properly store medication and the facility staff failed to provide a separately locked, permanently affixed compartments for storage of controlled drugs in three of five medication rooms. 1. Fluticasone for Resident #81 and Humalog for Resident #170 were sitting out on top of Medication Cart #1 on the Midlothian unit unsupervised. 2. In three of five medication rooms the facility staff failed to provide a separately locked, permanently affixed compartment for storage of refrigerated controlled drugs. The findings included: 1. Fluticasone for Resident #81 and Humalog for Resident #170 were sitting out on top of Medication Cart #1 on the Midlothian unit unsupervised. On 04/29/2019 at 10:42 AM, this surveyor and Surveyor C observed a bottle of fluticasone and a vial of Humalog insulin on the top of Cart 1 unsupervised. The cart was up against the wall in the hall of the Midlothian unit near resident rooms. Within one minute of this observation, LPN J approached the med cart. When asked about the importance of not leaving medications unsupervised, LPN J stated, Because then anyone can get them and it's a safety issue. On 04/30/2019, the facility staff provided their policy entitled, Medication Storage in the Facility. Section E under the header Procedures documented, Except for those requiring refrigeration or freezing, medications intended for internal use are stored in a medication cart or other designated area. On 04/30/2019 at 7:05 PM, the DON was notified of findings. When asked about the expectation for storing medications securely, the DON stated, No meds should be left on the cart unsupervised. On 04/30/2019 at approximately 7:15 PM, the DON stated they had no further information or documentation to offer.

Based on observations and staff interviews, the facility staff failed to assign staff with appropriate skill set to effectively carry out the functions of food and nutrition services. The facility staff assigned a dietary aide to the 3-compartment sink before he received the training and competencies to do so. The findings included: On 04/29/2019 at approximately 10:15 AM, this surveyor requested to observe a check of the three compartment sink. Employee D was washing pots at the first sink. There were three pots in the three compartment sink. Employee H walked up to the three compartment sink and removed the pots and returned them to the first compartment. When asked why he removed the pots from the third compartment, he stated, Because they had soap on them. It was noted at that time that Employee H also drained all the solution out of the three compartment sink and began to refill it. When this surveyor asked why he emptied the sink when we were going there to test it, he stated, Sorry about that. When asked who was responsible for preparing the three compartment sink, he stated the staff member assigned to it. When Employee D was asked how to prepare the three compartment sink, he stated this was his first time working the three compartment sink. He also stated he had not been working at the facility long. Employee H prepared the three compartment sink and inserted the indicator into the solution. The value was 500 ppm. The acceptable range was 150 - 400 ppm according to the manufacturer's instructions on the wall above the sinks. Employee H added water to the solution and retested it. The result was between 200 - 400 ppm. On 04/30/2019 at approximately 10:00 AM, a policy on training new kitchen staff was requested. On 04/30/2019 at approximately 4:00 PM, Employee H was asked about the process for training new employees in the kitchen. He stated that new employees rotate to the different areas in the kitchen to learn the job. When asked about Employee D, he verified he was a new employee. When asked if Employee D had completed training to work the 3-compartment sink, he stated, Someone called out so he was pulled there. This surveyor and Employee H entered the kitchen area and observed the staff schedule posted on the wall by the office in the kitchen. He showed how Employee D was scheduled to work in Area H. Then he pointed to the section where a staff member was designated an A for absent. Employee H explained he pulled a staff member from the 3-compartment sink to cover for the absent employee and then reassigned Employee D from Area H to the 3-compartment sink. When asked if he had any evidence Employee D completed training for the 3-compartment sink, he stated, No. He also stated, I was supervising him for that position. When asked who filled up the 3-compartment sink yesterday morning (04/29/2019 at approximately 10:15 AM) when Employee D was assigned there under his supervision, Employee H stated, I don't know. An interview with Employee D was requested. Employee H called Employee D who was working nearby, and joined the conversation. When asked about working at the 3-compartment sink the previous day, Employee D stated that was his first time working in that area. When asked if he prepared the 3-compartment sink, he stated, NO, because I didn't know how to do it. He also stated he asked another employee with experience to do it. At 04/30/2019 at approximately 7:15 PM, the DON stated they had no further information or documentation to offer. No policy on training new kitchen staff was presented.

3. The facility staff failed to perform proper hand washing prior to meal service. During observation of the evening meal on 4/28/19 in the Midlothian dining room from 5:55pm until 7:26pm, Employee P, dietary aide failed to perform proper hand washing. At approximately 6:25pm, Employee P, a dietary aide, washed his hands, used his bare-hand to turn off the water. When Employee P was asked if he had been trained on proper hand washing, Employee P stated, yes ma'am. When asked if he performed proper hand washing techniques, Employee P stated, no, I used my hand to turn off the water and not a paper towel. Employee P then made no attempt to re-wash his hands properly, Employee P proceeded to done gloves and begin serving meal plates. Employee O, Assistant Food Services Director was present and witness to the interactions with Employee P. Review of the facility policy entitled, Handwashing policy number: 800-841.3, Purpose statement read: Proper handwashing technique is used for the prevention of transmission of infectious diseases. The Policy statement read: All personnel working in the facility are required to wash their hands before and after resident contact, before and after performing any procedure, after removing gloves, after handling soiled items, after having contact with blood or other potentially infectious substances, after sneezing or blowing nose, after using the restroom, before handling food and when hands become obviously soiled. The Procedure read: 7. With a clean, dry paper towel, turn faucet off. No further information was provided. 4. The facility staff failed to serve food in a sanitary manner in the Midlothian dining room. During observation of the evening meal on 4/28/19 in the Midlothian dining room, at approximately 6:43pm, CNA K was observed to take a plate from the kitchenette with two servings of chicken salad into the dining room. CNA K served several plates from a tray she was carrying and returned the plate with the two servings of chicken salad to the kitchenette. Employee P, dietary aide then scooped the chicken salad from the plate, into the serving container where the chicken salad was being served from, and Employee P then continued to serve other plates from that supply of chicken salad. Once residents were served in the dining room, carts consisting of three shelves were rolled into the kitchenette. CNA's then started putting condiments, silverware and beverages on trays on each shelf of the cart, and Employee P plated the food and provided the CNA's with plates of food, which was placed on the trays. The CNA's then took the cart to the hallways, in and out of resident rooms, to serve residents who were eating in their rooms. The carts were then returned to the kitchenette, entering the food preparation and distribution area, to be filled again. The carts were not wiped down or sanitized in anyway prior to re-entering the food service area. No further information was provided. 5. The facility staff failed to label and date food stored in the fridge in the Midlothian kitchenette. On 4/28/19 at 7:26pm in the fridge in the Midlothian kitchenette 12 burgundy bowls, 11 with lids, 1 without any cover were observed without any label as to the contents or the date prepared. When Employee P, dietary aide was asked what the items were, Employee P stated, it is the desserts for the pureed diets. On 4/29/19 at 8:50am a burgundy bowl was observed in the fridge in the Midlothian kitchenette. It did have a lid covering the contents, there was no labeling to indicate the contents or date of when it was prepared. When Employee U, a dietary aide was asked what was in the bowl, Employee U stated, I have no clue, I think someone may have left that there last night. No further information was provided. Based on observation, staff interview, and facility documentation, the facility staff failed to follow proper sanitation practices facility-wide and failed to serve food with proper sanitation practices and at proper holding temperature in one of six dining rooms. 1. A facility staff member held a pen and the thermometer in her gloved hand simultaneously while temping the pureed eggs, the pureed sausage, and the sausage gravy. The pen hovered over the food and touched the edges of the food container at times during the temping process. 2. According to the facility's sanitizer solution log, the three compartment sink was not tested for three days in April to ensure the pots were effectively sanitized and chemical contamination was avoided. 3. The facility staff failed to perform proper hand washing prior to meal service. 4. The facility staff failed to serve food in a sanitary manner in the Midlothian dining room. 5. The facility staff failed to label and date food stored in the fridge in the Midlothian kitchenette. The findings included: 1. A facility staff member held a pen and the thermometer in her gloved hand simultaneously while temping the pureed eggs, the pureed sausage, and the sausage gravy. The pen hovered over the food and touched the edges of the food container at times during the temping process. On 04/29/2019 at approximately 8:15 AM, Employee H, the certified dietary manager, and this surveyor entered the unit 1 kitchen to observe Employee J temp the food and serve breakfast to the residents in the unit 1 dining room. Employee J was wearing gloves, placed the thermometer in the scrambled eggs, and the reading on the thermometer was 162 degrees Fahrenheit. Employee J then reached into her pants pocket with her gloved hand to retrieve a pen and wrote the temperature in the temperature log book. Employee J repositioned the pen in her hand so she could simultaneously hold the thermometer and then proceeded to temp the pureed eggs. Employee J pulled the thermometer out of the pureed eggs, wiped the pureed eggs off the thermometer and stated the temperature was 142 degrees Fahrenheit. This surveyor stated the value was not visualized and requested a re-check. Employee H again placed the thermometer in the pureed eggs and the temperature reading was 130 degrees Fahrenheit. Employee H stated, I will take these back to the kitchen (to reheat). Employee H took the pureed eggs back to the kitchen and Employee J continued to temp the food on the steam table with the pen and the thermometer in her gloved hand. The temperature of the pureed sausage was 147 degrees Fahrenheit. The pen touched the side of the container as she moved the thermometer around in the pureed sausage container. The temperature of the sausage gravy was 151 degrees Fahrenheit. When asked if she should be holding the pen while measuring the food temps, Employee J stated, No, I shouldn't but I'm trying to write (the temps) too. Employee J measured the temperature of the biscuits which was 129 degrees Fahrenheit and stated she would take these back. Employee J measured the temperature of the oatmeal (144 degrees Fahrenheit) and Employee H returned with the pureed eggs. The temperature of the pureed eggs was rechecked and measured 153 degrees Fahrenheit. 2. According to the facility's sanitizer solution log, the three compartment sink was not tested for three days in April to ensure the pots were effectively sanitized and chemical contamination was avoided. On 04/29/2019 at approximately 10:00 AM, this surveyor was with Employee H in the main facility kitchen and requested to see the sanitizer logs. For 04/26/2019 - 04/29/2019, there was no documentation about sanitizer testing. When asked what the expectation was for checking the three compartment sink, Employee H stated it should be checked after each meal. When asked about 04/26/2019 - 04/29/2019, Employee H stated, I was on vacation. Also, the facility's Sanitizer Solution Log document had six columns with the headers Date, Area (Pot and Pan), AM (morning), Initials (staff), PM (afternoon), and Initials (staff). Under the headers AM and PM, there were 2 sub-columns each entitled, S (satisfactory) and U (unsatisfactory). For 04/19/2019, 04/22/2019 - 04/25/2019, there was a check mark for both satisfactory and unsatisfactory. There were no ppm (parts per million) values recorded and there was not a column to record for each meal as Employee H indicated was the expectation. On 04/30/19, dietary policies pertaining to kitchen infection control, food holding temps, and protocol for preparation of the three compartment sink were requested. A facility policy on handwashing was provided. It was not specific to proper sanitation and food handling practices. A policy entitled, Accuracy and Quality of Tray Line Service was provided. Section 6 documented, All foods will be covered. Hot foods will be kept hot (>135 degrees F) and cold foods will be kept cold (<41 degrees F). Cooking of hot foods will be completed no more than 30 minutes prior to meal service. At 04/30/2019 at approximately 7:15 PM, the DON stated they had no further information or documentation to offer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. For Resident #105, the facility staff failed to accurately code a Morse Fall Scale/Risk assessment. Resident #105 was initially admitted to the facility on [DATE], with a readmission date of 4/24/19. Resident #105's diagnoses included but were not limited to: heart failure, atrial fibrillation, hypertension, chronic obstructive pulmonary disease, and chronic pain syndrome. Resident #105's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 2/22/19 was coded as an admission assessment. Resident #105 was coded as having a BIMS (brief interview for mental status) score of 8, which indicated moderate cognitive impairment. Resident #105 was coded as requiring extensive assistance of one staff member for transfers, dressing and personal hygiene. Review of Resident #105's clinical record to include, physician orders, careplan, nursing notes, hospital records, and fall risk assessments revealed that Resident #105 sustained a fall on 4/23/19, which resulted in the resident being transported to the hospital for treatment. Upon Resident #105's return on 4/24/19, nursing completed a Morse Fall Scale/Risk assessment on 4/24/19 at 15:18 and question A, asked has the resident ever fallen before? Nursing answered the question as No. This incorrect response lead to an inaccurate fall risk score, for Resident #105. No further information was provided. Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain accurate and readily accessible medical records for four residents (Resident #198, Resident #179, Resident #452, Resident #105) in a sample size of 60 residents. 1. For Resident #198, the social worker did not document social services notes in the clinical record but kept notes in a soft file in her office. 2. For Resident #179, the social worker did not document social services notes in the clinical record but kept notes in a soft file in her office. There are inconsistencies in the bowel and bladder status documentation and the bowel and bladder elimination record is incomplete. 3. For Resident #452, there was no physician's order for oxygen but the Medication Administration Record listed oxygen at 2 liters per minute continuous and the sign-off as administered was incomplete. 4. For Resident #105, the facility staff failed to accurately code a Morse Fall Scale/Risk assessment. The findings included: 1. For Resident #198, the social worker did not document social services notes in the clinical record but kept notes in a soft file in her office. Resident #198, a [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses include but not limited to osteomyelitis, diabetes, and hypertension. Resident #198's most recent MDS with an Assessment Reference Date of 04/17/2019 was coded as an admission assessment. The Brief Interview for Mental Status was coded as 15 out of possible 15 indicative of no cognitive impairment. Functional status for transfers and dressing were coded as requiring extensive assistance from staff. Having an active discharge plan in place was coded as Yes. On 04/28/2019 at approximately 5:00 PM, an interview with Resident #198 was conducted. When asked about planning for discharge, Resident #198 stated someone in therapy asked him about stairs in his house. Resident #198 stated he had to be able to walk before going home. He also stated that he had not spoken with a social worker about discharge planning. On 04/29/2019, the clinical record was reviewed and no social worker notes were located. On 04/30/2019 at approximately 11:40 AM, an interview with Employee K, a social worker, was conducted. When asked about the social services process for new admissions, she stated she tries to meet with the resident in the first three days of arrival and have a care plan meeting, including the family, in the first 14-20 days. When asked if she had met with Resident #198, she stated, Yes and presented a file from her office. Employee K stated these were the notes from the meeting and they were dated 04/15/2019. When asked about her process for documenting social services information, she stated she does not document in the electronic health record but documents on paper and keeps it in her office soft file. When asked if there were social service notes in the hard chart, she stated, No, it's horrible. When asked if the information in her soft file was considered part of the clinical record, she stated, Yes. When asked why it was important to put social services notes in the hard chart as part of the clinical record, Employee K stated, In case someone wants to know social history or their discharge plan. A copy of social services policy was requested. On 04/30/2019 at approximately 6:15 PM, Employee K stated that they don't have a social services policy. On 04/30/2019 at approximately 6:30 PM, Employee T verified there was not a social services policy but offered to provide a social worker job description. On 04/30/2019 at approximately 7:00 PM, a copy of the Medical Social Worker job description was provided. Under the heading Specific Statement of Responsibilities, there were 14 bulleted statements. One statement documented, Facilitates a strengthening of communication between [facility] staff and the residents, their families, and significant others. Another bulleted statement documented, Conduct social history assessments, facilitate care team meetings, and accurately document case load status. At 04/30/2019 at approximately 7:15 PM, the DON stated they had no further information or documentation to offer. 2. For Resident #179, A) the social worker did not document social services notes in the clinical record but kept notes in a soft file in her office. B) There are inconsistencies in the bowel and bladder status documentation and the bowel and bladder elimination record is incomplete. Resident #179, an [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses include but not limited to displaced fracture lateral malleolus right fibula, cerebral infarction without residual deficits, cognitive communication deficit, diabetes, muscle weakness, and dysphagia. Resident #179's most recent Minimum Data Set with an Assessment Reference Date of 04/12/2019 was coded as an admission assessment. The Brief Interview for Mental Status was coded as 11 out of possible 15 indicative of moderate cognitive impairment. Discharge plan was coded as 'yes' meaning there was an active plan in place for Resident #179 to return to the community. Resident #179's overall expectation/goal was not coded. Bowel and bladder was coded as occasionally incontinent. Pertaining to the social services documentation: On 04/29/2019 at 11:35 AM, an interview with Resident #179 was conducted. When asked if she has met with a social worker about discharge planning, Resident #179 stated, No. On 04/30/2019 at 12:50 PM, an interview with a social worker, Employee K, was conducted. When asked if there were social services notes in the clinical record (electronic or hard chart), Employee K stated, No. Employee K also stated there was a care plan meeting on 04/11/2019 and her notes on the meeting were in the soft file. When asked if the information contained in the notes was part of the clinical record, she stated, Yes. When asked why there were no social services notes in the clinical record, she stated that she first wanted to write it up in a neater format. On 04/30/2019 at approximately 6:15 PM, Employee K stated that they don't have a social services policy. On 04/30/2019 at approximately 6:30 PM, Employee T verified there was not a social services policy but offered to provide a social worker job description. On 04/30/2019 at approximately 7:00 PM, a copy of the Medical Social Worker job description was provided. Under the heading Specific Statement of Responsibilities, there were 14 bulleted statements. One statement documented, Facilitates a strengthening of communication between [facility] staff and the residents, their families, and significant others. Another bulleted statement documented, Conduct social history assessments, facilitate care team meetings, and accurately document case load status. Pertaining to the bowel and bladder documentation: On 04/29/2019 at approximately 11:45 AM, Resident #179 was interviewed. When asked about any concerns with bowel elimination, Resident #179 stated she recently started having a problem with constipation. When asked when she last had a bowel movement, she could not remember. She also stated that Sometimes it's a very small amount. Resident #179 also stated she was not in discomfort currently. On 04/29/2019, the active physician's orders for April 2019 were reviewed. There were no orders for a stool softener, laxative, or other medications to prevent/alleviate constipation. On 04/30/2019, the electronic care plan was reviewed. Bowel and bladder continence were not addressed. The paper copy baseline care plan provided by the facility staff documented continent for bowel. The CNA care plan documented incontinent under the header Toileting. On 04/30/2019, a copy of the bowel elimination documentation for April 2019 was requested. The facility provided a flowsheet entitled, Bowel and Bladder Elimination with a date range of 04/01/2019 through 04/29/2019. When asked to interpret the meaning of the coding for daily documentation, the DON looked at the form and stated she would get a staff nurse to assist with answering the question. On 04/30/2019 at approximately 5:45 PM, LPN T was interviewed to explain the meaning of the codes on the bowel and bladder elimination flowsheet. She explained each shift could have up to 4 characters in the space provided. The first character coded bowel continence, the second character coded the size of the bowel movement, the third character coded bowel consistency, and the fourth character coded urinary continence. She also stated that when there were only 2 characters in the space provided, it was because a bowel movement did not occur so only bowel continence and urinary continence would be coded. For the day shift dated 04/20/2019 at 1:30 PM, the coding for bowel and bladder elimination indicated Resident #179 was continent and had a medium-sized, formed/normal bowel movement. All subsequent documentation on the flowsheet ranging from 04/20/2019 at 4:39 PM through 04/29/2019 at 6:59 AM was coded as a 2 meaning No bowel movement according to the legend on the bottom of the page. There were 6 shifts in that time range where documentation did not occur: 04/21/2019 (dayshift), 04/23/2019 (dayshift), 04/26/2019 (dayshift), 04/27/2019 (evening shift), 04/28/2019 (dayshift), and 04/29/2019 (evening shift). When asked when Resident #179 last had a bowel movement, LPN T stated according to the flowsheet, the last bowel occurred on 04/20/2019 (10 days ago) unless it occurred where there are empty spaces in the documentation. On 04/30/2019 at approximately 6:00PM, an interview with LPN U was conducted. When asked when Resident #179 last had a bowel movement, LPN U referred to the electronic health record and stated, She must have had one recently because she did not trigger alert. When asked if she received information in nurse-to-nurse verbal report about it, she did not answer. She stated that sometimes residents have a bowel movement and do not tell staff. LPN U continued to refer to electronic health record and stated, She is a one-person assist so staff would know if Resident #179 had a bowel movement. When asked why it is important to monitor bowel elimination, LPN U stated, Because there might be an obstruction or some medical issue. On 04/30/2019 at approximately 6:05 PM, this surveyor and LPN U entered Resident #179's room. Resident #179 was observed awake and sitting up. When asked if she had concerns with bowel elimination, Resident #179 stated she had problems with constipation. When asked when she last had a bowel movement, Resident #179 stated she had a bowel movement earlier today and that it was normal. LPN U asked Resident #179 if she was having any discomfort and Resident #179 stated, No. In summary, social services notes were documented in a soft file and inaccessible to the healthcare team. Also, there was incomplete documentation of Resident #179's bowel elimination status and conflicting information on bowel continence status in the clinical record. At 04/30/2019 at approximately 7:15 PM, the DON stated they had no further information or documentation to offer. 3. For Resident #452, there was no physician's order for oxygen but the Medication Administration Record listed oxygen at 2 liters per minute continuous and the sign-off as administered was incomplete. Resident #452, an [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses include but not limited to non-displaced fracture posterior wall of right acetabulum, congestive heart failure, obstructive sleep apnea, hypertension, and peripheral vascular disease. There was no Minimum Data Set information available. On 04/30/2019, the active physician's orders (including telephone orders) were reviewed. An order for oxygen could not be located. A pre-typed sentence that documented, ____O2 via nasal cannula @ ____LPM/HS/PRN (liters per minute/at bedtime/as needed) but it was not checked as selected and the blank to fill in the amount of liters was also blank. The Medication Administration Record was reviewed. An entry dated 04/27/2019 documented, O2 (oxygen) via nasal cannula @ 2LPM (liters per minute) continuous for shortness of breath. Every shift. It was signed off as administered every shift beginning on night shift 04/27/2019 through the night shift on 04/29/2019 with the exception of the evening shift on 04/29/2019 where the administration field is blank. At 04/30/2019 at approximately 7:15 PM, the DON stated they had no further information or documentation to offer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed for 2 residents (#151, #95) in the sample size of 37 residents to provide facility sponsored individualized activities. 1. For Resident #151, the facility staff failed to provide individual activities. 2. For Resident #95, the facility staff failed to provide individual activities. The Findings included: 1. Resident #151 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #151's diagnoses included Psychosis, Anxiety Disorder, and Dementia. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 2/14/18, coded Resident #151 as having a Brief Interview of Mental Status Score of 3. This score is indicative of severely impaired cognition. On 3/14/17 a review was conducted of Resident #151's clinical record. The care plan read, 3/22/17. The resident sometimes interrupts group activities by yelling out, asking for personal assistance and attention. She has some cognitive deficits and physical limitations. But, she likes visits from family, music therapy and Sunday School programs. On 03/14/18 at 10:47 AM, Resident #151 was observed sitting alone asleep at the nurse's station. She was reclined on an oversized easy chair with her legs elevated. For about 30 minutes, no staff were at the nurse's station. No interaction with staff or other residents was initiated. 03/15/18 11:18 AM Resident # 151 was observed sitting alone near nurses station in an easy chair with her feet up. For about 30 minutes, no staff were at the nurse's station. No interaction with staff or other residents. was observed. The resident will attend group activities and she likes a lot of attention. She yells out a lot. I document behaviors in the computer. We have daily documentation of their involvement in activities according to staff. The clinical record, including the Activities section did not contain any evidence of Resident #151 having participated in any facility sponsored activities. The Wellness Coordinator was asked to show the surveyor where she had documented Resident #151's attendance and participation in activities. She stated that she was unable to find any documentation. 2. Resident #95 was a [AGE] year old who was admitted to the facility on [DATE]. Her diagnoses included Brain Injury, Anxiety, Hypertension, Mood Affective Disorder, Major Depressive Disorder, Delusional Disorder and Anemia. On 03/14/18 at 10:57 A.M., Resident #95 was noted sitting up in her bed yelling. She denied any discomfort. She stated that she had not been invited to any activities. She stated that she wasn't invited to the St. Patrick's Day party scheduled for that afternoon. She denied receiving any visits by activities staff. Resident #95 requested that the surveyor not leave her room, and was invited to stay for an extended period of time to keep her company. On 3/14/18 a review was conducted of Resident #95's clinical record, revealing a Care Plan. It read, aggressive outbursts within group activities often offending, disrupting or distracting other residents. She swears loudly at staff and other residents. 03/15/18 02:24 PM Interview with Wellness Coordinator (Employee C -Activities) regarding Resident #151, and Resident #95. When asked to describe the resident's attendance and participation in activities, the Wellness Coordinator stated, We remind them of how others expect to be treated. We take them for a walk, try to redirect them. They will have a choice of coloring, newspaper, cards, read books or converse with a staff member who is not busy. The people who don't come out, I invite them to the activities. I document each residents attendance daily along with any behaviors. When asked to show where her documentation was located, she was unable to do so. On 3/15/18 at 4:00 P.M. the facility Administrator (Administration A) was informed of the findings. No further information was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review and facility documentation review the facility staff failed for 1 resident (Resident #189) of 37 residents in the survey sample to ensure appropriate services were provided to prevent urinary tract infections. 1. Resident #189's catheter drainage bag and tubing were observed on the floor while resident was sleeping in bed. The findings included: Resident #189, an [AGE] year old, was admitted to the facility on [DATE]. Her diagnoses included urine retention, anxiety, dementia, depression, diabetes, dysphagia, and hyperlipidemia. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 3/2/18. Resident #189 had a Brief Interview of Mental Status score of 12 indicating moderate cognitive impairment. She required extensive assistance with activities of daily living. She was coded to have an indwelling catheter. Resident #189 had a physician order dated 3/14/18 for the catheter Foley catheter #16F with 10 cc (cubic centimeter) balloon to straight drain Dx (diagnosis): Urinary Retention. On 3/14/18 at 8:10 a.m., Resident #189 was observed sleeping in bed. The bed was in the lowest position. The bottom of the catheter drainage bag was touching the floor and the tubing was laying on the floor. On 3/15/18 at 10:45 a.m., an interview regarding infection control was conducted with the Director of Nursing (DON). The DON stated that she expected the tubing of the bag not to touch the floor. The facility policy titled Urethral Catheter Care read 6. The only place, in the closed system, intended to be open is the empty spout at the bottom of the drainage bag. (Note: caution should be taken not to allow the end of the spout to touch anything). The Administrator and DON were notified of the issue at the end of day meeting on 3/15/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility documentation review, clinical record review, the facility staff failed to to administer oxygen in a manner to prevent the spread of infection for one Resident (Resident # 15). For Resident # 15, on 03/13/18 the oxygen tubing was not dated as to when it had been changed. The findings included: 1. Resident # 15 was an [AGE] year old female admitted to the facility on [DATE] with the diagnoses of, but not limited to: Chronic Embolism, Major Depressive Disorder, Breast Cancer, COPD (Chronic Obstructive Pulmonary Disorder), Atherosclerotic Heart Disease, Chronic A-Fib (atrial fibrillation), IBS (Irritable Bowel Syndrome), Anxiety Disorder, Insomnia. The most recent Minimum Data Set (MDS) was an admission Assessment with an Assessment Reference Date (ARD) of 12/11/2017. The MDS coded Resident #15 with a BIMS (Brief Interview for Mental Status) of 14/15 indicating resident is cognitively intact. Resident # 15 requires extensive physical assist of one staff person with activities of daily living except required supervision and set up only for eating; she was also coded as always incontinent of bowel and bladder. Resident # 15 was coded as requiring oxygen therapy. 03/13/18 02:26 PM Resident # 15 Observed lying in bed O2 @ 2 lpm via nasal cannula in place. Oxygen concentrator was on with humidifier canister partially full however no date was found on tubing or canister. Review of the clinical record revealed physician's orders dated for oxygen at 2 liter per minute (lpm). Review of the facility oxygen administration policy revealed documentation that tubing should be changed weekly. On 3/16/2018 at 2 PM, an interview was conducted with the Administrator who stated, The oxygen tubing is changed throughout the facility on Tuesdays on 11-7 shift and should be dated at the time of change. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed for 1 resident (Resident #103 ) of 37 residents in the survey sample to ensure medications were available for administration. For Resident #103, the breathing treatment medication Acetylcysteine Solution 20% was unavailable for administration. The findings included: Resident #103, a [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included respiratory failure, hypertension, insomnia, dry eye syndrome, cerebral palsy, and diabetes. The most current Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 1/23/18. Resident #103 was coded with a Brief Interview of Mental Status score of 15 indicating no cognitive impairment. He required extensive assistance with activities of daily living. The following nursing notes were documented in the clinical record: 1/20/18 at 2:46 p.m. Pharmacy called and will send ASAP (as soon as possible). RP (responsible party) and MD (doctor) aware. 1/21/18 at 11:17 p.m. Pharmacy notified and will be sending ASAP. MD and RP made aware. On 3/15/18, an end of day meeting was held with the Administrator and Director of Nursing (DON). At this time, it was reviewed that it was documented in the nursing notes that a medication was unavailable for administration on 1/20/18 and 1/21/18. The facility staff were asked to identify the medication that was unavailable. The following day, the DON provided copies of the 1/20/18 and 1/21/18 nursing notes documented in the above writing. When asked what medication was unavailable, the DON stated that she needed to check. The DON returned later in the day with a copy of the January 2018 Medication Administration Record (MAR). She had highlighted the medication Acetylcysteine Solution 20% and highlighted the 9:00 a.m. dose on 1/20/18 and 1/21/18. The DON stated that this was the medication that was unavailable on these dates. Resident #103 had a physician order dated 1/16/18 for Acetylcysteine Solution 20%, 1 vial inhale orally every 12 hours for SOB (shortness of breath) related to Respiratory Failure. According to the January 2018 MAR, the Acetylcysteine Solution 20% was not administered on 1/20/18, 1/21/18 and the morning dose on 1/22/18, a total of five doses. The Administrator and DON were notified of the issue at the end of day meeting on 3/16/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed for 1 resident (Resident # 151) in the survey sample of 37 residents, to review and renew a PRN (as needed) order for psychotropic medication every 14 days. The facility staff failed to review and renew a PRN order for Ativan for approximately 7 months. During that time, the order was never limited to 14 days duration. The Findings included: Resident #151 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #151's diagnoses included Psychosis, Anxiety Disorder, and Dementia. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 2/14/18, coded Resident #151 as having a Brief Interview of Mental Status Score of 3. This score is indicative of severely impaired cognition. On 3/14/17 a review was conducted of Resident #151's clinical record. The care plan read, 3/22/17. The resident sometimes interrupts group activities by yelling out, asking for personal assistance and attention. She has some cognitive deficits and physical limitations. Medication as ordered. Resident #151's clinical record contained the following signed Physician's Order, 3/1/18. Ativan Tablet 0.5 MG by mouth every 8 hours as needed for anxiety. Start Date 8/22/17. On 3/15/18 a review was conducted of facility documentation, revealing a medication policy. It read, Unnecessary Medications and Appropriate Psychoactive Medication. Dated June, 2014. As needed PRN antipsychotic drugs should only be used when the resident has a specific condition for which antipsychotic drugs are indicated. On 03/16/18 at 12:06 P.M. an interview was conducted with the facility Administrator (Administration A). She stated that she was aware that PRN orders for psychotropic medications must be renewed every 14 days. No further information was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review and clinical record, the facility staff failed to ensure 5 residents (Residents # 106, 115, 175, 30, and 95) were assessed (Level I) (1) or referred for Level II (2) PASARR (Preadmission Screening and Resident Review) after development of mental disorders. 1. For Resident # 106, the facility staff failed to ensure that a PASARR II was obtained after the development of mental disorders. 2. Resident #115's PASARR was not dated. 3. Resident #175 did not receive a PASARR (preadmission screening and resident review) on admission. 4. Resident #30 did not have a Level I PASARR on admission. 5. For Resident #95, the facility staff failed to ensure that a PASARR II was obtained after the development of mental disorders. The findings included: 1. For Resident # 106, the facility staff failed to ensure that a PASARR II was obtained after the development of mental disorders. Resident # 106 was admitted to the facility originally in 2005 and readmitted on [DATE] with diagnoses of but not limited to: Psychosis, Dementia with behaviors, Mood Disorder, Chronic Obstructive Pulmonary Disease, Dysphagia, Arthritis, Hernia without obstruction and contracture. The most recent Minimum Data Set (MDS) was a Quarterly assessment with an Assessment Reference Date (ARD) of 1/26/18. The MDS coded Resident # 106 with a BIMS (Brief Interview for Mental Status) of 99 indicating severe cognitive impairment; Resident # 106 required extensive to total assistance of one to two staff persons with activities of daily living; always incontinent of bowel and bladder. Review of the clinical record was conducted on 3/14/2018 at 9 AM. Review of the record revealed no PASARR (Preadmission Screening and Resident Review) on the hard chart nor in the electronic record. Review of the Psychiatric Evaluation notes from September 2017 - February 2018 revealed diagnoses of Mood Disorder, Dementia and Psychosis. Resident # 106 also was prescribed Psychiatric Medications: Aricept 10 milligrams by mouth at hour of sleep for Dementia, Seroquel 25 milligrams by mouth every morning and 50 milligrams by mouth at hour of sleep for Psychosis, Namenda 10 milligrams by mouth twice daily for Dementia and Buspar 5 milligram by mouth 3 times daily for anxiety. The Administrator (Administration A) stated she searched the closed record and found that there was a level I PASARR done on the resident during her initial admission to the facility in 2005. The Administrator presented a copy of the Level I PASARR from 6/14/2005 which recommended no referral for a Level II because the individual has a primary diagnosis of dementia (including Alzheimer's disease) and does not have a diagnosis of MI (mental illness). The Administrator stated there was no other information about the PASARR process on the record. Thorough review of the record revealed no repeat PASARR after Resident # 106 was diagnosed with a change in mental status to include mental illness diagnoses of Psychosis and Mood Disorder. On 3/16/2018 at 12:15 PM, an interview was conducted with the Facility Administrator (Administration A) who stated The process is broken. We will have a policy going forward. We don't have a policy regarding completing a level 2 PASARR. Who ever diagnoses it, works with the psychiatric consultant-(name of ) Services- to complete the level 2 PASARR. No further information was provided. 5. For Resident #95, the facility staff failed to ensure that a PASARR II was obtained after the development of mental disorders. Resident #95 was a [AGE] year old who was admitted to the facility on [DATE]. According to her initial Physician Orders dated 2/16/15, upon admission her diagnoses were Brain Injury, Anxiety, Hypertension, and Anemia. Resident #95's subsequent additional diagnoses documented on Physician's Orders were as follows: Mood Affective Disorder 6/15/15 Major Depressive Disorder 10/1/15 Delusional Disorder 2/4/16 After the development of the above-mentioned mental disorders, a PASARR II was not done. The Minimum Data Set, which was an Annual Assessment, with an Assessment Reference Date of 1/20/18, coded Resident #95 as having a Brief Interview of Mental Status Score of 3. This score indicates severely impaired cognition. On 3/13/18 a review was conducted of Resident #95's clinical record, revealing a PASARR I dated 2/16/15. The PASARR I documented that Resident #95 did not have a serious mental illness. It read, No referral for Level II needed because individual does not meet the applicable criteria for serious MI (Mental Illness) or MR (Mental Retardation) or related condition. On 03/16/18 at 12:15 PM, an interview was conducted with the facility Administrator (Administration A). She stated, The process is broken. We will have a policy going forward. We don't have a policy regarding completing a level 2 PASARR. Whoever is diagnoses it, work with the psychiatric consultant-[company name] - to complete the level 2 PASARR 2. Resident #115's PASARR was not dated. Resident #115 was admitted to the facility on [DATE]. Her diagnoses included Dementia without behavioral disturbance, major depression and bipolar disorder. Her most recent Minimum Data Set assessment was an annual assessment with an assessment reference date of 1/30/18. She was coded with a moderate cognitive impairment and required extensive assistance of one to two staff members with activities of daily living. Review of Resident #115's Level I PASARR revealed there was no date on the assessment. It was unclear if this assessment had been done prior to admission. 3. Resident #175 did not receive a PASARR (preadmission screening and resident review) on admission. Resident #175 was admitted to the facility on [DATE]. Her diagnoses included Dementia, Parkinson's Disease, psychosis and hallucinations. The resident was receiving Seroquel (antipsychotic) as well as an antidepressant. Her most recent Minimum Data Set assessment was an annual assessment with an assessment reference date of 2/21/18. She was coded with a no cognitive impairment and required extensive assistance of one to two staff members with activities of daily living. On 3/13/18, during the initial tour, Resident #175 made an allegation of abuse by a resident in the facility. The accused resident was chair bound and was unable to propel her gerichair to the resident's room. 3/6/18 revealed a psychiatric note that hallucinations have improved. Review of the clinical record revealed the resident did not have a Level I PASARR. After questioning, the Administrator presented a Level I PASARR dated 3/18/18, which was completed by the Administrator. On 3/14/18 at approximately 10:00 AM, the Administrator stated, We know there is a failure in the system and it will be corrected. 4. Resident #30 did not have a Level I PASARR on admission. Resident #30 was admitted to the facility on [DATE]. Her diagnoses included Dementia, depression, anxiety and psychosis. Her most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 12/19/17. She was coded with a moderate cognitive impairment and required extensive assistance of one to two staff members with activities of daily living. Review of the clinical record revealed the resident did not have a Level I PASARR. After questioning, the Administrator presented a Level I PASARR dated 3/18/18, which was completed by the Administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review, and clinical record review, the facility staff failed for 8 residents (Resident #176, #55, #149, #193, #115, #8, #175, #93) of the survey sample of 37 to ensure a PASARR screening was conducted prior to admission to the nursing facility. 1. For Resident #176, the Preadmission Screening and Resident Review (PASARR) was not completed prior to admission to the facility. 2. For Resident #55, the Preadmission Screening and Resident Review (PASARR) was not completed prior to admission to the facility. 3. For Resident #149, the Preadmission Screening and Resident Review (PASARR) was not completed prior to admission to the facility. 4. For Resident #193, the Preadmission Screening and Resident Review (PASARR) was not completed prior to admission to the facility. 5. Resident #115 was not referred for a Level II PASARR when diagnosed with bipolar disorder. 6. Resident #8 was not referred to for a Level II PASARR when diagnosed with paranoia. 7. Resident #175 was not referred to for a Level II PASARR when diagnosed with paranoia. 8. Resident #93 was not referred for a Level II PASARR when diagnosed with Schizophrenia, anxiety and depression. The findings included: 1. For Resident # 176, the Preadmission Screening and Resident Review (PASARR) was not completed prior to admission to the facility. Resident # 176 was admitted to the facility on [DATE] with diagnoses of but not limited to: Major Depressive Disorder, Dementia, Depression w/ SI (suicidal Ideation), Diabetes Type II, Hypertension, Coronary Artery Disease, Left Anterior Descending Peripheral Vascular Disease, S/P L BKA (status post left Below Knee Amputation) S/P TMA Right Foot (status post Trans Metatarsal Amputation of Right foot), Popliteal -Tibial bypass. Resident #176 's Most recent MDS (Minimum Data Set) assessment was a Quarterly Assessment with an ARD (Assessment Reference Date) dated 2/27/2018 and coded Resident # 176 with a BIMS (Brief Interview for Mental Status) score of 10, indicating moderate impairment. On 3/14/2018, a review of Resident Records was started. Resident #176 MDS flagged as No PASARR Level II with Diagnosis. Review of the clinical record revealed no documentation of a PASARR assessment being done prior to admission. On 3/15/2018 at approximately 9:30 a.m. the Facility Administrator was asked to submit a copy of Resident # 176's PASARR from admission. A copy of PASARR Level I was submitted. No PASARR Level II was done at time of admission or thereafter. Review of the document for Resident #176 revealed the Preadmission Screening and Resident Review (PASARR) was not dated prior to admission to the facility, date was completely omitted. The Administrator was asked when a Resident should have a PASARR completed. She stated that it should occur during the pre-admission process. Interview with Administrator (Administration A) 03/16/18 12:15 PM The process is broken. We will have a policy going forward, we don't have a policy regarding completing a Level II PASARR. Whoever diagnoses it, works with the psychiatric consultant-Ascend Services- to complete the level II PASARR. No further information was provided. 2. For Resident # 55, the Preadmission Screening and Resident Review (PASARR) was not initiated prior to admission to the facility. Resident #55's Initial Date of admission was 08/26/2014 with Resident diagnoses of but not limited to: Tachycardia, Dementia NOS (not otherwise specified) with behaviors, Recurrent Depressive Psychosis, Traumatic Brain Injury, Osteomyelitis, Cardiac Murmur, Protein deficiency, Calcium deficiency Pressure Ulcer Stag IV. Resident #55's most recent MDS (Minimum Data Set) Assessment was a Quarterly Assessment with an ARD (Assessment Reference Date) of 01/03/2018. The MDS coded Resident # 55 with a BIMS (Brief Interview for Mental Status) score of 9, indicating moderate impairment. On 3/14/2018, a review of Resident Records was started. Resident #55 MDS flagged as No PASARR Level II with Diagnosis On 3/15/2018 at approximately 9:30 a.m. the Facility Administrator was asked to submit a copy of Resident # 55's PASARR from admission. PASARR Level I was submitted. No PASARR Level II was done at time of admission or thereafter. The Administrator was asked when a Resident should have a PASARR completed. She stated that it should occur during the pre-admission process. Interview with Administrator (Administration A) 03/16/18 12:15 PM The process is broken. 3. For Resident #149, the Preadmission Screening and Resident Review (PASARR) was not completed prior to admission to the facility. Resident #149's Initial Date of admission was 12/10/2015. Resident #149's most recent MDS (Minimum Data Set) assessment was a Medicare 14-Day Assessment with an ARD (Assessment Reference Date) of 2/26/2018. Resident #149's MDS reported a BIMS (Brief Interview for Mental Status) of 13, indicating minimal impairment. Resident #149's diagnoses included: Hypertension, Hyperlipidemia, Non-Alzheimer's Dementia, Major Depressive Disorder, Non-ST-Elevated Myocardial Infarction, Hypothyroidism, Atrial Fibrillation, Gastro-Esophageal Reflux Disease, Dysphagia, and Cognitive Communication Deficit. On 3/13/2018, a review of Resident Records was started. Resident #149's MDS flagged as not having a completed PASARR. On 3/14/2018 at approximately 10:00 a.m. the Facility Administrator was asked to verify the status of the Resident's PASARR. The Administrator stated that she would investigate it. On the morning of 3/15/2018, the Facility Administrator stated to survey staff that Resident #149 did not have PASARR completed. The Facility Administrator stated that she had gone ahead and completed it and provided survey staff with a document entitled SCREENING FOR MENTAL ILLNESS, MENTAL RETARDATION/INTELLECTUAL DISABILITY, OR RELATED CONDITIONS. The document was dated 3/15/2018. The Administrator was asked when a Resident should have a PASARR completed. She stated that it should occur during the pre-admission process. No further information was provided. 4. For Resident #193, the Preadmission Screening and Resident Review (PASARR) was not completed prior to admission to the facility. Resident #193's Initial Date of admission was 01/23/2018. Resident #193's most recent MDS (Minimum Data Set) assessment was a Medicare 30-Day Assessment with an ARD (Assessment Reference Date) of 3/02/2018. Resident #193's MDS reported a BIMS (Brief Interview for Mental Status) of 13, indicating minimal impairment. Resident #193's diagnoses included: Urinary Tract Infection, Dysphagia, Anemia, Melena, Thrombocytopenia, Major Depressive Disorder, Obstructive Sleep Apnea, Atrial Fibrillation, Congestive Heart Failure, Diabetes Mellitus Type 2, Dementia, Psychosis, Chronic Kidney Disease Stage 4, Neurogenic Bladder, Anxiety, and Hypertension. On 3/13/2018, a review of Resident Records was started. Resident #193's MDS flagged as not having a completed PASARR. On 3/14/2018 at approximately 10:00 a.m. the Facility Administrator was asked to verify the status of the Resident's PASARR. The Administrator stated that she would investigate it. On the morning of 3/15/2018, the Facility Administrator stated to survey staff that Resident #193 did not have PASARR completed. The Facility Administrator stated that she had gone ahead and completed it and provided survey staff with a document entitled SCREENING FOR MENTAL ILLNESS, MENTAL RETARDATION/INTELLECTUAL DISABILITY, OR RELATED CONDITIONS. The document was dated 3/15/2018. The Administrator was asked when a Resident should have a PASARR completed. She stated that it should occur during the pre-admission process. No further information was provided. 5. Resident #115 was admitted to the facility on [DATE]. Her diagnoses included Dementia without behavioral disturbance, major depression and bipolar disorder. Her most recent Minimum Data Set assessment was an annual assessment with an assessment reference date of 1/30/18. She was coded with a moderate cognitive impairment and required extensive assistance of one to two staff members with activities of daily living. Review of Resident #115's Level I PASARR (undated) revealed that this resident did have not have a current serious mental illness. The resident was diagnosed with bipolar disorder. Bipolar disorder is a disease listed in the DSM (diagnostic and statistical manual of mental disorders). Resident #115 was diagnosed with bipolar disorder on 1/26/18. The resident was not referred for a Level II PASARR. The resident is being treated at the facility by a psychiatrist. 6. Resident #8 was not referred to for a Level II PASARR when diagnosed with paranoia. Resident #8 was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's, paranoia and anxiety. Her most recent Minimum Data Set assessment was an annual assessment with an assessment reference date of 12/7/17. She was coded with a moderate severe impairment and required extensive assistance of one staff member with activities of daily living. Review of the clinical record revealed a Level I PASARR (undated) which was checked no for serious mental illness. Subsequently the resident was diagnosed with paranoia; at the psychiatric examination on 2/13/18, Resident #8's Seroquel (antipsychotic) was increased due to her paranoia. There was no Level II PASARR completed. 7. Resident #175 was not referred to for a Level II PASARR when diagnosed with paranoia. Resident #175 was admitted to the facility on [DATE]. Her diagnoses included Dementia, Parkinson's Disease, psychosis and hallucinations. The resident was receiving Seroquel (antipsychotic) as well as an antidepressant. Her most recent Minimum Data Set assessment was an annual assessment with an assessment reference date of 2/21/18. She was coded with a no cognitive impairment and required extensive assistance of one to two staff members with activities of daily living. On 3/13/18, during the initial tour, Resident #175 made an allegation of abuse by a resident in the facility. The accused resident was chair bound and was unable to propel her gerichair to the resident's room. 3/6/18 revealed a psychiatric note that hallucinations have improved. Review of the clinical record revealed the resident did not have a Level I PASARR. After questioning, the Administrator presented a Level I PASARR dated 3/18/18, which was completed by the Administrator. Review of the diagnosis list revealed the resident was diagnosed on [DATE] with psychosis and hallucinations on 8/7/15. No referral for a Level II was evident. 8. Resident #93 was not referred for a Level II PASARR when diagnosed with Schizophrenia, anxiety and depression. Resident #93 was admitted to the facility on [DATE]. Her diagnoses included Depression, schizophrenia and anxiety. Her most recent Minimum Data Set assessment was an annual assessment with an assessment reference date of 1/18/18. She was coded with a no cognitive impairment and required extensive assistance of one to two staff members with activities of daily living. Review of the clinical record revealed the resident did not have a Level I PASARR. After questioning, the Administrator presented a Level I PASARR dated 3/15/18, which was completed by the Administrator. Review of the medication list revealed the following medications: Abilify (antipsychotic), Effexor (antidepressant) and Buspar (anti-anxiety). Review of the care plan dated 1/26/18 revealed on 9/21/15 that the resident was taking an antipsychotic medication for schizophrenia. There was no referral for Level II PASARR. On 3/14/18 at approximately 10:00 AM, the Administrator stated, We know there is a failure in the system and it will be corrected.